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 ORIF with plating for the fibula and K-wire for the tibia should be performed with careful consideration of the delayed presentation and potential for increased callus formation and soft tissue contracture. The procedure involves several critical steps, starting with patient positioning, where the patient is placed 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 particular attention to irrigation with saline (without additives) as recommended for management of open wounds in major extremity trauma 1. The procedure begins with a lateral longitudinal incision over the fibula to expose the fracture site, taking care to protect the superficial peroneal nerve. The fracture is identified, debrided of callus formation (which will be more substantial due to the 1.5-month delay), and anatomically reduced. A fibular plate (typically one-third tubular or anatomic fibular plate) is applied and secured with screws. Next, a medial incision is made over the medial malleolus to expose the tibial fracture. After debridement and reduction, 1-2 K-wires (typically 1.6-2.0 mm) are inserted from the tip of the medial malleolus into the distal tibia to stabilize the fracture. These may be supplemented with a tension band wire or cannulated screws depending on bone quality and fracture pattern. Intraoperative fluoroscopy confirms proper reduction and hardware placement. The wounds are irrigated, closed in layers, and dressed, following the principle that definitive fixation of fractures at initial débridement and primary closure of wounds in selected patients may be considered when appropriate 1. Postoperatively, a below-knee splint is applied for 2 weeks, followed by a removable boot for 4-6 weeks. Weight-bearing is typically restricted for 6-8 weeks, with progressive weight-bearing thereafter based on radiographic healing. Physical therapy begins after splint removal, focusing initially on range of motion exercises and progressing to strengthening and proprioception. The delayed presentation (1.5 months) may necessitate more extensive soft tissue release and bone debridement to achieve reduction, and healing time may be prolonged compared to acute fractures. Key considerations include:

• Careful soft tissue management to minimize the risk of surgical site infection, as emphasized in the AAOS clinical practice guideline summary 1
• Meticulous attention to anatomical reduction and stable fixation to promote optimal healing and functional outcome
• A tailored postoperative rehabilitation program to address the potential for increased stiffness and weakness associated with delayed treatment.

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 several steps:
  • Preoperative Evaluation: Evaluate the patient's overall health, medical history, and the extent of the fracture 2.
  • Surgical Approach: Perform an open reduction and internal fixation (ORIF) of the fracture, using plating for the fibula and K-wire for the tibia 3, 4.
  • Reduction and Fixation: Reduce the fracture and fixate it using the chosen method, ensuring proper alignment and stability of the ankle joint 4.
  • Syndesmosis Repair: If necessary, repair the syndesmosis using a suture-endobutton device to provide anatomical mobility and quicker return to weight-bearing 4.
  • Postoperative Care: Allow early weight-bearing at 3 weeks postoperatively, as it does not increase markers of radiographic failure compared to late weight-bearing 3.
  • Follow-up: Monitor the patient's progress and adjust the treatment plan as needed to ensure proper healing and recovery 2.

Key Considerations

• The treatment of bimalleolar ankle fractures in older adults requires rigorous analysis and consideration of the patient's overall health and local conditions 2.
• The use of anatomical locking plates can be an advance in the treatment of fragility fractures, allowing for return to weight-bearing in certain conditions 2.
• Immediate protected weight-bearing can be considered on a case-by-case basis, depending on the extent of the trauma, patient compliance, and treatment carried out 2.

Relevant Studies

• A study published in Cureus found that early weight-bearing at 3 weeks postoperatively does not increase markers of radiographic failure compared to late weight-bearing 3.
• A study published in Orthopaedics & traumatology, surgery & research : OTSR discussed the treatment of bimalleolar fractures in elderly patients, highlighting the importance of rigorous analysis and consideration of the patient's overall health and local conditions 2.
• A study published in Journal of orthopaedic trauma described the indications and surgical technique for management of a bimalleolar ankle fracture requiring repair of the syndesmosis 4.