Left Tibia Pilon Open Fracture Open Reduction and Internal Fixation with External Fixator
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Table of Contents
Tibial plafond or pilon fractures account for 5 to 10% of all lower extremity fractures and are associated with high energy trauma. They are the result of predominantly axial loading resulting in a typical three fragment and comminuted pattern.1 These fractures have a high rate of non-union, mal-union, and wound healing issues due to weak metaphyseal bone, a lack of robust soft tissue coverage, and complex intra-articular extension.
Early studies demonstrating higher rates of complications after acute management have promoted a strategy of “staged” management.2,3 In this approach, the initial injury is initially stabilized with the use of temporary external fixation and definitive fixation is delayed until soft tissues are amenable to primary closure of incisions. While staged management has been considered the standard of practice, more recent work has reported good outcomes with acute definitive fixation in well selected patients.4,5
In this manuscript and video, we demonstrate a tibial pilon fracture managed acutely with a hybrid fixation approach combining internal fixation with external fixation.
A focused history should include the patient’s age, past medical history, and functional status and should elucidate the mechanism of injury. The primary concern in acute management of tibial pilon fractures—especially when considering acute internal fixation—is the integrity of the soft-tissue envelope. The examiner must uncover any medical conditions, medications, or social habits that may compromise the skin or delay would healing. Important examples include diabetes, peripheral vascular disease, use of immunosuppressive medications, long-term corticosteroid use, and active smoking or other nicotine use. High-energy injuries in a young patient suggest a larger zone of soft-tissue injury and will be more likely to lead to significant swelling in the days following injury. Low-energy mechanisms, such as are often seen in geriatric patients, may not cause as much additional damage to the surrounding tissues.
In this case, the patient is a 44-year-old female who sustained a fall going downstairs the day before presentation to our emergency department. Her past medical history is significant for anxiety, depression and active smoking. Her body mass index (BMI) is 25. She initially presented to another institution where she was diagnosed with an Gustillo-Anderson type 1 open left tibia and fibula fracture and received intravenous cefazolin. Her leg was splinted for preliminary immobilization prior to transfer to our intuition. By the time of admission to our institution, 24 hours had elapsed since injury. Laboratory markers obtained were unremarkable, hematocrit and white blood cell count were within normal limits.
In the case of high-energy lower extremity injuries, the entire extremity must be assessed. First, assess for open wounds that can be directly associated or in continuity with the fracture site in the zone of injury. Emergency department management of open injuries should include early irrigation to remove any obvious foreign bodies or gross contamination of the wound. In our institution we perform a saline lavage in the emergency department of all open wounds associated with fractures, then proceed to cover the wound with a gauze soaked in iodine solution. After evaluating for open wounds, the overall state of the rest of the soft tissues should be considered. The amount of swelling should be noted; absence of skin wrinkling suggests significant edema that may compromise would healing. Any fracture blisters should be recognized and covered with a petroleum-impregnated dressing. Displaced fracture fragments may cause skin tension that can impede perfusion and lead to skin breakdown. Skin threatening is indicated by blanched skin overlying a bony fragment and must be recognized. After assessment of the wounds and other overlying skin defects, a complete neuromotor and vascular exam must be performed.
Documentation of the level of sensation, and function of muscular groups along with the presence or absence of pulses and good capillary refill must be performed. When concerns exist for a vascular injury computed tomography (CT) angiography obtained for further definition of the vascular injury after stabilization of the fracture.
Our patient’s overall physical exam of the left lower extremity was significant for obvious deformity with a small wound (< 1 cm) on the medial side of ankle. The soft tissue was otherwise well maintained. There was minimal swelling of the leg with no fracture blisters. No further areas of skin threatening were noted. The leg was soft and all compartments were compressible. The patient was tender to palpation over the ankle but had a painless passive range of motion of the knee and toes. She was able to activate the anterior tibialis, extensor hallucis longus, and flexor hallucis longus muscles. Sensation was intact in the distributions of the saphenous, sural, and superficial and deep peroneal nerves. Positive palpable pulses were evident over the dorsal pedis and posterior tibialis arteries. Toes were well perfused.
Radiographs should be obtained upon presentation. Initial radiographs should consist of views of the whole tibia and fibula to determine proximal extent of the injury as well as an ankle series that includes a mortise (15-degree internal rotation) view to assess alignment and comminution at the tibial plafond. CT scan is a crucial and routine component of the preoperative evaluation for most tibial plafond fractures. CT scans have been shown to improve understanding of the number and location of fracture fragments, extent of articular involvement, and location of the major fracture line.6 CT assessment frequently leads to changes in the surgical plan compared to use of radiographs alone.6 Axial CT images are particularly useful for identifying major fracture fragments and planning placement of surgical incisions.1
Imaging obtained in this case included tib-fib x-rays demonstrating a distal tibia and fibular fracture. The fibular fracture was a simple transverse fracture above the level of the syndesmosis. In the lateral view, shortening and apex posterior angulation of the fracture was noticed. The distal tibia fracture was an oblique fracture at the same level of the fibular fracture. Intra-articular extension was difficult to assess in both antero-posterior (AP) and lateral views.
A CT scan obtained of the lower extremity demonstrated the typical “Y-shaped pattern” in the axial cuts at the level of the tibial plafond. A very comminuted Volkmann (posterolateral) fragment, an also comminuted Chaput (anterolateral) fragment and a medial malleolar fragment were observed in the axial cuts.
In the coronal view, the tibia was noticed to fall in valgus at the level of the long oblique fracture line in the metaphysis, also in the coronal view there was a small impacted and flipped fragment in the middle of the plafond.
Tibial plafond fractures are treated operatively in nearly all cases due to high rates of malunion with nonoperative treatment.7 Initial management may consist of placement of a provisional uniplanar ankle-spanning external fixator if there is concern for the status of the soft tissues, such as significant edema and/or fracture blister formation. If used, external fixation usually remains in place for 7–21 days until swelling has subsided and the skin is amenable to closure of incisions. Conversely, acute definitive internal fixation may be attempted if swelling is minimal. Definitive external fixation, often with a thin-wire frame, may be used in select patients at extremely high risk for wound healing complications. In recent years, some surgeons have advocated for utilizing primary tibiotalocalanceal (TTC) fusion via retrograde intramedullary nailing of the hindfoot as definitive treatment of pilon fractures in some low-demand elderly patients, patients with poorly controlled diabetes, and/or cases with extreme articular comminution. However, hindfoot nailing achieves ankle stability at the expense of loss of both ankle and subtalar joint motion and therefore remains reserved for limited cases.8 In the vast majority of cases, definitive surgical management consists of open reduction internal fixation (ORIF) with plate and screw constructs.
