Bimalleolar Ankle Fracture Open Reduction and Internal Fixation
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Table of Contents
Ankle injuries are common, occurring most often among young males and older females. The ankle joint is crucial for stability and gait, making these injuries a significant source of disability.
Ankle injuries are usually treated operatively when there is loss of joint congruity and stability, and in this video, Dr. Agarwal-Harding takes us through the operative fixation of a bimalleolar ankle fracture. He talks about understanding why operative intervention is recommended, techniques involved, and other considerations.
Ankle injury; bimalleolar fracture; ankle fracture; bimalleolar ankle fracture.
The ankle is a hinge-type joint made up of the tibia, fibula, and talus. It is usually described as a mortise and tenon joint that is crucial for ambulation and gait stability. Injuries to the ankle joint are common, with an estimated incidence of 4.22/10,000 person-years in the United States1 and a bimodal peak distribution among young males and older females,2 most often due to high-energy and low-energy injuries respectively.3
The ankle is stabilized medially and laterally by osseous-ligamentous structures. On the medial side, this comprises the medial malleolus of the tibia and the deltoid ligament complex. On the lateral side, this comprises the distal fibula or lateral malleolus and the syndesmosis complex. One or both complexes can be disrupted in rotational ankle injuries, either as bony disruption (fracture) or ligamentous disruption (sprain or rupture). Bimalleolar or bimalleolar-equivalent ankle fractures, which specifically involve both these medial and lateral osseous-ligamentous structures, are the most common types of ankle fractures and cause joint instability, with lateral shift of the talus.4,5 These injuries often require operative fixation to restore joint congruency and prevent post-traumatic arthritis.6
Beyond the physical impact of these injuries, they also have larger economic and social implications.7,8 Surgical repair of an ankle fracture costs an estimated $8,000–$20,000 and may require up to 3 months of lost work-hours for one patient.9 Additionally, there have been reports on the psychosocial impact of ankle injuries, including the need for counseling and social support as part of rehabilitation.10,11
The patient is a 59-year-old woman who presented to the emergency department with right ankle pain following a fall down stairs. She had no additional injuries from this trauma. Vital signs were within normal limits. There was no other relevant past medical history.
The patient was well-appearing and breathing comfortably on room air. The right lower extremity examination revealed a visibly deformed right ankle. The skin was intact with swelling over the lateral and medial ankle. She was able to grossly fire her extensor hallucis longus and extensor digitorum muscles as well as the flexor hallucis longus and flexor digitorum muscles. She had intact sensation in all peripheral nervous distributions of the foot. There was no tenderness to palpation of the proximal fibula. Her foot was warm and well-perfused.
Anterior-to-posterior (AP), mortise, and lateral radiographs showed a bimalleolar ankle fracture with distal fibular fracture at the level of the syndesmosis (Weber B) and a displaced medial malleolus fracture. Subsequently, the patient underwent manual reduction via a Quigley maneuver12 and stabilization with a plaster of Paris splint in the ED.
In general, the Ottawa ankle rules are a set of evidence-based guidelines established to assist with clinical decision-making regarding whether ankle radiographs are required for a patient presenting with an ankle injury in the emergency department.13 While they have been widely adopted and found to streamline the use of radiographs,14 there are concerns about potentially missing serious injuries, leading to variants or modifications of these recommendations.15 The authors recommend that local orthopedic leadership customize hospital policies about who needs ankle imaging to the availability of x-ray imaging and epidemiologic or mechanism-related risk factors.
In general, the three radiographs obtained for the current patient—AP, mortise, and lateral views—are the gold standard for identifying and characterizing ankle fractures. Additional imaging may be needed to identify additional injuries commonly associated with rotational ankle injuries. In Maisonneuve fractures, the rotational injury travels beyond the ankle, up the interosseous membrane between the tibia and fibula, and exits as a proximal fibular fracture. Patients with ankle fractures should be routinely examined for proximal fibular pain, and if present orthogonal tibia-fibular imaging should be performed. It is our recommendation that patients with an isolated medial malleolus fracture or isolated medial clear space widening should have full length tibia/fibula x-rays to evaluate for a Masionneuve type bimalleolar or bimalleolar-equivalent injury.
Some rotational ankle injuries may present as fractures, ligamentous ruptures, or both. While fractures may be more obvious on radiographs, ligamentous disruption may be more subtle. These can be identified by atypical widening between bones usually tethered by the intact ligament. Some important parameters to assess in these radiographs include increased tibio-fibular clear space or decreased tibio-fibular overlap on the mortise view, which represent syndesmotic injury, as well as medial clear space widening, representing deltoid ligament injury.16
Magnetic Resonance Imaging (MRI) scans are not routinely used in the evaluation of the ankle but may be used when radiographs do not provide sufficient information when there is a high clinical index of suspicion of subtle injuries, particularly ligamentous injuries. By contrast, Computed Tomography (CT) is often used in high-resource settings to characterize complex, comminuted fractures to formulate a preoperative plan for surgical fixation.5,17–19
The bony, ligamentous and tendinous components of the joint all contribute to the stability of the joint and are frequently injured in rotational ankle fractures, leading to a disruption of the normal anatomy of the ankle joint and instability. It is well-known that the ankle joint is poorly tolerant of instability,20 and in the absence of restoration of normal anatomy and joint congruence in a timely fashion, post-traumatic arthritis, pain, and functional limitations are likely to result.21,22
Ankle fractures can be treated conservatively or surgically, depending on whether the fracture is stable and the patient fit for surgery. At presentation, it is important to reduce the ankle and apply a splint to maintain the reduction, emphasizing concentric reduction of the tibiotalar joint and minimizing lateral shift of the talus by reducing the medial clear space.23 After initial stabilization and reduction, a decision can be made on which treatment modality to adopt for each patient. Conservative management may be acceptable in stable, minimally-displaced fractures and when patients are not medically fit for surgery. Bimalleolar-equivalent fractures, which are characterized by a fibular fracture and medial deltoid ligament disruption with widening of the medial clear space, and bimalleolar ankle fractures are inherently unstable and are typically treated surgically.24 If a patient has severe soft tissue swelling, an initial external fixation may be placed temporarily with planned conversion to definitive open reduction and internal fixation (ORIF) once the soft tissue swelling has decreased and permits safe surgical incisions to be made without risking wound complications.5,25
Depending on the lateral malleolar fracture morphology, the standard fixation aims to compress across the fracture site by applying a lag screw and neutralization plate or a compression plate alone.5,26 However, there has been recent interest in intramedullary fixation of fibular fractures, especially among individuals who may not be able to tolerate more extensive soft tissue dissection, with largely positive results.27–29 Regarding the medial malleolus, lag screws or tension band wires are typically used for fixation.30 In vertical fractures, buttress plates may be utilized.5
Syndesmotic injury often occurs with bimalleolar fractures. This is assessed intraoperatively with the Cotton or hook test, which involves the application of a distracting force orthogonal to the distal fibular surface while watching for a widening of the syndesmotic gap under direct visualization or fluoroscopy.31,32 A surgeon may also assess this gap on a neutral and external rotation stress mortise view under fluoroscopy.16,31 Screws, suture buttons, and other constructs are used to repair the syndesmosis, all with favorable outcomes.33,34 The authors recommend using whatever device is locally available and most comfortable for the performing surgeon, although screws are our implant of choice given the significantly lower cost.
