Open Reduction and Internal Fixation of a Trimalleolar Ankle Fracture
After the operative leg has been marked, anesthesia is induced and the patient is brought to the operating room.
- Positioning of Leg
- Patient positioned supine with arms out or tucked
- Trochanter roll placed under patient
- Prep/Sterilization of Surgical Site
- Shave surgical site
- Wash and sterilize entire leg
- Cover Site with Ioband Adhesive Sterile Sheet
- Seal calf and toes
- Make Skin Markings
- Apply Tourniquet
- Exsanguinate the extremity up to the thigh
- Apply pressure
- Surgical Time Out
- Identify patient, problem, correct side, procedure to be performed, medications given prior to procedure, expected time to completion
- Make a Lateral Skin Incision
- Along subcutaneous border of fibula
- Angle slightly anteriorly distally
- Incision into Fascia
- Superficial peroneal nerve branches at subcutaneous or fascial level
- Once on bone, make space for plate
- Expose fracture site with a 2mm periosteotomy on each side
- Clean out fracture site with small curette
- Perform Fibular Reduction with Pointer Forceps
- Grab distal fibula and pull traction to achieve length
- Fit and Contour Fibular Plate
- Contour six-hole ⅓ tubular plate using locking towers for grip to match distal fibula
- Position and use K-Wires to fix provisionally
- Proximal Non-locking Screw
- Drill through both fibular cortices with a 2.5mm drill
- Use depth gauge to determine length
- 4.0mm non-locking screws should be used initially to contour plate to the bone
- Note: Using slightly longer screws allows for better purchase in the medial cortex
- Distal Non-locking Screw
- Repeat above steps
- Fill Remaining Gaps with Locking Screws
- It is important to use locking screws, especially distally at the level of the lateral malleolus, to prevent skin irritation due to prominence
- Once complete, use clamps to pull on fibula (Cotton test) and assess status of syndesmosis
- Exposure of Syndesmosis
- Provisional K-Wire Fixation
- Fix the Tillaux fragment to the tibia
- Use a second K-Wire to fix the fibula to the tibia
- 1st Syndesmotic Tricortical Screw
- Drill through three cortices with 3.2mm drill
- Drill to, but not through, the medial cortex of the tibia
- Measure with depth gauge
- Use a 4.5mm cortical screw
- Lag Screw fixation of Tillaux Fracture
- Drill through fragment into tibia with 3.2mm drill
- Use 4.0mm partially threaded cancellous screw to lag by design
- 2nd Syndesmotic Tricortical Screw
- Repeat steps for 1st syndesmotic screw
Medial Malleolus Fixation
- Prep Medial Side
- Mark approach - in this case, a curved approach anterior to the medial malleolus
- Make Medial Incision
- Be cautious of the posterior tibial tendon and saphenous nerve
- Reduce Fragment with Pointed Reduction Clamps
- Provisional K-Wire Fixation
- Use two K-Wires to keep fragment from rotating
- 1st Tibia Lag Screw
- Drill though fragment into tibia with 3.2mm drill
- Use 4.0mm partially threaded cancellous screw
- 2nd Tibia Lag Screw
- Repeat above steps
- Take AP and Lateral X-ray Images to Confirm Reduction and Construct Placement
Irrigation and Wound Closure
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.
My name is Michael Weaver, I am a trauma surgeon here at the Brigham and Women's Hospital in Boston, and today we have a 23 year old gentleman with a trimalleolar ankle fracture. He was involved in a high-speed motor vehicle collision last night and presented with a dislocated ankle and a pulseless foot. So we reduced in the emergency room and placed in a splint and now we're going to be taking care of his ankle fracture definitively.
One of the important things to recognize on the AP radiograph is the direction of dislocation. In this case he has a lateral dislocation and that's going to be important because that's going to be directing your fixation to try to prevent failure and redisplacement in the future. And then also it's important to recognize the syndesmosis injury here. Here his talus is dislocated into the space of the syndesmosis and it's obviously wide, so that's something that we're going to have to address surgically. I typically like to perform an open reduction of syndesmosis. I think it's really important to really see the reduction. A lot of studies show that it's difficult to get that perfect especially if you were relying on radiographs alone. And a lot of CT data postoperatively show there's some residual subluxation of the syndesmosis, so I like to really see that. And then in his case he does have some threatened skin on the medial side of so we may not be able to fix the medial malleolus today. That is just going to depend on how things look, but he has some swelling on the lateral side. He's got a good wrinkle sign and the skin looks appropriate to proceed. So we're going to start on the lateral side and go from there.
