Lower Leg, Ankle, Foot, and Other Lower-Extremity Procedures

OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF THE TIBIAL PLATEAU FRACTURE

SURGICAL CONSIDERATIONS

Description: ORIF of the tibial plateau or proximal tibia fracture involves making a longitudinal incision along the proximal leg, lateral to the knee, obtaining a reduction by direct visualization of the fracture fragments, and applying plates and screws along the tibia for rigid internal fixation. An iliac crest bone graft may be necessary. A proximal tibial osteotomy involves correcting malalignment (valgus and varus) of the lower extremity by excising a wedge of bone from the tibia and correcting the mechanical axis.

Usual preop diagnosis: Tibial plateau or proximal tibial fracture; nonunion/malunion of the tibial plateau or proximal tibia; degenerative arthritis of the knee, with varus or valgus deformity

▪ SUMMARY OF PROCEDURES

	ORIF Tibial Plateau Fracture	Proximal Tibial Osteotomy
Position	Supine	⇚
Incision	Lateral to knee, usually; medial, rarely	Transverse or lateral incision
Special instrumentation	Special plates, screws; reduction clamps; radiolucent table	⇚
Unique considerations	Intraop radiographs or I.I.; tourniquet	⇚
Antibiotics	Cefazolin or cefamandole 1 g iv q 6-8 h × 48 h	⇚
Surgical time	˜2.5-3 h; more, depending on difficulty	⇚
Closing considerations	Splint, cast while anesthetized	⇚
EBL	< 200 mL	⇚
Postop care	Multiple-trauma victim → ICU; others → PACU; ± CPM	PACU → ward
Mortality	Rare, except in severe multiple trauma	None
Morbidity	Compartment syndrome: 10-20%	< 25%
	Wound infection: 7-15%	˜2%
	DVT (symptomatic): 3-5%	2%
	Delayed union, nonunion, malunion: < 5%	⇚
	Peripheral nerve damage: 3%	0.2%
	Intraarticular fracture: 2%
Hypotension (multiple trauma) Leg-length discrepancy Osteomyelitis, septic arthritis Respiratory distress and fat embolism Vascular complications
Pain score	7	7

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Lower-Extremity Procedures, p. 1083.

Suggested Readings

1. Atesok K, Doral MN, Whipple T, et al: Arthroscopy-assisted fracture fixation. Knee Surg Sports Traumatol Arthrosc 2011; 19(2):320-9.

2. Thomas CH, Athanasiov A, Wullschleger M, Schuetz M: Current concepts in tibial plateau fractures. Acta Chir Orthop Traumatol Cech 2009; 76(5):363-73.

INTRAMEDULLARY NAILING, TIBIA

SURGICAL CONSIDERATIONS

Description: In intramedullary nailing of the tibia, a metal nail is placed into the medullary canal of the tibia to stabilize (or prevent) a fracture. The affected leg generally is placed in traction, on a fracture table, via stirrup or calcaneal pin. Following the incision, an awl is used to make an entry hole in the proximal metaphysis of the tibia, through which a guide wire is introduced. The guide wire is placed across the aligned fracture, and the nail is introduced and driven over the guide wire. Before nail insertion, the medullary canal often is reamed to allow use of a larger nail. Most nails are interlocked both proximally and distally with screws that pass from the bone through holes in the nail.

Usual preop diagnosis: Fracture, nonunion or malunion of the tibia

▪ SUMMARY OF PROCEDURE

Position	Supine, on fracture table. Consider inducing anesthesia before moving patient.
Incision	Proximal longitudinal incision over the patellar tendon; stab wound for screws
Special instrumentation	Nails, screws, and insertion instruments; intramedullary reamers; I.I.
Antibiotics	Cefazolin 1 g iv preop
Surgical time	2 h
Closing considerations	No splint or cast
EBL	200 mL
Postop care	PACU → room
Mortality	Minimal
Morbidity	Compartment syndrome: < 5% Infection: < 2% Neuropraxia: < 1 %
Pain score	5

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Lower-Extremity Procedures, p. 1083.