The overarching principle guiding ankle fracture repair is to restore joint stability and achieve an anatomic reduction. In bimalleolar fractures, at least two components of the mortise construct of the joint are affected, making conservative measures such as immobilization in a cast or boot often insufficient to achieve the stability necessary to achieve adequate fracture healing. Currently, operative fixation is the recommended treatment for bimalleolar fractures, unless there are significant contraindications.23
Patients with diabetes mellitus are at a high risk of complications related to poor wound healing, slow fracture healing, and peripheral neuropathy with progressive Charcot neuroarthropathy.35 In a series of 84 patients with ankle ORIF and diabetes by Costigan et al, 1 in 7 patients developed postoperative complications, the most common being infection (12%).36 If absent pedal pulses or peripheral neuropathy was present, a patient was at higher risk of developing a complication. To mitigate these complications, many surgeons advocate supplemental fixation with temporary transarticular Steinmann pin placement, syndesmotic screw placement regardless of Cotton/hook test result, multiple syndesmotic screw placement, or external fixation.35 In patients with complicated diabetes and complex fractures, some surgeons instead suggest primary ankle arthrodesis with a tibiotalocalcaneal intramedullary nail procedure, with outcome reports demonstrating a limb salvage rate of 96% and maintained ambulation in 81%.37
Ankle fractures are one of the most common orthopaedic complaints in the emergency department, accounting for more than 5 million injuries annually in the United States.1 The Danis-Weber/AO classification was developed to help characterize fracture pattern and guide treatment: Weber A fractures occur below the level of the syndesmosis, Weber B fractures at the level of the syndesmosis, and Weber C fractures above the syndesmosis. From A to C, the risk of an associated syndesmotic injury increases; as the risk of an associated syndesmotic injury increases, the resultant instability further drives the treating physician toward operative management.38 In displaced bimalleolar fractures such as the one sustained by the current patient, there is a loss of the ankle mortise, and most experts recommend ORIF of the malleoli for this injury.38,39 The current video demonstrates one of the most common fixation constructs applied for bimalleolar fractures: interfragmentary screw and neutralization plate to fix the distal fibula and partially-threaded cannulated screws to fix the medial malleolus. Syndesmotic screws were not used due to a negative Cotton/hook test.
The main goal of rotational ankle injury surgery is to restore joint stability. The primary drivers of ankle stability rely medially on the deltoid ligament complex and lateral on the syndesmotic ligament complex, which includes the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), interosseous ligament (IOL), and interosseous membrane (IOM).40 The tibiofibular articulation stability is largely driven by these ligaments due to high variability in the tibial incisura. A key to reducing the syndesmosis is to restore fibular length, thus better approximating ligamentous remnants and restoring the lateral talar buttress. Patients with syndesmotic malreduction go on to have worse functional outcomes.41
Syndesmotic fixation can either be rigid or dynamic. Rigid fixation is best used in diabetic or neuropathic patients and patients with osteoporotic bone, typically with two or more tri- or quadri-cortical screws. A drawback to rigid fixation is the potential for screws to break or become symptomatic, requiring an eventual reoperation for hardware removal. Dynamic fixation, such as with a suture button, is more forgiving for minor malreductions and is a better mimic of physiologic fibular motion. Although suture buttons are initially more expensive than cortical screws, cost-effectiveness analyses find that the lower rate of hardware removal ultimately makes dynamic fixation more cost-effective than rigid fixation. A meta-analysis of level I studies suggests that the American Orthopaedic Foot & Ankle Society Score (AOFAS) at 24 months was superior in patients with dynamic fixation, while there was no difference in the Olerud Molander Ankle Score (OMAS) patient-reported outcome instrument.42,43 However, a randomized control trial of pronation-external rotation ankle fractures with a minimum of 6 years of follow up demonstrated no differences in OMAS, questioning whether these earlier differences persist with longer term follow-up.44
After wound closure and dressing placement, patients are placed in a short leg splint with a posterior slab holding the ankle in neutral plantar/dorsiflexion and a U-shaped slab protecting the medial and lateral ankle. This splint is for soft tissue protection and immobilization. The patient is immobilized in the splint for 2 weeks, then transitioned to a removable boot for 4–6 additional weeks, which can be removed for a gentle range of motion activities and hygiene. The patient remains non-weight bearing for 6 weeks, then gradually can bear weight as tolerated depending on fracture healing on radiographs.
- Stryker distal fibula small fragment anatomically-contoured locking plate and screws
- Stryker Asnis 4.0-mm cannulated screws
None.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Scheer RC, Newman JM, Zhou JJ, et al. Ankle fracture epidemiology in the United States: patient-related trends and mechanisms of injury. J Foot Ankle Surg. 2020;59(3):479-483. doi:10.1053/j.jfas.2019.09.016.
- Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691-697. doi:10.1016/j.injury.2006.04.130.
- Hoogervorst P, Bergen CV, Van den Bekerom M. Management of osteoporotic and neuropathic ankle fractures in the elderly. Curr Geriatr Rep. 2017;6(1):9-14. doi:10.1007/s13670-017-0196-y.
- Shibuya N, Davis ML, Jupiter DC. Epidemiology of foot and ankle fractures in the United States: an analysis of the National Trauma Data Bank (2007 to 2011). J Foot Ankle Surg. 2014;53(5):606-608. doi:10.1053/j.jfas.2014.03.011.
- Lampridis V, Gougoulias N, Sakellariou A. Stability in ankle fractures: diagnosis and treatment. EFORT Open Rev. 2018;3(5):294-303. doi:10.1302/2058-5241.3.170057.
- Tantigate D, Ho G, Kirschenbaum J, et al. Timing of open reduction and internal fixation of ankle fractures. Foot Ankle Spec. 2019;12(5):401-408. doi:10.1177/1938640018810419.
- Murray AM, McDonald SE, Archbold P, Crealey GE. Cost description of inpatient treatment for ankle fracture. Injury. 2011;42(11):1226-1229. doi:10.1016/j.injury.2010.08.023.
- Noback PC, Freibott CE, Dougherty T, Swart EF, Rosenwasser MP, Vosseller JT. Estimates of direct and indirect costs of ankle fractures: a prospective analysis. J Bone Joint Surg Am. 2020;102(24):2166-2173. doi:10.2106/JBJS.20.00539.
- Bielska IA, Wang X, Lee R, Johnson AP. The health economics of ankle and foot sprains and fractures: a systematic review of English-language published papers. Part 2: The direct and indirect costs of injury. Foot Edinb Scotl. 2019;39:115-121. doi:10.1016/j.foot.2017.07.003.
- Mehta SS, Rees K, Cutler L, Mangwani J. Understanding risks and complications in the management of ankle fractures. Indian J Orthop. 2014;48(5):445-452. doi:10.4103/0019-5413.139829.
- McKeown R, Kearney RS, Liew ZH, Ellard DR. Patient experiences of an ankle fracture and the most important factors in their recovery: a qualitative interview study. BMJ Open. 2020;10(2):e033539. doi:10.1136/bmjopen-2019-033539.
