Surgical Discussion

Patient positioning:  Recovery position.

Anatomical surgical approach:  Lateral and medial posteromedial.

My approaches were planned to allow confident reduction of the fibular comminution which is more predictable through a direct lateral approach and needing access to the die punch I need to enter through the bed of tibialis posterior. Therefore, a lateral and MPM is easiest in this case. The MPM can be curved anteriorly along the tib post course to allow access the anterior collicular fracture.

The MPM approach allowed me to open the PL fragment fracture plane to reduce the die punch with a small osteotome. This was K wired in position before application of plate. The PL fragment was then reduced and fixed with a type 3 plate, which fitted best in this case. Note, that the most lateral distal screw is not used as this would encroach on the incisura. The initial buttress screw in the type 3 plate was removed following fibular fixation, to allow syndesmosis fixation.

Postoperative protocol:   2 weeks NWB in a back slab. Conversion to Vacuum cast boot at 2 weeks to allow full weightbearing. Wean out of boot at 6 weeks.

Orthopaedic implants used:   Orthosolutions (Volition)