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Open Reduction and Internal Fixation of a Trimalleolar Ankle Fracture

Michael Weaver, MD
Brigham and Women's Hospital



My name is Michael Weaver, I am a trauma surgeon here at the Brigham and Women's Hospital in Boston, and today we have a 23 year old gentleman with a trimalleolar ankle fracture. He was involved in a high-speed motor vehicle collision last night and presented with a dislocated ankle and a pulseless foot. So we reduced in the emergency room and placed in a splint, and now we're going to be taking care of his ankle fracture definitively.

One of the important things to recognize on the AP radiograph is the direction of dislocation. In this case, he has a lateral dislocation, and that's going to be important because that's going to be directing your fixation to try to prevent failure and redisplacement in the future. And then also, it's important to recognize the syndesmotic injury here. Here his talus is dislocated into the space of the syndesmosis, and it's obviously wide so that's something that we're going to have to address surgically. I typically like to perform an open reduction of the syndesmosis. I think it's really important to really see the reduction. There are a lot of studies show that it's difficult to get that perfect especially if you were relying on radiographs alone. And a lot of CT data postoperatively show there's some residual subluxation of the syndesmosis, so I like to really see that. And then in his case, he does have some threatened skin on the medial side, and so we may not be able to fix the medial malleolus today. That’s just going to depend on how things look. But he has some swelling on the lateral side, but he's got a good wrinkle sign and - and the skin looks appropriate to proceed. So we're going to start on the lateral side and go from there.


So when I'm doing ankle fracture surgery, I like to have platform built up so I can get orthogonal views without changing the position of the legs. So I like to build it up on a platform - and then also a pretty good bump under the hip so the - the foot’s pointing straight up. That gives you good access to the lateral and medial side. Then I think, especially in trauma patients, it’s important to do a pre prep, so you can use Hibiclens or alcohol or something, but you want to get that skin really clean before - before you do your final prep.

Nice and supple. One of the important things, particularly when you're doing surgery around a high-energy ankle injury, is quality of the skin. You know, this - this patient is a young patient with good skin. He's got a fair amount of swelling, but the important thing is the - the skin is still dull - it's not shiny. If you have shiny skin, that's a sign that it's not going to take an incision very well. And he still develops nice wrinkles. The other thing that I find that’s really important is that it's supple - you know, you can move that skin around. If things get kind of woody and tight, then that's a really bad sign, and you're going to have trouble closing it. But I think this looks like it's going to be okay.

Actually would you mind helping for a second? We just need to get that clip prepped so we can get it wrapped, you know? You just like lift a little or something. Alright, so this is my standard setup for an ankle fracture. We got our platform. I like to use these kind of disposable drapes that let you get lateral views and keep yourself sterile, and then I’m - I'm pretty fanatical about it - but I like Ioban covering everything. Alright, there we go, and then just a small little towel under the - under the leg. Alright.

Incision is going to be just a little bit posterolateral. So one trick is you can feel the fibular head here. So if you feel the fibular head to the tip of that, that's going to be a straight line between the two, and you want to be slightly behind it. So I think you're really - I think - yeah, I think it's good, yeah. You don't want to be too far in the back especially at the tip cuz you're going to see your syndesmosis over the front. Alright, I think that’s good. Alright. fdsfdsl Tourniquet at 275 please. Up in a few seconds. Tourniquet up please. Alright.

He's got a broken right ankle. We're going to do surgery to fix it. He's in the supine position. Right side is marked and draped. We have a small fragment locking set in the room. So we use Ancef and vancomycin for all cases that involve metal cuz there's a higher incidence of - of MRSA infection in the community now. Squeeze in the other leg for DVT prophylaxis. This case is going to take about an hour to slightly longer than that. We're not anticipating any blood loss or critical steps.


