Pearls & Pitfalls Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I Preparation identify joint involvement and articular step-off (>25%, >2mm requires ORIF) standard OR table with radiolucent end C-arm from contralateral side Positioning prone with feet at end of bed rolls under chest and knees and bump under hip for neutral rotation Approach posterolateral approach to ankle between FHL (tibial nerve) and peroneal muscles (SPN) Reduction lobster claw or pointed clamps with hand rotation to reduce fibular fracture move to posterior malleolus and free up fragments Fixation place buttress plate 1/3 tubular or T-plate over posterior malleolus anterior to posterior screws and 1/3 tubular plate over fibula Syndesmosis Exam perform Cotton test / external rotation stress test to determine if syndesmosis injured 1 or 2 screws, 3.5/4.5mm, tricortical or quadricortical Postoperative 2 wks non-weight bearing in postmold sugartong splint 4-6 wks in CAM boot with progression of weight bearing and range of motion exercises Planning & Preparation Template Fracture identify amount of joint involvement and articular step-off (>25%, >2mm requires ORIF) posterior malleolus fractures <25% of joint surface and <2mm articular step-off can be treated non-operatively in short leg walking cast vs. cast boot CT often needed to evaluate percentage of joint surface involved xrays can be unreliable for measurement identify ankle fracture pattern (Lauge-Hansen SA, SER, PA, PER) and associated injuries need to evaluate syndesmotic injury with stress exam stiffness of syndesmosis restored to 70% of normal with isolated posterior malleolus fixation alone Table and Imaging standard OR table with radiolucent end c-arm from contralateral side perpendicular to table monitor at foot of bed in surgeon direct line of site Equipment & Positioning Equipment 2.0/2.5mm drills, 2.7/3.5mm cortical screws, 4.0mm cancellous screws, 1/3 tubular plates (Synthes Small Fragment Set) c-arm Patient Position prone with feet at the end of the bed rolls under chest and knees bump under hip to get limb into neutral rotation thigh tourniquet placed while patient supine high on thigh before flipping prone Approaches Posterolateral Approach to Ankle internervous plane between FHL (tibial nerve) and peroneal muscles (SPN) incision along posterior border of fibula protect SPN proximally access fibula with posterior retraction of peroneals access posterior malleolus with anterior retraction of peroneals blunt dissection between FHL and peroneals elevate FHL off of posterior tibia retract FHL medially Posterior Malleolus and Fibula ORIF Approach stack of blue towels under anterior ankle to elevate limb mark out lateral malleolus, anterior and posterior borders of fibula, borders of Achilles place dry lap over marked incision exsanguinate limb and inflate tourniquet incision ~6-8cm in length along posterolateral border of fibula Soft Tissue Dissection (Fibula) 15 blade through skin then tenotomy scissors to spread subcutaneous tissue with minimal soft tissue stripping identify SPN with more proximal fractures dissect out SPN and retract take fascia down sharply over posterior border of fibula anterior to peroneal tendons full thickness flaps over fibula access fibula with posterior retraction of peroneals sharp dissection down to bone with subperiostel dissection at fracture edges extraperiosteal dissection proximal and distal to fracture site with knife and wood handled elevator Fracture Preparation and Reduction (Fibula) clean out fracture site using freer to open fracture site curettes, small rongeur, dental pick, and irrigation to remove hematoma and interposed soft tissue use lobster clamp and pointed clamps to reduce fracture use hand rotation and contralateral thumb to help guide fragments together lobster clamp has good hold on bone while pointed clamps have a more fine-tuned feel for reduction need to be perpendicular to vector of fracture line place temporary kwires to provisionally fix fragments Soft Tisue Dissection (Posterior Malleolus) access posterior malleolus with anterior retraction of peroneals identify interval between peroneals and FHL blunt dissection down to fascia fascial incision is medial elevate FHL off of