What is the step-by-step procedure for Open Reduction Internal Fixation (ORIF) with plating of a distal tibia and fibula fracture?

From the Guidelines

The surgical procedure for open reduction and internal fixation (ORIF) of distal tibia and fibula fractures involves several key steps, with the goal of restoring anatomic alignment and stability to the ankle joint, allowing for earlier mobilization and promoting proper healing of these weight-bearing bones.

Preoperative Preparation

The patient is positioned supine on a radiolucent table after administration of appropriate anesthesia and prophylactic antibiotics (typically cefazolin 1-2g IV) 1. The surgical site is prepped and draped in sterile fashion.

Surgical Approach

For the fibula, a lateral approach is used with a longitudinal incision over the distal fibula. After dissection through subcutaneous tissue, the fracture is identified, reduced anatomically, and temporarily held with K-wires. A contoured one-third tubular or locking plate is then applied to the lateral aspect of the fibula and secured with appropriate screws. For the tibia, either an anteromedial or anterolateral approach is used depending on the fracture pattern and soft tissue condition 1. The incision is made, taking care to preserve the saphenous vein and nerve. After exposure of the fracture, anatomic reduction is achieved and verified with fluoroscopy. A pre-contoured distal tibia plate or locking plate is applied, with locking screws in the distal fragment and cortical or locking screws proximally.

Intraoperative and Postoperative Care

Intraoperative fluoroscopy confirms proper reduction and hardware placement. The wounds are irrigated, hemostasis achieved, and closure performed in layers. A well-padded splint is applied with the ankle in neutral position. Postoperatively, patients remain non-weight bearing for 6-8 weeks, with early range of motion exercises beginning at 2 weeks if fixation is stable 1. Some key considerations in the management of these fractures include:

• The use of antibiotic prophylaxis, with evidence supporting the use of short course, single agent regimens using cephalosporins to prevent adverse outcomes in open fractures 1.
• The potential benefits of local antibiotics, such as antibiotic beads, in managing traumatic fractures 1.
• The importance of timely surgical intervention, with patients with open fractures ideally being brought to the OR for débridement and irrigation as soon as reasonable and before 24 hours post injury 1.

Key Points

• Anatomic reduction and stable internal fixation are crucial for promoting proper healing and preventing complications.
• Timely surgical intervention and appropriate antibiotic prophylaxis are essential for preventing surgical site infections.
• Early range of motion exercises and non-weight bearing status are important for preventing stiffness and promoting proper healing.

From the Research

Step-by-Step Procedure for Fracture Distal Tibia Fibula by ORIF with Plating

The procedure for fracture distal tibia fibula by open reduction and internal fixation (ORIF) with plating involves several steps:

• Preparation: The patient is prepared for surgery, and the affected leg is cleaned and draped in a sterile manner.
• Incision: A single incision is made from the anterolateral side, as described in studies 2, 3, 4, to approach both the tibia and fibula fractures.
• Exposure: The fibular fracture is exposed and fixed first, followed by the exposure and fixation of the lateral aspect of the distal tibia.
• Reduction: The fractures are reduced, and the bone fragments are aligned anatomically.
• Plating: A plate is applied to the lateral aspect of the distal tibia to stabilize the fracture, as described in study 5.
• Fixation of fibula: The fibula is fixed using a separate plate or screw, as described in study 5, to improve rotational alignment.
• Closure: The incision is closed, and the wound is dressed.

Considerations and Variations

• The use of a single incision from the anterolateral side can minimize soft-tissue complications and reduce the risk of wound healing problems, as described in studies 2, 3, 4.
• The decision to fix the fibula should be based on the specific fracture pattern and the need to improve rotational alignment, as described in study 5.
• The choice of implant, such as intramedullary nails or minimally invasive plate osteosynthesis, should be based on the specific fracture characteristics and the surgeon's preference, as described in studies 5, 6.
• The surgical approach and technique should be tailored to the individual patient's needs and fracture pattern.

Key Points

• The use of a single incision from the anterolateral side can simplify the surgical approach and reduce complications.
• The fixation of the fibula can improve rotational alignment and stability of the fracture.
• The choice of implant and surgical technique should be based on the specific fracture characteristics and the surgeon's preference.
• The procedure should be performed by an experienced surgeon with expertise in orthopedic trauma surgery, as described in studies 2, 3, 4, 5, 6.