Open Reduction Internal Fixation of Distal Fibula Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left pilon fracture.
2. Left distal fibular malunion.
POSTOPERATIVE DIAGNOSES:
1. Left pilon fracture.
2. Left distal fibular malunion.
OPERATION PERFORMED: Open reduction and internal fixation of left distal fibula.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: The patient is now six plus weeks status post definitive treatment of his left pilon involving the weightbearing surface. We were unable to stabilize his distal fibular fracture due to the fracture blister, and thus, it was left not reduced. We were able to return at this time to correct the deformity on his distal fibula to correct the mortise. Operative consent was obtained prior to the procedure.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed under general anesthesia. Preoperative antibiotics were given. Time-out was performed to identify the correct extremity. The left lower extremity was sterilely prepped and draped in the usual fashion with the leg exsanguinated.
Approach to the distal fibula was carried out. We were able to identify the fracture site. The oblique osteotomy was able to be made with an osteotome. Once this was able to mobilize the soft tissue around the area of osteotomy, an 8-hole 3.5 DCP plate was able to be contoured to lengthen the distal fibula. Once we were done with this, we were able to get six cortices proximally and one cancellous screw distally and one syndesmosis screw to lengthen the fibula and reduce the malunion. Intraoperative film was taken to verify our reduction. We were satisfied with the mortise as well as the screw placement.
Once that was done, the wound was copiously irrigated. Closure was then performed in layer. Sterile dressing was placed, and the patient was placed in a well-padded short leg posterior splint. We will see the patient back in two weeks for staple removal and start range of motion of his left ankle.