ORIF may be accomplished using several surgical approaches. Each approach utilizes a different intramuscular interval to primarily expose a specific aspect of tibia and/or fibula. Often, multiple approaches are combined. The planned incisions and approaches should be tailored to the patient’s unique fracture pattern while considering any wounds around the ankle.1 The most common approaches used are anterolateral, anteromedial, and posterolateral. In the anterolateral approach, the interval between the anterior compartment tendons and fibula is utilized. An incision is made in line with space between the 3rd and 4th metatarsals, starting distal to the ankle joint, and extended to approximately 5 cm proximal to the joint.9,10 Care must be taken to avoid injury to the superficial peroneal nerve. The tendons of the anterior compartment are lifted and retracted medially to expose the lateral distal tibia and anterior plafond. The anteromedial approach exploits the space between the tibialis anterior (TA) tendon and the medial malleolus to expose the medial column of the tibia. The incision starts medially just distal to the medial malleolus and curves anteriorly more proximally along the TA. A skin flap can be raised to expose the medial malleolus and medial tibia and the TA and adjacent anterior compartment tendons can be retracted laterally to expose the anterior joint line. In the case of an associated fibula fracture, the anteromedial approach may be combined with a direct lateral approach for fibula fixation.10 The posterior column of the tibia is most often accessed via a posterolateral interval between the flexor hallucis longus (FHL) and peroneus longus (PL) tendons. This approach is typically performed with the patient prone. The posterolateral incision is made halfway between the Achilles tendon and lateral malleolus. The deep fascia is exposed, taking care to avoid injury to the sural nerve. The fascia is opened and the peroneal tendons retracted laterally. The posterior tibia is exposed by elevating the distal muscle fibers of the FHL. An associated fibula fracture can typically also be accessed and fixated through the posterolateral incision. Many other approaches have been described and are often employed, including direct anterior and posteromedial approaches.
In many cases, multiple surgical approaches may be needed to adequately reduce the fractures and apply fixation. Fixation of an associated fibula fracture is a common reason for using a second incision. The fibula can be accessed via a direct lateral approach that exploits the internervous interval between the extensor digitorum longus (deep peroneal nerve) and peroneus brevis (superficial peroneal nerve). Use of a second incision increases concerns regarding wound healing complications and necrosis of skin bridges. Typically it is thought that incisions must be separated by at least 7 cm. However, careful soft-tissue handling and closure of incisions using perfusion-preserving suture techniques can allow for smaller skin bridges. A prospective study of 46 pilon fractures found low risk of wound-healing complications with skin bridges that were on average 5.9 cm and with 83% being <7 cm when excessive soft tissue dissection and over-vigorous retraction were avoided and wounds were sutured using the Allgower-Donati technique.11 To reduce the risk of wound healing complications with multiple incisions, the location of all necessary incisions should be carefully planned preoperatively.
Once the fractured tibia is exposed, cortical fragments can be booked open to expose the impacted articular fragments. Individual fragments are manipulated and reduced using the intact talar dome as a template. Provisional reduction may be held with a combination of Kirchner wires (k-wires) and pointed reduction clamps. Definitive fixation is performed by applying anatomically contoured small fragment locking plates in positions that resist valgus or valgus collapse, depending on the fracture pattern. Independent 3.5-millimeter (mm) or 2.7-mm screws may be used between fragments to rebuild the articular surface.11,121314–17
The goals of treatment for tibial plafond fractures are anatomic reduction of the articular fragments to recreate a congruent articular surface, preservation of articular cartilage, and restoration of anatomic relationships and mechanical alignment of the leg and ankle joint.
Given the presence of an open fracture, surgery was indicated for this patient in an urgent fashion. The procedure began with wound exploration and irrigation and debridement to address the open fracture. An anteromedial incision was then selected as the primary approach taking two factors into consideration: 1) The CT scan suggested the fracture pattern could be fixed through this approach while also allowing access to the anteromedial corner of the ankle joint to visualize the joint for proper anatomic reduction, and 2) The open wound could be incorporated into the planned incision. Because skin swelling was minimal and an incision was already required for irrigation and debridement of the open fracture, we proceeded with acute ORIF. An external fixator was used for provisional stabilization intraoperatively and was left in place at the end of the case.
The use of an anteromedial approach was helpful to address the axial failure of the tibia with compression laterally, thus, the anteromedial approach would allow us to address this coronal deformity. Through this approach we were able to reduce both the Chaput and Volkmann’s fragment with k-wires and eventually fixation with the plate. The use of a second incision to address the fibula fracture helped to achieve length and restore alignment of both the tibia and the fibula.
Our patient’s injury resulted in a highly comminuted fracture that required both open reduction and internal fixation plus the additional application of an external fixator for further stability and to protect the underlying fixation and the soft tissues. The decision to apply an external fixator was made intra-operatively and helped to maintain the overall length and alignment of the tibia and fibula. Preoperative CT was useful to understand the fracture pattern and plan for an appropriate surgical approach.10
Presence of an open wound at the time of initial evaluation should prompt immediate initiation of intravenous antibiotic therapy. Antibiotic choice is determined by the soft tissue compromise of the injury, as determined by the Gustilo-Anderson classification.12 Many antibiotic protocols have been proposed. Most commonly, type I and type II fractures are treated with a 1st generation cephalosporin (e.g. cefazolin), while type III fractures are additionally given an aminoglycoside (e.g. gentamicin), while penicillin is added for extensive soil contamination. A more recently proposed protocol uses cefazolin for type I and II fractures and ceftriaxone for type III.13 To reduce decision-making burden on frontline providers in the emergency department, our institution uses a simplified protocol in which cefazolin is given for type I fractures and piperacillin-tazobactam is given for any fracture type II or higher.
Use of a thigh tourniquet intraoperatively can improve visualization of fracture fragments and reduce intraoperative blood loss. A tourniquet may be especially useful in treatment of pilon fractures as hematoma can obscure the reduction reads for small articular fragments. Tourniquet use comes at the cost of increased intraoperative and postoperative pain and carries small risks of nerve and muscle injury. Safe tourniquet practices should be followed including leaving the tourniquet inflated for no-longer than 2.5 hours consecutively and releasing the tourniquet for 10 minutes of reperfusion at the 2.5 hour mark and every hour thereafter.14
Fractures of the tibial plafond—often referred to as pilon fractures—are complex injures of the distal leg with significant bony and soft-tissue disruption. Historically, nonoperative treatment of tibial plafond fractures was associated with poor reduction of the articular surface, poor maintenance of mechanical alignment of the ankle, and low resulting function. Therefore, in present practice, these fractures are nearly always considered operative injuries.
