DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Trimalleolar ankle fracture on the right.
POSTOPERATIVE DIAGNOSIS: Trimalleolar ankle fracture on the right.
OPERATION PERFORMED: Open reduction and internal fixation, trimalleolar ankle fracture, without fixation of the posterior lip.
SURGEON: John Doe, DPM
ANESTHESIA: Spinal with monitored anesthesia care.
HEMOSTASIS: Thigh tourniquet at 300 mmHg for 90 minutes.
ESTIMATED BLOOD LOSS: Negligible.
DESCRIPTION OF OPERATION: The patient was identified and consent had been obtained. The patient was brought to the operating room and placed in the bed in the supine position. The patient was then interfaced with the appropriate monitors. Spinal anesthesia was initiated. After obtaining anesthesia, we went ahead and prepped and draped the right ankle and foot in the usual manner. We went ahead and elevated, exsanguinated, and tourniquet inflated.
Attention was then directed to the lateral aspect of the ankle first. Utilizing the linear incision over the lateral malleolus, the incision was taken to the skin and subcutaneous tissue down to the fracture site. The fracture site was noted to be markedly comminuted at this point and markedly osteopenic. We went ahead and reflected the periosteum and found both lateral malleolus distally and the proximal fibula shaft without difficulty.
Once we achieved some degree of anatomic restoration of length, we went ahead and temporarily fixated distally with a K-wire in the malleolus so as to maintain the length. Once that was done, we utilized a 1/3 semitubular plate from a Synthes set and secured that proximally to the fibula where good cortical bone was still appreciated. Once that was done, we went ahead and aligned the comminuted fragments and then the lateral malleolus in anatomic position and then placed several screws distally in the lateral malleolus.
Once we had that secure, we did not feel that the distal segment was stable enough, so we decided to place two screws in the plate through the fibula and doing a unicortical purchase of the lateral tibia to provide an additional amount of stability to the lateral malleolus comminuted section. Once that was done, we noted that the segment was significantly stiffer and more supported at the comminution site. We went ahead and placed the bones back in some degree of anatomic alignment at the comminution segment and covered that back up with the periosteum. The wound was now flushed copiously. We went ahead and closed that lateral side with a 0 Vicryl deep, 2-0 Vicryl subcutaneous and then skin closure with staples.
Attention was directed to the medial aspect where the patient had medial malleolar fracture. We went ahead and approached that through a medial approach parallel to the saphenous vein and nerve. The incision was taken through the skin and subcutaneous tissues and by blunt dissection was taken down to the capsule, and periosteum was reflected until the fracture fragment was identified. We went ahead and reduced that and placed two 50 mm screws in the distal segment back up into the distal tibia. This allowed for reduction, image intensification, and verified the reduction of the fracture at this point, and we were satisfied with it. We went ahead flushed the wound out, closed it with a 3-0 Vicryl subcutaneous and skin closure with staples. We put the patient into a posterior mold splint afterwards and will keep her in the hospital for pain management and monitor her wound status. The patient tolerated this entire procedure very well.