- Lightsey HMI, Yeung CM, von Keudell A. A brief guide to initial management of orthopedic injuries in the emergency department. Orthop J Harv Med Sch. 2019;20:52-61.
- Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;21(4):384-390. doi:10.1016/s0196-0644(05)82656-3.
- Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417. doi:10.1136/bmj.326.7386.417.
- Goost H, Wimmer MD, Barg A, Kabir K, Valderrabano V, Burger C. Fractures of the ankle joint: investigation and treatment options. Dtsch Arzteblatt Int. 2014;111(21):377-388. doi:10.3238/arztebl.2014.0377.
- Magan A, Golano P, Maffulli N, Khanduja V. Evaluation and management of injuries of the tibiofibular syndesmosis. Br Med Bull. 2014;111(1):101-115. doi:10.1093/bmb/ldu020.
- Sawant YN, Sanghvi D. Magnetic resonance imaging of ankle ligaments: a pictorial essay. Indian J Radiol Imaging. 2018;28(4):419-426. doi:10.4103/ijri.IJRI_77_16.
- Leung KH, Fang CX, Lau TW, Leung FK. Preoperative radiography versus computed tomography for surgical planning for ankle fractures. J Orthop Surg Hong Kong. 2016;24(2):158-162. doi:10.1177/1602400207.
- Black EM, Antoci V, Lee JT, et al. Role of preoperative computed tomography scans in operative planning for malleolar ankle fractures. Foot Ankle Int. 2013;34(5):697-704. doi:10.1177/1071100713475355.
- Lloyd J, Elsayed S, Hariharan K, Tanaka H. Revisiting the concept of talar shift in ankle fractures. Foot Ankle Int. 2006;27(10):793-796. doi:10.1177/107110070602701006.
- Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976;58(3):356-357.
- Donken CCMA, Al-Khateeb H, Verhofstad MHJ, van Laarhoven CJHM. Surgical versus conservative interventions for treating ankle fractures in adults. Cochrane Database Syst Rev. 2012;(8):CD008470. doi:10.1002/14651858.CD008470.pub2.
- Kyriacou H, Mostafa AMHAM, Davies BM, Khan WS. Principles and guidelines in the management of ankle fractures in adults. J Perioper Pract. 2021;31(11):427-434. doi:10.1177/1750458920969029.
- Ankle Fractures: Implications for Stability and Treatment.; 2020. Accessed June 20, 2024. Available at: https://www.youtube.com/watch?v=8qEDnxPpVUk.
- Wawrose RA, Grossman LS, Tagliaferro M, Siska PA, Moloney GB, Tarkin IS. Temporizing external fixation vs splinting following ankle fracture dislocation. Foot Ankle Int. 2020;41(2):177-182. doi:10.1177/1071100719879431.
- Tornetta P, Creevy W. Lag screw only fixation of the lateral malleolus. J Orthop Trauma. 2001;15(2):119-121. doi:10.1097/00005131-200102000-00008.
- Umbel BD, Sharpe BD, Reynolds C, Philbin TM. Intramedullary fixation of distal fibula fractures. Foot Ankle Spec. 2023;16(2):104-112. doi:10.1177/1938640021991735.
- Jain S, Haughton BA, Brew C. Intramedullary fixation of distal fibular fractures: a systematic review of clinical and functional outcomes. J Orthop Traumatol Off J Ital Soc Orthop Traumatol. 2014;15(4):245-254. doi:10.1007/s10195-014-0320-0.
- Ebraheim NA, Vander Maten JW, Delaney JR, White E, Hanna M, Liu J. Cannulated intramedullary screw fixation of distal fibular fractures. Foot Ankle Spec. 2019;12(3):264-271. doi:10.1177/1938640018790082.
- Parker L, Garlick N, McCarthy I, Grechenig S, Grechenig W, Smitham P. Screw fixation of medial malleolar fractures: a cadaveric biomechanical study challenging the current AO philosophy. Bone Jt J. 2013;95-B(12):1662-1666. doi:10.1302/0301-620X.95B12.30498.
- Hallbauer J, Schenk P, Herrmann L, et al. Objective assessment of syndesmosis stability using the hook test. J Clin Med. 2023;12(14):4580. doi:10.3390/jcm12144580.
- Stoffel K, Wysocki D, Baddour E, Nicholls R, Yates P. Comparison of two intraoperative assessment methods for injuries to the ankle syndesmosis. A cadaveric study. J Bone Joint Surg Am. 2009;91(11):2646-2652. doi:10.2106/JBJS.G.01537.
- Kortekangas T, Savola O, Flinkkilä T, et al. A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography. Injury. 2015;46(6):1119-1126. doi:10.1016/j.injury.2015.02.004.
- Zhang P, Liang Y, He J, Fang Y, Chen P, Wang J. A systematic review of suture-button versus syndesmotic screw in the treatment of distal tibiofibular syndesmosis injury. BMC Musculoskelet Disord. 2017;18(1):286. doi:10.1186/s12891-017-1645-7.
- Wukich DK, Kline AJ. The management of ankle fractures in patients with diabetes. J Bone Joint Surg Am. 2008;90(7):1570-1578. doi:10.2106/JBJS.G.01673.
- Costigan W, Thordarson DB, Debnath UK. Operative management of ankle fractures in patients with diabetes mellitus. Foot Ankle Int. 2007;28(1):32-37. doi:10.3113/FAI.2007.0006.
- Ebaugh MP, Umbel B, Goss D, Taylor BC. Outcomes of primary tibiotalocalcaneal nailing for complicated diabetic ankle fractures. Foot Ankle Int. 2019;40(12):1382-1387. doi:10.1177/1071100719869639.
- Michelson JD. Ankle fractures resulting from rotational injuries. J Am Acad Orthop Surg. 2003;11(6):403-412. doi:10.5435/00124635-200311000-00004.
- Kwon JY, Cronin P, Velasco B, Chiodo C. Evaluation and significance of Mortise instability in supination external rotation fibula fractures: a review article. Foot Ankle Int. 2018;39(7):865-873. doi:10.1177/1071100718768509.
- Bejarano-Pineda L, Guss D, Waryasz G, DiGiovanni CW, Kwon JY. The syndesmosis, part I: anatomy, injury mechanism, classification, and diagnosis. Orthop Clin North Am. 2021;52(4):403-415. doi:10.1016/j.ocl.2021.05.010.
- Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012;26(7):439-443. doi:10.1097/BOT.0b013e31822a526a.
- Shimozono Y, Hurley ET, Myerson CL, Murawski CD, Kennedy JG. Suture button versus syndesmotic screw for syndesmosis injuries: a meta-analysis of randomized controlled trials. Am J Sports Med. 2019;47(11):2764-2771. doi:10.1177/0363546518804804.
- Grassi A, Samuelsson K, D’Hooghe P, et al. Dynamic stabilization of syndesmosis injuries reduces complications and reoperations as compared with screw fixation: a meta-analysis of randomized controlled trials. Am J Sports Med. 2020;48(4):1000-1013. doi:10.1177/0363546519849909.
