Tibiofibular Osteotomy for the Treatment of Sneppen Type V Talar Body Fracture: A Case Report

Tibiofibular Osteotomy for the Treatment of Sneppen Type V Talar Body Fracture: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Tibiofibular Osteotomy for the Treatment of Sneppen Type V Talar Body Fracture: A Case Report Leijie Chen, Tengyun Yang, Zhou Liu, Bo Pu, Qihui Duan, Yingsong Wang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9338710/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Sneppen type V talar body fractures constitute rare, high-energy traumatic injuries typified by severe articular comminution and extensive soft-tissue compromise. Adequate surgical access is prerequisite for anatomical reduction and rigid internal fixation; however, conventional anterolateral and posterolateral approaches confer limited visualization of the posterolateral talar dome. This case report delineates the clinical utility of a syndesmosis-sparing modified combined tibiofibular osteotomy for the management of a highly comminuted Sneppen type V talar body fracture. Case presentation A 48-year-old male laborer sustained a right ankle injury following a fall from height, presenting with disabling pain, soft-tissue swelling, and restricted range of motion. Radiographic and computed tomographic (CT) evaluation confirmed a comminuted Sneppen type V talar body fracture involving the lateral and posterolateral talar dome with articular depression and displacement, concomitant with a fifth metatarsal base fracture. A single anterolateral approach was utilized to perform a combined tibiofibular osteotomy with preservation of the distal tibiofibular syndesmosis. The osteotomized segment, hinged on the intact posterior inferior tibiofibular ligament (PITFL) and posterior capsuloligamentous complex, was reflected posteroinferiorly, yielding unobstructed exposure of the lateral and posterolateral talar dome. Anatomical reduction of the talar body fragments was achieved with headless compression screws and Kirschner wires (K-wires). The osteotomy site was anatomically reduced and rigidly stabilized with two tibial lag screws and a fibular 1/3 tubular plate. A completely disrupted anterior talofibular ligament (ATFL) was anatomically repaired using a suture anchor. Postoperative imaging confirmed anatomical reconstruction. At the 3-month follow-up, the patient achieved painless full weight-bearing ambulation, with a visual analogue scale (VAS) score of 1/10 and an American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot score of 88. Osseous union was radiographically evident at both the fracture and osteotomy sites. Conclusions The syndesmosis-preserving modified combined tibiofibular osteotomy represents a safe and efficacious surgical strategy for highly comminuted Sneppen type V talar body fractures. This technique affords extensive posterolateral talar dome exposure while maintaining distal tibiofibular syndesmotic integrity and mitigating iatrogenic ligamentous injury. Early functional outcomes are favorable; however, long-term surveillance is mandatory to monitor for post-traumatic osteonecrosis and secondary osteoarthritis. Talar body fracture Sneppen type V Tibiofibular osteotomy Syndesmotic preservation Surgical approach Case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 7 Introduction Sneppen type V talar body fractures represent infrequent, high-energy orthopaedic injuries characterized by severe articular comminution, compromised osseous vascularity, and concomitant soft-tissue destruction, rendering them among the most challenging entities in foot and ankle reconstructive surgery. Anatomical reduction and rigid internal fixation are contingent upon adequate surgical visualization. Nevertheless, traditional soft-tissue approaches provide restricted access to the posterolateral talar dome[ 1 ]. Although ligamentous release may augment exposure, it predisposes to residual ankle instability[ 2 – 4 ]. Numerous osteotomy techniques have been developed to enhance surgical access, yet many imperil the structural and functional integrity of the distal tibiofibular syndesmosis and perimalleolar ligamentous complexes[ 5 – 7 ]. To surmount these limitations, we present a modified combined tibiofibular osteotomy with intact syndesmotic preservation, enabling extensive posterolateral talar dome visualization while minimizing iatrogenic soft-tissue injury. This report details the surgical technique and early clinical outcomes in a patient with a highly comminuted Sneppen type V talar body fracture, conducted in adherence to the CARE guidelines. Case Presentation Patient History and Preoperative Evaluation A 48-year-old male laborer presented to our orthopaedic service 4 hours following a fall from height, manifesting severe right ankle pain, periarticular soft-tissue swelling, and grossly restricted ankle kinematics. Physical examination revealed marked ankle deformity, lateral compartment tenderness, intact dorsalis pedis perfusion, and absent neurological deficits. Standard radiography and high-resolution CT with three-dimensional reconstruction confirmed