So when I'm doing ankle fracture surgery I like to have platform built up so I can get orthogonal views without changing the position of the legs. So I like to build it up on a platform and then also a pretty good bump under the hip so the foot points straight up. That gives you good access to the lateral and medial side. I think especially in trauma patients is important to do a pre prep, so you can use hibiclens or alcohol or something, but you want to get that skin really clean before before you do your final prep.
It's supple. One of the important things particularly when you're doing surgery around a high-energy ankle injury is the quality of the skin. This patient young patient with good skin. He's got a fair amount of swelling, but the important thing is the the skin is still dull - it's not shiny. If you have shiny skin that's a sign that it's not going to take an incision very well. And he still develops nice wrinkles. The other thing that I find this really important is that it's supple you know you can move that skin around. If things get kind of woody and tight and that's a really bad sign you're going to have trouble closing it, but I think this looks like it's going to be okay.
Actually looking might help on something we need to get that stuck so we can get it wrapped here. Flip a clip below or something. This is my standard setup for an ankle fracture. We got our platform. I like to use these kind of disposable drapes that let you get lateral views to keep yourself sterile and then I'm pretty fanatical about it that I like a ioband covering everything. Alright there we go and then just a small little towel under the under the leg.
Incision is going to be just a little bit posterolateral. So one trick is you can feel the fibular head here. So if you feel the fibular head to the tip of that that's going to be a straight line between the two. You want to be slightly behind it so I think you're really... You don't want to be too far in the back especially in this because you're going to see your syndesmosis over the front. Up in a few seconds. Tourniquet up please. Alright.
He's got a broken right ankle. We're going to do surgery to fix it. He's in the supine position. Right side is marked and draped. We have a small fragment locking set of the room. So we use ancep and vancomycin for all cases that involve metal cause there's a higher incidence of MRSA infection of the community now. Squeeze in the other leg for DVT prophylaxis. This case is going to take about an hour to slightly longer than that. We're not anticipating any blood loss or critical steps.
Incision. So the thing to watch out for here obviously is the superficial branch of the peroneal nerve. That's going to be proximally. The thing with that nerve is it lies right on the faccia so you can be in the fat on your okay. You know some people say you know you've got 7/10 centimeters from the tip of the malleolus, but I find the course is pretty variable, so I don't like to cut down to bone anywhere. You can go a little deeper. A couple wheaties please. I don't like to spread too much cause you want to dissect sharply. Pro-tip. There you go. So I want you to cut. There you go. There it is. It's broken. Safe and then go. That's what I mean by sharply. You don't want to rip it apart. You want to cut it. I thought you meant to find my nerve. Yeah I do if you find it. But if you don’t find it. Those are the peroneal tendons right there, right.
Now you come with the knife. There's the ball right. So you’re just going to open it up just like this. So the nerve’s going to be right up front here. But we don’t need to go up there. Yup so open the fascia, oops. Just the fascia. Now zip right through that. Now just keep going. Yup. Now you just got to, now you've actually released that. Good.
So we just open up the fascia over the peroneals and we’re going to be a little bit posterior here. Perfect. You don't want to strip any the periosteum off the bone, beyond that needed to see your reduction. So there's the fracture and there's that. So you want to make sure you leave that soft tissue on there. You don’t want to cut on the bone you want to cut down to bone right now. Release that. Real gently. Because you want to leave that periosteum on there. Now let’s just release the front here a little bit. So yeah you don't want it you want to worry about that now though so cut that way. There.
So now we’ve got our fibula. Got that get that. :ittle bit of combination but pretty clean fracture line. So when you're cleaning the fracture site a curette just moves things around. Use your Fraser to suck. See that suck the fracture right out. Especially in a fresh fracture like this you want to remove the blood and the clots. When they are real fresh like this it doesn't take much. The thing to look for is infolded periosteum that’s what’s going to block your reduction. That’s going to be an issue on the medial side. So you want to always try and use pointer reduction forceps because it’s less traumatic. You get more power with the tips of these points than with that. Oh yeah, he’s unstable. There it is. Okay.