- Lehtola R, Leskelä HV, Flinkkilä T, et al. Suture button versus syndesmosis screw fixation in pronation-external rotation ankle fractures: a minimum 6-year follow-up of a randomised controlled trial. Injury. 2021;52(10):3143-3149. doi:10.1016/j.injury.2021.06.025.
- Khojaly R, Rowan FE, Hassan M, Hanna S, Mac Niocail R. Weight-bearing allowed following internal fixation of ankle fractures, a systematic literature review and meta-Analysis. Foot Ankle Int. 2022;43(9):1143-1156. doi:10.1177/10711007221102142.
Cite this article
Akodu M, Berlinberg EJ, Batty M, McTague M, Agarwal-Harding KJ. Bimalleolar ankle fracture open reduction and internal fixation. J Med Insight. 2024;2024(454). doi:10.24296/jomi/454.
Procedure Outline
Table of Contents
- 1. Introduction
- 2. Surgical Approach
- 3. Tourniquet
- 4. Lateral Incision
- 5. Exposure with Care to Preserve Superficial Peroneal Nerve
- 6. Clearing Fracture Edges
- 7. Provisional Anatomic Reduction with Pointed Reduction forceps
- 8. Interfragmentary Screw
- 9. K-Wire to Prevent Rotation
- 10. Neutralization Plate Along the Lateral Fibula
- 11. Medial Incision
- 12. Exposure with Care to Preserve Saphenous Vein
- 13. Clearing Fracture Edges and Visualization of the Anteromedial Corner of the Tibiotalar Joint
- 14. Provisional Reduction with Two Guidewires
- 15. Two Partially-Threaded, Cannulated Screws
- 16. Final X-Rays
- 17. Cotton Test
- 18. Closure
- 19. Dressing and Short Leg Splint to Maintain Neutral Ankle
- 20. Post-op Remarks
- Place Plate and Hold with K-Wires
- One Bicortical Non-locking Screw Proximally and One Unicortical Locking Screw Distally
- X-Rays
- More Bicortical Non-locking Screws Proximally and Unicortical Locking Screws Distally
- Remove K-Wires
- X-Rays
- X-Rays
- X-Rays
Transcription
CHAPTER 1
So my name is Kiran Agarwal-Harding. I'm an orthopaedic trauma surgeon here at Beth Israel Deaconess. So our first case was a mid-fifties-year-old woman who unfortunately had a slip down some stairs, twisted her right ankle, and had a right bimalleolar ankle fracture. This was closed reduced by the residents. They did a nice job, but she - we luckily, we had some space, so we were able to get her in immediately to fix her today. Oftentimes, we send these patients home for a few days until we can get them electively scheduled. These are not emergency cases. But in this case, we had the availability, so we were able to take care of it the same day that she injured herself, which was lovely for her. So we admitted her from the hospital, from the emergency department to the hospital. And, you know, the surgery itself was done under a regional anesthetic with LMA. We did a right ankle, bimalleolar, fracture, open reduction, internal fixation. So the procedure is done with the patient in supine position. We usually use a little bone foam underneath the leg. I normally do it under tourniquet just because less bleeding allows for a speedier case. And then, of course, we always release a tourniquet at the end of the case to deal with hemostasis. We start usually on the lateral side, fixing the lateral malleolus. That's done through a very simple incision over the lateral malle, dissect down. There are some anatomic variants where you have to worry about the superficial peroneal nerve. So we always dissect through the soft tissues bluntly to protect that nerve if there is that variant where it crosses the fibula distally. In this case, you know, we would do that of course. We then identify the lateral malleolus fracture, the hematoma, peel back the periosteum slightly in order to visualize the fracture edges, and then we get it anatomically reduced and hold it provisionally with pointed reduction forceps. Typically, we do, you know, as typical lag screw with neutralization plate construct. That's what's described in all of our teaching. And, that's typically what I do. So that's done by, putting a screw perpendicular across the fracture plane and then putting a neutralization plate along the lateral fibula. Usually, we use bicortical non-locking screws proximally and unicortical locking screws distally. Once we finished fixing the fibula, we then turn our attention to the medial malleolus. That's done through a separate little incision on the medial side. There's a superficial saphenous vein there that we have to be careful of. So we retract that. We always make sure that we try not to bag it. We retract that anteriorly and then we try to visualize the anteromedial corner of the tibiotalar joint, which is where we want to get that perfect articular reduction. We hold the reduction provisionally and then hold it with two guidewires. We drill those guidewires once we are confirming the position and then put two partially-threaded cannulated screws over the guidewires, remove the guidewires, and then under fluoroscopy, we do what's called a cotton test, where we pull on the fibula under fluoroscopy to make sure that the syndesmosis is stable. If the syndesmosis is not stable, we typically put trans-syndesmotic screws in place, in order to hold the syndesmotic reduction. And so that'll be our procedure.
CHAPTER 2
We're doing a right bimalleolar ankle fracture, open reduction, internal fixation. I think you're going to need a little bit more of that incision. Let's get the c arm all prepped and draped as well and we will need a C-arm here as well. So let's take a look at our plate. Just, let's let's see where our plates are. Here we go. So I think most likely it's going to be this plate. Right? So we're going to need enough space for this plate. Right? That's my feeling. Alright. Yep. Okay.
CHAPTER 3
Alrighty. Alright. So we elevate, then exsanguinate. Don't have to go too crazy. It's just to collapse the veins. Right? Alright. Tourniquet up, please. Turning it up - 250? 250. Okay. Knife, please.
CHAPTER 4
Can I get a Schnidt, please? Alright. Incision. Alright, so I want you to, after you make the incision, use the Metzenbaum scissors and see if you can protect the superficial peroneal nerve. Okay? Yeah. I'll take some, Metz and some pickups.
CHAPTER 5
Okay. Knife back. Already in the hematoma there. Where our Bovie? Now you got it? Let me know if I'm safe and then I can buzz for you. Great. Two self-retainers, please. Excellent. So let's get down onto the bone up over here. Yeah. So just spread through this stuff here. Just until you're down to the bone. There we go. I think we can probably come through some of this stuff here. Get it open. There are always like little superficial veins in here. So that's why I'm using the Bovie. Good. So we're down to the bottom of the fibula there. Nice. That looks great. So I'll take the... Let's take a 15 blade so you can clean up the fracture edges. Let's get these in a little bit deeper.
CHAPTER 6
Yeah. You really wanna check that corner up here and this one back here. Exactly. Nice. Not too much, just a little bit. Yep. And then you get that edge because that's gonna be our read. Yeah. Just don't destroy the syndesmosis, which I think is intact in this case. Right? Can't tell until the fibula is fixed. Yeah. We'll obviously test it, but it looks like it's a Weber B. So it does look to me that it's probably stable given where the proximal fragment is. Some irrigation. There we go. Nice. You guys can't see it, but if you put this bump under there, and externally rotate it, it pops open that fracture a little bit. Yep. Recreate it, irrigate it. And next, I'm gonna take a couple pointed reduction clamps. Let's get the lights in a little bit better for you. Alright.