Surgeons are faced with a multitude of choices when planning operative treatment of tibial plafond fractures. Upon initial presentation of the injury, surgeons must decide for acute definitive fixation versus a staged approach with temporary external fixation. Data regarding acute vs staged management of pilon fractures is conflicting. The main consideration is the risk of wound complications after acute surgical fixation. Tibial pilon fractures are usually high energy injuries that quickly develop acute soft tissue swelling, including blistering. This is largely due to the thin of the ankle skin with little protective subcutaneous tissue. The tibia and fibula are both subcutaneous at the level of the ankle. In these cases, the application of an ankle-spanning external fixator has been a useful temporizing method to protect the traumatized soft tissue envelope, and to allow for safe staged definitive fixation when the soft tissues are improved and can better tolerate surgery (7 or more days later). In some cases external fixation can function as a definitive treatment.15,16,17 Other studies have demonstrated that acute open reduction and internal fixation (ORIF), when performed appropriately, respecting soft tissue integrity, with a proper incision size and location, can result in similar outcomes with less operative time and overall treatment cost.18–21 Some studies have demonstrated the efficacy and safety of early fixation, with clear criteria including no excessive soft tissue swelling and the absence of fracture blisters. There are a number of known variables that will increase risk of infection and wound complications regardless of the time of fixation (male gender, smoking and diabetes). Most of the recent studies agree that patients with a good soft tissue envelope, the presence of skin wrinkles, low energy and without significant comorbidities, acute fixation may be reasonable and safe.19,20
Presence of an open fracture demands a surgical incision for thorough irrigation and debridement. In such a case, surgeons may be more likely to opt for at least partial internal fixation in an acute fashion. Once deciding to move forward with definitive internal fixation, the surgeon must select the surgical approach(es) that will safely provide access to the crucial fracture fragments to be able to both reconstruct the tibial plafond and restore and maintain length and mechanical alignment of the tibia. Multiple surgical approaches have been described utilizing anterior, posterior, and lateral intramuscular intervals, each of which provides access to a specific region of the tibia.
In the case described in this video, an incision was required for irrigation and debridement of an open fracture. The traumatic wound was in the path of an incision for an anteromedial approach, which was utilized. Because this incision was being made and skin swelling remained minimal over 24 hours after injury, the soft tissue envelope was deemed appropriate and safe for acute surgical fixation and we elected to proceed with acute definitive ORIF. We performed a hybrid approach with both acute fixation complemented with external fixation. First, a transcalcaneal pin was placed to be able to pull traction and assist in the reduction of both the fibula and tibia for plating, allowing for restoration of anatomical length. A six-hole 1/3 non locking, semi tubular, 3.5-mm plate was applied to the fibula after reduction was achieved. K-wires were used for temporary stability.
After fixation of the fibula, an ankle spanning external fixator was constructed by adding Shantz pins to the tibia and connecting the appropriate clamps and bars. Anatomic alignment of the tibia that restored medial column length was then achieved using manipulation of the external fixator under fluoroscopic imaging and the frame was tightened. Then, an anatomically-contoured medial distal tibia 3.5-mm non-locking plate was applied spanning the area of comminution. Additional fixation was achieved with 3.5-mm screws perpendicular to the anterior to posterior fracture plane. Along with the application of the plate, the underlying bone void was filled with bone graft consisting of cancellous allograft chips. Wounds were then profusely irrigated with saline solutions and closed primarily with application of 1 gram of vancomycin powder during wound closure. While the external fixator is often removed following ORIF of tibial pilon fractures, in this case we elected to maintain it postoperatively. This was done for multiple reasons. First, given the comminution of the tibial cortex, the ex-fix provided increased stability during the early healing stages to guard against failure into valgus. Second, the patient had increased risk of wound healing complications given the open fracture and active smoking; maintaining the external fixator allowed for stability for soft tissue rest while leaving the incisions accessible for monitoring, which would not have been possible in a postoperative short-leg splint.
The patient was discharged home on postoperative day 4 after ambulating safely and independently with an assistive device and achieving proper pain management. The patient was made non weight bearing (NWB) on the operated limb and the external fixation device precluded any range of motion at the level of the ankle. First follow up was at 15 days post-op, and at that time the patient demonstrated a well-healed incision, and all hardware was intact on radiographic assessment. She was asked to remain NWB on the left lower extremity. At postoperative week 4, the patient was taken back to the operating room for external fixator removal and examination. Examination revealed a stable fixation construct without signs of hardware failure or other radiographic concerns.
- Large external fixator.
- Kirschner wires of various sizes.
- Weber reduction clamps of various sizes.
- Anatomically contoured distal tibial plates.
- Small fragment locking and non-locking plates.
- Small fragment locking and non-locking screws.
Citations
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- Tornetta P, Gorup J. Axial computed tomography of pilon fractures. Clin Orthop Relat Res. 1996;323(323):273-276. doi:10.1097/00003086-199602000-00037.
- Barei DP. Tibial Pilon Fractures. In: Tornetta P, Ricci WM, Ostrum RF, McQueen MM, McKee MD, Court-Brown CM, eds. Rockwood and Green’s Fractures in Adults. Ninth Edition. Wolters Kluwer; 2020:2752-3060.
- Cinats DJ, Kooner S, Johal H. Acute hindfoot nailing for ankle fractures: a systematic review of indications and outcomes. J Orthop Trauma. 2021;35(11):584-590. doi:10.1097/BOT.0000000000002096.
- Herscovici D, Sanders RW, Infante A, DiPasquale T. Bohler incision: an extensile anterolateral approach to the foot and ankle. J Orthop Trauma. 2000;14(6):429-432. doi:10.1097/00005131-200008000-00009.
- Assal M, Ray A, Stern R. Strategies for surgical approaches in open reduction internal fixation of pilon fractures. J Orthop Trauma. 2015;29(2):69-79. doi:10.1097/BOT.0000000000000218.
- Howard JL, Agel J, Barei DP, Benirschke SK, Nork SE. A prospective study evaluating incision placement and wound healing for tibial plafond fractures. J Orthop Trauma. 2008;22(5):299-305. doi:10.1097/BOT.0B013E318172C811.
- Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453-458.
- Rodriguez L, Jung HS, Goulet JA, Cicalo A, Machado-Aranda DA, Napolitano LM. Evidence-based protocol for prophylactic antibiotics in open fractures: improved antibiotic stewardship with no increase in infection rates. J Trauma Acute Care Surg. 2014;77(3):400-408. doi:10.1097/TA.0000000000000398.
