OPERATIVE / OT NOTES

ORIF with Plate Fixation - Femoral Shaft Fracture

PREOPERATIVE INFORMATION

INDICATION FOR SURGERY

• Femoral shaft fracture (specify: AO/OTA classification _____)
• Indication for plating over IMN: distal-third fracture / periprosthetic fracture (around hip or knee prosthesis) / femoral shaft nonunion / canal obstruction / narrow canal / vascular injury requiring plate as adjunct / previous hardware precluding nail / concomitant ipsilateral femoral neck fracture
• Failed / not amenable to intramedullary nailing

PREOPERATIVE CHECKLIST (Confirmed)

• Radiolucent table available
• C-arm / fluoroscopy unit (from opposite side of surgeon)
• Large fragment implant set: 4.5 mm narrow or broad dynamic compression plate (DCP) / locking compression plate (LCP) of appropriate length
• Locking screw set (if osteopenic bone)
• Periarticular precontoured plates if proximal/distal extension of fracture
• Reduction instruments: femoral distractor, Schanz pins, large reduction clamps, plate bender
• Drill, depth gauge, taps
• Contralateral limb radiograph available for templating (length, rotation)
• Intraoperative cell saver (high blood-loss risk)
• IV antibiotics given within 60 min of incision (Cefazolin 2g IV)

PATIENT PREPARATION

• Patient positioned supine on radiolucent table (or lateral decubitus for larger patients)
• In supine: bump placed under ipsilateral buttock to internally rotate hip, providing better lateral approach access; radiolucent triangle/foam bump under thigh to allow fluoroscopy without overlap of contralateral limb
• Entire limb from proximal groin to toes prepped and draped free into the field (to allow full limb manipulation and rotational assessment, and permit access to proximal femoral vessels if needed)
• Contralateral limb available for comparison of length and rotation when positioned supine
• Time-out performed: patient identity, operative site, procedure confirmed

ANAESTHESIA

• General anaesthesia (or regional per anaesthetist decision)
• IV access x 2 large-bore cannulae
• Foley catheter inserted
• Antibiotic prophylaxis confirmed

OPERATIVE PROCEDURE

1. Incision and Approach

• A lateral incision was made over the lateral aspect of the thigh, centered over the fracture site. The incision was extended proximally and/or distally as required (the lateral approach can be extended the entire length of the femur if needed).
• The iliotibial (IT) band was divided in line with the skin incision.
• The vastus lateralis fascia was incised and the muscle was separated from the posterior fascia toward the linea aspera.
• Perforating vessels from the profunda femoris were identified, ligated, and/or cauterized (perforators arise approximately every 3 cm perpendicular to the femur).
• The vastus lateralis was elevated subperiosteally off the lateral femur with care taken to limit stripping of soft tissue from the linea aspera (to preserve the primary nutrient vessel arising from the profunda femoris).
• The fracture was identified and visualized directly.

2. Fracture Reduction

• The fracture site was irrigated and debrided of hematoma and interposed soft tissue.
• Fracture reduction was obtained using:
  • Manual traction and manipulation
  • Schanz pin joysticks in the proximal and/or distal fragments
  • Femoral distractor (pins placed proximal and distal to fracture, away from the plate corridor)
  • Large reduction clamps applied to restore length, alignment, and rotation
• Length confirmed by comparison with contralateral limb.
• Rotation assessed by comparing the profile of the lesser trochanter on AP fluoroscopy with the contralateral side, and by clinical assessment of foot position.
• AP and lateral fluoroscopic images confirmed satisfactory reduction prior to implant placement.

3. Plate Selection and Contouring

• A 4.5 mm broad/narrow LCP (Locking Compression Plate) / DCP of appropriate length was selected.
  • Plate length chosen to allow a minimum of 3-4 cortices (bicortical) per main fragment on each side of the fracture.
  • For comminuted/bridge plating: plate length spans at least 2-3 times the fracture zone.
• Plate was contoured on the back table using a plate bender to match the lateral femoral cortex curvature.
• Plate positioned on the lateral femur with the center aligned over the fracture.

4. Implant Fixation

• Plate applied to the lateral femur spanning the comminuted zone without disturbing the fracture fragments.
• Screws placed in the proximal and distal main fragments only, maintaining the fracture environment (callus-based healing).
• Locking screws used in osteopenic bone (bicortical locking purchase).

