Surgical Discussion

Patient positioning:  Supin with a 45deg bump

Anatomical surgical approach:  Direct lateral

The patient was positioned supine on a radiolucent operating table, with the right leg elevated on a 45-degree pillow. A tourniquet was applied to the ipsilateral thigh, followed by a sterile preparation and draping of the operative field. A timeout was conducted, and two grams of cefazolin antibiotics were administered. Preoperative computed tomography (CT), magnetic resonance imaging (MRI), and plain film imaging revealed a perched anterior dislocation of the proximal tibiofibular joint. Notably, the common peroneal nerve was not entrapped, and there was no identifiable injury to the structures of the posterolateral corner, including the popliteus complex and the lateral collateral ligament. Local soft tissue examination indicated a rupture of the capsule and stabilizing ligaments of the proximal tibiofibular joint. A longitudinal incision was made over the palpable fibular head, measuring approximately seven centimeters in length, followed by subcutaneous dissection and splitting of the fascia. Exploration of the biceps muscle allowed for identification of the course of the peroneal nerve along its posterior margin. Dissection continued to the level of the fibular head, where neurolysis and mobilization of the nerve around the neck of the fibula were performed, ensuring no iatrogenic injury to the nerve during repositioning. Attempts to reduce the perched dislocation through manual manipulation were unsuccessful. Consequently, a secondary soft tissue window was created anterior to the tibiofibular joint, and the introduction of a blunt periosteal elevator facilitated the application of leverage, resulting in a satisfactory spontaneous relocation of the joint to its anatomic position. Live fluoroscopy demonstrated significant diastasis and instability of the joint despite anatomic reduction. Therefore, the decision was made to perform TightRope stabilization, ensuring protection of the nerve and utilizing multi-plane arthroscopy. The introduction of a 3.7-millimeter cannulated drill was executed in a quadricortical manner from a posterolateral to anteromedial direction, followed by the insertion of an Arthrex fibula syndesmosis TightRope, which was tensioned on the lateral side. Subsequent dynamic fluoroscopy confirmed anatomic reduction and stability. Joint irrigation was performed, followed by reinspection of the nerve, which exhibited no iatrogenic injuries. The procedure concluded with closure of the fascia, subcutaneous tissue, and running sutures for the skin. Sterile dressings and an elastic bandage were applied. No postoperative orthosis was deemed necessary.

Postoperative protocol:   FWB. No port 3Months