DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Left bimalleolar ankle fracture.
POSTOPERATIVE DIAGNOSIS:
Left bimalleolar ankle fracture.
OPERATION PERFORMED:
Left ankle open reduction internal fixation.
SURGEON: John Doe, DPM
ANESTHESIA: General.
PATHOLOGY: None.
HEMOSTASIS: Left pneumatic thigh tourniquet set at 300 mmHg.
ESTIMATED BLOOD LOSS: Less than 15 mL.
MATERIALS: 3.5 mm cortical screws x4, 4.0 mm cancellous screws x3, 22 gauge surgical steel wire, 1/3 tibial plate 6 holes and 0.062 inch K wires x2.
INJECTABLES: 20 mL of 0.5% Marcaine plain injected in a common peroneal and popliteal block fashion.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: Under mild IV sedation, the patient was wheeled back into the operating room and placed on the operating table in the supine position for left ankle open reduction internal fixation. A left pneumatic thigh tourniquet was placed about the patient’s left thigh.
The left lower extremity was then scrubbed, prepped and draped in the usual aseptic manner for left ankle open reduction internal fixation. The lower extremity was elevated and exsanguinated using an Esmarch bandage. The tourniquet was then inflated. Attention was then directed to the lateral aspect of the patient’s left leg where approximately a 7 cm to 8 cm linear incision was made overlying the patient’s fibula. The incision was deepened down in a layered fashion through skin and subcutaneous layers, superficial and deep fascia and periosteum utilizing a combination of sharp and blunt dissection. Care was taken to retract all vital neurovascular structures. All bleeders were cauterized and ligated as necessary.
Once down to the level of the periosteum, an incision was then made overlying the periosteum of the fibula and the periosteum was reflected off the fibula utilizing a key elevator. Once this was accomplished, the spiral oblique fracture of the left fibula was visualized and consistent with the previous x-rays. Utilizing a curette and irrigation with normal sterile saline, the fracture site was debrided of any fibrous clot that had formed or small bone fragments that were interposed between the main fibula pieces. Once the fracture site was essentially cleared out, the fracture was temporarily reduced utilizing bone reduction forceps. At this point, clinically, the fracture was reduced and compressed. However, intraoperative fluoroscopy was also used to visualize the left fibula and excellent alignment of the fracture site with restoration of the length of the fibula and reduction of any angulation or rotation was noted.
At this point, a 3.5 mm fully threaded cortical screw was placed from anterior and posterior at the angle of 45 degrees to the fracture site through the fracture line. This was done utilizing standard AO lag screw technique and the screw was tightened down. Excellent compression was noted at the fracture site and the alignment and length of the fibula was noted to still be in excellent position and verified utilizing the intraoperative fluoroscopy.
Next, utilizing 3.5 mm cortical screws proximally and two 4.0 mm cancellous screw distally, a one-third 6-hole tubular plate was placed along the lateral aspect of the patient’s left fibula with the thirdmost distal hole being left empty as it overlaid the fracture site and interfragmentary screw. Care was taken to contour the plate to the natural contour of the fibula and also to direct the distal cancellous screws in a slight proximal angulation to avoid entering the ankle joint.
Intraoperative fluoroscopy was used throughout this process and was checked again after all screws and plate was applied. Screws were deemed proper length and plate was fairly adhered to the fibula. The area was then copiously flushed with normal sterile saline and closed in a layered fashion utilizing 2-0 Vicryl, 3-0 Vicryl and stainless steel surgical staples.
Attention was then directed to the medial aspect of the patient’s left ankle where previous x-ray analysis showed a transverse avulsion fracture of the medial malleolus. Incision was then made approximately 4-5 cm in length linear extending from superior to inferior overlying the midline of the medial aspect of the distal tibia, extending from just distal to the medial malleolus and proximally from there. This incision was deepened down in a layered fashion. Care was taken to retract all vital neurovascular structures. All bleeders were cauterized or ligated as necessary. Upon visualization of the medial aspect of the patient’s left ankle, the fracture as noted in the x-ray was visualized intraoperatively. The deltoid ligament was able to be visualized also and noted to be intact.
The fracture site of the medial malleolus was then curetted of any blood or fibrous clot that had formed since the fracture to allow for cleaner interposition of the fracture fragments. Once the curetting was finished, the fracture fragments were realigned utilizing bone reduction forceps. Excellent alignment and compression of the fracture site was noted both clinically and also utilizing the intraoperative fluoroscopy. Attention was specifically noted to the ankle joint where no intra-articular stepoff was noted. Next, utilizing a K-wire driver, two 0.062 K-wires were driven from distal to proximal slight oblique angle, anterior and posterior and parallel to each other up from the distal medial malleolus into the mid medullary canal of the distal shaft of the left tibia. Intraoperative fluoroscopy was used in multiple planes and noted adequate position of these K-wires.
Next, having the periosteum reflected off the distal medial aspect of the patient’s left tibia proximal to the fracture site, a 4.0 cancellous screw was inserted from medial to lateral perpendicular to the long axis of the tibia, approximately 2 to 3 cm proximal to the fracture site. The screw was inserted to aid in the tension band fixation, which was in the process of being accomplished. Next, utilizing 22 gauge surgical stainless steel wire, tension band fixation was accomplished, utilizing a figure-of-eight maneuver hooking the wire around the proximal screw and distally around the 2 K-wires. The cerclage wire was then tightened down both anteriorly and posteriorly between the distal and proximal aspects of it utilizing a twisting motion. Upon tightening of the cerclage wire, compression was noted across the medial malleolar fracture site. The twisted crimped portion of the wire was then cut and shortened with care noted to keep the compression at these 2 sites. They were then bent back down and partially buried into the cortex of the medial aspect of the distal tibia to keep from being prominent underlying the skin.
Next, the distal aspect of the K-wires were cut short, bent at an acute angle and buried deep into the distal tip of the distal malleolus so as to stay firmly seated and also not to become prominent to the patient postoperatively. Once all the fixation was achieved, the wound was then copiously irrigated with normal sterile saline and closed in layered fashion utilizing 2-0 Vicryl, 3-0 Vicryl and surgical stainless steel staples. Final intraoperative fluoroscopy was then undertaken and excellent alignment of the ankle joint with compression of both medial and lateral fracture sites and alignment of the fracture fragment was noted. Dressings were then applied consisting of Adaptic, 4 x 4s, Kling, Kerlix and sterile Webril.
The tourniquet was deflated and prompt capillary response was noted to the left lower extremity. Next, a multi-layer dressing consisting of cast padding and Ace bandages were placed about to the patient’s left leg distal to the patient’s knee. A 5 inch posterior fiberglass splint was placed along the patient’s posterior left leg with care taken to keep the foot at 90 degrees. Also, a U-shaped 4-inch fiberglass splint was placed from medial to lateral in a stirrup fashion for additional support. Additional Ace bandages were placed over the fiberglass splint to keep them in place.
Next, the above-mentioned cocktail was injected into the patient’s left peroneal area and popliteal area for distal anesthesia to the patient’s left leg. The patient was then sent to recovery where she will be monitored for a sufficient period of time before being re-admitted back to the floor.