- Fitzgibbons PG, Di Giovanni C, Hares S, Akelman E. Safe tourniquet use: a review of the evidence. J Am Acad Orthop Surg. 2012;20(5):310-319. doi:10.5435/JAAOS-20-05-310.
- Pugh KJ, Wolinsky PR, McAndrew MP, Johnson KD. Tibial pilon fractures: a comparison of treatment methods. J Trauma. 1999;47(5):937-941. doi:10.1097/00005373-199911000-00022.
- Harrison WD, Fortuin F, Durand-Hill M, Joubert E, Ferreira N. Temporary circular external fixation for spanning the traumatised ankle joint: a cohort comparison study. Injury. 2022;53(10):3525-3529. doi:10.1016/J.INJURY.2022.07.034.
- Lavini F, Dall’Oca C, Mezzari S, et al. Temporary bridging external fixation in distal tibial fracture. Injury. 2014;45 Suppl 6(S6):S58-S63. doi:10.1016/J.INJURY.2014.10.025.
- Olson JJ, Anand K, Esposito JG, et al. Complications and soft-tissue coverage after complete articular, open tibial plafond fractures. J Orthop Trauma. 2021;35(10):E371-E376. doi:10.1097/BOT.0000000000002074.
- Flanagan CD, Lufrano RC, Mesa L, et al. Outcomes after acute versus staged fixation of complete articular tibial plafond fractures. J Orthop Trauma. 2023;37(6):294-298. doi:10.1097/BOT.0000000000002572.
- Olson JJ, Anand K, von Keudell A, et al. Judicious use of early fixation of closed, complete articular pilon fractures is not associated with an increased risk of deep infection or wound complications. J Orthop Trauma. 2021;35(6):300-307. doi:10.1097/BOT.0000000000001991.
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Cite this article
Merchan N, Hresko AM, Rodriguez EK. Left tibia pilon open fracture open reduction and internal fixation with external fixator. J Med Insight. 2025;2025(445). doi:10.24296/jomi/445.
Procedure Outline
Table of Contents
- 1. Introduction
- 2. Surgical Approach and Wound Irrigation
- 3. Traction Pin
- 4. Lateral Exposure
- 5. Reduction of Fibula Fracture to Restore Lateral Length and Alignment
- 6. Fixation of Fibula with Plate
- 7. Medial Exposure
- 8. Medial Reduction with K-Wires to Restore Medial Length and Alignment
- 9. Medial External Fixation with Plate and Bone Graft
- 10. Closure
- 11. Post-op Remarks
Transcription
CHAPTER 1
My name is Ken Rodriguez. I'm an orthopaedic trauma surgeon. I'm the chief of orthopaedics at Beth Israel Deaconness Medical Center in Boston. My practice is mostly high-energy trauma and community trauma, and a lot of geriatrics. The case for today is a 44-year-old female patient who fell down the stairs while carrying a mattress, sustaining a fairly high-energy distal tibia pilon and fibular fracture with a small opening. So it's a Gustilo type one fracture. She came in last night, she was temporized overnight with some splints, and she's going to the operating room today, both for debridement of the open fracture and for possible fixation if the condition of her soft tissues allows it. This may or may not include application of an external fixator for soft tissue management.
CHAPTER 2
X-ray, please. Picture. Okay, that's it. Put a little mark there, a transverse mark, guys. A mark, yeah. Okay, all right. She's very petite in her bones, right? Let's start by fixing the fibula just to line it up a little bit with a very small incision, right? That will allow us to kind of gauge the length a little bit better, at which point we're gonna do an external fixator. Yeah, can you back up a little bit? And we're gonna have to wash this little spot. I need you more, like significantly more. Thank you, yeah. So this is a great actual exposure here, right? That's gonna be our anteromedial incision? Yeah, so we could incorporate this into the incision, right, if we have to, depending on how much we want to do today, right? The problem is that once you open an incision, right, to perform a debridement... You're buying it. You're buying it, right? So, but given that it's - the open area is in the area of where an exposure is. Right, we have an anteromedial incision, right? We have a fibular incision over here, right, and that's probably what we should do. Okay, so let's do this. 15 blade, please. Let's just do a very modest exposure here, right? Something like this, right. Just enough to see what's going on. Can I have a Freer, please? And we're gonna do, so this is the open area, right? There's the, that's peri, a stripped periosteum, right? That's comminution, right? So we got a lot of comminution happening here, right? So let do it, let's start doing an irrigation here. We may be able to fix some of the anteromedial. I want to get that CT scan back up so I can decide. We may be able to just do an anterior medial plate with unicortical screws just to preserve the medial side, right, knowing that we're gonna, that we may have to come back posteriolaterally, and then here we would do a posteriolateral incision here. We have to be very careful about doing this. Yeah, that's gonna be... So in fact, let's move this a little bit anteriorly, right? I want to do it myself. Do you want a 2D camera? No, I just want the, yes, that's good. Now go up there and just scroll down. Yep, that's good. Keep going, go, go, go. It looks great, keep going so that we have, we can decide. Okay, right there. Yes, stay right there, okay. So we're gonna have access through the opening for this to the anteromedial side, right? Okay, irrigate that. That will take care of the open part of the incision, so we're gonna do it, irrigation. Don't take out any bone or anything. Then we're going to, then we're gonna repair the fibula, very cursively, which is like a small plate with small incisions and put an ex-fix, and that may be all we do today, right? So in preparation for the external fixator, let's get our stuff, the stuff that we're gonna need. So let's... Oh, you got a couple of calip pins. Awesome, you got these two. Yeah. Perfect, perfect. We're gonna take this, right? And we're gonna need a... One, two - one, two, three - one, two, three, four of these. The green, yeah. We're gonna need four of these. And then for her... What's the next shortest? Think we got 400. 350, 300 should be in there too. It looks like it goes from here. All right. These are too long. These might be okay. That's fine. Put those aside. Let's find one that matches that. There we go. Okay, so we're doing an irrigation, and there's no particularly loose bones. Everything looks okay, right? So we're going to put, we're gonna do our fibula next. We're gonna put the, we're gonna first put the pin, the transcalcaneal pin to put a little traction to help us with the fibula. Then we're gonna assemble the frame, and then we're gonna decide how much we actually do on this side, okay? So that'll be the plan. That will allow us to temporize this, you know. We'll go with one of these first, actually. Okay. Do these go on this as well? Well, yeah, same thing. Yeah. So from your perspective, like an acute care perspective, this is something that you will be doing all the time in a particular setting where you're the only surgeon, right? And it would involve a very cursory debridement of the open side. You gotta be a little careful though, when you have something like this that you're sending away, because putting an incision in the wrong place may burn a fixation approach later on. We are doing this in a few days, so I know that we're gonna do a, we looked at the CT scan carefully, and we know we're doing an anteromedial exposure, and we know if we're gonna do a lateral or posteriolateral exposure, so we're gonna be okay. Some people will plate the fibula thinking they're helping me when they send the case, and then I realize I need to do an anterolateral or a mediolateral portion. I just can't do it anymore because if I need the incision, that doesn't give me the approach forward or backwards, and it burns the bridge. So, if you're not gonna be doing the definitive care yourself, be as modest as possible, but feel free to put any kind of frame. The framework we're gonna do today is what I prefer to do, and I'll give you, I'll demonstrate a couple of alternative things. We're gonna do two Shantz pins, five-millimeter Shantz pins or four-millimeter Shantz pins in the front, and one or two transcalcaneal pins. Some people will put a single transcalcaneal pin and put four foot pins to prevent, to control the front reflection, but I just do two calcaneal pins, and that usually gives me enough time. So that's the one, that's the frame we'll assemble today. The advantage of having two calcaneal pins is that the more pins, the less likely it will get infected or soupy and the more durable, the recon, the frame will be. Sometimes in some situations, your patient might end up going to rehab or to jail or someplace where you're not gonna have access to the OR for your definitive care for many, many days. A sturdy frame helps you preserve the soft tissues. Okay, how many liters is that? Almost three. Three liters. Okay, once you run out, let me know and we'll start working. So that's gonna be one thing. The next thing we're gonna do is we're gonna do a small frag plate. We are gonna do something simple like this. Get this one out. All right, that's good enough.
