#2. OPEN REDUCTION AND INTERNAL FIXATION - ANKLE FRACTURE

PREOPERATIVE DIAGNOSIS: Right bimalleolar fracture.

POSTOPERATIVE DIAGNOSIS: Right bimalleolar fracture.

OPERATION PERFORMED: Open reduction and internal fixation.

SURGEON: George Washington, M.D.

ANESTHESIA: General endotracheal anesthesia.

INDICATIONS FOR PROCEDURE: The patient is a 59-year-old active female who sustained a displaced bimalleolar fracture a couple of days ago. She has been splinted and she has been elevating the extremity to control her swelling. She is brought to the operating room now to reduce her fractures and to restore her mortis congruity and stability. The risks and benefits as well as the alternatives to surgical treatment were discussed. The risks discussed included, but were not limited to, bleeding, infection, nerve or vessel injury, malunion, nonunion, failure of fixation, need for further operation, painful and retained hardware, as well as continued postoperative stiffness, pain, and inability to return to desired level of function. The risks associated with general anesthetic likewise were discussed and consent obtained to proceed.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken to the operating room where, in a supine position, general endotracheal anesthesia was induced. The right lower extremity was then prepped and draped in the usual sterile fashion. The limb was exsanguinated with gravity and the tourniquet inflated to 300 mmHg. The surgical incisions were marked out with a pen, prior to inflation. Medially, she did have some fracture blisters proximally but they were proximal to the proposed medial incision, as anticipated.
Attention was turned to the lateral malleolus first. An approximately 10-cm longitudinal incision was made with the #15 blade. Dissection was carried down sharply to the level of the fracture site. Fracture hematoma and interposed soft tissue was cleared. A pointed reduction clamp was used to facilitate reduction and it was reduced nicely under direct visualization. Anteriorly, there was some comminution associated with a soft tissue attachment, but the primary fracture line was nicely reduced. An interfragmentary screw was then placed from anterior to posterior after overdrilling the proximal cortex. It was measured, tapped, and then a screw of appropriate length was placed. The fracture site was then stable. The mini C-arm was brought in and this demonstrated that the fibular link had been nicely restored. A six-hole one-third tubular plate was then contoured to fit the lateral aspect of the fibula. It was then affixed to the fibula using cortical and cancellous screws of appropriate length. All achieved good fixation. Titanium implants were used because the patient has a nickel allergy. The fluoroscan was brought in again and it verified again appropriate position of all the implants. A single distal screw was a little bit too long, about 1-mm or so into the ankle joint itself, so this was exchanged.
Attention was then turned medially. An approximately 3-cm longitudinal incision was made, centered over the medial malleolus. A #15 blade was used to create this and dissection was carried down sharply to the fracture site itself. Once again, fracture hematoma was cleared as well as some interposed soft tissue. After restoring the fibular length, the ankle mortis was nicely reduced. The medial malleolar fragment was then reduced directly using a sharp reduction instrument and it was nicely reduced externally. A 2-mm K-wire was introduced from distal to proximal to secure this fragment. A 2.5-mm drill was then used in a parallel fashion posterior to this. The C-arm was brought in and this verified that the medial malleolus was nicely reduced and the mortis was congruent. For that reason, the K-wire and the drill were both replaced using partially-threaded cancellous screws which achieved good interfragmentary fixation. The small C-arm was once again brought in and this verified once again that the fracture fragments were nicely reduced. The mortis was congruent and the implants were in appropriate position. The fixation was stable throughout a full passive range of motion. This was verified in all views. Both wounds were then copiously irrigated. The subcutaneous tissues were closed using interrupted 3-0 Vicryl. The skin was closed using interrupted 3-0 nylon, both medially and laterally. A sterile compressive dressing was applied. A very well-padded posterior splint was then applied with medial and lateral supports so as to keep the foot in a position of neutral dorsiflexion. The tourniquet was released. The foot was well perfused.
The patient was awakened, extubated, and transferred to a recovery room bed. She was transferred to the recovery room in stable condition.