Surgical Discussion

Patient positioning:  The patient was positioned supine with the injured leg slightly elevated

Anatomical surgical approach:  A limited medial approach was used for the tibia to directly address the medial malleolar fragment and allow for MIPO technique application. The posterior malleolar fragment was addressed through indirect reduction techniques. Percutaneous techniques were employed for fibular stabilization using a 2.5mm titanium elastic nail inserted antegrade, avoiding the compromised lateral soft tissues.

The operative strategy was adapted to manage both the complex fracture patterns and the significant soft tissue injury. The decision against further syndesmotic fixation was made considering the satisfactory stabilization of the posterior syndesmosis and concerns over exacerbating soft tissue damage. The use of a titanium elastic nail for the fibula allowed for minimally invasive stabilization, respecting the soft tissue envelope.

Postoperative protocol:   Postoperative rehabilitation included non-weight bearing mobilization in an ankle orthosis for six weeks, followed by a gradual return to weight-bearing as tolerated.

Follow up:   Necrosis still resolving laterall at 10W (photo). RO TENS at 12weeks (fluro image)

Orthopaedic implants used:   Fragment-specific screws for tibial fixation; MIPO Syntehs distal medial locking plate; 2.5mm titanium elastic nail for fibular stabilization.