Incision. So the thing to watch out for here obviously is the superficial branch of the peroneal nerve. That's going to be proximally. And the thing with that nerve is it lies right on the faccia, so you can be in the fat and you’re okay. You know, and some people say - you know, you've got 7 to 10 centimeters from the tip of the malleolus, but I find the course is pretty variable - so I don't like to cut down to bone anywhere. Alright, good. You can go a little deeper cuz well - like I said - you’re in the fat, you’re okay. Good - a couple wheaties please. I don't like to spread too much cuz you want to dissect sharply. Pro-tip - are you ready? There you go. Okay, so I want you to cut. There you go. There it is. It's broken. Good. Safe and then go. That's what I mean by sharply. You don't want to rip it apart. You want to cut it. There you go. I thought you meant to find my nerve. Yeah, I do - if you find it, but if you don’t find it - alright, so those are the peroneal tendons right there, right? Insert the tissue. There you go - right.

Now you’re good with the knife. So there's the ball, right? Yeah. So you’re just going to open it up right like this. So the nerve’s going to be up front here. In fact, that’s probably it right there, but we know we’re safe. Yeah, come right here? Yeah. Alright, so just rip, rip. Yep - just open the fascia - just the fascia. Yep, now zip right through that. That’s good, cut. Good - and then just keep going a - above me. Yep, all the way. Yep. So you just go to - I want you to actually release that like that. Good.

So we just open up the fascia over the peroneals, and then we’re going to be a little bit posterior here. Perfect. You don't want to strip any the periosteum off the bone beyond that needed to see your reduction. So there's the fracture, and there's that. So you want to make sure you leave that soft tissue on there. Yep. You don’t want to cut on the bone - you want to cut down to bone. Yep, right here. Just release that real gently cuz you want to leave that periosteum on there. Good. A little more dissecting. Good - that’s plenty. Now let’s just release the front here a little bit. So like - yeah, you don't want to - you don’t want to worry about that nerve though, so cut that way. There.

So now we’ve got our fibula. We got that. We’ll get that. Little bit of comminution but pretty clean fracture line. So when you're cleaning the fracture site, the curette just moves things around - use your Fraser tip. Alright. You see that? You just suck the pressure right out. Especially in a fresh fracture like this, you do that to remove the blood on the clot. When they’re real fresh like this, it doesn't take much. The thing to look for is enfolded periosteum. That’s going to be what blocks your reduction, and that’s usually going to show on the medial side cuz that fails in tension. So you always want to try to use pointer reduction forceps because that is less traumatic. You get more power with the tips of these points than with that. Oh yeah, he’s unstable. Oh, there it is. There it is.

Okay, come on in for a shot. Come south for me please. X-ray. So that’s our mortise view, and it shows that our fibula is almost out to length - and our syndesmosis is not reduced, but that's okay cuz we're gonna start with the fibula and then work on the syndesmosis.

Well, I don't think we're going be able to a lag screw cuz there's a lot of anterior comminution. So - and we're reduced in the back anatomically there. It looks like we're pretty close. So, you know, unfortunately, you know, it's nice to get a lag screw, but this one we're not going to be able to. You see it was a pretty high energy injury. We didn't do any of this dissection. There's a lot of periosteum stripped around the fractures. Alright, so 1/3 tubular plate. So for most - most ankle fractures, you're gonna use a 1/3 tubular plate. I like the locking plate - not cuz I think you ever need the strength of the locking screws especially in a young person - but because distally - I like to use locking screws cuz they're less prominent than proximally. Some of the other sets you don't need that, but with the - this particular set, that kind of helps. And then also, one of things I really like to do is use the locking towers to help place the plate cuz we're going to use K-wires to hold it, and then once we're happy with our plate position, then we can place them, so. These plates are pretty flimsy, so they'll kind of contour themselves. But I'm just going to give it a little bit of a bend - little bit of bend to better contour it, and the key thing is, if you're going to do that, you want to keep those locking towers in cuz that's going to preserve the - the locking. Possibly - we’ll see.

