Surgical Discussion

Patient positioning:  The patient was initially positioned prone to allow access to the posterior aspect of the ankle joint. This positioning facilitated the posteromedial and posterolateral approaches for reduction and fixation of the posterior malleolus.

Anatomical surgical approach:  A posteromedial approach was made by incising along the medial border of the Achilles tendon, retracting it laterally to expose the posterior aspect of the tibia. A separate posterolateral approach was performed by incising along the lateral border of the Achilles tendon, retracting it medially to access the fibula and lateral aspect of the posterior tibia. The fibula was reduced and temporarily held with Kirschner wires. The articular surface was disimpacted, bone grafted, and temporarily held with wires before applying a buttress plate to each fragment through their respective approaches.

The surgeon noted that reducing the fibula first and holding it with wires facilitated the reduction of the posterior malleolus. The fibula was not plated initially to avoid obstructing radiographic visualization during posterior malleolus reduction. After addressing the posterior elements, the patient was repositioned supine to address the small, comminuted medial malleolus fracture, which was fixed using a separate medial approach.

Postoperative protocol:   Postoperatively, the patient was placed in a splint with non-weight bearing status for 6 weeks. Progressive weight bearing was initiated at 6 weeks, with full weight bearing anticipated by 10-12 weeks post-surgery.

Follow up:   Not specified

Orthopaedic implants used:   Buttress plates, Kirschner wires, bone graft