POSTOPERATIVE DIAGNOSIS: Right ankle trimalleolar fracture dislocation.

PROCEDURE PERFORMED: Right trimalleolar fracture, open reduction and internal fixation with syndesmotic repair.

ORTHOPEDIC IMPLANTS USED.
1. Synthes stainless steel 1/3 tubular plate.
2. Synthes stainless steel 4.0 cannulated screws.
3. Synthes stainless steel 3.5 cortical lag screw.
4. Arthrex TightRope.

DESCRIPTION OF PROCEDURE: The patient identified the right lower extremity as the operative site. Consent was verified for the procedure. The patient was brought back to operating room #24 and placed under general anesthesia. All bony prominences were subsequently padded as the patient was given 2g of Ancef IV 30 minutes prior to starting the case. The right lower extremity was prepped with sterile ChloraPrep and draped in a sterilely appropriate fashion. Surgical procedure began with evaluation and inspection of the soft tissue envelope to the right lower extremity. There was severe soft tissue swelling, ecchymosis and soft tissue compromise distally, most likely due to continued ongoing swelling to the right lower extremity. Due to the patient’s skin condition, we potentially avoided the open formal approach to help minimize soft tissue complications. Based off the amount of soft tissue swelling and ecchymosis present at this time, it would still be at least 4 to 6 weeks before the patient would qualify for an open approach and as such, the fracture would have most likely healed and displaced position, so we proceeded with minimally invasive fixation.

Surgical procedure began with reduction of the right fibula. A small 2cm incision was placed directly over the fibula fracture. Pointed reduction clamp was inserted. A small stab incision was made distally as a 3.5 lag screw was then passed up the intramedullary canal of the right fibula into the proximal fibula. Anatomic length, alignment, rotation of the distal fibula was noted. The pointed reduction clamp was subsequently removed. A small incision was made directly over the medial malleolar fracture line and interposed periosteum was removed using a rongeur. Guidewires for 4.0 cannulated screws were then percutaneously passed across the fracture, achieving lag screw fixation of the medial malleolus. Intraoperative cotton testing was performed and syndesmotic injury was apparent. A one-third tubular plate was positioned directly over the lateral comminution of the fibula and anchored to the tibia using a cancellous screw. An Arthrex TightRope was then predrilled while syndesmotic reduction was maintained. The Arthrex TightRope was cinched, tightened and postoperative cotton test was negative at this time.