Open reduction internal fixation ankle

PREOPERATIVE DIAGNOSIS:
Left bimalleolar ankle fracture, unstable.
Right Weber A lateral malleolus fracture, nondisplaced and stable.

POSTOPERATIVE DIAGNOSIS:
Left bimalleolar ankle fracture, unstable.
Right Weber A lateral malleolus fracture, nondisplaced and stable.

PROCEDURE PERFORMED:
Open reduction internal fixation, left lateral malleolus.
Application of short leg splint, right lower extremity.

ANESTHESIA: General.

DESCRIPTION OF THE PROCEDURE: After obtaining informed consent, was brought to the operating room whereupon the smooth induction of general anesthesia was performed the doctor. The patient was positioned in supine fashion on the operating room table and the bilateral ankles were evaluated under static and stress views fluoroscopically. Neutral and valgus stress views of the right ankle demonstrated no displacement of the distal lateral malleolus fracture or the mortise. However, on the left displacement of the lateral mortise and talar tilt was noted with valgus stress confirming instability and necessity for operative stabilization. Therefore, a bump was placed under the left hip, a tourniquet was placed on the left proximal thigh, and the left lower extremity was prepped and draped in the standard sterile fashion. After exsanguination of the extremity with an Ace wrap, the tourniquet was inflated to 250 mmHg.

An approximately 8 cm incision was made in longitudinal fashion over the distal lateral malleolus. The skin was dissected sharply and the subcutaneous tissue was dissected bluntly down to the level of the periosteum which was incised sharply to expose the bone. The oblique fracture pattern with mild nondisplaced comminution was identified about the lateral malleolus at the level of the syndesmosis. Once the bone was fully exposed, the fracture was reduced and stabilized using a lobster claw clamp. The bone quality was noted to be quite soft, therefore, stabilization with a locked one-third tubular plate was selected as opposed to the usual nonlocking plate. A six-hole locked one-third tubular plate was selected from the Synthes set and contoured to match the lateral aspect of the distal fibula. Three holes were placed distal to the major fracture line and three holes proximal. Proximally, three locking 3.5 mm cortical screws were placed in a bicortical fashion. Distally, the two distal-most screws were placed in a unicortical fashion to avoid the lateral ankle mortise. The third screw was placed directly at the subchondral bone just below the fracture line. The reduction appeared anatomic and stable under direct visualization. This, as well as good hardware placement, was confirmed using intraoperative fluoroscopy in AP and lateral views.

The wound was copiously irrigated with normal saline and closed in layers with 2-0 Vicryl suture used for the fascia in a simple interrupted fashion. The subcutaneous tissue was closed using 30 Monocryl in simple buried fashion. Staples were placed at the level of the skin. A sterile dressing was applied and a well padded, well molded splint was placed on the left lower extremity.

The tourniquet was released for a total tourniquet time of 53 minutes. There were no intraoperative complications.

At this point, the right lower extremity was splinted with a well padded, well molded short leg splint on the right.

The patient was awakened from anesthesia and taken to the recovery room in stable condition.

ESTIMATED BLOOD LOSS: Minimal.

PLAN: Postoperatively, the patient will be for strict non-weight bearing and elevation of bilateral lower extremities. She will be discharged to home when she is comfortable on p.o. pain medication, tolerating a diet, and able to transfer independently. Physical therapy consultation will be obtained if necessary. She will return to my office on for wound check, x-rays in plaster, and a change to bilateral short-leg casts.

codes: 
Code: 
27814
Code Type: 
CPT
Code: 
27786
Code Type: 
CPT
Code: 
79.36
Code Type: 
ICD-9
Code: 
93.54
Code Type: 
ICD-9
Code: 
0QSG04Z
Code Type: 
ICD-10
Code: 
2W3LX1Z
Code Type: 
ICD-10