a comminuted Sneppen type V talar body fracture involving the lateral and posterolateral talar dome with articular surface incongruity and fragment displacement (Figs. 1, 2 ). An associated fifth metatarsal base fracture was concurrently identified. Surgical Technique Preoperative Planning Preoperative assessment comprised standard ankle radiography, high-resolution CT with 3D reconstruction, and magnetic resonance imaging (MRI) to delineate syndesmotic ligamentous integrity and soft-tissue status. Surgical intervention was deferred for 2 weeks to permit resolution of periarticular soft-tissue edema. The combined tibiofibular osteotomy was selected to facilitate direct visualization-guided anatomical reduction. Positioning and Surgical Approach The patient was positioned supine with an ipsilateral hip bolster to enable lower extremity internal rotation. A pneumatic tourniquet was applied to the proximal thigh. A 12-cm curvilinear incision was executed along the anterolateral ankle interval, extending distally to the lateral malleolar tip. Superficial peroneal nerve branches were identified and meticulously protected. The extensor retinaculum was incised, and the third peroneal muscle and extensor digitorum longus tendons were medially retracted with preservation of the peroneal artery perforating branch. Blunt dissection exposed the anterolateral distal tibia and fibular metaphysis. Peroneal tendons were posteriorly retracted. The ATFL was identified and preserved as a reparative landmark. Combined Tibiofibular Osteotomy Osteotomy initiation was performed at the midpoint of the distal tibial articular surface to ensure comprehensive posterolateral talar dome coverage. The osteotomy trajectory extended at a 45° angle from the tibial origin to the fibular lateral cortex (Fig. 3 ). Technical Tip 1 (Pre-drilling) Pre-osteotomy pre-drilling of planned fixation sites and provisional application of fixation implants (tibial lag screws/small plate, fibular 1/3 tubular plate) facilitates precision osteotomy fragment reduction post-reduction. Technical Tip 2 (Interdigitating “Jigsaw” Osteoclasis) A thin sagittal saw was utilized for sequential fibular and tibial cortical osteotomy, with termination 2–3 mm proximal to the tibial articular cartilage. Remaining osseous bridging was carefully fractured using a broad osteotome, creating an irregular interdigitating articular margin that enhances rotational stability and resists shear displacement during reduction. Reflection and Surgical Exposure The tibiofibular osteotomy fragment, anchored by the intact syndesmotic complex, was reflected posteroinferiorly. The preserved PITFL and posterior capsuloligamentous complex functioned as a native soft-tissue hinge. With the ankle in plantarflexion and gentle anterior drawer stress, over 80% of the lateral and posterolateral talar dome was exposed, providing optimal working space for comminuted fragment reduction. Fracture Reduction and Internal Fixation Intraoperative inspection following osteotomy fragment reflection revealed severe talar body comminution, posterolateral fragment displacement, and chondral surface depression. Talar body fragments were reduced via a deep-to-superficial sequential reduction technique. Anatomical reduction was verified under direct visualization. Definitive fixation was achieved using 2.5-mm and 3.0-mm headless compression screws for major fragments, with 1.2-mm K-wires for supplementary stabilization of comminuted articular segments(Fig. 4 ). Intraoperative imaging confirmed anatomical reduction of the talar body fracture (Fig. 5 ). Osteotomy Reduction and Fixation Technical Tip 3 (Anti-compression Kerf Compensation) A sagittal saw blade was temporarily inserted into the osteotomy gap prior to fragment reduction to compensate for saw kerf-related bone loss, preventing over-reduction and articular step-off during compression fixation. Following fluoroscopic confirmation of osseous alignment, the tibial segment was stabilized with two lag screws, and the fibular segment with a contoured 1/3 tubular plate and screws. Intraoperative fluoroscopic images confirming satisfactory reduction and fixation of the tibiofibular osteotomy segment (Fig. 5 ). Ligamentous Repair The completely disrupted ATFL was anatomically repaired using a 4.5-mm suture anchor to restore lateral ankle functional stability. Postoperative Management Layered closure of the capsuloligamentous and soft-tissue layers was performed. The ankle was immobilized in a neutral position via cast or functional splint. Sutures were removed at 2–3 weeks, with initiation of non-weight-bearing active range-of-motion exercises. Partial weight-bearing was permitted at 6–8 weeks based on radiographic healing, with progression to full weight-bearing at 3 months postoperatively. Postoperative Clinical Course Postoperative CT images verifying anatomical reduction and rigid fixation (Fig. 6 ). At the 3-month follow-up, radiographs demonstrated solid osseous union at both fracture and osteotomy sites (Fig. 7 ). The patient achieved painless full weight-bearing ambulation. The VAS score improved