What is the step-by-step procedure for managing a 1.5-month-old bimalleolar fracture with Open Reduction Internal Fixation (ORIF) using plating for the fibula and Kirschner wire (K-wire) for the tibia?

From the Guidelines

The surgical management of a 1.5-month-old bimalleolar ankle fracture using open reduction internal fixation (ORIF) with plating for the fibula and K-wire for the tibia is a complex procedure that requires careful planning and execution to achieve optimal outcomes in terms of morbidity, mortality, and quality of life.

Preoperative Planning

The patient is positioned supine on the operating table with a bump under the ipsilateral hip to facilitate access to both malleoli. After administering appropriate anesthesia and applying a tourniquet, the surgical site is prepped and draped, with irrigation with saline (without additives) recommended for management of open wounds in major extremity trauma, as per the AAOS clinical practice guideline summary 1.

Fibular Approach

For the fibular approach, a lateral longitudinal incision is made over the distal fibula, carefully identifying and protecting the superficial peroneal nerve. The fracture site is exposed by dissecting through the subcutaneous tissue and periosteum. Due to the 1.5-month age of the fracture, fibrous tissue and early callus formation must be removed to achieve anatomical reduction. The fracture is then reduced under direct visualization and temporarily held with reduction clamps. A pre-contoured one-third tubular or anatomical fibular plate is selected and secured with appropriate screws (typically 3.5mm cortical screws).

Medial Malleolus Approach

For the medial malleolus, a curved anteromedial incision is made, and the fracture site is exposed. Given the age of the fracture, the medial malleolus may require freshening of the fracture edges to promote healing. The fragment is reduced and temporarily held with reduction forceps. One or two K-wires (typically 1.6-2.0mm) are then inserted from the tip of the medial malleolus into the tibial metaphysis. The K-wires may be cut beneath the skin or left protruding for later removal.

Intraoperative and Postoperative Care

Intraoperative fluoroscopy is used throughout to confirm anatomical reduction and proper hardware placement. After irrigation, the wounds are closed in layers, and a well-padded posterior splint is applied with the ankle in neutral position. Postoperatively, the patient remains non-weight bearing for 6-8 weeks, with the K-wires typically removed at 6-8 weeks if left protruding. Progressive weight bearing begins after radiographic evidence of healing, usually around 8-12 weeks post-surgery, with physical therapy initiated to restore range of motion and strength. This approach provides stable fixation while accommodating the challenges of an older fracture, including potential malunion, fibrous tissue formation, and osteopenia at the fracture site, as supported by the AAOS clinical practice guideline summary 1.

Key Considerations

• The use of temporizing external fixation remains a viable option for the treatment of open fractures in major extremity trauma, as per the AAOS clinical practice guideline summary 1.
• Definitive fixation of fractures at initial débridement and primary closure of wounds in selected patients may be considered when appropriate, with no favored treatment observed 1.
• The patient's overall health, activity level, and potential for compliance with postoperative instructions should be considered when determining the optimal treatment plan.

From the Research

Step-by-Step Procedure for 1.5 Months Old Fracture Bimalleolar Managed by ORIF with Plating for Fibula and K-Wire for Tibia

• The procedure for managing a 1.5 months old fracture bimalleolar involves open reduction and internal fixation (ORIF) with plating for the fibula and K-wire fixation for the tibia 2.
• The first step is to assess the fracture and determine the best course of treatment. This may involve imaging studies such as X-rays or CT scans to evaluate the extent of the fracture and any potential complications.
• Once the decision to proceed with ORIF has been made, the patient is prepared for surgery. This typically involves administering anesthesia and positioning the patient to allow for optimal access to the fracture site.
• The next step is to make an incision over the fracture site and carefully dissect the tissue to expose the bone. The fracture is then reduced, and the bone fragments are aligned and stabilized using plates and screws for the fibula and K-wires for the tibia.
• The use of K-wires for tibia fixation is a common practice, as it provides sufficient stability for the bone to heal, especially in the early stages of rehabilitation 3.
• After the fixation is complete, the incision is closed, and the patient is taken to the recovery room for post-operative care.
• Post-operative care typically involves pain management, wound care, and monitoring for potential complications such as infection or nerve damage.
• The patient is also advised to follow a rehabilitation protocol, which may include early weight bearing (EWB) to promote healing and prevent stiffness 4.
• EWB has been shown to be safe and effective in promoting fracture union and preventing complications such as hardware loosening or failure 4.

Potential Complications and Considerations

• Potential complications of ORIF with plating and K-wire fixation include infection, nerve damage, and hardware failure.
• The use of K-wires for tibia fixation may also be associated with a higher risk of complications such as wire migration or breakage.
• However, studies have shown that the use of K-wires can provide sufficient stability for the bone to heal, especially in the early stages of rehabilitation 3.
• The decision to use EWB or late weight bearing (LWB) should be made on a case-by-case basis, taking into account the individual patient's needs and fracture characteristics 4.