EXTERNAL FIXATION, TIBIA

SURGICAL CONSIDERATIONS

Description: Fractures of the tibia are fixed with percutaneous pins that are clamped to an external frame. Stainless steel pins are drilled into the proximal and distal fragments of the fracture through stab wounds in the skin and subcutaneous tissues. Usually 2-3 pins are placed on either side of the fracture. Pin clamps and an external frame are attached and the fracture aligned with the assistance of the I.I. or under direct vision. Following fracture alignment, the pin clamps and frames are tightened to hold fracture alignment. External fixation is often used with open fractures. Small-pin fixators (e.g., Ilizarov) are used for fracture fixation, leg lengthening, and treatment of bony defects. Wound irrigation and debridement often accompany application of the fixation frame.

Usual preop diagnosis: Tibial fracture; tibial nonunion or malunion; tibial shortening

▪ SUMMARY OF PROCEDURE

Position	Supine
Incision	Stab wounds. Small-pin fixator may require metaphyseal incision for osteotomy.
Special instrumentation	Pins; fixation frame; I.I.
Antibiotics	Cefazolin 1 g iv preop
Surgical time	0.5-1 h Small-pin fixator: 3-5 h
Closing considerations	May be open fracture (usually left open)
EBL	50 mL; small-pin fixator, 100 mL
Postop care	PACU → room
Mortality	Minimal
Morbidity	Infection: 15% Compartment syndrome: < 2% Neuropraxia: < 1%
Pain score	2-3

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Lower-Extremity Procedures, p. 1083.

OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF DISTAL TIBIA, ANKLE, AND FOOT FRACTURES

SURGICAL CONSIDERATIONS

Description: ORIF is nearly always required for displaced fractures involving the ankle or joints in the foot. A longitudinal incision is made over the fractured medial and/or lateral malleoli. Dissection is carried directly down to the bone, and the fracture is identified and reduced under direct vision.

Open fractures may require irrigation and debridement. The fractures are realigned under direct vision and fixed and stabilized with pins, plates, and/or screws. An intraop radiograph is obtained to confirm reduction and placement of hardware. The incisions are closed and a splint or cast is applied.

Usual preop diagnosis: Fracture of the distal tibia, ankle, or foot

▪ SUMMARY OF PROCEDURES

	ORIF Ankle	With Irrigation and Debridement
Position	Supine	⇚
Incision	Longitudinal over fracture site	⇚ + extension of existing wound
Special instrumentation	Pins, plates, and screws; tourniquet; x-ray or I.I.	⇚
Antibiotics	Cefazolin 1 g iv preop	⇚
Surgical time	2 h	2-3 h
Closing considerations	Splint or cast while anesthetized	Splint or cast; may leave wound open.
EBL	50 mL	100 mL
Postop care	PACU → room	⇚
Mortality	Minimal	⇚
Morbidity	Wound dehiscence: 10%	⇚
	Loss of reduction: 7%	⇚
	Infection: 3%	15%
Pain score	4	4

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Lower-Extremity Procedures, p. 1083.

Suggested Readings

1. Mandi DM: Ankle fractures. Clin Podiatr Med Surg 2012; 29(2):155-86, vii.

2. Shindle MK, Endo Y, Warren RF, et al: Stress fractures about the tibia, foot, and ankle. J Am Acad Orthop Surg 2012; 20(3): 167-76.

