Open Reduction Internal Fixation (ORIF) Distal Fibular Fracture (Lateral Malleolus)

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS

Fracture of the lateral malleolus with or without deltoid ligament injury

CONTRAINDICATIONS
  • Significant ankle swelling
  • Infection or skin disease at the site of the surgery
  • Severely osteoporotic bone
EQUIPMENT
  • Fracture table
  • Fluoroscopy unit
  • Lag, cortical, and cancellous screws
  • Intramedullary device
  • 4.5-mm malleolar screw
  • Kirschner wires
  • Small-fragment set
  • 3.5-mm dynamic compression plate
  • No. 0 nonabsorbable suture
ANATOMY
  • The ankle joint/mortise and the inferior tibiofibular joint
  • The tibiofibular joint: anterior tibiofibular ligament, posterior inferior tibiofibular ligament, transverse tibiofibular ligament, interosseous ligament
  • The ankle joint: hinged joint that is formed by the medial and lateral malleoli and the talus (which sits centered between the malleoli)
  • Lateral ankle joint ligaments
    • Anterior talofibular ligament (ATFL)
    • Calcaneofibular ligament (CFL)
    • Posterior talofibular ligament
  • Deltoid ligament
    • Superficial part is fan shaped and composed of tibionavicular and tibiocalcaneal components.
    • Deep part is shorter and heavier and composed of anterior and posterior tibiotalar components.

PROCEDURE
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The full content of this section includes:
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  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
TECHNIQUES
  • Post-Procedure: Fixation of the Lateral Malleolus
  • Post-Procedure: Repair of the Deltoid Ligament and Internal Fixation of the Lateral Malleolus

Post-Procedure: Fixation of the Lateral Malleolus

POST-PROCEDURE CARE
  • Immobilize the ankle in a posterior plaster splint in neutral position.
  • Remove the splint 2 to 4 days after surgery and replace with a removable splint or fracture boot if the bone stock is good and fixation is secure.
  • Protect the ankle in a short or long leg non-weight-bearing cast for 8 to 12 weeks if skin condition, poor bone quality, or tenuous fixation is present.
  • Begin range-of-motion exercises when the splint is removed.
  • Restrict weight bearing for 6 weeks, then allow 50% weight bearing with full weight bearing restricted until 12 weeks.
  • Use a 5-mm heel wedge for 4 to 6 months if the deltoid ligament was repaired.
COMPLICATIONS
  • Infection
  • Delayed union or nonunion
  • Hardware failure
  • Painful hardware
ANALYSIS OF RESULTS

Studies have demonstrated very high rates of success for bony union of lateral malleolar fractures using the techniques described here. The most common complication was symptomatic hardware because of the superficial nature of fixation on the lateral side of the ankle.

OUTCOMES AND EVIDENCE
  • Brown, Dirschl, and Obremsky: 31% of patients had lateral hardware pain after plate and screw fixation of unstable ankle fractures; 23% required hardware removal, with only half of those obtaining pain relief.
  • Tornetta and Creevy: lag screw versus lateral plate and screw fixation; the lag screw group had no nonunions, loss of reduction, or soft-tissue complications; 2% complained of lateral pain compared to 17% in the plate/screw group.
  • Kim and Oh: 93% satisfactory results in noncomminuted Danis-Weber type B fractures with lag screw only fixation.
  • Koval et al: 89% healing in osteopenic fibular fractures treated with plate fixation augmented with intramedullary Kirschner wires; biomechanical testing showed that the augmented plates had 81% greater resistance to bending.
  • Breederveld et al: equally good functional results with immediate and delayed open reduction and internal fixation, but shorter hospital stays and less immediate post-op pain in the group treated with immediate surgery.
  • Konrath et al: no difference in complications, reduction, motion, or operative time between early (less than 5 days) and delayed surgery for closed Danis-Weber type B bimalleolar or bimalleolar-equivalent fractures.

Procedure: Fixation of the Lateral Malleolus


Post-Procedure: Repair of the Deltoid Ligament and Internal Fixation of the Lateral Malleolus

POST-PROCEDURE CARE
  • Immobilize the ankle in a posterior plaster splint in neutral position.
  • Remove the splint 2 to 4 days after surgery and replace with a removable splint or fracture boot if the bone stock is good and fixation is secure.
  • Protect the ankle in a short or long leg non-weight-bearing cast for 8 to 12 weeks if skin condition, poor bone quality, or tenuous fixation is present.
  • Begin range-of-motion exercises when the splint is removed.
  • Restrict weight bearing for 6 weeks, then allow 50% weight bearing with full weight bearing restricted until 12 weeks.
  • Use a 5-mm heel wedge for 4 to 6 months if the deltoid ligament was repaired.
"
COMPLICATIONS
  • Infection
  • Delayed union or nonunion
  • Hardware failure
  • Painful hardware
ANALYSIS OF RESULTS

Studies have demonstrated very high rates of success for bony union of lateral malleolar fractures using the techniques described here. The most common complication was symptomatic hardware because of the superficial nature of fixation on the lateral side of the ankle.

OUTCOMES AND EVIDENCE
  • Brown, Dirschl, and Obremsky: 31% of patients had lateral hardware pain after plate and screw fixation of unstable ankle fractures; 23% required hardware removal, with only half of those obtaining pain relief.
  • Tornetta and Creevy: lag screw versus lateral plate and screw fixation; the lag screw group had no nonunions, loss of reduction, or soft-tissue complications; 2% complained of lateral pain compared to 17% in the plate/screw group.
  • Kim and Oh: 93% satisfactory results in noncomminuted Danis-Weber type B fractures with lag screw only fixation.
  • Koval et al: 89% healing in osteopenic fibular fractures treated with plate fixation augmented with intramedullary Kirschner wires; biomechanical testing showed that the augmented plates had 81% greater resistance to bending.
  • Breederveld et al: equally good functional results with immediate and delayed open reduction and internal fixation, but shorter hospital stays and less immediate post-op pain in the group treated with immediate surgery.
  • Konrath et al: no difference in complications, reduction, motion, or operative time between early (less than 5 days) and delayed surgery for closed Danis-Weber type B bimalleolar or bimalleolar-equivalent fractures.
Procedure: Fixation of the Lateral Malleolus
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