Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table, with the affected limb elevated and supported to allow for optimal access to the lateral, posterior, and medial aspects of the ankle.

Anatomical surgical approach:  A posterolateral approach was utilized for fixation of the posterior malleolus, followed by an anterolateral approach for syndesmotic stabilization. A modified medial approach was employed for addressing the medial gutter and deltoid ligament reconstruction. Extensive debridement of scar tissue from the syndesmosis and medial gutter was performed.

Intraoperatively, a mobile nonunion of the fibula was identified, contributing to valgus loading and failure of initial fixation. The fibula was lengthened to match the contralateral side and stabilized with locking plate fixation. Deltoid ligament reconstruction and syndesmotic stabilization were performed using screws and anterior inferior tibiofibular ligament (AITFL) repair. Autologous distal tibial bone grafting combined with osteogenic synthetic material was used to address the fibular nonunion.

Postoperative protocol:   Postoperatively, the patient followed a conservative rehabilitation protocol with non-weight bearing for three months. Early active and passive range of motion exercises were initiated with physical therapy once the wound had healed.

Follow up:   Not specified.

Orthopaedic implants used:   Locking plate for fibular fixation, syndesmotic screws, AITFL repair constructs, distal tibial autograft, osteogenic synthetic material for fibular nonunion.