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ORIF

Surgery on Unstable Ankle Fractures

What is ORIF?

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Most unstable injuries to the bones of the foot and ankle require surgery. ORIF stands for Open Reduction Internal Fixation. Open means a surgical incision so the surgeon can access the broken bone. Reduction means the surgeon will align the bones back together (as perfectly as possible). Internal fixation means the surgeon will then hold the bones back together while they heal with an implant. Normally the implant is a metal plate and screws but many other implants are becoming available.

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Some unstable fractures can go to theatre the same day or the next day but many times the swelling is so severe that at least 5 days are needed to let the swelling subside before surgery. Understandably the days waiting are frusterating however provided your fracture is relatively aligned in the temporary half plaster there is no harm in waiting for up to 14-18 days after injury.

What can I expect on the day of surgery?

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  • The surgery will normally be under a general anaesthetic.

  • Overnight stay is common and patients must be safe on crutches before leaving the hospital.

  • Some patients may decide to stay in a private rehabilitation centre for the first few weeks rather than go directly home.

  • I will numb the lower leg with local anaesthetic so that you will be comfortable when you wake.

  • You will be placed in a plaster back slab (half plaster).

  • You will keep your plaster clean and dry.

  • You will be shown how to mobilise non weight bearing with crutches

  • Before you are discharged you will need to be shown how to give yourself blood thinner injections

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What are the risks and complications?

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The vast majority of patients do recover well. Ankle fractures can carry a poor prognosis if the joint is rather, well, smashed. The more places that the bone breaks in and the more ligaments that are disrupted - the harder the recovery will be and the more chance that the ankle will have problems such as stiffness and arthritis.

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Some patients need extra physio due to swelling or stiffness. Complications include infection, blood clots (DVT), nerve damage, vascular injury, tendon injury, stiffness, arthritis, failure of fixation, need for further surgery, delayed and nonunion of the fracture, Complex Regional Pain Syndrome (CRPS) and osteomyelitis.

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Particularly for patients with long-standing diabetes and vascular compromise, there is the risk of Charcot arthropathy, severe infection, severe disruption of the blood supply and loss of the limb.

When can I drive?

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The best guide that you are safe to return to driving is that you are able to walk well without crutches out of a plaster or a splint. The usual time scale also depends on whether you had surgery on your right or left foot and whether you drive a manual or an automatic

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  • Right side and all car types: 6 weeks - 10 weeks (depending on your injury)

  • Left side and manual car:     6 weeks - 10 weeks (depending on your injury)

  • Left side & automatic car:      2 weeks

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How long should I take off work?

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The time you require off from work depends on what type of job you do. The first two weeks of healing are critical and so you must have this time off work. Many people are able to work from home and so if you can avoid commuting in the first six weeks, you will find that your ankle does better. If your employer can be flexible with your activity at work you may be able to do some lighter duties or reduced hours from 2-3 weeks onward. If you are going back to work on light duties, you must also consider how you will travel to work, If you work on your feet all day, do a manual job, or are required to wear dress shoes you may need 8-10 weeks before you are back at work.

Clear Advice About DVT

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A DVT is a Deep Vein Thrombosis or a blood clot in the leg. A blood clot can occur after the trauma of ankle fracture because the leg is swollen, there may have been injury to the deep veins and because the leg is immobilised in plaster. You can help prevent a blood clot by keeping your knee moving. Keeping yourself hydrated is also helpful to prevent a DVT. Finally elevating your leg ABOVE the level of your heart will minimise the amount of swelling you have which will also help to prevent a DVT. You will be given blood thinners for the first two weeks when you are at your least active.

