DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Displaced right distal fibular fracture.
POSTOPERATIVE DIAGNOSIS: Displaced right distal fibular fracture.
OPERATION PERFORMED: Open treatment with internal fixation, right distal fibular fracture.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, PA-C
ANESTHESIA: General
DESCRIPTION OF OPERATION: After satisfactory general anesthesia was obtained, with the patient in the supine position, a pneumatic tourniquet was placed up to the right proximal thigh with appropriate padding. The patient was given 1 gram of intravenous Ancef as prophylaxis prior to the start of procedure. The right side was bolstered upward and supported with a beanbag. All bony prominences were carefully padded. Great care was taken in patient positioning.
Fluoroscopy was used to inspect the ankle. External rotation stress revealed no obvious widening or diastasis of the syndesmosis or medial tibiotalar crease space. There was moderate displacement in the distal fibular fracture noted. A lateral longitudinal incision was then made over the distal fibular fracture site of length of approximately 12 cm. Sharp and blunt dissection was performed. Hemostasis was obtained with electrocautery. The superficial peroneal nerve was identified and noted to be lying over the distal fibula at the proximal aspect of the wound. This was carefully freed up and transposed slightly anteromedially. The nerve was carefully protected throughout the procedure.
The fibular fracture site was exposed in a subperiosteal fashion. Organized hematoma was debrided. The fracture site was irrigated with normal saline solution. Fracture surface was exposed in subperiosteal fashion. The capsule was noted to be fairly intact over the anterolateral ankle, and visualization of the tibiotalar joint was not readily afforded. It was not felt that capsulotomy was indicated.
Open reduction of the fracture was carefully performed, obtained with reduction clamp. Lag screw fixation was accomplished using 2 AO titanium screws. The first was a fully-threaded cancellous screw, and the second, a fully-threaded cortical screw. Both were countersunk and inserted in wide fashion. Despite relatively soft bone quality, satisfactory fixation was achieved. The reduction clamp was removed. A 6-hole tibial plate was then contoured to the lateral distal fibula. This was affixed with AO titanium screws. Two 4.0 mm fully-threaded cancellous screws were used distally, and three 3.5 mm fully-threaded cortical screws were used proximally. Satisfactory fixation was achieved again, despite the soft bone quality.
The wound was irrigated with copious amount of normal saline solution. The ankle was inspected with FluoroScan, demonstrating anatomic-appearing alignment and good hardware position. External rotation stressing did not reveal any apparent instability by the syndesmosis with deltoid.
The wound was irrigated with copious amount of normal saline solution. The wound was closed in layers using 2-0 Vicryl interrupted suture to close the periosteum and deep fascia in interrupted fashion. Care was taken to protect the superficial peroneal nerve. The subcu was approximated using 2-0 Vicryl interrupted buried sutures. Skin was closed using staples. Regional ankle block was performed using approximately 30 mL of 0.5% plain Marcaine solution. Sterile dressings were applied.
The tourniquet was released with good reperfusion of the foot noted. There was good color and capillary refill. An extremely well-padded, short-leg fiberglass cast was then applied to the foot and ankle in neutral alignment. Once the cast had hardened, it was split anteriorly, removing a 1 cm section. Anesthesia was reversed. The patient returned to the recovery room in stable condition. Instrument and sponge counts were correct. No complications.