CHAPTER 7
One more pointed to me. There it is. You want me to clamp that there? No, I think we can come up here with that one because this one's still gapped. You probably have a little combination there, Yeah. Yeah. I think you're a little bit rotated with this piece. Here, I'll tell you what. Let me take that other pointed. You got it? Yeah. I think the... Yeah, that's better. It's a little rotated. A little external rotation. It's pretty good there. You happy up at the top at the, anterior aspect? Right there. Yeah. Great. You wanna put a screw in it or you just hold it provisionally with pins and then plate it? I think a screw would be nice. Yeah? Yeah. Right there. Okay. Go off a little bit. Yeah, well, your pointed is right where you want to put it probably. I could maybe switch right behind it. Let me take another pointed. And angle... Let me just adjust your positions here. You got another pointed? Yeah. Do you mind moving your hand here? Let me just adjust this guy here maybe. That hopefully will hold. And then you got the angle for your right hand. Put that one over here. I think that's pretty anatomic. Yeah. Alright. Just to get a little, So just free up your tissue there. You wanna use the Bovie? Mhmm. Go for it. Relax on here one minute. Okay. There would be good. Mhmm. Alright. Freer? Let me just clear that up for you. Good. Nice angle. So, yeah, you're gonna go right across, yeah? Yep. Alright, good. Okay. Just put an interfrag one. I don't think we need to do a lag. I think so.
CHAPTER 8
Alright. Then just a - 2.6 drill. So he's going - just because they can't see - he's going p to a, or a to p? A to P. It's almost always, just like the same orientation. The fracture line's like this. Mhmm. So you're putting a screw, like, kinda coming from the top and angling down and distal. This way. Okay. It's the same as the one we just removed. Yep. Yeah. I guess so. It's almost the same fracture as the... Let's see that retractor. Yeah. Let's get an Army-Navy. Army. It's okay. I think I got it. You have the angle? So I just wanna make sure I'm not going too far medial. So let's just - okay. Depth gauge. Probably a sixteen. I like to guess. Makes me feel special when I get it right. A fun game. Yeah. So these ones - it's, is it this little divot? No. No. No. It's a it's at the top there. So it's a twenty, I think. Twenty. Okay. Oh, I was so far off. Two zero. Well, we're pretty distal. Distal, we're aiming oblique. Is it gapping? I think you missed it. Yeah. It's gapping. Back it up. Check your angle again. Let's take this out of your hands so that you got two hands. Hold that. Yeah. Maybe it was Yeah. I think you probably just like the angle was slightly off. Let's just get it better. Yeah, just pushed in. There it is. Okay. Yep. You got it? That looks better. Happy with it? I'm happy with it. That looks great. Alright. One, one six k-wire, please.
CHAPTER 9
Drive that from here across just to give us a little bit extra fixation up at the top of it. A little bit higher. Yep. Good. Is that across? I think so. Good. Alright. Let's see. Moment of truth. Good. Good. Alright. Plate, please. Got it.
CHAPTER 10
Two k-wires. Is that plate too big? Oh, I think we could probably get away with a little shorter. What's the next shortest one down? Can I see that? Let me just borrow it. Because our pressure in here. That's gonna go here. Yeah. We can probably go shorter. You're right. If we were to go there, that's through for sure. Knife, please. Knife. Thank you. Let me take a little bit more skin for you there. Knife back. Let's let's make sure it's all the way down here so we get enough fixation. You want to adjust that? Further, further. Yeah. Well, I don't know. I mean, it really wants to fall with contour right there. I know what you're saying, but then it hangs up. You can always contour it if you want to. Let me give it a feel. That's yeah. I mean, we're we're proximal from that tip, but the contour of the plates won't fit. It's gonna be good there, huh? Yeah. K-wires? I'll just drive one into there. Mhmm. One more here. And then how's our- rotations good there? I think so. Yeah. Alright. Then what I like to do is bend these, and that kind of pushes it down against the bone. And then you wanna get a screw in there? You can just do one. Okay. Okay. We'll take the, 2.6 drill.
You wanna do a locking screw and then a non-locking, or non-locking then locking? Yeah. Then a locking here. I can try and still get down there. Yeah. Do a non-locking first. Non-locking? I think so. Okay. We're centered, yeah? Depth gauge. Got it. Twelve. What do you think? Sounds right. Fourteen. Twelve. You're out of soda. I do. Non-locking. Thank you. You don't have to completely kill it. Just sort of suck it down a little bit and then we'll adjust. Yeah. It's taking well. Okay. Happy with that or you want it down more on the bone? I don't know. That's what I was looking at. Seeing if we can we can just take it right there. Pointed reduction? The locking and just let it be. Yeah. Let's see if maybe we can adjust it a little bit. I don't know if that's gonna do anything. Nah. Yeah, just drill it. I think you're good. Good. Alright. Say twelve again. Locking. Can I give it a feel? Usually, these are a little bit longer than that. I was expecting like thirteen, almost fourteen, but... I don't wanna... Yeah. Twelve is fine. Yeah. twelve is okay. Alright. Twelve, please. Beautiful. All right. Let's come in for an x-ray, please.
All right. Everybody covered? Okay. X-ray there, please. Great. That looks nice. Yeah. Just rotate it, get a little bit better mortise. X-ray there again? Good. I think that looks nice. Let's come to a lateral. Yeah. That's good. Alright. X-ray there, please. X-ray there. Beautiful. Yeah, very nice. One more shot, x-ray there? Yeah, that's great. X-ray. Nice. Okay. Thank you very much. You can come out for a little bit. So let's do the remaining three up at the top and then let's fill the distal cluster because I think we're all beyond the fracture there.
So remember, you're a little bit on the anterior surface of the fibula here. So just keep that in mind. Okay? Feel that with your finger. Feel where you are? Yeah. I see. Yeah. So you're gonna aim a little bit posterior. Okay? You wanna go for this whole this, second... Yeah, you're gonna fill them all up. Those four. Okay. So aim this way? A little bit. That's a little bit much. Yeah. That's good there. Yeah. Alright. Should feel two cortices. Yeah? One. No plunging. Good. Very nice technique. Give that a measure. It will probably be a twelve. Non-locking. Yeah. a twelve. Twelve, please. Remember your angle. Yes, sir. Thank you, Jack. Yep. Drop your hand just a little bit. There it is. Good bite. Yep. We'll give them all a final tighten at the end. Don't worry. Okay. Great. Can you see everything? Yes. I can. Good. Bring this up. No. No. Just rotate like that. Oh. I see. Yes. For now. Yeah. We'll go back. Another twelve, please. Non-locking twelve. Miles, you want to drill the distal ones while we go? Save a little time? Sure. Get the very bottom one. Good bite?Excellent. Good bite. Is that a nice long one? Fourteen long thing. Just about sixteen, but it's... See if you can get to sixteen. Just wiggle wiggle the thing in a little bit. Yeah. Sixteen. Sixteen, please. Alright. Locking. Drop your hand. That's a little bit of aggressive angle. Good. Eleven - say twelve again or do you wanna...? Twelve is fine. Okay. Twelve is fine. Alright. I'll do a twelve non-locking, please. You got the angle, Elyse? Nice. It's a bit of a steep angle compared to what you drilled. Okay. Yeah. And you're not perpendicular to the foot. So you want your drill line perpendicular to this plate. It's gonna be about that. Mhmm. And And it looks like the screw is doing what you wanted it to do. What I wanted it to do. No. Like, it's it's doing the right thing. Keep keep screwing, see what happens. Yeah. Seems like that's getting your bite. Right? Yep. Alright. We'll do a sixteen again. Locking. I think you can probably fill this one up too. Yeah. Just aim it down if you can. The Freer. So he does that. Is there a switch to turn it into a ratchet as opposed to Yeah. It's already on the ratchet, but you have to get some gauge of something before it works for you. Okay. When I'm screwing, I want to do the same thing. You have all the way to the right. Middle works just like a standard screwdriver. The left will be your ratchet. Did that lock in, Miles? Yeah. Alright. Drill back. Drill the last one. See if you can angle it a bit like that. Yeah. Depth gauge? Thank you, Jack. The sixteen locking? Yeah. You're not out through the other side? Yeah. Nice. This one was just barely, but I took off enough. Oh, Okay. Good. Good. I lock in? Quite. Yeah. Can I feel it? That looks like it locked. Yeah, that's good. Okay. Alright, k-wire driver, please.