from 8 preoperatively to 1 at 3 months, with an AOFAS ankle–hindfoot score of 88. Follow-up Protocol Given the elevated risk of post-traumatic talar osteonecrosis associated with Sneppen type V fractures, a minimum 2-year long-term follow-up is planned to monitor for avascular necrosis (serial MRI/radiography) and delayed post-traumatic osteoarthritis. Discussion Sneppen type V talar body fractures represent a formidable reconstructive challenge in foot and ankle surgery due to extensive articular comminution, constrained surgical access, and tenuous talar osseous vascularity. Anatomical reduction and rigid fixation are dependent upon adequate surgical exposure; however, conventional approaches provide insufficient posterolateral talar dome access. The modified combined tibiofibular osteotomy described herein addresses these limitations by delivering extensive posterolateral talar dome visualization while preserving distal tibiofibular syndesmotic integrity. This technique is adapted from the original Bluman and Antosh description, with modifications tailored specifically for comminuted talar body fractures rather than osteochondral lesions[ 8 ]. Key technical refinements include pre-drilling for precision reduction, controlled interdigitating osteoclasis for enhanced stability, and anti-compression kerf compensation to prevent articular incongruity. Relative to isolated fibular osteotomy[ 5 , 6 ], the combined osteotomy affords broader surgical exposure via en bloc reflection of the syndesmosis-linked segment. Compared with tibial (Chaput) osteotomy[ 7 , 9 ], the combined approach provides superior posterolateral talar dome visualization. Critically, syndesmotic preservation obviates the need for secondary ligamentous reconstruction and mitigates postoperative ankle instability risk. This case yielded favorable clinical outcomes, including successful anatomical reduction, rapid osseous union, and excellent 3-month functional scores. Notwithstanding, several limitations are acknowledged: this is a single-case report with short-term follow-up, prolonged surveillance is required to evaluate long-term osteonecrosis rates and durable functional outcomes. Furthermore, this technique demands advanced osteotomy approach proficiency and is not indicated for minimally comminuted fracture patterns. Conclusions The syndesmosis-preserving modified combined tibiofibular osteotomy is a safe and effective surgical modality for the management of highly comminuted Sneppen type V talar body fractures. This approach provides extensive lateral and posterolateral talar dome exposure while maintaining tibiofibular syndesmotic integrity and minimizing iatrogenic ligamentous injury. Early functional outcomes are promising, however, long-term follow-up is essential to assess the durability of clinical results and monitor for late complications. Abbreviations ATFL Anterior talofibular ligament PITFL Posterior inferior tibiofibular ligament VAS Visual analogue scale AOFAS American Orthopaedic Foot and Ankle Society Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board of Kunming Medical University. Written informed consent was obtained from the patient prior to study participation. Consent for publication Written informed consent was obtained from the patient for the publication of this case report and accompanying clinical images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Competing interests The authors declare no potential conflicts of interest. Clinical trial number not applicable. Funding The acquisition of clinical data was supported by grants from the Yunnan Provincial Department of Science and Technology Program (No. 202403AC100008, 202505AS350011), the Yunnan Provincial Department of Education Science Research Fund Project (No. 2024J0258), and the Institutional Science and Technology Program of the Second Affiliated Hospital of Kunming Medical University (No. 2022yk09). Author Contribution LJC, YSW, HY contributed to the conception and design of the study. Surgical procedures were performed by LJC, ZL, BP, and QHD. Patient data were collected and analyzed by LJC and TYY. The original manuscript was drafted by LJC. The manuscript was critically revised for intellectual content by YSW and HY. All authors have read and approved the final manuscript. Acknowledgements Not applicable. Data Availability The datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request. References Malagelada F, Dalmau-Pastor M, Vega J, Dega R, Clark C. Access to the talar dome surface with different surgical approaches. Foot Ankle Surg. 2019;25(5):618–22. Mayne AIW, Lawton R, Reidy MJ, Harrold F, Chami G. A comparison of surgical exposures for posterolateral osteochondral lesions of the talar dome. Foot Ankle Surg. 2018;24(2):107–9. Lambert L-A, Mangwani J, Davies MB, Molloy AP, Mason LW. The lateral transligamentous approach to the talar dome. Foot Ankle Surg. 2021;27(7):767–71. Mabit C, Tourné Y, Besse JL, Bonnel F, Toullec E, Giraud F, Proust J, Khiami F, Chaussard C, Genty C. Chronic lateral ankle instability surgical repairs: the long term prospective. Orthop Traumatol Surg