Pearls & Pitfalls Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I Preparation characterize fracture pattern, comminution, metaphyseal bone loss, shortening, and angulation evaluate soft tissue injury, open wounds, fracture blisters, deformity, compartments external fixator often used for acute management prior to ORIF (10-14 days) Positioning supine with feet at end of bed on radiolucent table c-arm from contralateral side. Approach anterolateral approach: between peroneus tertius and brevis, incision in line with 4th ray anteromedial approach: medial to tibialis anterior tendon sheath, incision centered on distal tibia then curving medial across joint Bony Preparation and Reduction identify fracture site and book open anterolateral vs. anteromedial fragment tamp down and restore articular surface join smaller fragments to larger fragments in a systematic fashion with kwires, then join articular surface to tibia shaft Fixation 2.7 vs. 3.5 mm lag screw anterior to posterior to join large fragments together anterolateral vs. medial plate with at least 3 screws above (3.5 cortical) and 3 below (2.7 mm locking). allograft chips and autologous bone graft for distal tibia bone defect, tamp into place Postoperative non-weight bearing in splint vs. external fixator, crutches for ambulation, serial compartment checks evaluate union and fracture consolidation on serial xrays range of motion exercises and advance weight-bearing at 2-3 months Planning & Preparation Template Fracture characterize fracture pattern, amount of comminution, metaphyseal bone loss, shortening, and angulation commonly 3 fragments according to ankle ligaments: medial malleolar (deltoid), anterolateral (AITFL, Chaput), and posterolateral (PITFL, Volkmann) fragments CT often performed after placement of spanning ankle external fixator to delineate fracture fragments once length restored 75% of fractures have associated fibula fractures Extremity Exam evaluate degree of soft tissue injury, open wounds, swelling (fracture blisters), and deformity, await return of skin wrinkles prior to ORIF to decrease wound complications for 10-14 days spanning external fixator uses ligamentotaxis to decrease soft tissue swelling document distal neurovascular status check for signs of compartment syndrome identify comorbidities (diabetes) and social factors (smoking) that correlate with complications and poor outcomes Imaging AP/Lat/Mortise views of ankle, AP/Lat views of tibia/fibula CT scan of ankle after external fixator placement location and angulation of fracture fragments influences surgical approach severely comminuted fractures with poor bone quality may require definitive management with external fixator vs. tibiotalar arthrodesis Equipment & Positioning Equipment Synthes Variable Angle Locking Ankle Fracture System Synthes Small Fragment Set 1.2mm kwires osteotomes c-arm fluoroscopy radiolucent OR table Position patient supine with feet at the end of the bed, small bump under ipsilateral thigh, tourniquet on thigh if external fixator in place need to scrub down frame and pins thoroughly as this is a source of contamination OR Setup and C-arm radiolucent OR table c-arm from contralateral side perpendicular to bed Approaches Anterolateral internervous plane between peroneus tertious and brevis, mark out lateral malleolus and course of peroneus tertius incision 2-3cm anterior to anterior border of fibula in line with 4th ray down to ankle joint identify and protect SPN in subcutaneous tissue immediately under skin incise fascia and extensor retinaculum in line with skin incision anterior compartment tendons elevated and retracted medially can extend distally to talonavicular joint if needed Anteromedial mark out medial malleolus and distal tibia crest, incision medial to tibialis anterior tendon sheath incision centered on distal tibia then curving medial across ankle joint elevate full thickness skin flaps, leave tibial anterior tendon sheath intact anterior compartment tendons elevated and retracted laterally Surgical Technique Approach often necessary to leave external fixator fully or partially intact during approach and fracture reduction/fixation to maintain traction and fracture length if multiple approaches used must maintain ~7cm distance between full thickness skin flaps to decrease wound complications mark out desired approach, exsanguinate extremity and inflate tourniquet incision with 15blade through skin, tenotomy scissors for subcutaneous tissue maintain full thickness flaps, incise fascia and extensor retinaculum in line with skin incision knife down to bone, subperiosteal elevation of muscles and tendons off of anterior border of tibia and fibula with wood handled elevator and knife need to visualize extent of fracture fragments medially and laterally Bony Preparation and Reduction identify distal tibia fracture site and book open anterolateral vs. anteromedial fragment, clean out with rongeur, curettes, dental pic use osteotomes to tamp down impacted central piece a central bone void should remain, inspect talus for OCD lesions at the same time (microfracture as needed with kwire) attach medial malleolus to impacted central fragment and lateral malleolus with kwires can use additional medial incision to expose medial fragment and reduce using k-wires need to join smaller fragments to larger fragments in a systematic fashion with kwires to restore articular surface, then join articular surface to tibia shaft use pointed reduction clamps to reduce larger fragments Fixation once adequate reduction obtained place 2.7mm lag screw (2.0 mm drill) anterior to posterior to join fragments together place anterolateral vs. medial plate with at least 3 screws above (3.5 cortical) and 3 below (2.7 locking) key is metadiaphyseal screws distally in subchondral bone to support distal tibia articular surface, need to be parallel to joint check plate contour and make sure no riding up off the distal tibia place medial malleolus 1/3 tubular plate with 3.5 cortical screws to buttress down medial fragment insert allograft chips and autologous bone graft for distal tibia bone defect Fibula Fixation (Optional) clean out fracture site using freer to open fracture site curettes, small rongeur, dental pick, and irrigation to remove hematoma and interposed soft tissue use lobster clamp and pointed clamps to reduce fracture using hand rotation and contralateral thumb to help guide fragments together place 2.7mm lag screw (2.0 mm drill) perpendicular to fracture line if possible determine length of 1/3 tubular plate needed (~6-8holes) and check placement on fluoro place plate directly lateral for neutralization and insert 3 screws (3.5 mm) above and below fracture site Confirm Hardware Position take final fluoro AP/Lat/Mortise of ankle and AP/Lat of tibia/fibula check screw lengths to ensure no penetration into ankle joint or surrounding tendons check limb length, rotation, and alignment Closure Irrigation & Hemostasis deflate tourniquet irrigate and cauterize peripheral bleeding vessels place medium hemovac drain exiting proximal and lateral Closure fascia and retinaculum closure with 0-vicryl, watch out for SPN laterally subcutaneous with 2-0 vicryl and skin closure with 3-0 nylon Dressing soft incision dressings and postmold sugartong splint for immobilization vs. pin site dressings if external fixator maintained Postoperative Care Immediate Post-op non-weight bearing in splint vs. external fixator, crutches for ambulation serial compartment checks x24 hours drain out post-operative day 1 DVT prophylaxis x3 weeks 2 Weeks wound check sutures removed repeat xrays of ankle and tibia/fibula 8-12 Weeks xrays to evaluate union and fracture consolidation range of motion exercises to ankle advance weight bearing status and rehabilitation Complications Document Complications wound breakdown (10%) superficial/deep infection (5-15%) symptomatic hardware malunion nonunion post-traumatic arthritis (30-70% depending on articular injury) ankle stiffness neurovascular injury