Come on in for a shot. Come South for me please. X-ray. So that’s our mortise view. It shows that our fibula is almost out to length And our syndesmosis is not reduced, but that's okay cause we're going to start with the fibula and then work on the syndesmosis.
Well I don't think we're going be able to a lag screw because there's a lot of anterior combination so and we're reducing the back anatomically there. It looks like we're pretty close. So unfortunately it's nice to get a lag screw but this one we're not going to be able to. You see it was a pretty high energy injury. We didn't do any of this dissection. There's a lot of periosteum stripped around the fractures so 1 through 2 tubular plate. So for most most ankle fractures you going to use that 1 through 2 tubular plate. I like the locking plate not cause I think you ever need the strength of the locking screws especially in a young person, but because distally I like to use locking screws cause they're less prominent than proximally. Some of the other sets you don't need that but with this particular set that kind of helps. And then also one of thing I really like to do is use the locking towers to help place the plate cause we're it is K wires to hold it and then we're happy with our plate position so we can play some. These plates are pretty flimsy so they'll kind of contour themselves, but I'm just going to give it a little bit of a bend little bit of bend to better contour it. The key thing is if you're going to do that you want to keep those locking towers in cause that's going to preserve the the locking. Magnificent.
So I like to just set the plate in place clinically and then I'm going to take a couple pictures and if we're happy with that then we will use it. So you can put your K wire in distally pull on it get your length and then put another K wire on that holds it. It's a really nice way of doing that but then it still lets you adjust your reduction a little bit in terms of flexion and extension. One cortex only. Alright.
X-ray there. That’s a little bit more than one cortex. X-ray. Alright, so we have enough holes above and below the fracture there. So now we're out to length and that looks like and we've got that by reading the posterior aspect of the fibula here and then also radiographically. So now let’s go to a lateral view and see where our plate’s at. So this drape is nice cause it let’s you do that and then just put it back instead of wasting sheets. X-ray that. Hold on. X-ray there. Save that.
So that's a true lateral of the ankle, and we can tell that by looking at the talus and also the plafond. And our plate’s sitting square on the fibula proximally and then coming a little bit proximally just what we wanted. Now that looks nice. Alright good. Do an AP. Give us a shot. Go live for a second. Stop there. So we're looking at length. There are three things. The first thing is to talar tibial tilt so if the talus is tilted then it's way off so that's that's a really bad sign of the talus is tilted with respect to the tibia. So that's the first thing. You can see our joint is parallel so that's good. The second thing is the parallelism between the tibia or sorry the talus and the fibula. See how can I comes stay together and this parallel lines are go down there. So that's a sign you are out to length. Then Chitan’s line. So you want to follow it up. If you look real carefully kind of curves and hooks at the top and that lines up with the bottom so those are kind of the things I look at to say where I am at. Alright.
So you always want to start with non locking screws. If you start with locking screws you're not going to come tight to the bone and it's not going to lock it down, right. Distally I want use locking screws for prominence so let's just start right there. What you're feeling for two cortesis. That's a sign that you're in the middle that's one, two. Good. That’s just a check, so that’s a back up check to know your plate centered on the fibula because you found the midular cannal.
A lot of people do the depth gauge wrong. So you hook it like that, feel it hook, and then push hard. It looks like 12 but I want you to put a 14 in anyway. I think a lot of people leave their screws short. You know you want the screw to be out of the other side of the bone. It’s got to be. It’s got to be. Unless there’s something very important on the other side. Like a tendon, like if you are doing a distal radius fracture. X-ray. Save that. See you can see are starting to reduce it and that's the ideal screw length. The tendency is to want to leave it flush with the bone. You need it to stick out cause the tap of the screw. So you’ve got to have it out like that.
So again non-locking screw ⅓ tubular plate contour the bone. We get it close and then the screws do the work. If you do a big beefy plate like a LCD then you’re going to have to contour it yourself. But this plate will do itself. High technology, self contouring, self contouring technology. X-ray. X-ray.
Do you have a freer? There’s a piece there. Do you see it? Again let's get this sucker and look back there. So you can see we have an anatomic reduction on the posterior cortex and then on the front where there's just a lot of common is a little pieces so that's… X-ray. You can see there's a little bit of flaking there the posteriorly, so we know we have length from looking at it but then we have the radiographic confirmation to0. X-ray there. X-ray there. Let’s go to a lateral. X-ray there. That looks pretty nice we got a good straightened out by externally rotating. X-ray there. We are going to bring the fibula into view of you do you see some combination but you follow that anterior cortico line and it looks good. And we're not getting there yet but we're going to reduce the syndesmosis in a sitting on the posterior third of the tibia which is where it's supposed to live. So it's starting to look at that way to.