So these bent ones, you just clamp them here and then we can wiggle them out like this. Okay? Preferably in one go. Okay, these you can oscillate out. Hand that to you. Thank you. I got that. Thank you. Alright. Come on in for an x-ray.
Alright, let's get our x-rays there. Can you zoom in for us a little bit? Get a better mortise. Beautiful. Come distal just a hair. Good. That looks nice. Save that. They're all saving. They're all saving. Yeah. Seems pretty stable. Yeah. That's your stress? All right. Save that as our stress view. Okay. Very good. Let's go to the medial side. You can come on. Oh, let's get a lateral. Yeah. X-ray there. Raise the machine, please. Great. X-ray there. Great. Come down distal. Yep. Beautiful. Alright. Save that, please. Let's get one more shot there. Great. Excellent. Alright. Thank you so much. Let's come to the other side.
CHAPTER 11
Let's see that anterior edge, see our shoulder. Can I borrow the pen? Yep. Yeah. I would - I tend to go a little bit further down for aiming your screws. Alright. You know? I agree with you. That's the end of it there. And I like that. Something like that. Right? Alright. Okay. Mark- knife, please. Is there a ten or fifteen? Ten blade. And two Senns to me, please. Yeah. Watch out for the saphenous. If we can avoid bagging it, let's try.
CHAPTER 12
Thank you. Can I get this in for you? You wanna come through that? We got a Freer? Got it. We got a Hohmann? Where are the Hohmanns? There they are. Thanks. No. You're good. Go ahead. Come a little deeper for you.
CHAPTER 13
Now always the periosteum flips down on the proximal piece so just peel that off. There we go. Yep. Nice. Some irrigation, please. There we go. The talus got a little banged up there. You see that? Yeah. A little bit of traction. Delamination. Can I get a fifteen blade? Second Adson. Sorry, I stole your Adson. Yeah. That's plenty. Yeah. Don't go too crazy. You can see the anterior margin there. Now how do you wanna reduce it? Do you wanna put, like, a little hole in the proximal tip proximal fragment? First do you have a dental pick? Free yourself up down posterior. Make sure you got everything there. You can see it, huh? One more Hohmann. Knife back. Hold that there. Oh, nice.
CHAPTER 14
Easy. Easy. Not too aggressive. There we go. That looks pretty nice there. You want me to hold it while you drive the wires? Yeah. How's the corner? Let's see. That's alright. Let me take that. Yeah. That looks good. Yeah. That's really nice. Yeah. So that's nice there. Okay. K-wires? The guidewires for the... For the 4-0? Yeah. Yep, right there. And you see the corner there, so you should be able to get it perfect. Yeah. These are threaded? Yeah. Okay. Is there a tissue or, like, some type of tissue? Yeah. Just to help me steer a little bit? Alright. That's probably fine for now. Yeah. Wanna go for another while we're here? Yeah. I think so. Let's see. Search for a good time. Great. Alright. Come in for an x-ray, please. I'm wondering if I'm gonna feel like I'm too... Think you're too deep? It's too medial on the side. I don't know. Oh, okay. Let's see. Sometimes, yeah, it seems like it should be further in, but... Let's see.
X-ray there. Come down a little bit. Yeah. One of those is too close to the shoulder, huh? Your angle is a little bit shallow too. Gotta get in more, and come in more lateral. Yeah. Come on out. Alright. Probably just need to expose that soft tissue a little more. So do it one at a time so that we don't lose our reduction. Yeah. I just want to take some of this tissue. I think this tissue's what's kind of blocking things. I guess I can just go straight through it. Yeah. You can. Maybe take out one of the k-wires first, and remember it's threaded. So do it on reverse. This guy maybe. I think this is your worst one. Because this is the one that's too through the shoulder. This one is... Let me get that dental pick. Yeah. Yeah. So aim like sort of up there. Yeah. Exactly. That's much better. Is there anywhere else for the dental pick? You want me to move the dental pick? You want to check that? Sure. Come on in for an x-ray. Looks better to me. Yeah, hopefully it's not floating out too far that it doesn't seem like it's going to do enough for us. It doesn't seem like it can do in the for us. Too deep. Alright. Come on out. Here. Just, can you stay there? You wanna stay there? Yeah. You're just being too aggressive with the position there. Come on out. Come on in. One more shot. Yeah, not bad. I think you're still a little bit shallow. Right? So you could probably go up a little bit more, but I think it's not bad. Yeah. It looks good. Alright. You can come on out with the x-ray. Let me get the Hohmann in there again. A little bit convergent. A little bit convergent there. Here, just adjust it before you get the x-ray. You can march a little bit more interior, I think. That's a little deep. Come out a little bit. Here. Can I help you? You want further out here? Here. I want you to go I want you to go right there. I just think that's gonna be lateral, or medial. Too medial, you think? I don't know. Let's see. I think I like this one the best. Yeah. That's nice. A little divergent there but that's okay. Let's come to the other view. We're going to do forty-five's I think. Right, Corey? Isn't that what we usually do? Yeah, around there. X-ray there? X-ray there. Yeah. I think that's okay. Alright. You can come on out. Usually, to make it look pretty, we like to have them exactly parallel. But it's functional. I'll get this one right there and make it just right. You want to get it better? Okay. Sure. One more try, just for posterity's sake. This one. I think the reduction is perfect. Are you going in reverse? I think you got more space back here. Not so deep. Just here. Parallel to this? You're aiming a little anterior. You see what I mean about aiming a little interior? A little converging. That looks pretty good. Are you a little deep or are you good? Okay. Good. Come on in for an x-ray. Yeah, x-ray there. Good. That's nice there. Let's get a better shot. Can you slide distal? Beautiful. Okay. Let's come to the other view. Nice. Okay. That's fine. One more shot there. Okay. See, you see how much of the mal you have there? You have like there are the two - two hills of the medial mal and you're sort of in between the two. So you have a lot more posterior if you want to put one there. You see what I mean? Yeah. You're saying on the posterior colliculus or just in the valley? Right now, you're sort of like in the anterior part of the valley. Right? So you could put one in the posterior colliculus. That would probably be better. But I don't know where the fracture exits. Can you see where it exits? Okay. So you're okay putting one in the posterior colliculus. A little, like a little anterior to it. I think you're actually good. That looks really nice there. X-ray there. Yeah. I think that's nice. Okay. Alright. Let's pop the cortex and put the screws in. You want an x-ray first? Yeah. Sure. Just to confirm.