REPAIR NONUNION/MALUNION, TIBIA

SURGICAL CONSIDERATIONS

Description: This procedure is used to treat a fracture that has not healed or was misaligned upon healing. The fracture is mobilized, usually grafted with autogenous or allograft bone, and realigned. With an anterior approach, a longitudinal incision is made anteromedial or anterolateral to the shaft of the tibia. Dissection is carried directly down to the bone and the nonunion identified. If the tibia is approached with a posterolateral incision, the patient is turned prone and a longitudinal incision is made just posterior to the fibula. Dissection is carried down posteriorly to the interosseous membrane, to the tibia, and the procedure becomes identical to the anterior approach. Tissue interposed between the bone ends may or may not be debrided. The cortex of the bone adjacent to the nonunion is roughened with an osteotome. Autogenous or allograft bone is placed adjacent to or in the nonunion site. In the case of a malunion, the bone may be osteotomized with a saw or osteotomes to allow realignment. If skeletal fixation is used, a plate may be attached to the bone through the same incision. Alternatively, an intramedullary nail may be placed through an incision anterior to the tibial tubercle. If an intramedullary device is used, the canal may be reamed with intramedullary reamers prior to placement of the nail. A third type of skeletal fixation is the external fixator that stabilizes the nonunion via percutaneous pins placed into the proximal and distal tibia, which are then spanned by a device with pin clamps at both ends. An intraop x-ray is often used to confirm fixation and placement of devices; alternatively, an I.I. may be used.

Variant procedure or approaches: Autogenous bone grafting from the iliac crest is commonly used to stimulate healing. An incision is made directly over the iliac crest, and muscles are stripped from the crest and table of the ilium. Osteotomes and gouges are used to remove either the inner or outer table of the ilium and cancellous bone between the two tables. The wound is closed over a suction drain.

Usual preop diagnosis: Ununited or malunited fracture

▪ SUMMARY OF PROCEDURES

	Basic Repair	With Iliac Graft	With Skeletal Fixation
Position	Supine (prone with posterior lateral graft)	⇚	⇚
Incision	Anteromedial or posterolateral to shaft of tibia	Anteromedial; parallel to iliac crest
Special instrumentation	Tourniquet; x-ray or I.I.	⇚	Pins, plates, screws, rods, external fixator; tourniquet; x-ray or I.I.
Antibiotics	Cefazolin 1 g iv preop. (If infected nonunion anticipated, antibiotics are withheld until cultures are obtained.)	⇚	⇚
Surgical time	2 h	2.5 h	3 h
Closing considerations	Splint or cast applied while anesthetized.	⇚	No splint or cast
EBL	100 mL	200-300 mL	⇚
Postop care	PACU → room	⇚	⇚
Mortality	Minimal	⇚	⇚
Morbidity	Thrombophlebitis: 5%	⇚	⇚
	Compartment syndrome: 1%	⇚	⇚
	Infection: 1%	⇚	⇚
	Hematoma: < 1%	5%	1-3%
Pain score	5	8	5-8

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Lower-Extremity Procedures, p. 1083.

Suggested Readings

1. Mechrefe AP, Koh EY, Trafton PG, DiGiovanni CW: Tibial malunion. Foot Ankle Clin 2006; 11(1):19-33, vii.

2. Ng A, Barnes ES: Management of complications of open reduction and internal fixation of ankle fractures. Clin Podiatr Med Surg 2009; 26(1):105-25.

ARTHROSCOPY OF THE ANKLE

SURGICAL CONSIDERATIONS

Description: Ankle arthroscopy is usually a diagnostic procedure, although it may be used for debridement or removal of loose bodies. The ankle joint generally is inspected through anterolateral and anteromedial portals (entry wounds). Posterolateral and posteromedial portals also may be used. Each portal is made via a 5-mm stab wound in the skin (Fig. 10.6-1); then instrumentation is placed, using trochars. If the ankle joint is tight, a mechanical distractor (external fixator distraction apparatus spanning the ankle joint) may be used. The distractor is attached to the bones via percutaneous pins, as in the case of the application of an external fixator. The portals are closed with sterile tape or a single suture. Debridement may be used to reduce local or generalized articular damage.

Figure 10.6-1. Portals for ankle arthroscopy. A: Anterior anatomy and portals. The anterolateral and anteromedial portals are used routinely. B: Posterior anatomy and portals. The posterolateral portal also is used routinely. (Redrawn from Ferkel RD: Arthroscopic Surgery: The Foot and Ankle. Lippincott-Raven: 1996.)