Ok good. So happy with our plate placements and our reduction. We are going to leave room for our syndesmosis. That screw you put in already is probably going to become a syndesmotic screw. So why don't we... This is contoured nicely so let’s put a locking screw here. Or if you want you could fill it up top, that could be another thing you could do. Stay with 25. I’ll take an army navy. What the length of that screw? Call it out. 14 please. Measure anyways, just to measure. Notice we’re taking any x-rays we don't need anything. We have it set. 14 please. So you see I like to play a little on the posterior side so the top of the fibulas’ up here. This is posterior but it's not all the way posterior that's cuase of the peroneals here. So you can see there’s the peroneus brevis and so you want this plate up here so that's not going to interfere with those peroneals. They're not going to get tendonitis, but being out of the way here could be a little less prominent and a little stronger cause you are little bit further in the back. All the way to the far cortex but not through.
So this is where I like to use a couple locking screws and it's just just purely for hardware promise. There's no other reason you know good bone like this doesn't need it for strength. 16 is fine.
What’s our T time. 14? 31 minutes. 28 back.
Another 16. You don't want to be out the other side here cause it'll bother him. Distally it;s in the joint and then even up there if it's too long it'll irritate the syndis spaces. X-ray there.
Okay so now we finished our fibular fixation. Do you have a clamp so now you can do a cotton test. Ee know it's unstable from her pre-op right and even just clinically, it seems to move around. Grab that fibula and I’ll pull on it. X-ray. You can see it’s gapping not quite as bad as you think right, but still gapping. So we’ve got to fix that.
Alright. Can I see a pick up and a knife? So we have the fibula fixed and now we have to reduce the syndesmosis. This is something I like to actually see. So I am going to open up this. We know the syndesmosis is disrupted, so I don't have to worry too much about cutting the ligaments here in the front. We are going to come right over the front. This is the area of syndesmosis right here. Alright great. Okay.
Despite all that spraining and the X-ray disruption, there's some of that capsule left intact there, right. But it’s clearly incompetent because it’s letting us move more than it should. That must have been torn off and now it's kind of released in there. So this is interesting here. So you know I was dissecting over the front and this is the syndesmosis right here and it looks intact. I was surprised because the talus is so subluxed, but if you look up in the front here there is actually a fracture line on the tibia. And so what's happened is there's a small talo fragment so instead of the syndesmosis failing through the ligament it just pulled off a little flake of bone here. And you can actually kind of see that on that x-ray there. So what we are going to do is just reduce that and pin it. So I've got it. I can see the front of it there. That's reduce nicely so I'm just going to hold that and then you're going to pin it.
Just above my thing. Good. Don’t need that anymore. Come north. X-ray there. Good so now we restored that relationship there. So I'm just going to reduce the syndesmosis manually by compressing just it a little bit and then I want you to put another pin this time through the fibula into the tibia. Yup. X-ray. X-ray. X-ray. X-ray. Go live for a second. Stop there. So I like to get that view. So that's a mortise view where you’ve got a nice dark line on the talus and a nice dark line on the fibula and that means you're looking down a corridor of bone. So the rotation of the fibula has to be correct with respect to the talus, which is kind of our goal after all. This one we're pretty sure we got a good reduction of the fibula because we are looking at it anatomically from the back side. Looks good. Alright.
So now we have to take out our previous cortical screw and replace that one with a syndesmotic screw. 25 Drill. So I like to put these on under see on just to get them parallel to the joint. There is a debate about how many cortices and how many screws and what size so I don't think there's really a right answer. You can use a tightrope if you like or some other kind of suture device but I use 2 tricortical 3.5 mm screws. Parallel to the joint right. Remember you are a little bit posterior. Yup. Not a lot. Come south for me a little bit. X-ray. X-ray. Good. Let me feel. X-ray. Now it feels like bone. X-ray. Depth gauge. And that’s in bone there see. 45.
With a gentleman like this young guy I tend to take out my syndesmotic screws out at 3 months. You don't want to take them out before that though. If you leave them in too much longer than that sometimes they’ll break.