posterior tibia retract FHL medially identify FHL by flexing hallux and watching for muscle belly movement need to protect and retract posterior tibial neurovascular bundle medial to FHL place self retainers and incise periosteum over post mal with 15blade clean fracture site as above with fibula do not release PITFL off of fragment as this will destabilize syndesmosis and devitalize fragment Fracture Preparation and Reduction (Posterior Malleolus) clean out fracture site using freer to open fracture site curettes, small rongeur, dental pick, and irrigation to remove hematoma and interposed soft tissue mobilize fracture fragments fracture should reduce with reduction of fibula reduce with direct pressure pushing down onto fragment Fixation place buttress plate 1/3 tubular or T-plate two 3.5mm screws (2.5mm drill) anterior to posterior in T-plate distal 2 screws proximal into distal tibia check placement of plate and screws under fluoro make sure screws are perpendicular to bone do not want distal screws (typically 40mm) to protrude anterior and irritate tibialis anterior after fixing posterior malleolus move back to fibula fracture place lag screw (2.7mm screw/2.0mm drill) followed with 1/3 tubular plate using antiglide technique on posterior aspect of fibula place 2-3 3.5mm bicortical screws (2.5mm drill) most distal screw will likely be 4.0 cancellous since it’s close to joint and/or syndesmosis check plate and screw positions with fluoro on AP and Lat views Syndesmosis Exam & ORIF Cotton Test reduction tenaculum is placed ~2cm above joint and lateral pull applied opening of the syndesmosis on mortise view is indicative of a positive stress test External Rotation Stress Test firmly hold proximal tibia while contralateral hand dorsiflexes and externally rotates foot if increased opening of tibia-fibular overlap syndesmosis is injured anterior-posterior instability exam is most sensitive for syndesmosis injury Syndesmosis Reduction formally open the anterior aspect of the syndesmosis (anterior to fibula) remove interposing tissue if preventing reduction place Weber pointed clamp or large periarticular clamp across syndesmosis one tine on medial tibia and other on lateral fibula hold foot in neutral dorsiflexion and inspect syndesmosis from lateral incision tighten clamp to maintain reduction inspect syndesmosis from lateral incision to ensure anatomic reduction Fixation use 2.5mm (or 3.5mm) long drill bit to drill across fibula into tibia drill bit orientation parallel to joint 2-4cm above joint drill bit is angled ~20-30° posterior to anterior due to fibular position in syndesmosis can drill either 3 or 4 cortices can use either 3.5/4.5mm screws remove large clamp obtain final AP, mortise, and lateral radiographs Closure Irrigation & Hemostasis irrigate wounds thoroughly and deflate tourniquet if used cauterize any bleeding vessels watch out for SPN laterally Close Fascia deep fascial closure over plate with 0-vicryl ensure no entrapment of the SPN 2-0 vicryl for subcutaneous tissue 3-0 nylon for skin with horizontal mattress stitches in diabetics or patients with high risk for skin breakdown, use modified Allgower-Donati stitch to reduce tension on skin Dressing & Splint soft incision dressing followed by postmold sugartong splint with extra padding under heel for immobilization crutches or walker for ambulation Postoperative Care 2 Weeks wound check and remove sutures remove splint and place in short-leg cast boot, non-weight bearing can allow ROM if soft tissue is appropriate 6 Weeks advance weight-bearing status in CAM boot advance rehabilitation if syndesmotic screw(s) placed need to be non-weightbearing 12 Weeks advance weight-bearing if diabetic, insensate, or syndesmotic screws present syndesmotic screws to stay in for at least 12 weeks can remove or leave in place no difference in outcomes with removal syndesmotic screws will loosen or break if maintained Complications Document Complications wound breakdown (4-5%) superficial and deep infections (1-2%, up to 20% in diabetics) peroneal irritation from posterior fibula antiglide plating iatrogenic injury to SPN during fibula exposure, PITFL, posterior tibial neurovascular bundle during FHL exposure post-traumatic arthritis