Res. 2010;96(4):417–23. Prewitt E, Alexander IJ, Perrine D, Junko JT. Bimalleolar Osteotomy for the Surgical Approach to a Talar Body Fracture: Case Report. Foot Ankle Int. 2012;33(5):436–40. Vaghela KR, Clement H, Parker L. Syndesmosis preserving osteotomy of the fibula for access to the lateral talar dome. Foot Ankle Surg. 2016;22(3):210–3. Tochigi Y, Amendola A, Muir D, Saltzman C. Surgical approach for centrolateral talar osteochondral lesions with a n anterolateral osteotomy. Foot Ankle Int. 2002;23(11):1038–9. Bluman EM, Antosh IJ. Technique Tip: Tibiofibular Osteotomy for Increased Access to the Lateral Ankle Joint. Foot Ankle Int. 2008;29(7):735–8. Garras DN, Santangelo JA, Wang DW, Easley ME. A quantitative comparison of surgical approaches for posterolateral osteochondral lesions of the talus. Foot Ankle Int. 2008;29(4):415–20. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 17 May, 2026 Reviews received at journal 11 May, 2026 Reviewers agreed at journal 11 May, 2026 Reviewers invited by journal 07 May, 2026 Editor invited by journal 16 Apr, 2026 Editor assigned by journal 13 Apr, 2026 Submission checks completed at journal 13 Apr, 2026 First submitted to journal 06 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9338710","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":641594144,"identity":"4ac5a2fe-b4b4-4834-8c35-ef9b23cd734a","order_by":0,"name":"Leijie Chen","email":"","orcid":"","institution":"The Second Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Leijie","middleName":"","lastName":"Chen","suffix":""},{"id":641594145,"identity":"9663bc64-efd2-4e56-96f0-92399208d7ff","order_by":1,"name":"Tengyun Yang","email":"","orcid":"","institution":"The Second Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Tengyun","middleName":"","lastName":"Yang","suffix":""},{"id":641594146,"identity":"38f0754a-a158-4dc4-a462-273e39a044e9","order_by":2,"name":"Zhou Liu","email":"","orcid":"","institution":"The Second Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhou","middleName":"","lastName":"Liu","suffix":""},{"id":641594148,"identity":"b51e7ca7-51dd-4132-9bf2-fd7580377993","order_by":3,"name":"Bo Pu","email":"","orcid":"","institution":"The Second Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Pu","suffix":""},{"id":641594149,"identity":"1062336c-8e81-4ad9-b514-851347932704","order_by":4,"name":"Qihui Duan","email":"","orcid":"","institution":"The Second Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qihui","middleName":"","lastName":"Duan","suffix":""},{"id":641594155,"identity":"63434a38-5bd3-4057-b7fc-1493483b76c2","order_by":5,"name":"Yingsong Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAoklEQVRIiWNgGAWjYNCCCgk5eRK1nLEwNmwgSQdjW0UiwwFiVRvc7jGT/DlPIoGxgfnhoxtEablzxkyad5tEHjsDm7FxDlFabuRuk2bcJlHM2MDDJk20FsmfcyQSGw6QokWCt4EULZI38j9b8xyTMDZsJtYvfDfSEm/+qKmTk2dvfviYKC0KBxhYJMAsZmKUg4B8AwPzB2IVj4JRMApGwQgFAKvQL2FoWcu9AAAAAElFTkSuQmCC","orcid":"","institution":"The Second Affiliated Hospital of Kunming Medical University","correspondingAuthor":true,"prefix":"","firstName":"Yingsong","middleName":"","lastName":"Wang","suffix":""},{"id":641594156,"identity":"36d1fbed-d2b4-4e9a-b3fe-6700ed4b7599","order_by":6,"name":"Hui Yang","email":"","orcid":"","institution":"The Third Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hui","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2026-04-07 03:08:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9338710/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9338710/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109444558,"identity":"f359f4fa-3f64-4ca5-a400-d757563fe895","added_by":"auto","created_at":"2026-05-18 08:01:36","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":116343,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative radiographs.\u003c/p\u003e","description":"","filename":"image1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9338710/v1/b9ef70523763db66f94d1855.jpeg"},{"id":109760127,"identity":"bde52240-dfed-44b5-9126-a5a49ac64f52","added_by":"auto","created_at":"2026-05-22 07:28:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4720678,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative CT images. A–D, Axial views. E–H, Sagittal views. I–L, Coronal views.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-9338710/v1/619df3b9348b48f2a61aa296.png"},{"id":109759540,"identity":"b97fd4ba-492d-488b-935a-f21fa2a0a5b6","added_by":"auto","created_at":"2026-05-22 07:27:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":4222837,"visible":true,"origin":"","legend":"\u003cp\u003eDiagrams of the tibiofibular osteotomy.\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-9338710/v1/c73bc199af6bd5312c944a05.png"},{"id":109761056,"identity":"3ff4fc0e-1420-4696-8bfc-2981cf3c247a","added_by":"auto","created_at":"2026-05-22 07:29:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":10667615,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative images demonstrating exposure and fixation. A, Combined tibiofibular osteotomy using a sagittal saw and osteotome. B, Posteroinferior reflection of the osteotomy fragment exposing the lateral talus. C, Temporary K-wire fixation for comminuted talar body reduction. D, Definitive headless compression screw fixation.