Drop that hand. You don't want to kill this. It just needs to be snug. X-ray. Good. Alright so pretty happy there. We're going to put independent screw fixation actually to fix this piece but I want you know I want the extra this is a pretty small flake of bone so don't want to rely on one screw up here to protect our syndesmosis. So we have our syndesmotic screw but we are going to put another screw in there. Way over here. X-ray. That’s it. Too far. That looks pretty good. X-ray. X-ray. Depth gauge. Xray. That’s on the fracture. Is it really? 40 4-0 partially threaded consala screw please. Yup. That looks good. Wire driver. We’re okay. X-ray. Excellent. Way down there. X-ray. Good.X-ray. So see that's nice.
With syndesmotic screws you’ve got to make sure aiming from down to up. 35 cortical screw. It’s going to be a 40. Farside, alright. You don’t ever want to put anything down on power. Like I said you don’t want to kill this just down. You can over-reduce. X-ray. X-ray. X-ray there. X-ray. Let’s come to a lateral. so the rotation of the fibula looks good. Syndesmosis looks reduced, and we look like we have a natural.. so far.
Now we just need to decide if we're going to the medial side. So there’s only two syndesmotic screws. The distal screw is actually in the tibia. There’s not great bone there, it’s a pretty small flake so I didn’t want to rely on just that. So the syndesmotic screws do the work but that little screw there will help hold it. Xray there. So here we can see again. A perfect lAteral of the ankle. We can tell why the plafond as well as a talus. Our fibula is sitting posteriorly with respect to the tibia. It’s you know it's kind of center of the junction between the middle and distal thirds of the tibia. That’s approximately where you are expecting to see a syndesmosis. Here we know we did because we actually have that read in the front, reducing that talo-fragment. Normally you have a read right here actually looking at the syndesmosis. And then our joint looks good so everything looks good. And it’s just a matter of the medial side.
So he has a little pressure ulcer on the medial side. The skin looks good but there's a little blackish area. So going to have to be careful about that okay.
See this is one that you can't do percutaneously cause you can see it's all flipped and caddywhompus. What are you worried about? Uh the saphenous coming down here. Wheaties. I believe in a real generous incision on the medial side. You want to really see it and reduce it. If you look carefully there's always infolded periosteum. Like I said there’s nothing you’re worried about there. You want to protect the skin by keeping for full thickness flaps. A lot of people do a curved incision like that kind of is a routine. I typically try to make straight incision so I don't like to do that but in him there's a little ulcer. The advantage of it is you really want to see the anterior portion of the reduction of the medial mal. That's going to be your reduction read and then you put your screws are going to be coming in from a little bit further down and so it kind of helps that way if you are making a smaller incision. I kinda think I like extensile so I also right. Try to make it straight if you're in trouble. For him I think this is the right move.
Alright so if you look in here this is real common, so this is this thing failed in tension. Alright. So this is the fracture. You can actually see the posterior tibial tendon is right back there. The kinda key thing here is this is the medial mal and if you look in here this is periosteum and it's folded in so there because it falls in tension that's going to suck the periosteum in and kind of buckle. So often it will be draped over here kinda like this portion of periosteum in the back. But then here you can see this whole big piece of periosteum see that there and that’s what’s stopping it from being reduced. You can’t do this percutaneously. You’ve got to get it out. So I would actually cut this band of periosteum. Flip this out of the way and flip the periosteum a little bit. So some of this kind of stretch and pull the periosteum. I was going to take that right after. This was hurting earlier. Release.
I try not to just robotically put two screws up the medial mal. I want to look at the obliquity the fracture you know try to put them in perpendicular to the fracture. Can you actually going to be a little up here. That’s going to live up like that. Pretty good reed there. This anterior crux is really important. So you see that’s reduced in there nicely.
Why don’t we check that with an x-ray? X-ray. There we go. There’s your AP and that’s an anatomic reduction. So save that. X-ray. Alright so I’m happy with reduction to the medial side. We're going to provisionally use a K wire. I don't use cannulated screws to the medial side. I use regular screws. So we will take a 25 drill ready. Partially threaded cannulas screws. So here, where's the fracture? The fracture line is not very transverse, it’s oblique. So we're actually going to be up here. This way. We are going to do two screws. This K wire’s going to be where one of the screws is and you can see that we like that so you can use that as a reference for your other screw. Depth gauge please. 40. Wire driver. X-ray there.