So I like to just set the plate in place clinically. And then I'm gonna take a couple pictures, and if we're happy with that, then we will use that. So you can put your K-wire distally, pull on it, get your length, and then put another K-wire that holds it. It's a really nice way of doing that, but then it still lets you adjust your reduction a little bit in terms of flexion, extension. One cortex only.

Alright, x-ray there. That’s a little bit more than one cortex. X-ray. Alright, so we have enough holes above and below the fracture there. So now we're - we’re out to length it looks like, and we got that by reading the posterior aspect of the fibula back here and then also radiographically. And now let’s go to a lateral view and see where our plate is. So this drape’s nice cuz it let’s you do that, and then you just put it back - you’re not wasting sheets. That looks good - worth a shot there. X-ray there. Hold on. X-ray there. Save that.

So that's a true lateral of the ankle, and we can tell that by looking at the talus and also the plafond. And our plate’s sitting - the plate’s sitting square on the fibula proximally and then coming a little bit posteriorly distal, which is what we’re looking for. And that looks nice. Alright, good. Back up to an AP. Give us a shot. Go live for a second. Stop there. So when we're looking to figure the length, there are three things. The first thing is ta - talar tibial tilt, so if the talus is tilted, then it's way off. So that's - that's a really bad sign if the talus is tilted with respect to the tibia. So that's the first thing. You can see our joint’s parallel, so that's good. The second thing is the parallelism between the tibia - or sorry, the talus and the fibula. See how it kind of comes together and there are some parallel lines that go down there? So that's a sign you’re out to length. And then Shenton’s line - so you want to follow it up, and if you look real carefully, the - the fibula kind of curves and hooks at the top, and that lines up with the bottom. So those are kind of the three things I look at to say - alright, I got length.

So you always want to start with non-locking screws. If you start with locking screws, you're not going to contour the plate to the bone, and it's not going to suck it down, right? Distally, I want use locking screws for prominence, so let's just start right there. What you're feeling for is two cortices. That's a sign that you're in the middle - see, that's one, two. Good. So it’s - that’s just a check, right? So that’s a back up check. Now you know your plate’s centered on the fibula cuz you found the medulla canal.

A lot of people do the depth gauge wrong. You hook it like that - so it’s one hand. You feel that hook, and then you go down - and you push it pretty hard. You want this down - 12, but I want you to put a 14 in anyway. I think a lot of people leave their screws short. You know, you want the screw to be out of the other side of the bone. It’s got to be. It’s got to be. The only time you don’t want that is if there’s something really important on the other side that you don’t want to irritate - like a tendon - like you’re doing a distal radius fracture. X-ray. Save that. Alright, so you can see our screws are starting to reduce it, and that's the ideal screw length, alright? So the tendency is to want to leave it flush with the bone - you need it to stick out cuz the tap of the screw. You got to have it out like that.

So again non-locking screw - that’s going to let this 1/3 tubular plate contour the bone. We get it close, and then the screws do the work. If you do a big beefy plate, like a LC-DCP plate, then you’re going to have to contour it yourself, but this plate will do itself. It’s high technology, self contouring - self contouring technology. Maybe not killer on this one. X-ray. X-ray. X-ray.

Do you have a Freer? Got a little piece there. See it? That’s what we’re seeing in the x-ray, isn’t it? Again, let's get this sucker and look back there. Grab this down here. So you can see we have an anatomic reduction on the posterior cortex there, and then on the front there, there's just a lot of comminuted pieces. And so that’s why our x-ray - you can see there's a little bit of flaking there, but posteriorly, we’re perfect. So we know we have length from looking at it, but then we have the radiographic confirmation too. X-ray there. X-ray there. Let’s go to a lateral. X-ray there. So that looks pretty nice. We got a good straight - and now if I externally rotate - x-ray there. We’re gonna bring the fibula into view. You see some comminution, but you follow that anterior cortical line - and it looks good. And we're not getting there yet, but we're going to reduce the syndesmosis in - it’s sitting on the posterior third of the tibia, which is where it's supposed to live. So it's starting to look good that way too.