CHAPTER 3
Okay, put away the irrigation materials. Suck that water out. Let's put this here. All right, you guys hold it like that. So the first thing we're gonna do is something very, very simple. I need a marking pen. So when I put the traction pin, right, it has to go in the calcaneus. It is very typical to make a mistake and put it too posterior and too distal. Too distal, you'll miss, you'll go through the fleshy pad. So I usually figure out, where is it that you wanna put traction? You wanna put traction somewhere through here. So there's your medial mal. So I'm gonna guess somewhere here and here, okay? So make a small incision right there. Just enough with a 15, and we're gonna take a Schnidt. From these two dots? On the more posterior one. Just the size of a screw head, yeah. Okay, that's it, that's it. So now you do it, you go like this. Knife back to you, right. Do hou have a Schnidt, not a right angle? Yeah, right, so we're gonna, so we have good bone contact there, right? Let's be a little careful with this, right? So it's a very hefty, hefty thing. Don't press yet. So I'm looking at the orientation of this, right? Okay, go. Okay, bit more. Okay, stop. That's gonna be our first thing. Okay, so now we'll take this. You're gonna be our preliminary traction. Okay. And you're gonna provide a little bit of traction like this, right? Just nah, it's too flimsy. Let's do it by hand here, but I need your hands out of the way so you don't get radiated. Yeah, so you'll do one here, right? Hold it there. Not yet. We'll do that at the end, don't worry about it, and you'll just kind of control your traction like this. So stand over there. So I just put, there you go.
CHAPTER 4
Just a very, okay, so Andrew, open up about this much. Just open something like this, and I'll take a dissecting scissor and a small Cobb. That's good, that's good. Okay, can you guys reposition the lights a little bit better for me? Internally rotate for me and I'll take a forceps. Yeah, get a little bit better light. Okay. Better? Can I, yeah, that's better, thank you. I'll take that Cobb. Okay, so I can see there's a significant overlap here, right? Yeah. So pull it a little harder now. Yeah, that's gonna be hard. Okay, relax. Be careful here. What's that? Army-Navy. And that's it. What's that, Nelson? Want that again? The peroneal tendon. Yeah, peroneal nerve. Superficial peroneal nerve. So let's just be a little careful, right? I'm missing that. Well, it's how you get in trouble, right? So you have to be... Dissecting scissor. The little forceps again. Self-retractor, please. So that, see, this is superficial peroneal nerve. So we're gonna be a, and it's a pretty prominent one, which is great. You can see it. Hold onto that. All right, there it is, right? It's always waiting to cause trouble. Very prominent one, wow. Very big nerve, right? So you wanna make sure that we mobilize it out of the way so we don't get in trouble. Okay, so... Yeah, it doesn't do anything. Okay. All right, so now, it's okay, it's okay. I'll take the Cobb. So we got a little bit of bone there. Right, a little bone there. Okay, we'll take two reduction clamps, the little ones.
CHAPTER 5
And we're just gonna, now we're gonna help ourselves to some traction, so pull a little harder. All right. I'll switch this for a lobster claw. And I'll switch this one, eh, maybe not. Okay, ready, pull. I'll switch this for a lobster claw too, please. Can we have the table higher, like a foot please? Another foot up? Yeah. Internally rotate for me. Good? Keep going. That's great, thank you, right there. Suction in there. Okay, let's see if we can put this together. There she goes. Okay, so let's adjust this a touch. There. Okay, that feels pretty good. You can relax with your tension now, but not entirely, just a bit. Let's suck in there one more time. Can I take a Freer please? So it's not perfect. Right? Feels a little bit off in some way. It's rotated, correct, so let's... Externally rotate the foot a little bit more? Internally rotate the leg is more helpful than externally rotating the foot. Let the, I'll manage the foot. Okay. That looks better. That looks better. All right, so now...
