Updated: 10/9/2017

Tibial Plafond Fracture ORIF with Anterolateral Approach and Plate Fixation

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Preoperative Patient Care

A

Intermediate Evaluation and Management

1

Obtain focused history and perform focused exam

  • evaluate degree of soft tissue injury
  • open wounds
  • swelling (fracture blisters)
  • deformity
  • check soft tissue for wrinkles
  • await return of skin wrinkles prior to ORIF to decrease wound complications for 10-14 days
  • check compartments
  • identify risk factors that correlate with complications and poor outcomes
  • comorbidities
  • diabetes
  • social factors
  • smoking

2

Appropriately interprets basic imaging studies

  • AP/Lat/Mortise views of ankle, AP/Lat views of tibia/fibula
  • characterize fracture pattern, amount of comminution, metaphyseal bone loss, shortening, and angulation
  • commonly 3 fragments according to ankle ligaments: medial malleolar (deltoid), anterolateral (AITFL, Chaput), and posterolateral (PITFL, Volkmann) fragments
  • 75% of fractures have associated fibula fractures
  • location and angulation of fracture fragments influences surgical approach
  • severely comminuted fractures with poor bone quality may require definitive management with external fixator vs. tibiotalar arthrodesis
  • CT scan
  • often performed after placement of spanning ankle external fixator to delineate fracture fragments once length restored

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

4

Provides post-operative management and rehabilitation

  • immediate Post-op
  • non-weight bearing in splint vs. external fixator, crutches for ambulation
  • 2 weeks post-op
  • wound check
  • sutures removed
  • repeat xrays of ankle and tibia/fibula
  • 8-12 weeks postop
  • xrays to evaluate union and fracture consolidation
  • range of motion exercises to ankle
  • advance weight bearing status and rehabilitation
B

Advanced Evaluation and Management

1

Provides comprehensive assessment of complex fracture patterns on imaging studies

2

Recognizes indications for and provides non-operative treatment of an unstable fracture

  • diabetes
  • medical comorbidities
  • noncompliance
C

Preoperative History and Physical

1

Obtain history and perform basic physical exam

  • document neurovascular status
  • check compartments

2

Order basic imaging studies

  • order biplanar radiographs of the tibia and weight bearing triplanar radiographs of the ankle

3

Splint fracture appropriately

  • place in posterior splint with stirrups

4

Perform preoperative consent

  • wound breakdown (10%)
  • superficial/deep infection (5-15%)
  • symptomatic hardware
  • malunion
  • nonunion
  • post-traumatic arthritis (30-70% depending on articular injury)
  • ankle stiffness
  • neurovascular injury

Operative Techniques

E

Preoperative Plan

1

Template fracture

  • template fracture pattern and instrumentation

2

Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • Synthes Variable Angle Locking Ankle Fracture System
  • Synthes Small Fragment Set
  • 1.2mm kwires
  • osteotomes

2

Patient positioning

  • patient supine with feet at the end of the bed, small bump under ipsilateral thigh, tourniquet on thigh
  • if external fixator in place need to scrub down frame and pins thoroughly as this is a source of contamination

3

OR setup and C-arm

  • radiolucent OR table
  • c-arm from contralateral side perpendicular to bed
G

Superficial Dissection

1

Incorporate External Fixation into Approach Strategy

  • If necessary leave external fixator fully or partially intact during approach and fracture reduction/fixation to maintain traction and fracture length

2

Draw out anterolateral incision and any additional incisions.