Alright, good. So happy with our plate placements - we’re happy with our reduction. So now what we’ll do is pull up that. We got to leave room for our syndesmosis. We probably - that screw you put in already is probably going to become a syndesmotic screw. So why don't we - this is contoured nicely, so we’ll put a locker on here, or actually, if you wanted, you could fill it up top too - that would be other thing you could do. Let’s stay with 2-5. I’ll take an Army-Navy. What’s the length of that screw? Call it out. 14. Yep. 14 please. Measure anyways just to - we’re getting measure. And notice we’re taking any x-rays. We don't need any, right? Cuz we - we had it set. We have our reduction. We have our plates in the right place. 14 please. So you see, I like to plate a little on the posterior side, so the top of the fibulas’ up here. This is posterior, but it's not all the way posterior. That's cuz the peroneal’s here. So you can see there’s the peroneus brevis, and so you want this plate up here so that it’s not going to interfere with those peroneals. They're not going to get tendonitis, but being out of the way here, it’s going to be a little less prominent and a little stronger cuz you’re a little bit further in the back. All the way to the far cortex but not - but not through.

So this is where I like to use a couple locking screws, and it's just - just purely for hardware promise. There's no other reason. You know, good bone like this doesn't need it for strength. Seems a little bit long for a 16. 16 is fine.

What’s our T time? 14? 31 minutes. 2-8 back.

Another 16. You don't want them to be out the other side here cuz it'll bother him. Yep. Distally, it’s in the joint, and then even up there - you know, if it's too long, it'll irritate the syndes spaces. Yep, x-ray there.

Okay, so now we’ve finished our fibular fixation. Could - do you have a clamp? So now you can do a cotton test. We know it's unstable from our pre-op, right? And even just clinically, like it seems to move around. But I grab that fibula, and I pull on it. X-ray. You can see it’s gapping - not quite as bad you’d think, right? But still gapping. So we got to fix that. Yep. Alright.


Alright, so put your clamp down this way. Can I see a pickup and a knife? Alright, so we have the fibula fixed, and now we got to reduce the syndesmosis. And this is something I like to actually see. Alrights, so we’re going to open up this - and we know the syndesmosis is disrupted, so I don't have to worry too much about cutting the ligaments here in the front. We’re just going to come right over the front here, and this is the area of the syndesmosis, right here. Right here. Alright, there we go. Okay.

Despite all of that spraining and the x-ray dis - disruption, there's some - some of that capsule is left intact there, right? But it’s - it’s clearly incompetent cuz it’s letting us move more than it should. So that - that must have been torn off, and now it's kind of released in there. So this is interesting here. So, you know, I was dissecting over the front - and this is the syndesmosis right here, and it looks intact - and I was surprised because the talus is so subluxed, but if you look up in the front here, there’s actually a fracture line on the tibia. And so what's happened is there's a small talo fragment. So instead of the syndesmosis failing through the ligament, it just pulled off a little flake of bone here, and you can actually kind of see that on that x-ray there. So what we are going to do is just reduce that and pin it. So I've got it. I can see the front of it there. That's reduced nicely. So I'm just going to hold that, and then you're gonna pin it.

Just above my - just above my thing. Yep, and aiming north a tiny bit so you don't get in the joint. Good. Don’t need that anymore. Come north. X-ray there. There you go, and so now we’ve restored that relationship nicely. So I'm just gonna - I’m just gonna reduce the syndesmosis manually by compressing it a little bit, and then I want you to put another pin - this time through the fibula into the tibia. Yep. Okay. Yep. X-ray. X-ray. X-ray. X-ray. Go live for a second. Stop there. So I’d like to get that view. So that's a mortise view where you’ve got a nice dark line on the talus and a nice dark line on the fibula, and that means you're looking down a corridor of bone. So the rotation of the fibula has to be correct with respect to the talus, which is kind of our goal after all. This one we're pretty sure we got a good reduction of the fibula cuz we're looking at it and it's anatomic on the back side, so we're good there. Alright, that looks good. Alright.

