DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left open grade 2 pilon fracture.
POSTOPERATIVE DIAGNOSIS: Left open grade 2 pilon fracture.
OPERATIONS PERFORMED:
1. Removal of external fixator, left ankle.
2. Open reduction and internal fixation, left pilon fracture.
3. Open reduction and internal fixation, left fibular fracture.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 250 mL.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and laid supine on the OR table. After general anesthesia was induced, the left lower extremity was prepped and draped in the usual sterile fashion after a tourniquet was placed upon his left thigh. The external fixator was kept in place. Next, the left lower extremity was prepped and draped in the usual sterile fashion.
An anterolateral approach to the pilon was performed using approximately a 12 cm incision. This incision was extended up in line with the fourth toe. We did not go anteromedially because of the previous traumatic wound, which was a transverse wound over the anteromedial aspect of the distal tibia. Dissection was carried down to the level of the extensor digitorum longus tendons, and the interval between this tendon and the tibialis anterior was opened. Care was taken to protect the neurovascular bundle.
Dissection was carried down to the level of the fracture. The preoperative CT scans, which had been reviewed, showed the articular surface to be well reduced without any comminution. There was a comminuted anterior metaphyseal segment. C-arm fluoroscopy was used to confirm overall acceptable alignment of the distal tibia on both the AP and lateral fluoroscopic images. The anterior portion of the distal metaphysis was noted to be comminuted. A 7-hole anterolateral locking plate from the Synthes set was selected and fashioned to the anterolateral aspect of the tibia. The distal portion, which was a locking plate portion of the plate, was positioned directly over the comminuted segment and this segment was pushed down using a ball spike obtaining a better reduction of this segment.
Next, four screws were placed in the proximal fragment followed by four locking screws in the distal fragment. Excellent fixation was obtained. C-arm fluoroscopy was again used to confirm excellent position of the plate as well as all screws, none of which were intra-articular. Good reduction of the fracture was obtained. Next, the wound was thoroughly irrigated and closed in layers. Staples were used to close the skin. Attention was then directed towards the fibular fracture.
A posterolateral incision was made ensuring that there was at least 6-7 cm skin bridge between the anterolateral skin incision and the lateral incision for the fibula. Dissection was carried down proximally to the level of the fibula. The distal fibula was highly comminuted, and we did not feel that we could get good screw purchase in the distal fragment. The purpose of plating the fibula was simply to obtain fixation proximally and use the plate as a buttress over the distal comminuted portion. An 8-hole composite plate from the DePuy set was selected. The distal one-third tubular portion of the plate was contoured to fit over the distal aspect of the fibula. Two screws were placed in the proximal fragment.
C-arm fluoroscopy showed that the tibiofibular space was widened. Therefore, one syndesmosis screw was placed across the four cortices through the fibular plate. This screw was placed in lag screw fashion, and excellent compression was obtained bringing the tibia and the fibular joints together in more of an anatomic position. Next, the wounds were thoroughly irrigated with normal saline. The lateral incision was closed using 2-0 Vicryl suture followed by staples for the skin. Prior to closure of both wounds, the tourniquet had been deflated, and hemostasis was obtained. Next, sterile dressings were applied.
Of note, the external fixator had been removed prior to final fixation of the tibial fracture. The ex-fix pins were removed at the conclusion of the procedure, and the ex-fix pin sites were curetted out and irrigated with normal saline. Sterile dressings were applied over these wounds as well. The patient was then placed into an AO splint that was well padded. The patient was then awakened from anesthesia, transferred back onto a stretcher, and taken to the PACU for recovery. There were no complications.