 

If you were to develop a DVT you would likely have some symptoms and so it is very helpful if know what to look for:

  • The leg (above the ankle) would become hard, heavy, swollen, painful and/or red and the plaster my become more uncomfortable

  • If you were to have any of the above symptoms you would have to have your plaster removed and a scan to look for a blood clot and then be treated with blood thinners at a higher dose

  • During office hours this can usually be done through the fracture clinic if you are an NHS patient and through my private office if you are a private patient. Out of hours if you should go to A&E

If the blood clot were to move to the lungs you would have a pulmonary embolism which is a medical emergency

  • The symptoms of a pulmonary embolism are breathless & chest pain- Call 911

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The recovery after surgery on an ankle fracture

Nutrition

  • Take Vitamin D (25ug) and ensure good sources of Calcium in Diet (yoghurt, cheese, milk, oily fish, dark green vegetables and fortified cereals) and do so for the first 3 months after surgery

  • Ensure diet has good sources of vitamin C (Fresh Fruit and Vegetables)

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Instructions while in a half-plaster cast (a back slab) 0-2weeks:

  1. Elevate Leg Above Heart

  2. Keep plaster dry

  3. Keep plaster intact

  4. Please remember that the more time spent standing or walking, the more swollen your ankle and foot will be and the worse your healing will be

  5. Non-weightbearing on injured leg with the aid of crutches

  6. Unless you are already on a blood thinner (for a medical condition) you will be given blood thinners.

 

Instructions while in a plaster cast (if your surgeon decides you need plaster after 2 weeks):

  1. Elevate Leg Above Heart

  2. Keep plaster dry

  3. Keep plaster intact

  4. Please remember that the more time spent standing or walking, the more swollen your ankle and foot will be and the worse your healing will be

  5. Follow the weight bearing instructions you are given

  6. Discuss whether or not to have crutches with your surgeon.

 

Instructions once into a removable splint:

  1. Continue to elevate leg to level of heart

  2. Please remember that the more time spent standing or walking, the more swollen your ankle and foot will be and the worse your healing will be.

  3. You may need to wear a DVT stocking to help keep your swelling under control

  4. Follow the weight bearing instructions you are given

  5. You must use the aircast boot to stand and walk

  6. Work on range of motion exercises

  7. Contrast bathing

  8. Local modalities to reduce swelling

  9. Start to work on strengthening when swelling improves and range of motion is near normal

  10. Theraband Resistance

  11. Progress to the Surrey Stages to Strengthen Ankle

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You make take the boot off at night and to do your physiotherapy

Physio Exercises: Get your ankle moving! Do the following every waking hour 10-15 times

A)  Alternate the ankle between dorsiflexion and plantarflexion

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B) Alternate the ankle between inversion and eversion

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C) Draw the Alphabet with your big toe. This will encourage the ankle to move in all directions.

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D) Seated Calf Raise

  1. Sit in a chair

  2. Lift your heel as far as possible while keeping your toes on the floor.

  3. Repeat 10 x

Standing stretches

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Not until you are told you can stand on the leg out of the splint

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THE ‘SURREY STAGES’ PHYSIOTHERAPY STRENGTHENING PROGRAM

 

BRONZE AWARD

DOUBLE HEEL RISES (DHR)

  • You can go up and down on tiptoes in sets of 3, slowly and 15 reps in each

  • You can stand on a skipping rope and adjust your foot position

  • You can hold a DHR for 15 seconds

  • It can be difficult to progress to the next award level because the ankle will take double the weight when you move to lifting the good leg to lower only on the operated leg.

  • You are better to stay at the bronze award level but to add in a back pack with increasing weight as you feel ready for more

  • When you have done this for some time you will be ready to progress to the silver award level

 

SILVER AWARD

DOUBLE HEEL RISES WITH A LIFT

  • May need to add weight in backpack on DHR to reach silver level

  • You go up on both feet but lift unoperated leg and lower slowly only on operated leg

  • 3 sets, working up to 15 reps in each

  • You can stand both feet on a wobble board

  • You can hold a solid DHR for 20 seconds

 

GOLD AWARD

SINGLE HEEL RISES

  • 3 sets, working up to 15 reps in each

  • You can stand on one foot on wobble board

  • You can hold a solid DHR for 40+ seconds

 

PLATINUM AWARD

  • Progress to hopping in all directions

  • Double Hops

  • Gentle jogging to reintroduce running

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