Trimalleolar ankle fracture: ORIF with fibular plate and medial-malleolus TBW

1. Preoperative planning

• Confirm union and ankle congruity on AP, mortise, and lateral radiographs. Obtain CT if posterior-malleolar union, screw trajectory, or syndesmotic status is uncertain.
• Document the implants: lateral fibular plate and screws, medial screws or tension-band construct, posterior-malleolar fixation, and any syndesmotic screw or suture-button.
• Position supine on radiolucent table with a bump under ipsilateral hip. Prepare and drape to above knee so external-rotation and syndesmotic testing can be performed. Use fluoroscopy.
• Plan to address the posterior malleolus first when direct posterior reduction is needed, then fibula, then medial malleolus. Confirm mortise and syndesmosis at the end.

2. Posterior malleolus ORIF

1. Use a posterolateral approach when direct reduction is required.
2. Protect the sural nerve and short saphenous vein. Work between the peroneal tendons and flexor hallucis longus as appropriate.
3. Debride interposed hematoma or periosteum only enough to obtain reduction.
4. Reduce the posterior fragment under direct visualization and fluoroscopy.
5. Temporarily hold with K-wires.
6. Definitively fix with a posterior buttress plate, lag screws through a plate, or selected anterior-to-posterior screws depending on fragment morphology and bone quality.
7. Confirm a smooth joint surface, no posterior talar translation, and no intra-articular hardware.

3. Lateral malleolus ORIF with plate

1. Make a longitudinal lateral incision centered on the fibula.
2. Protect the superficial peroneal nerve anteriorly and the sural nerve posteriorly. Minimize stripping and preserve peroneal tendon sheath/peritenon.
3. Clear only the fracture surfaces needed for reduction.
4. Restore fibular length, rotation, and alignment. A pointed reduction clamp and temporary K-wire can help.
5. Insert an interfragmentary lag screw if fracture configuration permits.
6. Apply a neutralization plate or posterolateral antiglide plate, selected according to fracture pattern.
7. Use fluoroscopy to check fibular length, mortise symmetry, screw position, and absence of joint penetration.
8. Assess syndesmosis after fibular and posterior-malleolar fixation using direct visualization when needed plus fluoroscopic stress testing. If unstable, anatomically reduce it before placing syndesmotic fixation.

4. Medial malleolus fixation: tension-band wiring (TBW)

1. Use a curved or longitudinal medial incision. Protect the saphenous vein and nerve.
2. Expose the fracture, remove only interposed tissue preventing reduction, and inspect for deltoid-ligament or posterior tibial tendon interposition if reduction is blocked.
3. Anatomically reduce the medial malleolus and temporarily hold with a pointed clamp or K-wire.
4. Insert two parallel K-wires from the fragment into the distal tibia, ensuring stable bicortical or secure proximal purchase without violating the ankle joint.
5. Place a transverse drill hole or cortical anchor proximal to the fracture as the tension-band point.
6. Pass stainless-steel wire in a figure-of-eight configuration around the K-wires and through the proximal anchor point.
7. Tension the wire while maintaining reduction, then bend and bury K-wire ends and wire twists away from skin and tendon irritation.
8. Confirm compression across the fracture on fluoroscopy and verify no intra-articular K-wire placement.

• Divergent or inadequately seated K-wires.
• Prominent wire twist or pin ends causing medial skin irritation.
• Failure to bury the wire construct.
• Inadequate reduction due to soft-tissue interposition.
• Using TBW for a large vertical fragment better treated with lag screws or a buttress construct.

5. Final checks and closure

• AP, mortise, and lateral fluoroscopy: restored fibular length, medial clear space, talar alignment, posterior-malleolar reduction, and no joint penetration.
• Perform external-rotation or hook test if syndesmotic injury was suspected.
• Irrigate, achieve meticulous haemostasis, and close layers without tension.
• Apply sterile dressing and well-padded splint in neutral position.
• Postoperative weight-bearing depends on fixation stability, posterior-malleolar injury, bone quality, and syndesmotic fixation protocol.

Implant removal after healed trimalleolar ORIF

Removal sequence

1. Confirm union first
   • Clinical assessment plus AP, mortise, and lateral radiographs.
   • CT if union is uncertain, especially at the posterior malleolus.
2. Prepare for difficulty
   • Obtain prior operative notes and implant details.
   • Have compatible screwdrivers, extraction devices, broken-screw set, K-wire cutters, trephines, and fluoroscopy available.
   • Rule out infection: obtain inflammatory markers and plan multiple deep cultures if there is drainage, raised markers, loosening, or intraoperative suspicion.
3. Lateral plate removal
   • Reopen the previous lateral incision.
   • Protect superficial peroneal nerve, sural nerve, and peroneal tendons.
   • Expose plate only as much as needed. Clear screw heads fully before engaging the screwdriver.
   • Remove screws in a controlled sequence, generally retaining one screw until the plate is fully freed and all others are removed.
   • Remove plate carefully, particularly around peroneal tendons.
   • Inspect tendons if there was posterolateral pain or plate/screw prominence.
4. Medial TBW removal
   • Reopen previous medial scar and protect saphenous structures.
   • Expose and cut the wire, then remove figure-of-eight wire.
   • Straighten or cut bent K-wire ends and extract each K-wire along its insertion path.
   • Avoid forceful traction that can fracture a wire or damage the medial soft-tissue envelope.
   • Remove any accompanying medial screws after confirming union.
5. Posterior-malleolus or syndesmotic implant removal
   • Remove only if symptomatic or clinically indicated.
   • For syndesmotic screws, reassess mortise stability before and after removal as required.
   • Routine removal of an intact or broken syndesmotic screw is generally not supported. Campbell advises against routine removal unless symptoms such as stiffness limiting dorsiflexion are present; early removal risks recurrent diastasis. Campbell's Operative Orthopaedics, 15th ed, “Removal of Fixation” section.
6. Finish
   • Fluoroscopic check for retained fragments, cortical defects, and ankle congruity.
   • Send deep cultures if infection is suspected before antibiotics are modified.
   • Counsel about temporary post-removal pain, wound problems, refracture risk through screw holes, and individualized weight-bearing restrictions.

Key operative principle