CHAPTER 15
Yeah. So I think forty-five, partially-threaded are gonna be just fine. Forty-six. Forty-six. Is that fine, Miles? You measured it. Do you wanna use this to get down to the bone? Just expose it so you don't tear up the soft tissues? Let's get our retractor back in. Self-retainer. Thank you. There we go. Thank you. Good. I think you're good there. Yeah. That's nice. Alright. Do one at a time. Uh-oh. Where's your soft tissue guide? Mhmm. Good. Let's take the screw. Let me take that dental pick back. So you wanna leave both wires in and do one at a time at least, otherwise the whole thing can rotate on you. Oh, gotcha. The other thing I wanted to ask is I I feel like convergence I've heard previously is good because it allows for fixation and extra planes. Why in this situation is it bad for these two screws to be convergent? Not even converge, like your base of fixation is just like a little off, isn't it? Okay. I think it's better if you diverge, if anything. Good. I think you're probably good there. Good bite? Yeah. Good. Alright. Drill back, please. So the problem with convergence is that your - your point of rotation is distal to you. Right. Yep, yep, you know what? I think my brain is mentally confusing the two. That's the weighted reduction last night that I stayed for. Sorry about that. That's better - going out in different ways holds it more bone. Right? It becomes more apparent when you just have, like, supracondylars and things. Right. You realize, like, yeah, if you're converging, you might have a center of rotation or crossing point right at your fracture, which takes out your... Nice. Don't plunge too deep. Feel good? Yeah. It looks amazing. Okay. Alright. Come on in for an x-ray. Good bite? Yeah. That was not so, like, amazing to be honest. This one was stronger. Well, let's see how deep you are. Maybe you're not deep enough. Yeah, could still be off.
Come on in. Oh, we can get an AP first. Yeah. X-ray there. Good. That looks lovely. You happy with that, Miles? Good. Come over to the other view. X-ray there. Great. I think you have a little ways to go for the posterior one. That's probably why. Just stay right there for us, and then we can get the k-wire driver - oh, you got it loaded. Amazing. Thank you. There it is. There it is. X-ray there? That looks better. All right. You want to take the k-wires out? You got good bites on both of them, right? Beautiful. Yes.
CHAPTER 16
Okay. Should we get our final x-rays? X-ray there, please. Let's get a really nice lateral there. AP? An x-ray? Oh, sorry, x-ray? That's it. Beautiful. Okay. Come to the other view, please. X-ray there. Great. Let's get the ankle out. Yep. X-ray there. Great. That's our mortise. Looks lovely. Thank you very much.
CHAPTER 17
Alright. So let's do our Cotton test. So we'll put this pointed reduction onto the fibula there. X-ray there. Center on there again. X-ray. Center a little bit better. Good. X-ray. So that's without stress. Now we're gonna stress the x-ray. X-ray again. Not gapping. That's perfect. Okay. Negative Cotton test.
CHAPTER 18
Alright. Tourniquet down, please. Two wet laps. So we'll just hold pressure as the tourniquet goes down. We're all done with x-ray. Thank you very much. Deflating. So we'll just hold a little bit of pressure. Alright. I'll take 2-0 Vicryl, 3-0 Monocryl, and 3-0 nylons. Irrigation, please. Watch your hand there. I got this. A little bit more, please. Looks like we got a little bleeder there. Adsons, please. Thank you. Yep. Buzz. One more irrigation, and then I'll take the Vicryl on my side. 2-0 Vicryl, yeah. 2-0 Vicryl only for the deep layer, guys. Okay? See if you guys can cover the plate a little bit. I'll do the deep layer, you do superficial. Okay? So what I like to do is just sort of see if I can reapproximate the soft tissue layers over here. You know, just to create a little bit more stability. Let's see if we can bury that. Stability of the soft tissues, that is. The bony stability is there, huh? This is just to help, like, cover up the, the screws so that the scar has a place to go and knows what it's supposed to do. I don't know. Thank you. I think that's gonna be fine. Alright. Monocryls, please. 3-0 Monocryl. Thank you. You see it, huh? Yeah. Yeah, so we try to preserve that. Anytime we have native anatomy try to preserve it, you know? Like, I mean, people will tell you the saphenous isn't important. And if you bag it, it's not the end of the world. Right? But we do like to try to preserve things if we can. Being a strain into the foot and all that, you know? Yeah. Because everyone complains of the swelling. Sure. Yeah. I mean, the plastic surgeons will tell you that all these things, like, really matter, you know. And when it comes to soft tissue, I tend to believe them. Let's start from up here. Elyse, are you good? Do you need a, step stool or something? I'm good. Okay. Thank you though. She coming together okay over there? Yep. I want you guys to do Monocryl for the subcutaneous layer, yeah? All our k-wires, k-wire tips, they're all accounted for? K-wire tip. Yes, sir. Excellent. Thank you. All the way to the distal part of it. First one's ready. Thank you. Just simples, please. Yeah. 3-0 nylons, please. Toradol's fine. Thank you. Looking okay? Not too much bleeding? Thank you. So just simple stitches like this. Yeah? I'll show you the size I want them. And really try to evert the edges if you can. I don't want any inverted skin edges. You see how that's everting? Yep. Yeah. Where do you wanna stand? You good there? Yeah. I can do this. Yeah. That's fine. Alright. The needle back protected. The 3-0 Vicryl? Monocryls. You wanna do Monocryl? Okay. 3-0 Monocryl. What are we doing with these Monocryls? Are we doing interrupteds, or are we doing deep dermals. He said deep dermals. Let me hand some of these things back to you. We don't need so many laps up here. It'll close down if I just close it. Yeah, I mean, if you close it down, it should be fine. Nice job, man. Here, let me throw a couple just for purposes of expediency. Yep. Get her off the table because we got a big case next. That looks nice. That looks really nice. Very nice stitch. I'm trying not to when I do that, it'll just crunch on the skin. Yeah. Try not to do that. Yeah. Can I get a 3-0 Prolene as well at the very end? We'll take two of those. You got one more nylon for me? I'm sure they're gonna need one on that side too. One of these is not supposed to be there. There we go. Probably three more stitches there. Let's get you a fresh one. Another nylon, please. Of course. Yeah. Please do. Looking beautiful over there, Maz? Yeah, just started our dermals, so... Not coming together yet. Just covered the plate. Do a surgeon's not for the first throw. Oh, you did. Never mind. Sorry. So rather than try to grab the needle head on like that with the Adsons, try to grab it from the side. That way you have more surface area. It's okay. Don't worry. Keep tying. Questions? Here's the other trick with the Adsons. Instead of grabbing it and pinching the skin just grab it and pull the skin with one tooth, you know. And that everts the edge for you nicely. You see? And same thing on this side. Just evert the edges like that. Okay? See if you can do that. That way you don't pinch the skin and traumatize it too much. How'd that work for you? I think a little better. I think one of the Monocryl's is right under there. Uh-huh. I had trouble like - so you're saying like this. Yeah. Technically, you're supposed to grab it with a needle driver, but that's okay. Alright. We got that Proline for me? Do you need one more at the very end? Yeah, why not? You got Prolene? Because I like to overrun these in ankles that have just been done acutely with a Prolene. I'll show