So now we have to take out our previous cortical screw and replace that one with a syndesmotic screw. Alright. 2-5 Drill. So I like to put these on under seeing just to get them parallel to the joint. There is a debate about how many cortices and how many screws and what size, so I don't think there's really a right answer. You can use a tightrope if you like or some other kind of suture device, but I use two tricortical 3.5 millimeters screws. Parallel to the joint, right? Remember, you’re a little bit posterior. Yep. Not a lot - just a little. Can you see how that sprays? Come south for me a little bit. X-ray. X-ray. Good. Let me feel. So I can feel them in bone there - x-ray. Now that feels like bone. X-ray. Depth gauge. And that’s in bone there, see? 45.

With a gentleman like this young guy, I tend to take my syndesmotic screws out at 3 months. You don't want to take them out before that though. If you leave them in too much longer than that, sometimes they’ll break.

Listen. Drop that hand. Go in there. You alright? You don't want Achilles - should just be snug. X-ray. Good. Good. Alright, so pretty happy there. We're - we’re going to put independent screw fixation actually to fix this piece, but I want - you know, I want the extra - you know, this is a pretty small flake of bone, so I don't want to rely on one screw up here to protect our syndesmosis. So I have syndesmotic screws, but we’re going to put another screw in here. Parallel to the joint. We’re actually way over here. X-ray. Looks pretty good. That’s it. Yep. 2-5 next. X-ray. X-ray. Depth gauge. X-ray. That’s out the fracture. Is it really? X-ray there. 40 4-0 partially threaded cancellous screw please. Yep. That looks good. Wire driver. 2-5. Do you want me to get a new battery? We’re okay. X-ray. Excellent. Remember that angle, right? Way down there. X-ray. Good. X-ray. So see - that's nice.

For the syndesmotic screws, you’ve got to make sure you’re aiming from down to up. 3-5 cortical screw. It’s going to be a 40. If you hit the far side, it will destroy the fibula, alright? Cuz you don’t have a hole there. You don’t ever want to put anything down on power. Like I said, you don’t want to kill this - it’s just down. Alright, you don't want that cuz you can over-reduce that. X-ray. X-ray. X-ray there. X-ray. Let’s come to a lateral. So the rotation of the fibula looks good. The syndesmosis looks reduced, and we look like we have enough devices.

Now we just need to decide if we're gonna do the medial side. So there’s - there’s only two syndesmotic screws? The distal screw’s in Taloc-y's - so it’s - it’s actually in the tibia - not great bone there. It’s a pretty small flake, so I didn’t want to rely on - on just that. So the syndesmotic screws are doing the work, but that little screw there is kinda gonna help hold it. X-ray there. Good. So here we can see again a perfect lateral of the ankle, and we can tell that by the plafond as well as the talus. Our - our fibula is sitting posteriorly with respect to the tibia. It’s - you know, the - it's - it’s kind of centered at the junction between the middle and distal thirds of the tibia. So that’s - that’s approximately where you’re expecting to see his syndesmosis. Here we know we’re good, cuz we actually have that read in the front, reducing that - reducing the talo-fragment. Normally, you’d have a read right here actually looking at the syndesmosis. And you can see that’s right where it belongs, so that looks good. And then our joint looks good, so everything looks nicely there. And it’s just a matter of the medial side. Alright.


So he has a little pressure ulcer on the medial side. The skin looks good, but there's a little black ulcer. So we’re gonna have to be a little careful about that.

