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Open Reduction and Internal Fixation of a Trimalleolar Ankle Fracture
Table of Contents
Anesthesia
After the operative leg has been marked, anesthesia is induced, and the patient is brought to the operating room.
Prep
- Leg Positioning
- Patient positioned supine with arms out or tucked
- Trochanter roll placed under patient
- Prep/Sterilization of Surgical Site
- Shave surgical site
- Wash and sterilize entire leg
- Draping
- Cover Site with Ioban Adhesive Sterile Sheet
- Seal calf and toes
- Make Skin Markings
- Apply Tourniquet
- Exsanguinate the extremity up to the thigh
- Apply pressure
- Surgical Time Out
- Identify patient, problem, correct side, procedure to be performed, medications given prior to procedure, expected time to completion
Fibular Fixation
- Make a Lateral Skin Incision
- Along subcutaneous border of fibula
- Angle slightly anteriorly distally
- Incision into Fascia
- Superficial peroneal nerve branches at subcutaneous or fascial level
- Once on bone, make space for plate
- Expose fracture site with a 2-mm periosteotomy on each side
- Clean out fracture site with small curette
- Perform Fibular Reduction with Pointed Reduction Forceps
- Grab distal fibula and pull traction to achieve length
- Fit and Contour Fibular Plate
- Contour six-hole ⅓ tubular plate using locking towers for grip to match distal fibula
- Position and use K-wires to fix provisionally
- Proximal Non-locking Screw
- Drill through both fibular cortices with a 2.5-mm drill
- Use depth gauge to determine length
- 4.0-mm non-locking screws should be used initially to contour plate to the bone
- Note: Using slightly longer screws allows for better purchase in the medial cortex
- Distal Non-locking Screw
- Repeat above steps
- Fill Remaining Gaps with Locking Screws
- It is important to use locking screws, especially distally at the level of the lateral malleolus, to prevent skin irritation due to prominence
- Once complete, use clamps to pull on fibula (Cotton test) and assess status of syndesmosis
Syndesmotic Fixation
- Exposure of Syndesmosis
- Provisional K-Wire Fixation
- Fix the Tillaux fragment to the tibia
- Use a second K-wire to fix the fibula to the tibia
- First 3.5-mm Syndesmotic Tricortical Screw
- Drill through three cortices with 3.2-mm drill
- Drill to, but not through, the medial cortex of the tibia
- Measure with depth gauge
- Use a 4.5-mm cortical screw
- Lag Screw Fixation of Tillaux Fracture
- Drill through fragment into tibia with 3.2-mm drill
- Use 4.0-mm partially threaded cancellous screw to lag by design
- Second 3.5-mm Syndesmotic Tricortical Screw
- Repeat steps for first syndesmotic screw
Medial Malleolus Fixation
- Prep Medial Side
- Mark approach - in this case, a curved approach anterior to the medial malleolus
- Make Medial Incision
- Be cautious of the posterior tibial tendon and saphenous nerve
- Reduce Fragment with Pointed Reduction Clamps
- Provisional K-Wire Fixation
- Use two K-Wires to keep fragment from rotating
- First Tibia Lag Screw
- Drill though fragment into tibia with 3.2-mm drill
- Use 4.0-mm partially threaded cancellous screw
- Second Tibia Lag Screw
- Repeat above steps
Final Images
- Take AP and Lateral x-ray Images to confirm reduction and construct placement