\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-9338710/v1/838ba3e45fa82ee104b9dede.png"},{"id":109799600,"identity":"832e9cee-8580-44d8-88f7-64451a345ed3","added_by":"auto","created_at":"2026-05-22 15:32:19","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":8185410,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative fluoroscopic images confirming satisfactory reduction and fixation of the talar body and tibiofibular osteotomy segment.\u003c/p\u003e","description":"","filename":"image5.png","url":"https://assets-eu.researchsquare.com/files/rs-9338710/v1/dffff81674a545d0aa1ad172.png"},{"id":109799365,"identity":"b4be8d9b-3f40-46ad-881e-4009353e0239","added_by":"auto","created_at":"2026-05-22 15:27:26","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":4270174,"visible":true,"origin":"","legend":"\u003cp\u003eThree-month postoperative radiographs demonstrating osseous union at the talar fracture and tibiofibular osteotomy sites.\u003c/p\u003e","description":"","filename":"image7.png","url":"https://assets-eu.researchsquare.com/files/rs-9338710/v1/a42f30171d1512edac9e1f4a.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Tibiofibular Osteotomy for the Treatment of Sneppen Type V Talar Body Fracture: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSneppen type V talar body fractures represent infrequent, high-energy orthopaedic injuries characterized by severe articular comminution, compromised osseous vascularity, and concomitant soft-tissue destruction, rendering them among the most challenging entities in foot and ankle reconstructive surgery. Anatomical reduction and rigid internal fixation are contingent upon adequate surgical visualization. Nevertheless, traditional soft-tissue approaches provide restricted access to the posterolateral talar dome[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although ligamentous release may augment exposure, it predisposes to residual ankle instability[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Numerous osteotomy techniques have been developed to enhance surgical access, yet many imperil the structural and functional integrity of the distal tibiofibular syndesmosis and perimalleolar ligamentous complexes[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. To surmount these limitations, we present a modified combined tibiofibular osteotomy with intact syndesmotic preservation, enabling extensive posterolateral talar dome visualization while minimizing iatrogenic soft-tissue injury. This report details the surgical technique and early clinical outcomes in a patient with a highly comminuted Sneppen type V talar body fracture, conducted in adherence to the CARE guidelines.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient History and Preoperative Evaluation\u003c/h2\u003e \u003cp\u003eA 48-year-old male laborer presented to our orthopaedic service 4 hours following a fall from height, manifesting severe right ankle pain, periarticular soft-tissue swelling, and grossly restricted ankle kinematics. Physical examination revealed marked ankle deformity, lateral compartment tenderness, intact dorsalis pedis perfusion, and absent neurological deficits. Standard radiography and high-resolution CT with three-dimensional reconstruction confirmed a comminuted Sneppen type V talar body fracture involving the lateral and posterolateral talar dome with articular surface incongruity and fragment displacement (Figs.\u0026nbsp;1, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). An associated fifth metatarsal base fracture was concurrently identified.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Technique\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative Planning\u003c/h2\u003e \u003cp\u003ePreoperative assessment comprised standard ankle radiography, high-resolution CT with 3D reconstruction, and magnetic resonance imaging (MRI) to delineate syndesmotic ligamentous integrity and soft-tissue status. Surgical intervention was deferred for 2 weeks to permit resolution of periarticular soft-tissue edema. The combined tibiofibular osteotomy was selected to facilitate direct visualization-guided anatomical reduction.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePositioning and Surgical Approach\u003c/h3\u003e\n\u003cp\u003eThe patient was positioned supine with an ipsilateral hip bolster to enable lower extremity internal rotation. A pneumatic tourniquet was applied to the proximal thigh. A 12-cm curvilinear incision was executed along the anterolateral ankle interval, extending distally to the lateral malleolar tip. Superficial peroneal nerve branches were identified and meticulously protected. The extensor retinaculum was incised, and the third peroneal muscle and extensor digitorum longus tendons were medially retracted with preservation of the peroneal artery perforating branch. Blunt dissection exposed the anterolateral distal tibia and fibular metaphysis. Peroneal tendons were posteriorly retracted. The ATFL was identified and preserved as a reparative landmark.