Usual preop diagnosis: Trauma; infection; arthritis

▪ SUMMARY OF PROCEDURES

	Arthroscopy	Arthroscopy + Debridement
Position	Supine	⇚
Incision	0.5 cm portals (incisions)	⇚
Special instrumentation	Arthroscopic video system; small biters and graspers	⇚ + shaver
Unique considerations	± Tourniquet. May use distractor with pins through tibia and calcaneus.	⇚
Antibiotics	Cefazolin 1 g iv preop (optional)	⇚
Surgical time	1 h	1-2 h
Closing considerations	No splint; incisions injected with local anesthetic.	⇚
EBL	Minimal	50 mL
Postop care	PACU → home	⇚
Mortality	< 0.01%	⇚
Morbidity	Hemarthrosis: 5%	⇚
	Thrombophlebitis < 2%	⇚
	Infection: < 1%	⇚
Pain score	2-3	3

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Lower-Extremity Procedures, p. 1083.

Suggested Readings

1. Glazebrook MA, Ganapathy V, Bridge MA, Stone JW, Allard JP: Evidence-based indications for ankle arthroscopy. Arthroscopy 2009; 25(12):1478-90.

2. Jennings MM, Bark SE: Practical aspects of foot and ankle arthroscopy. Clin Podiatr Med Surg 2011; 28(3):441-52.

3. Lui TH: Arthroscopy and endoscopy of the foot and ankle: indications for new techniques. Arthroscopy 2007; 23(8):889-902.

ANKLE ARTHROTOMY

SURGICAL CONSIDERATIONS

Description: Arthrotomy of the ankle is the opening of the joint for drainage, debridement, or fracture treatment. The joint usually is opened with an anterolateral midline or anteromedial longitudinal incision. Tendons and neurovascular structures are carefully retracted to expose the joint capsule, which is then opened in line with the skin incision. After intraarticular pathology is addressed, careful closure of the capsule is performed, taking care to obtain good hemostasis.

Usual preop diagnosis: Infection; trauma; arthritis

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Lower-Extremity Procedures, p. 1083.

ANKLE ARTHRODESIS

SURGICAL CONSIDERATIONS

Description: An ankle fusion may need to be performed for severe pain 2° arthritis of the ankle. In most cases, an anterior approach is made to the ankle joint. An alternative approach is through the medial malleolus. The ankle joint is exposed, and the surfaces of the joint are debrided either with osteotomes or a burr. Cancellous bone is exposed on the distal tibia and talus, and the joint is clamped together either with a simple external fixation device with pins going through the distal tibia and talus, or with bone screws that go from the distal tibia into the talus. The wound is closed over a drain, and a splint may be applied.

Usual preop diagnosis: Arthritis of the ankle

▪ SUMMARY OF PROCEDURE

Position	Supine
Incision	Anterior midline over distal tibia
Special instrumentation	Tourniquet; external fixator or bone screws
Unique considerations	Intraop radiographs; tourniquet use
Antibiotics	Cefazolin 1 g iv preop
Surgical time	2 h
Closing considerations	May be splinted; suction drain.
EBL	100 mL
Postop care	PACU → room
Mortality	Minimal
Morbidity	Nonunion (late): 15% Thrombophlebitis: 10% Hematoma: 5% Wound dehiscence: 5% Infection: 1%
Pain score	8

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Lower-Extremity Procedures, p. 1083.

REPAIR/RECONSTRUCTION OF ANKLE LIGAMENTS

SURGICAL CONSIDERATIONS

Description: Lateral ankle ligaments may be repaired acutely, but generally are reconstructed at a later date, if necessary, with the peroneus brevis used in most reconstructions. An incision is made posterior to the distal fibula, curving around the lateral malleolus and ending in the anterolateral foot. The peroneus brevis tendon is identified and detached from its musculotendinous junction in the leg, and the peroneus brevis muscle is sutured to the peroneus longus tendon. A hole is drilled from anterior to posterior in the distal lateral malleolus; then the detached end of the peroneus brevis tendon is threaded through the hole. It is then attached to either the calcaneus or the talus, anterior to the lateral malleolus, with a staple or by suturing into a hole in the bone. The skin and subcutaneous tissues are closed and a splint or cast is applied.

Usual preop diagnosis: Lateral instability of the ankle