you. Just like a nice loose layer. It's It's a plastic surgery move. It just sort of gives you another layer of reinforcement. So you're saying just leave it like this and then come like that? Precisely. I think you're probably okay. If you want to, you can. It's certainly not gonna hurt. Can I get another Prolene, please? One more Prolene. Sorry. Suture popped off the end of the needle. Thank you. Excellent. Nice job, Jack. Thank you. Needle back. Light handle's here. It's contaminated. Sorry. Prolene, please. And I'll take the Adsons. Thanks. Alright. Somehow I have a knot in there. Might be okay. I think so. Nah, I don't love that. Let's redo that guy. Scissors? Got it. So much for my Prolene layer. This is the third time I've tried to do it. Oh no. I know, I keep failing. It's just like adds like a second, like, belt and suspenders. Yeah. As the swelling occurs, I think that it just helps. Cut that for me. Just shorten. Yeah. That's perfect. I was going to split the difference there. It's starting to... You just do this nice and loose, you know. Go like in the middle. Split the - oh, I thought you were saying we split the difference and you do one and I do one. Straight in the middle because it's... The gap went posteriorly. So - you see, you go there, it's gonna pull this and it's just gonna create this giant... It's just nice and loose. Nice and loose there. I think the Prolene is, like, very cosmetic. Like, it's not gonna create, like a big tissue reaction with big railroad tracks or anything. Mhmm. Great. Alright. Prolene stitch back. Alright. Wet and a dry for our side. How you guys doing over there? We're just finishing up the deep dermal Monocryl. Okay. Looks nice. So guys, you saw how I did the Prolene on this side. You see just like overrun it, overrun it very loosely. Just as an extra layer. Xeroform, 4x4's. Three ABD's. Sterile web roll, and then we'll splint. Could we get a six-inch and two four-inch splint material? Oh, yeah. That's plenty. He just needs one more stitch, I think. Oh, great. Thank you. Do you need sterile Webril? Yes, please. I need all the dressing. We'll need a little bit more of this stuff. Excellent. Thank you. And I need two more of these, I think. You're gonna get the four inch maybe. And it doesn't have to be sterile. Thank you. Yeah. Can I get one more of these, the six-inch plasters? Yeah. Thank you. Thank you. You're welcome. Can we contaminate that back table with the splints? Is that okay? Yeah, that's contaminated already. Well, can we get a Flex-Master? The big one. Yeah. You got it. Thanks. Excellent. Let me hand these to you for the trash there. The sharps. We got another 3-0 Prolene for them. We'll probably need two. It's a little bit of a longer wound. And could you cut this into strips for me? Like long wise? Just two of them. You ready for Prolene? Yep. Cool, so you saw how we did on the other side, nice and loose. Oh, yeah, that's fine, yeah, it's great. Nice and loose, Miles. One more Prolene to - I think so. Seems like it's long enough. Yeah. And it really shouldn't be cinching down the wound at all. Okay? Then you can probably cut this one in half. That's great and then we got the 4x4's as well. Probably one will be fine. Nice and loose? Very loose. Too tight, Elyse, looser than that. Very loose. Good. They'll take a wet and a dry soon. You guys all done? Alright. Put a clean towel underneath, a wet and a dry. Get it all nice and clean. There's a blue towel right here. Watch the scissors underneath that towel jack on that side. Alright. Xeroform. One Xeroform to them, please. A long one and a short one to Jack. Jack, you got a short one for you. Yeah.
CHAPTER 19
Let's put the table down in just a second. 4x4's, and then guys one ABD for each wound and then one for the heel. Okay? Ready to dip them? I just don't want to dip them too early. You'll be fine. I think you'll be okay. They seem like they're moving pretty expeditiously. Alright. Great. Sterile Webril is right here, Miles. Sterile Webril to them. That's not sterile anymore. Sorry about that. One more sterile Webril. Here you go. Table down, please. All the way. How'd I guess with the length? Did I do okay? It seems fine. Good. Grab the Flex-Master. Okay. Okay. That's good. Loose, loose, loose. I got it. I got it. Alright. Alright. Drape's down, please. Do you have a pair of shears or scissors? Where are they? Thank you. Tape, please. Thank you. Thank you, sir. Yeah. One more. Thank you.
CHAPTER 20
So the case went well, very smoothly. Did it exactly as we had described. We started first with the lateral malleolus. In this case, we got a really nice reduction, and we were able to get great compression using two pointed reduction forceps. So I didn't feel like we needed to do a lag screw. The lag screw is where you drill a larger hole in the near cortex so that the screw can pass it without catching the near cortex, and it only grabs with the threads in the far cortex to pull compression. I thought we had enough compression, so I just did what's called an interfragmentary. I just drilled with a 2.5 drill and then put a 3.5 screw across. That seemed perfectly adequate. Now to prevent rotation of the two fragments, I then placed an additional k-wire just distal to it, and that held everything really nicely while we put that lateral plate on. One little trick that you'll see in the video is at the distal end of the fibula, I placed a k-wire and then bent it, and that can sometimes help you push the plate down against the bone. Because the proximal aspect to the plate, you can drill bicortically and place that cortical screw, which will suck the plate down to the bone. But with the locking screws distal, you can't do that. So holding the plate down to the bone is nice. It prevents the soft tissues from getting irritated in the future and the patient feeling that prominent plate there. So lateral malleolus went really well. I wasn't expecting there to be any syndesmotic disruption. But, of course, we checked that after fixing the medial malleolus. You know, we had a little bit of trouble getting our guidewires aimed exactly the kind of angle that we wanted, but I think once we got them in the right position, then everything went smoothly. Our reduction of the medial malleolus, I was very happy with that. Our Cotton test showed and our external rotation stress test showed that there was no syndesmotic instability, so there's no need for any syndesmotic screws. Although, if you look at our x-rays, we left space for those two screws if we were to need them. In this case, we didn't need them. The syndesmosis was stable. So afterwards, you know, closed up. This was an acute fracture that we took immediately. And, you know, she wasn't swollen enough to require external fixation or anything. But, as we brought the tissues together, there was minimal tension. But just as she swells, I added an extra layer of this 3-0 Prolene, running loose stitch that I learned from plastic surgery colleagues of mine. And that's just extra reassurance for wound healing that it won't dishis open. Patient was then placed in a short leg splint, which is pretty standard. Gotta make sure that the ankle is in neutral and not in equinus. And the patient will be non-weight bearing now for about six weeks. And we'll have the patient come back to my clinic in two weeks, at which time we'll take off the splint. We'll take out the sutures if the wounds are healed, check an x-ray, of course, and then keep the patient non-weight bearing in a boot, which can come on and off for hygiene, but without any weight bearing through the ankle for an additional four weeks. Once the patient hits that six week mark, then we start increasing weight bearing from there if the x-rays look good.