Surgical Discussion

Patient positioning:  The patient was positioned supine with the affected limb externally rotated to facilitate access to the posteromedial aspect of the ankle.

Anatomical surgical approach:  A posteromedial approach was utilized, involving an incision along the posterior border of the medial malleolus. Careful dissection was performed to retract the flexor retinaculum and expose the obstructing tendons, allowing for reduction of the talar head through the buttonhole in the plantar talonavicular capsule.

The reduction was challenging due to the buttonhole entrapment of the talar head. Initial attempts with external fixation and various instruments were unsuccessful. Successful reduction was achieved by addressing the buttonhole entrapment directly through the posteromedial approach. The subtalar joint was noted to be in good condition post-reduction, although the risk of avascular necrosis remains high.

Postoperative protocol:   Postoperative rehabilitation included non-weight bearing with immobilization in a splint for 6 weeks, followed by gradual weight-bearing as tolerated with physical therapy focusing on range of motion and strengthening exercises.

Follow up:   Not specified

Orthopaedic implants used:   External fixator, 2.5mm Schanz pins