  • use internervous plane between peroneus tertius and brevis, mark out lateral malleolus and course of peroneus tertius
  • When using multiple approaches used must maintain ~7cm distance between full thickness skin flaps to decrease wound complications

3

Exsanguinate extremity and inflate tourniquet

4

Make incision

  • start 2-3cm anterior to anterior border of fibula in line with 4th ray down to ankle joint
  • identify and protect SPN in subcutaneous tissue immediately under skin
  • incise fascia and extensor retinaculum in line with skin incision
  • retract and elevate anterior compartment tendons medially
  • If needed extend distally to talonavicular joint
  • Anteromedial approach
  • mark out medial malleolus and distal tibia crest, incision medial to tibialis anterior tendon sheath
  • make incision centered on distal tibia then curving medial across ankle joint
  • elevate full thickness skin flaps, leave tibial anterior tendon sheath intact
  • elevate anterior compartment tendons and retracted laterally
H

Deep Dissection

1

Use sharp dissection down to bone

2

Perform subperiosteal elevation

  • use a wood handled elevator and knife to elevate the muscles and tendons off of the anterior border of the tibia and fibula
  • need to visualize extent of fracture fragments medially and laterally
I

Bony Preparation and Intraarticular Reduction

1

Prepare fracture site

  • identify distal tibia fracture site and book open anterolateral vs. anteromedial fragment
  • clean out with rongeur, curettes or dental pic

2

Use osteotomes to tamp down impacted central piece

  • a central bone void should remain
  • inspect talus for OCD lesions at the same time
  • perform microfracture technique with kwire as needed

3

Join fragments together

  • attach medial malleolus to impacted central fragment and lateral malleolus with kwires
  • can use additional medial incision to expose medial fragment and reduce using k-wires
  • join smaller fragments to larger fragments in a systematic fashion with kwires to restore articular surface
  • join articular surface to tibia shaft
  • use pointed reduction clamps to reduce larger fragments
J

Fixation

1

Fix anterior and posterior fragments

  • place 2.7mm lag screw (2.0 mm drill) anterior to posterior to join fragments together
  • place anterolateral vs. medial plate with at least 3 screws above (3.5 cortical) and 3 below (2.7 locking)
  • key is metadiaphyseal screws distally in subchondral bone to support distal tibia articular surface
  • need to be parallel to joint

2

Check anatomic placement of plate

  • check plate contour and make sure no riding up off the distal tibia

3

Fix plate to bone

  • place medial malleolus 1/3 tubular plate with 3.5 cortical screws to buttress down medial fragment
  • insert allograft chips and autologous bone graft for distal tibia bone defect
K

Fibula Fixation (Optional)

1

Prepare fracture site

  • clean out fracture site using freer to open fracture site
  • use curettes, small rongeur, dental pick, and irrigation to remove hematoma and interposed soft tissue

2

Perform reduction

  • use lobster clamp and pointed clamps to reduce fracture using hand rotation and contralateral thumb to help guide fragments together

3

Place lag screw

  • place 2.7mm lag screw (2.0 mm drill) perpendicular to fracture line if possible

4

Place final fixation

  • determine length of 1/3 tubular plate needed (~6-8holes) and check placement on fluoro
  • place plate directly lateral for neutralization and insert 3 screws (3.5 mm) above and below fracture site
L

Confirm Intraarticular reduction and Hardware Position

1

Take final fluoro AP/Lat/Mortise of ankle and AP/Lat of tibia/fibula

  • check screw lengths to ensure no penetration into ankle joint or surrounding tendons

2

Check limb length, rotation, and alignment

N

Wound Closure

1

Irrigation & Hemostasis

  • deflate tourniquet
  • irrigate and cauterize peripheral bleeding vessels
  • place medium hemovac drain exiting proximal and lateral

2

Closure

  • fascia and retinaculum closure with 0-vicryl, watch out for SPN laterally
  • subcutaneous with 2-0 vicryl and skin closure with 3-0 nylon

3

Dressing

  • soft incision dressings and postmold splint with stirrups for immobilization vs. pin site dressings if external fixator maintained

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • Serial compartment checks x24 hours
  • IV fluids
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • drain out post-operative day 1
  • appropriately orders and interprets basic imaging studies
  • xrays of the ankle in postop

2

Appropriate medical management and medical consultation

3

Inpatient physical therapy

  • non weightbearing
  • crutches for ambulation

4

Discharge home appropriately

  • pain meds
  • outpatient PT
  • schedule follow up appointment in 2 weeks
R

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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