So that look really nice. That was really good placement there. The idea is that to have that kind of around the corner to take the joint. But if you are around on the medial side it kind of bothers people. That looks really good. Alright back out for a second.
So we’ve got one more screw and then we will check our final X-rays. Do you have a screw driver? I am going to show you the angle. So this is the angle. Good. I often leave the drill in cause that just holds your angle. You're not going to need a depth gauge here cause you know the length already.
You really have to have secure fixation, when you're putting this in because the bone is pretty dense and those are cansela screws. So when it’s in the medial mal it will really put a torque on in. So here we have a monster bite on the other one that's really compressing it, so it's going to hold it; otherwise, you really should have two points of fixation like a clamp and a screw or clamp and a K wire or something. You see interdigitating, which is nice. That's a nice bite.
Let’s come in for our final pictures make sure we are happy with everything. It’s kinda hard to see through the ioband but there’s a little black mark there and that’s from the pressure from the having his ankle dislocated. X-ray. X-ray there. Save that. X-ray. Go live for a second. Stop there. Save that. Come to a lateral. So you can see the position those screws are a little bit different than normal. The anterior one is more proximal that's because of the obliquity the fracture we wanted to start a little bit further up the malleolus to make sure there was perpendicular. X-ray. X-ray. X-ray. Xray. X-ray. X-ray there. X-ray there. Go live for a second. Stop there. X-ray there. Save that.
So there’s our lateral again. You can actually see the fibula behind that plate. We’ve got our anatomic reduction there so we know we got our length. The obliquity of the screws is very different but we know we have a fracture on the malleolus and we want to stay perpendicular. That looks good. Alright.
So on the skin I try to use a no touch technique with my pickups. You know I use I don't ever pinch the skin I'm using it as a hook to pull and push, but I don’t ever pinch. Particularly high-energy ankle injuries, calcaneus, talus, pylon fractures, high energy ankle fractures it’s worth dealing with.
So this is that little bit of extra are here and you know we made our incision well clear of it and the skin edges look very healthy so I'm hopeful. We didn't have too much of a choice. If it was minimally displaced I probably would have left it even if it was displaced to begin with and reduces nicely but it was flipped around really badly so. The soft tissue is only going to get worse.
I tend not to do horizontals. Vertical and simples are better for the blood supply. And I think it's really important I think a lot of people put their stitches too close together you know you got to give space to let them breathe. you don't want to put them in too tight. There are only going to get tighter as the soft tissue swells. I think a nice closure can really help prevent a lot of problems.
He's going to need a Hollywood splint so what that means is I leave me splints on until follow-up and someone like this to complain of pain. So someone might release the splint, so I want you to put a sterile dressing on first.
So there are a number of outcomes for ankle fractures. You know radiographically you know we're going to follow this patient to make sure that the fractures unite. Clinically the early worry is infection and so we need to follow him very closely to make sure he doesn't have an infection. The infection rate of ankle fractures is actually fairly high and probably ranges somewhere between three and five percent and this guy's definitely an increase risk because of the high energy nature of his injury and the medial ulcer that he had. And then as far as clinical outcome measures, there's been a lot of development regarding that in here we do something a little bit differently than lot of centers. We use computer adaptive testing and do we use an outcome measure called The Promise measures and these were developed with the NIH. And they are a good way of getting a very specific outcome on your patient and there's some software that you can use online actually to do that. So we follow them clinically and also with outcome measures.
Infection is a big problem with these injuries and I think it happens a lot more than we think. And be very careful with the soft tissues waiting if there's a lot of swelling and saying you know this is we just have to wait this out and waiting two weeks for the swelling come down I think it's completely appropriate a lot of the time. And then from a surgical standpoint once you're in the operating room I think you know respecting the soft tissues respecting the blood supply to the bone, not stripping the fracture fragments beyond what you need to to see the reductions is really important to get the things to heal. And then really focusing on getting that fibular length if you can get an anatomic reduction it's easy. But a lot of times if it's, you’re not going to be able to do that and in restoring the fibula like this one of the most important things and as far as restoring ankle stability and patient outcome so I think making sure you get it out to length is next important. And we discussed in the case a little bit about how to do that with the x-rays if you can't get an anatomic read.
And then beyond that regardless of what you do with the end of the case the talus is squarely under the tibia and it's secure. You know checking that syndesmosis making sure it's okay and making sure everything's reduced really important.
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