Open Reduction and Internal Fixation of a Trimalleolar Ankle Fracture

After the operative leg has been marked, anesthesia is induced, and the patient is brought to the operating room.

1. Leg Positioning
   • Patient positioned supine with arms out or tucked
   • Trochanter roll placed under patient
2. Prep/Sterilization of Surgical Site
   • Shave surgical site
   • Wash and sterilize entire leg
3. Draping
4. Cover Site with Ioban Adhesive Sterile Sheet
   • Seal calf and toes
5. Make Skin Markings
6. Apply Tourniquet
   • Exsanguinate the extremity up to the thigh
   • Apply pressure
7. Surgical Time Out
   • Identify patient, problem, correct side, procedure to be performed, medications given prior to procedure, expected time to completion

8. Make a Lateral Skin Incision
   • Along subcutaneous border of fibula
   • Angle slightly anteriorly distally
9. Incision into Fascia
   • Superficial peroneal nerve branches at subcutaneous or fascial level
   • Once on bone, make space for plate
   • Expose fracture site with a 2-mm periosteotomy on each side
   • Clean out fracture site with small curette
10. Perform Fibular Reduction with Pointed Reduction Forceps
    • Grab distal fibula and pull traction to achieve length
11. Fit and Contour Fibular Plate
    • Contour six-hole ⅓ tubular plate using locking towers for grip to match distal fibula
    • Position and use K-wires to fix provisionally
12. Proximal Non-locking Screw
    • Drill through both fibular cortices with a 2.5-mm drill
    • Use depth gauge to determine length
    • 4.0-mm non-locking screws should be used initially to contour plate to the bone
    • Note: Using slightly longer screws allows for better purchase in the medial cortex
13. Distal Non-locking Screw
    • Repeat above steps
14. Fill Remaining Gaps with Locking Screws
    • It is important to use locking screws, especially distally at the level of the lateral malleolus, to prevent skin irritation due to prominence
    • Once complete, use clamps to pull on fibula (Cotton test) and assess status of syndesmosis

15. Exposure of Syndesmosis
16. Provisional K-Wire Fixation
    • Fix the Tillaux fragment to the tibia
    • Use a second K-wire to fix the fibula to the tibia
17. First 3.5-mm Syndesmotic Tricortical Screw
    • Drill through three cortices with 3.2-mm drill
    • Drill to, but not through, the medial cortex of the tibia
    • Measure with depth gauge
    • Use a 4.5-mm cortical screw
18. Lag Screw Fixation of Tillaux Fracture
    • Drill through fragment into tibia with 3.2-mm drill
    • Use 4.0-mm partially threaded cancellous screw to lag by design
19. Second 3.5-mm Syndesmotic Tricortical Screw
    • Repeat steps for first syndesmotic screw

20. Prep Medial Side
    • Mark approach - in this case, a curved approach anterior to the medial malleolus
21. Make Medial Incision
    • Be cautious of the posterior tibial tendon and saphenous nerve
22. Reduce Fragment with Pointed Reduction Clamps
23. Provisional K-Wire Fixation
    • Use two K-Wires to keep fragment from rotating
24. First Tibia Lag Screw
    • Drill though fragment into tibia with 3.2-mm drill
    • Use 4.0-mm partially threaded cancellous screw
25. Second Tibia Lag Screw
    • Repeat above steps

26. Take AP and Lateral x-ray Images to confirm reduction and construct placement