What is the recommended post-operative care for a patient after Open Reduction Internal Fixation (ORIF) surgery?

Post-Operative Care After ORIF Surgery

Begin early mobilization within 30 minutes on the day of surgery and progress to 6 hours daily thereafter, combined with multimodal opioid-sparing analgesia and aggressive VTE prophylaxis to optimize recovery and prevent complications. 1

Immediate Post-Operative Management (Day 0-1)

Pain Control

• Implement multimodal opioid-sparing analgesia as the cornerstone of pain management 1
• Administer combination of paracetamol (acetaminophen) and NSAIDs orally as baseline analgesics unless specific contraindications exist 1
• Reserve opioid-containing medications as last resort only, using lowest effective doses 1
• Consider regional blocks or local anesthetic techniques when appropriate for orthopedic procedures 1

Early Mobilization Protocol

• Mobilize patients for 30 minutes on the day of surgery 1
• Progress to 6 hours of mobilization daily starting postoperative day 1 1
• Early mobilization (within 2 weeks) significantly reduces time to discharge from therapy and accelerates return to work compared to delayed mobilization at 4 weeks 2
• Patients mobilized early demonstrate significantly greater range of motion at 4 and 6 weeks post-surgery 2

Monitoring Parameters

• Monitor respiratory rate, heart rate, blood pressure, oxygen saturation, level of consciousness, and surgical site regularly 1
• Establish tailored postoperative monitoring and escalation pathway specific to the surgical procedure 1
• Maintain core temperature ≥36°C with active warming measures 1

Venous Thromboembolism Prophylaxis

Continue aggressive VTE prophylaxis throughout hospitalization and consider extended prophylaxis for high-risk patients 1

• Use combination of compression stockings and/or intermittent pneumatic compression with either LMWH or unfractionated heparin 1
• Reassess VTE risk daily postoperatively using validated tools 1
• For very high-risk patients, combine pharmacological with mechanical prophylaxis 1
• Consider extended prophylaxis (4 weeks with LMWH) for patients with malignancy, inflammatory conditions, or other high-risk features 1
• Approximately one-third of VTEs occur after discharge, necessitating extended prophylaxis consideration 1

Wound and Infection Management

Antibiotic Prophylaxis

• Do not continue routine antibiotic prophylaxis into the postoperative period 1
• Preoperative antibiotics (first-generation cephalosporin) should be administered within 1 hour of incision only 1

Wound Monitoring

• Evaluate for signs of infection including erythema, drainage, fever, and elevated inflammatory markers 3
• Patients with diabetes require more vigilant monitoring due to increased infection risk 3
• Consider negative pressure wound therapy for high-risk surgical incisions, particularly in patients with diabetes or obesity 3

Deep Infection Management

• Deep infections require urgent surgical debridement of all necrotic tissue 3
• Remove hardware if infection involves the implants 3
• Initiate appropriate antibiotic therapy based on culture results 3

Catheter and Drain Management

Urinary Catheter

• Remove Foley catheter within 24 hours after surgery in the majority of cases 1
• Individualize removal timing only in patients with high risk of urinary retention 1
• Early removal (postoperative day 1) is safe even with epidural analgesia and reduces urinary tract infection risk 1

Surgical Drains

• Avoid routine use of nasogastric tubes and surgical drains 1
• Routine drainage does not decrease anastomotic leak rates, reoperation, or mortality 1

Nutrition and Fluid Management

Early Oral Intake

• Offer oral fluids as soon as patient is lucid after surgery 1
• Provide solid food within 4 hours after surgery 1
• Discontinue intravenous fluids by postoperative day 1 1

Fluid Balance

• Maintain near-zero fluid balance strategy 1
• Encourage oral intake once patient is fully recovered 1
• If IV fluids required beyond day 1, use hypotonic crystalloid with 70-100 mmol/day sodium and up to 1 mmol/kg/day potassium 1

Prevention of Postoperative Complications

Nausea and Vomiting

• Assess all patients for PONV risk factors 1
• Provide 2-3 antiemetics for high-risk patients 1
• Continue antiemetic therapy postoperatively as required 1

Ileus Prevention

• Implement chewing gum to reduce time to first bowel movement by approximately 1 day 1
• Consider oral laxatives (magnesium hydroxide with bisacodyl suppositories) to normalize gastrointestinal transit 1

Delirium Prevention (Age >65)

• Screen patients over 65 years regularly for postoperative delirium 1
• Implement non-pharmaceutical interventions: regular orientation, sleep hygiene approaches, and cognitive stimulation 1
• Minimize medication triggers for delirium 1

Hardware-Specific Considerations

Monitoring for Hardware Complications

• Evaluate for associated symptoms including pain, decreased range of motion, instability, or mechanical symptoms like popping 4
• Obtain plain radiographs to assess hardware position and integrity 4
• Consider advanced imaging (CT scan) if radiographs inconclusive but symptoms persist 4
• MRI may help evaluate soft tissue pathology, though hardware artifact may limit usefulness 4

Complication Rates

• Postoperative complications occur in approximately 54% of ORIF cases, with reoperation rates around 23% 5
• Plate-and-screw fixation may have higher complication rates compared to screws alone 5
• Most patients achieve excellent functional outcomes (DASH scores 98-100) in 81.7% of cases by 6 months 6

Special Population Considerations

Diabetic Patients

• Require more aggressive management and vigilant monitoring 3
• Higher risk of infection and impaired wound healing 3
• Special attention needed to prevent ulceration at fracture site 3

Smoking Cessation

• Educate patients regarding smoking cessation as smoking increases complication risk 3

Discharge Planning

Timing Considerations

• Surgical timing (early vs. delayed up to 14 days) does not significantly affect wound complications or functional outcomes for certain fractures 7
• Early mobilization protocols facilitate earlier discharge from therapy 2
• Patients mobilized within 2 weeks return to work significantly faster than those mobilized at 4 weeks 2

Ongoing Care

• Ensure appropriate weight-bearing status is maintained as prescribed by orthopedic surgeon 4
• Optimize bone health with adequate calcium and vitamin D supplementation 4
• Continue VTE prophylaxis as indicated, potentially for up to 12 weeks in high-risk patients 1