CHAPTER 6
Yep, and then we'll take that plate now. That plate we selected. Grab a Frazier tip, please. You want small or..? Small or big? Small. Small. So now we're gonna put our, so you guys keep your positions for now, right? This is just a one-third tubular from the small frag? Yeah, that's all we need. So we got two on one side, two on the other. It's actually a six-hole plate. You want an eight so you can? No, it's fine. Three and three. No, we're gonna do that. Okay, can I have a Kelly now? And we're gonna get ready with a 2.5-millimeter drill for Andrew. Okay, put one, put one, all right? I'm gonna do the goalposts. Put one screw, one screw right there, all right? The goalpost is when you put this on each side, right, to center the plate. You can put the one actually over there. Army-Navy please. So do the one there. Pull down a little bit like that, right? Okay, Andrew, go, put a - yeah. You need to go more that way, right? Go more, more. I'm so sorry. Come back out. So this is too difficult tool to use in this angle. So you have to really get outta the way. There you go, put your device in there now. Okay, go. 12, please. Yep, 12 non-locking. And maybe here. Is the Freer still here somewhere? It's right behind, yeah, right here. Give it to me. Okay, get ready with the drill one more time. Okay, good, good. Now come over here. We're gonna do the same thing here, right? Let me just secure you. Okay, do that one there. Now lift up your hand, there you go, there. And I go there, yeah? 12, please. Put it right there. Got very nice alignment. Okay, we're gonna do one on each, one more on each side. Awesome. Okay, drill again. Now I'm gonna borrow that Army-Navy from you, and you're gonna do, as we protect the nerve, do that one. All right, go ahead, yeah. 12-please. Okay, that prevents the place from rotating, and now we're gonna do one more on this side. Internally rotate the leg. Put your hand there, thank you. See there? Yeah, go. Another 12, please. Lift your hand, there you go. Is it going in? Then something's amiss, yeah. Okay, so let's do one more. Way here. Okay, take this off. Can you help me with the, adjusting the light so I get more light here? What a very prominent nerve, huh? I will take a small Cobb, please. Very large. Are you in the hole there? Someone suck there if they could. Okay, go. Okay, can I have a sticker for this? Yeah, go. It's okay. Another 12, please. Don't capture it - don't entrap the nerve, right? I can't help you. Do you, yeah. Okay. All right, that's nice. Okay, can relax there. That gives us length in a very easy way to do. Okay, come in with the C-arm for a second, please. Picture. Can I have a Freer, please? Picture. Come to full lateral, please. Look how long the fibula is, right? That's an outrageously long fibula. That tells me that we may be a little bit short on the tibia, right? Okay, picture there. Okay, go a bit more distal, which is that way. Picture there. That looks pretty good, right? So obviously it's a little bit off picture. There you go. It's a little bit off, but not outrageous, right? Picture there. That is a remarkably improved alignment, right? Yeah, even just with the fibula, right? Picture. So that's a little bit off there, so we do this. Picture. Okay. Let me think about this. So her swelling is not bad. We do have one chance at trying to put a medial plate, getting, securing that kind of alignment. So let's do that, let's come out.
CHAPTER 7
Can I have a 15 blade? I'm gonna give you these. These are gonna be important for you. When I say traction, you just give a little bit of traction like that, right? So I'm expanding across the open side, right? Schnidt and a forceps - and a dissecting scissors. Okay. All right, and there's like a very large vein. This patient has gigantic veins and gigantic veins and nerves, huh? Very cool. That's like what a 6', 300 pound guy would have for, great for CABGs huh? That's the vein that gets grafted all, like harvested to do, they still do CABGs, right? Right. With saphenous? Saphenous vein, right? Yeah. Right, so let's see which way we can move this vein. Right, we can move it front or back depending on which way we need to do our thing. So there's a lot of hematoma here, right? Let's get that out because that was the open... Well, let's just figure this out. Can I take the Weitlaner please? Thank you. This, we're gonna have to open this. You know, she has to. Cobb please. We're gonna, if we're gonna put a plate, we're gonna have to expose a little bit of the periosteum, just enough so we can see what's actually going on, you know what I'm saying? Can I have a, what are they called? They're called like baby Hohmanns. I'm gonna give you some tools back. I'll take this back and you can take this back, thank you. There, let's take a look. Let's cut this. No, no, that's a good one. That's a standard baby Hohmann versus the fat baby Hohmann. All right. So that allows us to see that. I'll take the blade again please. Here you go. Dissecting scissor please. We're gonna get another three liter back. We're gonna clean up a bit better now that we have it exposed. There we go, right. So this is what I was getting at. Let's Bovie this branch of the saphenous right there. And let's Bovie that branch of the saphenous right there, and now we can let this little saphenous fall backwards. Okay, so we have a little bit of hematoma and stuff here. So this is at length now here, right, and we got alignment in there. We're gonna go in a minute to kind of look at the - Bovie please. Look at the CT. All right. Okay, you can leave that there. So this, these are separate pieces, right? This is a separate piece. This is a separate piece. Let's get into the joint a little bit. I always get into the anterolateral corner of the joint here. It's kind of important so that we can understand what's happening. There we go, right. So you see the... Right? Hold it, now you see interior, the entire interior surface of it. Okay, this is it, right, okay.
CHAPTER 8
So now, can I take the toothpick tool, please? Give a little yank and not so much, a little bit less aggressive. We are looking at the joint inside. A little, little irrigation, please. Suck in the joint. Right, and I'm looking at, you were saying that there was a piece of joint missing. Posterolateral. Posteriorolaterally, right? Suck in there. That piece you were talking about here is cortex. Yeah, it's cortex. It's cortex, right? This is important. This is the cover that was going here. Can we save this little piece? So this gives me great, a great sense that we don't have to get too carried away here. Okay, let go here for a second. Right, hold the leg. You, okay, put your hand there in internal rotation and don't let go. Okay, that's gonna be here. Okay, can I take a 1.6-millimeter K-wire please? Hold it right there. Externally rotate a little bit. Are you good with those 1.6s? We're gonna need a series of three or four. You need some help? They're actually not in yet. Okay, let me go in there. Oh, we got 'em. Okay, so that goes here. Very super easy, right, and let go here, let go of the traction for a second. Let this kind of, suck in there. Suck in the corner so I can see the corner. And I think that goes there. Yeah, we need 1.6 K-wires. What do you have there available right now? 2.0 and 1.25. I'm gonna take a 1.25 for now then. We're gonna do just one like this. I need to make a single piece out of these two for now. Suck in the corner there for a second. I need to see what's going on. There's a little bit of bleeding there and I'm not sure where it's coming from. Can we reposition the lights? Hold it there. Thank you. Little bit of traction now. Pull, yeah. Thank you. I'll take another 1.6 please. Hold on. Pull hard there, like really hard. Both sides, yeah. There you go, thank you. Yeah, stand by with that. Can I give it, can I have it? Externally, internally rotate please. Hold here. Okay, can I have a Kelly please? Okay, now let go here for a second. Can I have a, hold here, hold the foot right there. Can I have a 1.25? You don't want the 1.6? 1.6 if you have it, yeah, yeah. They just found it. Gotcha. Thank you, that's great. Okay, so now, I thought it was secure. I guess it's not, huh? Hold, please. Awesome. Okay, let go, let go. Hold it there. Wire driver please. Here you go. It's a lot of... So where's his hole? Right? It's a bigger piece than what we took out, right? Yeah. Can I have a 1.6? One more. Take this, take all these tools away. Yeah, okay, let go for a second. See what happens. Yeah, it's just not holding up the way I want it. Okay, forget it. We have to do something else. We have a nice opposition in the back here. Do you have an ankle fracture here? Another what? Ankle fracture? Yes, yes we do. Leave it there. Let go. Internally rotate a lot. Thank you, stand by there. I can't get this to stay. I'm gonna have to put a frame. It's the only way we're gonna get it to work. Get a picture there, would you mind? See how this looks. Just like that, picture there please. A bit more. Can you gimme a mag one? Picture. Externally rotate a little bit. Picture. Can you go to lateral? Thank you. So this part here is what needs to be done. And it may be that we just - Schnidt, please. Suck in here. Clean the corner of the joint so I can see it. Yep. Okay, wire driver. Take this. A little traction on this. Just relax there, let it collapse. It's just not gonna work very well. Wire driver. Suck in there, please. Get a more appropriate suction device. Irrigation please. Weitlaner please. Traction. Reduction clamp. I need one of you guys to apply suction into the corner there so I can see this. Thank you. Stand by. Okay, right there. Very, very gently. K-wire again. Suck in the joint. Stand by. Yeah. Hold on, let's apply your clamp first so - 'cause it's gonna be important to secure reduction while we put the K-wire. So let me just... But I need you guys to show me into the joint as I apply this, right? Show me there. Okay, that's good. One more please. Thank you. Okay, now let's start over. We have a very nice distal piece, right, that matches. And this is not gonna, can I take the two four-millimeter Shantz pins, please? Okay, we're just struggling with a very inconsistent length. Let's just put, yeah, we're gonna do the ex-fix now. We know the fibula's good. So we just have to secure this in a way where we want it.