\u003c/p\u003e\n\u003ch3\u003eCombined Tibiofibular Osteotomy\u003c/h3\u003e\n\u003cp\u003eOsteotomy initiation was performed at the midpoint of the distal tibial articular surface to ensure comprehensive posterolateral talar dome coverage. The osteotomy trajectory extended at a 45\u0026deg; angle from the tibial origin to the fibular lateral cortex (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTechnical Tip 1 (Pre-drilling)\u003c/strong\u003e \u003cp\u003ePre-osteotomy pre-drilling of planned fixation sites and provisional application of fixation implants (tibial lag screws/small plate, fibular 1/3 tubular plate) facilitates precision osteotomy fragment reduction post-reduction.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTechnical Tip 2 (Interdigitating \u0026ldquo;Jigsaw\u0026rdquo; Osteoclasis)\u003c/strong\u003e \u003cp\u003eA thin sagittal saw was utilized for sequential fibular and tibial cortical osteotomy, with termination 2\u0026ndash;3 mm proximal to the tibial articular cartilage. Remaining osseous bridging was carefully fractured using a broad osteotome, creating an irregular interdigitating articular margin that enhances rotational stability and resists shear displacement during reduction.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eReflection and Surgical Exposure\u003c/h2\u003e \u003cp\u003eThe tibiofibular osteotomy fragment, anchored by the intact syndesmotic complex, was reflected posteroinferiorly. The preserved PITFL and posterior capsuloligamentous complex functioned as a native soft-tissue hinge. With the ankle in plantarflexion and gentle anterior drawer stress, over 80% of the lateral and posterolateral talar dome was exposed, providing optimal working space for comminuted fragment reduction.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFracture Reduction and Internal Fixation\u003c/h3\u003e\n\u003cp\u003eIntraoperative inspection following osteotomy fragment reflection revealed severe talar body comminution, posterolateral fragment displacement, and chondral surface depression. Talar body fragments were reduced via a deep-to-superficial sequential reduction technique. Anatomical reduction was verified under direct visualization. Definitive fixation was achieved using 2.5-mm and 3.0-mm headless compression screws for major fragments, with 1.2-mm K-wires for supplementary stabilization of comminuted articular segments(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Intraoperative imaging confirmed anatomical reduction of the talar body fracture (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eOsteotomy Reduction and Fixation\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eTechnical Tip 3 (Anti-compression Kerf Compensation)\u003c/strong\u003e \u003cp\u003eA sagittal saw blade was temporarily inserted into the osteotomy gap prior to fragment reduction to compensate for saw kerf-related bone loss, preventing over-reduction and articular step-off during compression fixation. Following fluoroscopic confirmation of osseous alignment, the tibial segment was stabilized with two lag screws, and the fibular segment with a contoured 1/3 tubular plate and screws. Intraoperative fluoroscopic images confirming satisfactory reduction and fixation of the tibiofibular osteotomy segment (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLigamentous Repair\u003c/h2\u003e \u003cp\u003eThe completely disrupted ATFL was anatomically repaired using a 4.5-mm suture anchor to restore lateral ankle functional stability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative Management\u003c/h2\u003e \u003cp\u003eLayered closure of the capsuloligamentous and soft-tissue layers was performed. The ankle was immobilized in a neutral position via cast or functional splint. Sutures were removed at 2\u0026ndash;3 weeks, with initiation of non-weight-bearing active range-of-motion exercises. Partial weight-bearing was permitted at 6\u0026ndash;8 weeks based on radiographic healing, with progression to full weight-bearing at 3 months postoperatively. \u003cb\u003ePostoperative Clinical Course\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePostoperative CT images verifying anatomical reduction and rigid fixation (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003e). At the 3-month follow-up, radiographs demonstrated solid osseous union at both fracture and osteotomy sites (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e7\u003c/span\u003e). The patient achieved painless full weight-bearing ambulation. The VAS score improved from 8 preoperatively to 1 at 3 months, with an AOFAS ankle\u0026ndash;hindfoot score of 88.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up Protocol\u003c/h2\u003e \u003cp\u003eGiven the elevated risk of post-traumatic talar osteonecrosis associated with Sneppen type V fractures, a minimum 2-year long-term follow-up is planned to monitor for avascular necrosis (serial MRI/radiography) and delayed post-traumatic osteoarthritis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSneppen type V talar body fractures represent a formidable reconstructive challenge in foot and ankle surgery due to extensive articular comminution, constrained surgical access, and tenuous talar osseous vascularity. Anatomical reduction and rigid fixation are dependent upon adequate surgical exposure; however, conventional approaches provide insufficient posterolateral talar dome access.