• A lag screw was first placed across the fracture at 90° to the fracture plane to achieve interfragmentary compression.
• The neutralization plate was then applied to the lateral femur and fixed proximally and distally to protect the lag screw from bending/torsional forces.

• Plate was pre-bent to produce slight over-bend (3-5°) to achieve even compression of medial cortex.
• Plate fixed to one fragment; the fracture was compressed using the DCP screw hole eccentricity or a plate tensioning device before fixing the opposite end.
• All screws were tightened sequentially.
• Final screw count and position confirmed fluoroscopically (AP and lateral).

5. Confirmation and Assessment

• Fluoroscopic AP and lateral views confirmed:
  • Satisfactory reduction (coronal and sagittal alignment)
  • Correct plate position and length
  • Adequate screw purchase in both fragments
  • Restoration of femoral length and rotation
  • No articular extension of fracture
• Clinical assessment of femoral rotation: axial rotation of hip compared to contralateral side.
• Femoral neck was assessed clinically and radiographically - no associated ipsilateral femoral neck fracture identified.
• Knee was assessed for ligamentous integrity after fixation.

6. Wound Closure

• Wound irrigated copiously with normal saline.
• Vastus lateralis re-approximated over the femur.
• IT band / deep fascia closed with absorbable suture (No. 1 Vicryl / PDS).
• Subcutaneous layer closed with 2-0 Vicryl.
• Skin closed with staples / 3-0 Nylon / 3-0 Monocryl (as appropriate).
• Drain placed if required (suction drain, removed at 24-48 hours).
• Sterile dressing applied.

OPERATIVE FINDINGS

POSTOPERATIVE ORDERS

1. Monitoring: Vitals q4h, neurovascular observations (pulse, capillary refill, sensation, movement) of operated limb q4h
2. Analgesia: As per pain protocol (IV PCA / oral multimodal)
3. Antibiotics: Continue IV antibiotics for 24-48 hours post-op per protocol
4. DVT Prophylaxis: LMWH (Enoxaparin 40 mg SC daily) / TED stockings / pneumatic compression device to contralateral limb - commence within 12-24 hours as appropriate
5. Drains: Record drain output; remove at 24-48 hours if output <30 mL/shift
6. Imaging: AP and lateral femur X-ray (weight-bearing, portable, or fluoroscopy) on Day 1 post-op
7. Mobilisation / Physiotherapy:
   • Early passive range of motion exercises to the knee and hip
   • Non-weight-bearing (NWB) or toe-touch weight-bearing (TTWB) with crutches/frame
   • Weight-bearing progression guided by fracture pattern and fixation stability:
     • Absolute stability (lag screw + neutralization): earlier WB progression possible
     • Bridge plating (comminuted): NWB until callus formation (typically 6-8 weeks)
8. Wound: Keep dry for 48 hours; check on Day 2 and Day 5
9. Follow-up: Clinic at 2 weeks (wound check, X-ray), 6 weeks (X-ray), 12 weeks, 6 months, and 12 months (or until radiological union)

COMPLICATIONS DISCUSSED (Consent)

• Infection (superficial / deep) - reported higher in open comminuted fractures
• Nonunion / delayed union (may require bone graft, revision plating, or exchange nailing)
• Malunion - angular or rotational malalignment
• Hardware failure (plate breakage, screw pullout, especially in osteopenic bone)
• Neurovascular injury (sciatic nerve, femoral artery/vein, profunda perforators)
• DVT / pulmonary embolism
• Refracture after hardware removal
• Knee stiffness / heterotopic ossification
• Fat embolism / ARDS (particularly in high-energy fractures)
• Compartment syndrome of the thigh

SURGEON SIGNATURE

• Periprosthetic fractures (around stable hip/knee prosthesis): require extensive lateral approach with direct reduction, lag screw + plating (as in Vancouver B1 / Lewis-Rorabeck type 1 fractures)
• Nonunions: may use adjunctive plate fixation around an existing IMN with good results; decortication and autogenous bone grafting often added
• Osteoporotic bone: use bicortical locking screws throughout; consider longer plate spanning more cortices
• Ipsilateral femoral neck fracture: check neck intraoperatively with fluoroscopy; if present, address the neck first before shaft plating (or use cephalomedullary nail instead)