CHAPTER 9
We did all this work. Yeah, it's gonna be fine. Well, how do you maintain that? We're gonna plate it. Oh, okay. Oh, we're totally gonna plate it. It looks great. This filling is not even so bad, but I need, but it's gonna be a very flimsy, it's gonna be like a 130 one-third semitubular plate. Okay, take your Shantz pin. Go a little lateral and then turn off, okay? Go. Are you in bone? No, you missed. Okay, hold on. Standby. Double medial. Yeah. Yeah. Okay, stop. Good. One more please. Can I have the clamp? Can I have the clamp, please? Lay it back, nice and parallel, right? Go ahead. Go. Okay, that's good for now. Can I have one more just like these? So this is just to compare. Yeah, that sounds right. We can adjust later on in a little bit if we need to, but let's just put this down so we can keep working. G handle. Not very parallel dock. We need a green, a green green. A second one? No. I need a polymer bar. Put it low. Put this on top, right, so you go 'cause we're gonna try to put it as posterior as we, can you please put that there, yeah? Right, so a little bit of this. Okay, could you assemble me a similar thing on the other side, just to balance it? What happened to the cover here? Didn't come with one. It didn't come with one. Can I have then the handle? Be ready to tighten it. You need a silver green, right? Just put a silver green there. Look at my side, right? So you wanna put it on the outside 'cause it makes it easy to visualize, right? I think that's a five millimeter. It's a five. No, no, no, just spin it. Oh, they're universal. Can we take a poly, another polymer bar please? All right, now let me stand where you're standing. Can you come in with a C-arm please? So we have to be a little careful, picture there. Guys, I need to see the screen. All of you need to get outta the way, thank you. Picture. Picture. Picture. Tighten this one here, tighten that side. The fibula doesn't need so much so, but I just don't want the - tighten proximal there. Tighten proximal there. Tighten proximally. Okay, stand by now. Something, something gave right now, okay. Push the bar a little bit higher? No, just let it be. Picture. Picture. Okay, tighten everything in. You want to push the bar now? No, tighten, just tighten it please. Tight proximally. And tighten this one with your hand, yeah. Just need it to stop moving so we can work the rest of the way. Picture there. See, when it stops moving it's easier. You can back out now. Now this, now we have a platform that we can work with. So let's take this. Looks very good. Eh, it always looks good at the end. It's just a little bit of fussing around to get there usually. So we know that this is gonna be like this. You want them back to you? It's just so comminuted and so damaged. Can I take a one-third, a, what kind of medial plate do you have? Even if you have to get fancy. Can you give me this, the skinny baby Hohmann please? Thank you. Do that there. Skinny baby Hohmann. No, he's got it. Thank you so much. Want the Synthes medial plate? Can you show it to me? They don't have it open. I can go grab it. Yeah, open a Synthes plate, yeah. Here's what we're gonna do. Show me that piece that we took out at the start. Could it be, is there some cortex here? What is that? Yeah. All right, we're gonna need demineralized bone matrix, guys? And cancel those bone chips. Smallest container possible. Five cc of DBM and 30 of cancellous. We need to fill a gap. On x-ray, are we gonna be a little overdistracted medially. No, it's fine. That's okay. We're gonna let it, remember we have a gap in the joint. The joint has a space. Yeah. So essentially I'm indexing right here, right? Okay. So I'm, I need to keep the length of this, right, because the problem is, it's not a clean fracture. It's like multiple pieces. Yeah. So you're gauging just by a radiographic appearance, how it looks, but you're looking at this here, you have nothing, there's no like edge to edge, so you can make it match and it fixes, so you just gotta eyeball it, right? And there is a... And I got great control of the posterior piece also right now. Right, that's where this goes, so... Do you have a K-wire? I'm gonna put my thumb at risk, but it's such a good reduction of the posterior piece. I'm gonna have to put a front-to-back K-wire. It's okay. Can I do with this what you were doing with your thumb? No, I gotta, I'm doing, I'm using the... Ah, perfect. Put your finger down there. Very gentle, all the way down. All the way back in. Right? Yeah. So, it's even. Pull your finger out so I can put mine. Good, good. All right, and now we're gonna put this here. And then we're gonna just shove this in. I need to span this. How's those little plates looking? That's the non-locking one, right? These are non-locking. So are the lockings out of commission? Yeah, we can go try to see if there's any downstairs. Can I have a Cobb, please? Thank you. A little bit less than ideal, but it works. This will hold it. Can I have a one, a 2.5 drill? We gotta take a chance with something here. You only got one set of distal lockings, huh, for the Synthes, bummer. Can I have the 2.5? We're gonna do a 3.5 hole drill and a screw in a second. Cortical non-locking. Give me 26 please. 26? Yes. Internally rotate. Yeah, you can let go there for one second, I got you. 26. Thank you. Bingo. Okay now, here comes a key thing. One, wire driver. It's gonna be perfect. Suction, guys, in the corner here. Irrigation please. I got it. Internally rotate. Okay, 2.5 drill please. I mean, I guess a 36. All right, wire drive - lift gauge. So that screw is gonna do what the K-wire is doing? Yes, but somewhat more modestly. That's a good one though. Gee, okay, let's go with, can we bring the C-arm in? Picture. See, it's not catching that anterolateral corner. That's what I was worried about. Come out. We're gonna try to catch that corner with that in a second. So I need you with this. I'm gonna use your... Yeah. I'm gonna use this as a grabber, right? Wire driver, please. Externally rotate for me for a second so I can get to the wire here. Okay, back to you. Freer. So I'm gonna grab you. This cal-pin's gonna push through the drape. Hmm? It doesn't matter. It may have to just, you may have to go with this. Bovie please. What's that? Bovie. Okay, I got you now. Let go here. What the hell is that back there? Okay. Did someone take the toothpick tool away? Yeah, thank you. It's right there. I just have to bring it down a touch. Wow, she was really a mess, huh? See that piece back there? Yeah. I just have to bring that. That's a nice fracture. I