DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right fibular fracture.
2. Right ankle syndesmotic disruption.
POSTOPERATIVE DIAGNOSES:
1. Right fibular fracture.
2. Right ankle syndesmotic disruption.
OPERATION PERFORMED:
1. Open reduction and internal fixation of the right fibular shaft fracture.
2. Fixation of the right syndesmotic disruption.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the supine position. He was administered general anesthesia and then prepped and draped in the usual sterile fashion. A longitudinal incision was made over the lateral aspect of the leg centered fluoroscopically over the fibular fracture to accommodate approximately an 8-hole one-third tubular plate. This incision was made through the skin and subcutaneous tissue down to the fascia. A small flap of skin was made for further closure because of the extreme swelling in his right lower extremity prior to the start of this case. The fascia was then split longitudinally as well. The peroneal muscles were then identified. Through blunt finger dissection, the peroneal muscles were retracted and stripped away from the lateral aspect of the fibula. A superficial peroneal nerve was identified anteriorly and bluntly retracted away from the operative site throughout the remainder of the case.
The fracture site was identified. A Freer periosteal elevator was used to fully expose the fracture site and laterally for placement of the plate. Vigorous irrigation and a curette were used to remove the hematoma at the fracture site to allow adequate reduction of the fibular fracture. With the use of a reduction clamp and longitudinal traction, the fibula was once again taken out to length and derotated to allow complete anatomic reduction. This was checked under fluoroscopic imaging and confirmed. An 8-hole one-third tubular plate was then placed over the fracture site. There were three screw holes that were proximal, one cortical screw in the fourth most proximal hole was placed in between two fracture fragments, and there were three distal holes placed. AP, lateral, and oblique radiographic views were taken to ensure that adequate reduction was obtained and maintained, and the patient did have complete anatomical reduction. This was also visualized at the fracture site.
The wound was then vigorously irrigated. It was closed using 0 Vicryl sutures in the fascia. Because of the extreme amount of swelling, the fascia could not be completely closed. It was loosely approximated as much as possible without putting undue tension on the repair. Then, 2-0 Vicryl was used in the subcutaneous tissue followed by some 4-0 Monocryl sutures in the subcuticular layer. Skin staples were used to further reinforce this tight wound closure to avoid spreading of the Monocryl suture layer.
Fluoroscope was then redirected to the level of the ankle. Small stab incisions were made over the level of both the medial and lateral malleoli. A hemostat was used to spread down to the malleoli for introduction of a large pelvic reduction clamp. The foot was fully dorsiflexed, and the pelvic reduction clamp was tightened under fluoroscopic imaging. This completely reduced the ankle mortise. Approximately 1 and 2 cm above the level of the ankle joint was identified fluoroscopically, and small incisions were made over the level of the fibula. The Arthrex TightRope syndesmotic fixation system was then placed. First, the adequate insertion site was identified fluoroscopically over the lateral aspect of the fibula. The drill hole was placed through the fibula and into the tibia. The Arthrex TightRope system was ensured under fluoroscopic imaging to be parallel to the joint surface. This was then placed through the drill holes of the fibula and tibia, and the passing needle was taken out the medial side under fluoroscopic guidance. This was tightened down. Again, this was repeated with the two fixation system, one approximately 1 cm and one 2 cm above the joint line. The FiberWire suture was then cut. Under fluoroscopic imaging, the ankle was then placed under a stress test. There was no widening of the mortise with the gentle stress test. These small stab incisions were then closed with 4-0 Monocryl sutures followed by Steri-Strips. Adaptic dressings, 4 x 4’s, Webril, and a short leg splint were then placed.
The patient awoke from anesthesia without complications and was transferred to the recovery room in stable condition. Estimated blood less was less than 50 mL. The tourniquet was not used throughout the case.