You know, and this is one that you can't do percutaneously cuz, you can see, it's all flipped around and caddywhompus. What are you worried about? To see the saphenous coming down here. Wheaties. I believe in a real generous incision on the medial side. You want to really see it and reduce it. If you look carefully, there's always infolded periosteum. You want to get a good - like I said, there’s nothing to be worried about. You want to protect the skin by keeping full thickness flaps. A - a lot of people do a curved incision like that - kind of is routine. I typically try to make straight incision. So I don't like to do that, but in him there's a little ulcer. The - the advantage of it is you - you really want to see the anterior portion of the reduction of the medial mal. That's going to be your reduction read. And then - but your screws are going to be coming in from a little bit further down, and so it kind of helps that way if you make a smaller incision. I - I kinda tend to think I like extensile, so - right. Try to make it straight if you're in trouble. For him, I think this is the right move.

Alright, so if you look right in here - this is real common. So this is - this thing failed in tension, alright? So this is the fracture. You can see - you can actually see the posterior tibial tendon is right back there. The kinda key thing here is this is the medial mal, and if you look in here, this is periosteum - and it's folded in so the - because it falls in tension, it’s going to suck the periosteum in and kind of buckle. So often it will be draped over here, kinda like this portion of periosteum in the back. But then in here, you can see this whole big piece of periosteum - you see that? That’s gotta - that’s what’s stopping it from getting reduced. You can imagine you’re trying to do that percutaneously. Yeah, you can’t do it. It’s not going to happen. You got to get that out of there. So I would actually cut this band of periosteum - cut it out. Right in the middle - back and forth. There you go. Then you’re going to flip this out of the way. And pull the periosteum back just a little bit, and now you can really get a good read, so. So some of this kind of stretch in from the periosteum is redundant. I’m just going to take that right after there’s a certain OE.

Time to release. I try not to just robotically put two screws up the medial mal. I want to look at the obliquity the fracture - you know, try to put them in perpendicular to the fracture. And you actually want to be able - here. And that’s going to lift - yep - up like that. Pretty good reed there. This anterior crux is really important. Let me see see if that’s reduced or not. Kind of in comminution and overall reduction.

So why don’t we check that with the x-ray? X-ray. There we go. So there’s your AP, and that’s an anatomic reduction, so save that. X-ray. Alright, so we’re happy with reduction of the medial side. We gotta proficiently help with a K-wire. I don't use cannulated screws to the medial side. I just like to use regular screws. So we took a 2-5 drill, and we’re going to use partially threaded cancellous screws. Alright, so here - where's the fracture line? Here. Yeah, so the obliquity of the fracture line is not very transverse like a normal ankle fracture; it’s a little oblique. Yep. So we're actually going to be up here - firing - firing this way. And we’re gonna do two screws. This K-wire’s gonna be where one of the screws is, and you can see that we like that. It’s a nice spot. So you can use that as a reference - right - for your other screw. Depth gauge please. Yeah, 40’s safe. Get a wire driver. X-ray there.

So that looks really nice. That’s great. Nice group placement there. The idea is to have that kind of around the corner - yeah. You got to be safe to the joint, but if you’re really around that medial side, it’s going to bother people. So I like to kind of tuck that in there like that. That looks really good. Alright, back out for a second.

So we’ve got one more screw, and then we’ll check our final X-rays. Do you have a screw driver? I am going to show you the angle. This one alright? Yep. So this is the angle of that last screw. Good. I’ll often leave the drill in cuz that just holds your angle. You're not going to use the depth gauge here cuz you know the length already.

You really have to have secure fixation when you're putting these in because the bone is pretty dense and those are can - can - or cancellous screws. So when they go through the medial mal, it’ll really put a torque on it. So here we have a monster bite on the other one that's really compressing it, so it's going to hold it. Otherwise, you really should have two points of fixation like a clamp and a screw or a clamp and a K-wire or something. You can see it’s interdigitating, which is nice. That's a nice bite.