need the fat baby Hohmann. Right there. Now. Oh, if it's nice now. Can I have the drill again? Take this off. Ah, yeah, I got the piece for sure 'cause I got my finger with it. Okay, now this is super important. Give me a 50 in power, yeah, and that captures that piece. Anterolateral corner, right? Okay, this is great. That's great, hold it there. Now can I take next the - the - the bone graft. All right, he's on the phone. Is that him? Okay. Can we fill that? Could you fill that with graft? This is great. Yeah, finger pack it, finger pack it. So what we're doing now is we are just, I'm putting a limit on this, right, like this and then we'll just - stop, it's stuck - finger packing that. Keep going. All right, keep going, keep going. Perfect. I need another, another forceps so we can both work. Good, good. Keep at it. Do you have a bone temp, like a Synthes bone temp? This is bone graft. Bone graft, yeah. This just fills the gap. Okay, perfect. Okay, and then we're gonna need another... Put a couple little bit more chipperoos there. Then we're gonna take these guys off. We got one screw there, we're gonna put one screw here. And then we're gonna take a break. That's good, and I'll take the little footprint. This little guy. Awesome, stand by. Here we go, masher. I - hold on. I pushed the other one out the way. I didn't mean to do that. I need to take this. What's that? Yeah, yeah, that all's fine. All right, that's good, that's good. Okay, take the DBM. Wire driver next. Right here? Yeah, yeah, just put that in. Just finger pack it. I am gonna hold it front and hold it back. You stuff it. Great. Good, good, good. Put some in the back, put some in the front. Can I have that little piece that we took out at the start? And a baby tweezer of some sort. Thank you, that's okay. That's enough. This cover is a little bit... Yeah, let's just go with that. Okay, wire drivers. We're gonna take a 2.5 drill one more time. Gaugey gauge, thank you. Let's take 40, 44. 44? Yep, and then we're gonna just let it be. We're gonna put a couple of more screw proximal but not too many, just enough to... Wire driver, take that out. You can let go of this. We're gonna need some irrigation. At what point do you want to like, fully tie all the? Can I take a - at the very end. I need a screwdriver. Watch over here. Yeah, go ahead. Okay, 2.5 drill, Army-Navy. You can take all these tools away. At what point do you want to fully tie? At the very end. At the very end, okay. 2.5 drill. So all this is just holding the anterior surface. Yeah, yeah. We don't know what's going on with the posterior. No, no, I'm go, well I know a little bit what's going on because I felt it with my finger. Okay. Right, but I'm gonna be very modest about it 'cause I know it's like a - depth gauge now. Two more screws. We're gonna do one more screw next. The next one is a 30, and the one after that is a 24. Okay, start with the 30? 30 and 24, yeah. Then we're gonna do a quick irrigation. Let's take a gram of vancomycin powder. Next one. So we're gonna use a gram of vancomycin powder to close over the wound, and we're gonna hope for the best, and because she's kind of fixed, we are not gonna do the second calcaneal pin. 24. Because she's, you know, she essentially is fixed at this point. Yep. We're gonna allow, however, the front piece is kind of a little bit floating and we recognize that. What we could do is - can I have the 2.5 drill one more time? I'm gonna try to get it right through those two screws. Depth gauge. Last screw, and so I'm putting my finger in the back, right? I'm pushing it up. Yes, it's on the back. The back piece is a giant piece. 40, let's go with a 44. It's a little of an exaggerated screw, but I wanna make sure that it grabs the posterior piece. A rather big screw. Yeah. 44. Thank you. Take that out, guys. All right. Push those little pieces in, see if all this closes, huh? Irrigation. I'm gonna take a number two nylon just to put some tension on this. You guys are gonna put the vanco, and you're gonna enclose in between the number two nylon, right? Come in and get a couple of pictures. Tighten, you can tighten the ex-fix now. Okay, can I have the handle please? Make it even. That's what I got. Yeah, and loosen up here. Okay, tighten now. Tighten this. Okay, so put a little vancomycin, let's take a quick look. A little vanco and do the best closure you can. Put the number two nylon in between. Okay, ready, picture there. Hold on, hold on, hold on, hold on. Can I - I'm gonna put a little more traction here, guys. Handle. Which one, right here? Oh, yeah. Okay, dude. Is it stretching? Picture. There you go, tighten it now. Picture again. I need, okay, this, everyone's tight. Let's get some nice pictures here. Picture, picture. Okay, I need you to do some percutaneous screws proximally. I need you to get one more up there, okay? And, but close this first. Close this first. I'll come back in about half an hour. This looks great. Can you get me a lateral? Picture there. Okay, guys. Oh yeah. Okay, good. Save that? Save that. Picture. X-ray there. Picture. Picture. X-ray there.
CHAPTER 10
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CHAPTER 11
So the case with our 44-year-old patient went very well. Thankfully, the soft tissues were quite benign, and there was no evidence of blistering or swelling. So our first step was to actually fix the fibula to restore lateral length and alignment. This was done through a small incision with just a short plate. At that point, I applied a external fixator frame consisting of two Shantz spins on the tibia and one calcaneal pin just to bring the medial side into traction, and I performed the medial exposure that included the open side. So it gave me an opportunity to debride very well and clean the open fracture. Once the fracture was at length, it was apparent that there was a significant amount of comminution, as the CT had suggested. I was able to restore alignment with a medial non-locking plate, which I used to rebuild the medial column, and the anterior aspect of the fracture was comminuted and required the placement of some bone graft and restoration of the anterior articular surface as well as the posterior fragment and at a low fragment. This was done all acutely and we were able to close the wound without significant issues, and we'll be treating the patient with external fixator for four weeks to temporize any soft tissue issues and to protect the repair. She will take approximately 12 weeks to heal if all is well and we will be advancing her weight bearing gradually over that time period.