The patient is positioned supine on a standard operating room table with a small bump placed under the ipsilateral hip so that the knee is straight up and down.

If a supracollicular medial malleolus fracture is present, it is repaired first as it will help restore congruence of the talus beneath the plafond, thereby assisting with reduction of the lateral malleolus.

Turning attention laterally, the ankle is positioned on bolsters placed at the level of the joint and not under the heel. Placing the bolters under the heel can cause anterior subluxation of the talus and cause a malreduction. The reduction maneuver is performed (see Reduction Techniques section). After assessing the reduction, a lateral incision is made over the posterior half of the fibula. Care is taken when dividing the subcutaneous tissue onto the periosteum, as the periosteum is located immediately subcutaneous. Sharp Weitlaner retractors can aid by applying tension to the skin causing the subcutaneous tissue to peel off the periosteum. Often there are rents in the periosteum due to the injury. Take care to leave the remaining periosteum intact; do not strip or further handle the fracture fragments. At this point, retractors should be removed as tension on the surrounding tissues can cause shortening of the fibula.

Prior to the lateral incision, the ankle is placed on a bolster. The foot is adducted and medially translated to center the talus in the mortise. This aids in obtaining fibular length as the lateral ankle ligaments typically remain intact. Fluoroscopic images are used to determine
fibular length (Fig. 14.1). Although the lateral cortex is comminuted, the medial cortex often involves a single fracture line and can be used to assess length. In addition, the talocrural angle is compared to the uninjured ankle to confirm fibular length.² Once the necessary reduction maneuver is confirmed, one can proceed with the approach.

After the extraperiosteal dissection is completed, a reduction is affected by manipulating the foot. A lateral fluoroscopic image is then obtained to ensure there is no angulation or translation of the fibula. Returning to the coronal plane imaging, a precontoured, underbent direct lateral fibular plate is placed directly lateral on the fibula. Take care to position the plate in the center of the bone by palpating the anterior and posterior borders of the fibular shaft as the intact soft tissues will preclude adequate visualization. A fluoroscopic lateral view will confirm appropriate position, which is essential as the plate must apply a direct medial force to accurately reduce the fracture. Any angulation at the fracture site must be corrected, often simply by adjusting the bolsters. Once appropriate position is confirmed, the plate is temporarily secured by Kirschner wires, provisional fixation pins, or a reduction clamp. Residual lateral translation will be corrected by the plate (Fig. 14.2). Bicortical nonlocking screws are then placed from proximal to distal, pushing the fibula (and the talus) medially to its position under the plafond. Fluoroscopic imaging confirms reduction.

The syndesmosis is then evaluated either by applying an abduction stress on the foot (if the medial malleolus is intact) or by using a clamp on a fibula to apply the stress (if the medial malleolus is a fracture that was repaired) and is reduced and stabilized if unstable.

Precontoured direct lateral fibular plates or straight one-third tubular small fragment plates that are contoured to the shape of the distal fibula are ideal. Underbent, flexible plates allow the plate to correct and buttress the lateral translation of the fibula. Nonlocking, bicortical screws are placed from proximal to distal within the plate to allow the implant to effect a reduction.

Postoperatively, patients are placed into a short leg cast and kept non-weight-bearing for 6 weeks. If syndesmotic fixation is needed, weight-bearing may be deferred for 12 weeks. Active and passive range of motion is started at 4 to 6 weeks.

Patients are positioned supine with a bump under the affected hip, which allows the leg to be easily internally rotated, granting access to the fibula.