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ORIF Ankle Fracture

CPT Technique
Indications Complications
Contraindications Follow-up Care / Rehab Protocol
Alternatives Outcomes
Pre-op Planning / Case Card Review References

synonyms: ORIF Ankle Fracture, open reduction internal fixation ankle

ORIF Ankle Fracture CPT

  • 27766(ORIF medial malleolus)
  • 27792(ORIF lateral malleolus)
  • 27814(ORIF bimalleolar ankle fracture)
  • 27822(ORIF trimalleloar fx; med and lat malleolus only)
  • 27823(ORIF trimalleolar fx, med, lat and posterior lip fixation)

ORIF Ankle Fracture Indications

  • Lateral malleolus fracture with tibio-talar instability
  • Lateral malleolus fracture with syndesmosis injury
  • Isolated medial malleolus fracture
  • Bimalleolar ankle facture
  • Trimalleolar ankle fracture

ORIF Ankle Fracture Contraindications

  • Soft tissue compromise - severe swelling
  • Active infection
  • Medical instability

ORIF Ankle Fracture Alternatives

  • Non-op treatment

ORIF Ankle Fracture Pre-op Planning / Special Considerations

  • Timing of surgery is dictated by the status of the soft tissues.  Ideally surgery is done before any true swelling or fracture blisters have developed.  Delayed surgery done when blisters have resolved, skin wrinkles normally (average14 days) has equivalent outcomes (Karges/Watson, JOT 1995;9:377).
  • Posterior malleolar fragments >25% of the plafond may be fixed via percutaneous clamp recution, reduction through the medical mallellar fracture or dircet reduction through a posterolateral or posteromedial approach.
  • Posterior approach only needed for oarge posterior malleolar fragments-prone position.  Incision between Achilles and peroneal tendons.  Avoid sural nerve. Find interval between FHL and peroneal tendons.   FHL is medial and protects posterior tibial artery/nerve.

ORIF Ankle Fracture Technique

  • Sign operative site.
  • Pre-operative antibiotics, +/- regional block.
  • General endotracheal anesthesia
  • Supine position with bump under ipsilateral hip. All bony prominences well padded.
  • Well-padded tourniquet placed high on the thigh.
  • Prep and drape in standard sterile fashion.
  • document osteochondral injuries which should be saught during ORIF.
  • Lateral malleolar fixation provided with posterior antiglide plate +/- lag screws. (Lamontagne J, JOT 2002;16:498).
  • Irrigate.
  • Close in layers.

ORIF Ankle Fracture Complications

  • Pulmonary embolism = 0.34%, Wound infection 1.44%, Revision ORIF = 0.82%, BKA = 0.16%, Mortality =1.07% (SooHoo NF, JBJS 2009;91:1042)
  • Nonuion
  • Infection
  • Painful hardware
  • Compartment Syndrome
  • CRPS
  • DVT / PE
  • We discussed the risks of surgery including, but not limited to: incomplete relief of pain, incomplete return of function, nonunion, malnunion, painful hardware, hardware failure, compartment syndrome, CRPS, DVT/PE and the risks of anesthesia including heart attack, stroke and death.

ORIF Ankle Fracture Follow-up care

  • Post-op: bulky jones dressing, NWB, elevation
  • 7-10 Days: Wound check, functional Air-Stirrup ankle brace (Aircast). Partial weight bearing as tolerated. Encourage daily active and passive range-of-motion exercises of the ankle and subtalar joints without the brace.
  • 6 Weeks: Assess xrays for union. Progress with activity / PT. Driving: may drive after 9 weeks for right leg. (Egol KA, JBJS 2003;85A:1185). Swelling is common after ankle sprain or fx. Rx=compression stocking (sigvaris, Jobst) 20-30mmHg
  • 3 Months: Begin sport specific rehab. Running, stair-climbing, and participation in sports are allowed only after a full range of motion of the ankle has been achieved
  • 6 Months: Return to sport / full activities.
  • 1Yr: Assess outcomes, F/U xrays.

ORIF Ankle Fracture Outcomes

  • Physical function and role physical scores remain significantly lower than US norms at 24 months after operative fixation. Smoking history, presence of a medial malleolar fracture, lower levels of education are significant independent predictors of lower physical function up to 3 months postoperation.(Bhandari M, JOT 2004;18:338).
  • Average time to full weightbearing = 7weeks, return to work = 8weeks after surgery with early weight bearing protocol. 100% good results; Olerud score (90 +/- 13 points). (Simanski CJ, JOT 2006;20:108).
  • See Ankle / Foot Outcome measures.

ORIF Ankle Fracture Review References