Alright, so let’s come in for our final pictures - make sure we’re happy with everything. And as you can see, it’s hard to see through the Ioban, but there’s a little bit of a black mark there - and that’s the pressure from the having his ankle dislocated. X-ray. X-ray there. Save that. X-ray. Go live for a second. Stop there. Save that. And then let’s come to a lateral. So you can see the position of those screws are a little bit different than normal. The anterior one is more proximal, and that's because of the obliquity of the fracture; we wanted to start a little bit further up the malleolus to make sure it was perpendicular. X-ray. X-ray. X-ray. Xray. X-ray. X-ray there. X-ray there. Go live for a second. Stop there. X-ray there. X-ray there. Save that.

So there’s our lateral again. You can actually see the fibula behind that plate. We’ve got our anatomic reduction there, so we know we got our length. And then the obliquity of those screws is very different than normal, but that’s cuz - once again, it’s an oblique fracture on the malleolus, and we want to stay perpendicular. That looks good. Alright.


So on the skin, I try to use a no-touch technique with my pickups. You know, I use - I don't ever pinch the skin. I'm using it as a hook to pull and push, but I don’t pinch. Particularly high-energy ankle injuries - calcaneus, talus, pylon fractures - high energy ankle fractures - it’s worth doing it.

So this is that little bit of extra here, and you know, we made our incision well clear of it. And the skin edges all look very healthy, so, you know, I'm hopeful. You know, we didn't have too much of a choice. If it was minimally displaced, I probably would have left it even if it - you know, was displaced to begin with - if it reduces nicely, but it was flipped around really badly, so. You know, the - the soft tissue’s only going to get worse.

I tend not to do horizontals. You know there are some - some plastic surgery stuff to show that - that vertical and simples are a little bit better for the blood supply. You know, I think it's really important - you know, I think a lot of people put their stitches too close together. You know, you got to give space to let it breathe, and you don't want to put them in too tight. You know, they’re only going to get tighter as the soft tissue’s swelling increases. Right. And again, a nice closure can really help prevent a lot of wound problems.

He's going to need a Hollywood splint. So what that means is I leave me splints on until follow-up. You do? And someone like this - they’re going to complain of pain. So someone’s going to release the splint, so I want you to put a sterile dressing underneath it they are not to remove.


So there are a number of outcomes for ankle fractures. You know, radiographically - you know, we're going to follow this patient to make sure that the fractures unite. Clinically, the early worry is infection, and so we need to follow him very closely to make sure he doesn't have an infection. The infection rate of ankle fractures is actually fairly high; it probably ranges somewhere between 3 and 5 percent. And, you know, this guy's definitely at increased risk because of the high energy nature of his injury and the medial ulcer that he had.

And then as far as clinical outcome measures, there's been a lot of development regarding that, and here we do something a little bit differently than lot of centers; we use computer adaptive testing and do - we use a - an outcome measure called “The Promise” measures, and these were developed with the NIH. And - and - and they are a good way of getting a very specific outcome on your patients, and there's some software that you can use online actually to do that. So he’ll be followed clinically but also with outcome measures.

Infection is a big problem with these injuries, and I think it happens a lot more than we think. And being very careful with the soft tissues, waiting if there's a lot of swelling, and saying you - know this is - we just have to wait this out, and waiting two weeks for the swelling to come down I think is completely appropriate a lot of the time.

And then from a surgical standpoint, once you're in the operating room, I think, you know, respecting the soft tissues, respecting the blood supply to the bone, not stripping the fracture fragments beyond what you need to - to see the reductions - it’s really important to get the things to heal. And then really focusing on getting that fibular length. If you can get an anatomic reduction, it's easy, but a lot of times - if it's comminuted, you’re not going to be able to do that. And - and restoring the fibular length is one of the most important things in as far as restoring ankle stability and - and patient outcomes, so I think making sure you get it out to length is important. And we discussed in the case a little bit about how to do that with the x-rays if you can't get an anatomic read.

And then beyond that - regardless of what you do at the end of the case - the talus is squarely under the - the tibia, and it's secure. You know, checking that syndesmosis, and making sure it's okay. And making sure everything's reduced is really important.