\u003c/p\u003e \u003cp\u003eThe modified combined tibiofibular osteotomy described herein addresses these limitations by delivering extensive posterolateral talar dome visualization while preserving distal tibiofibular syndesmotic integrity. This technique is adapted from the original Bluman and Antosh description, with modifications tailored specifically for comminuted talar body fractures rather than osteochondral lesions[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Key technical refinements include pre-drilling for precision reduction, controlled interdigitating osteoclasis for enhanced stability, and anti-compression kerf compensation to prevent articular incongruity.\u003c/p\u003e \u003cp\u003eRelative to isolated fibular osteotomy[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], the combined osteotomy affords broader surgical exposure via en bloc reflection of the syndesmosis-linked segment. Compared with tibial (Chaput) osteotomy[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], the combined approach provides superior posterolateral talar dome visualization. Critically, syndesmotic preservation obviates the need for secondary ligamentous reconstruction and mitigates postoperative ankle instability risk.\u003c/p\u003e \u003cp\u003eThis case yielded favorable clinical outcomes, including successful anatomical reduction, rapid osseous union, and excellent 3-month functional scores. Notwithstanding, several limitations are acknowledged: this is a single-case report with short-term follow-up, prolonged surveillance is required to evaluate long-term osteonecrosis rates and durable functional outcomes. Furthermore, this technique demands advanced osteotomy approach proficiency and is not indicated for minimally comminuted fracture patterns.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe syndesmosis-preserving modified combined tibiofibular osteotomy is a safe and effective surgical modality for the management of highly comminuted Sneppen type V talar body fractures. This approach provides extensive lateral and posterolateral talar dome exposure while maintaining tibiofibular syndesmotic integrity and minimizing iatrogenic ligamentous injury. Early functional outcomes are promising, however, long-term follow-up is essential to assess the durability of clinical results and monitor for late complications.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eATFL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnterior talofibular ligament\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePITFL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePosterior inferior tibiofibular ligament\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVisual analogue scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAOFAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Orthopaedic Foot and Ankle Society\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eThis study was approved by the Institutional Review Board of Kunming Medical University. Written informed consent was obtained from the patient prior to study participation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e Written informed consent was obtained from the patient for the publication of this case report and accompanying clinical images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare no potential conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eClinical trial number\u003c/h2\u003e \u003cp\u003enot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe acquisition of clinical data was supported by grants from the Yunnan Provincial Department of Science and Technology Program (No. 202403AC100008, 202505AS350011), the Yunnan Provincial Department of Education Science Research Fund Project (No. 2024J0258), and the Institutional Science and Technology Program of the Second Affiliated Hospital of Kunming Medical University (No. 2022yk09).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLJC, YSW, HY contributed to the conception and design of the study. Surgical procedures were performed by LJC, ZL, BP, and QHD. Patient data were collected and analyzed by LJC and TYY. The original manuscript was drafted by LJC. The manuscript was critically revised for intellectual content by YSW and HY. All authors have read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMalagelada F, Dalmau-Pastor M, Vega J, Dega R, Clark C. Access to the talar dome surface with different surgical approaches. Foot Ankle Surg. 2019;25(5):618\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMayne AIW, Lawton R, Reidy MJ, Harrold F, Chami G. A comparison of surgical exposures for posterolateral osteochondral lesions of the talar dome. Foot Ankle Surg. 2018;24(2):107\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLambert L-A, Mangwani J, Davies MB, Molloy AP, Mason LW. The lateral transligamentous approach to the talar dome. Foot Ankle Surg. 2021;27(7):767\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMabit C, Tourn\u0026eacute; Y, Besse JL, Bonnel F, Toullec E, Giraud F, Proust J, Khiami F, Chaussard C, Genty C. Chronic lateral ankle instability surgical repairs: the long term prospective. Orthop Traumatol Surg Res. 2010;96(4):417\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrewitt E, Alexander IJ, Perrine D, Junko JT. Bimalleolar Osteotomy for the Surgical Approach to a Talar Body Fracture: Case Report. Foot Ankle Int. 2012;33(5):436\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaghela KR, Clement H, Parker L. Syndesmosis preserving osteotomy of the fibula for access to the lateral talar dome. Foot Ankle Surg. 2016;22(3):210\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTochigi Y, Amendola A, Muir D, Saltzman C. Surgical approach for centrolateral talar osteochondral lesions with a n anterolateral osteotomy. Foot Ankle Int. 2002;23(11):1038\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBluman EM, Antosh IJ. Technique Tip: Tibiofibular Osteotomy for Increased Access to the Lateral Ankle Joint. Foot Ankle Int. 2008;29(7):735\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarras DN, Santangelo JA, Wang DW, Easley ME. A quantitative comparison of surgical approaches for posterolateral osteochondral lesions of the talus. Foot Ankle Int. 2008;29(4):415\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":false,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Talar body fracture, Sneppen type V, Tibiofibular osteotomy, Syndesmotic preservation, Surgical approach, Case report","lastPublishedDoi":"10.21203/rs.3.rs-9338710/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9338710/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSneppen type V talar body fractures constitute rare, high-energy traumatic injuries typified by severe articular comminution and extensive soft-tissue compromise. Adequate surgical access is prerequisite for anatomical reduction and rigid internal fixation; however, conventional anterolateral and posterolateral approaches confer limited visualization of the posterolateral talar dome. This case report delineates the clinical utility of a syndesmosis-sparing modified combined tibiofibular osteotomy for the management of a highly comminuted Sneppen type V talar body fracture.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 48-year-old male laborer sustained a right ankle injury following a fall from height, presenting with disabling pain, soft-tissue swelling, and restricted range of motion. Radiographic and computed tomographic (CT) evaluation confirmed a comminuted Sneppen type V talar body fracture involving the lateral and posterolateral talar dome with articular depression and displacement, concomitant with a fifth metatarsal base fracture. A single anterolateral approach was utilized to perform a combined tibiofibular osteotomy with preservation of the distal tibiofibular syndesmosis. The osteotomized segment, hinged on the intact posterior inferior tibiofibular ligament (PITFL) and posterior capsuloligamentous complex, was reflected posteroinferiorly, yielding unobstructed exposure of the lateral and posterolateral talar dome. Anatomical reduction of the talar body fragments was achieved with headless compression screws and Kirschner wires (K-wires). The osteotomy site was anatomically reduced and rigidly stabilized with two tibial lag screws and a fibular 1/3 tubular plate. A completely disrupted anterior talofibular ligament (ATFL) was anatomically repaired using a suture anchor. Postoperative imaging confirmed anatomical reconstruction. At the 3-month follow-up, the patient achieved painless full weight-bearing ambulation, with a visual analogue scale (VAS) score of 1/10 and an American Orthopaedic Foot and Ankle Society (AOFAS) ankle\u0026ndash;hindfoot score of 88. Osseous union was radiographically evident at both the fracture and osteotomy sites.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe syndesmosis-preserving modified combined tibiofibular osteotomy represents a safe and efficacious surgical strategy for highly comminuted Sneppen type V talar body fractures. This technique affords extensive posterolateral talar dome exposure while maintaining distal tibiofibular syndesmotic integrity and mitigating iatrogenic ligamentous injury. Early functional outcomes are favorable; however, long-term surveillance is mandatory to monitor for post-traumatic osteonecrosis and secondary osteoarthritis.\u003c/p\u003e","manuscriptTitle":"Tibiofibular Osteotomy for the Treatment of Sneppen Type V Talar Body Fracture: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-18 08:01:31","doi":"10.21203/rs.3.rs-9338710/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"78987216563966732265967177082042518542","date":"2026-05-17T13:40:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T08:55:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213381527487791323668346041869941335670","date":"2026-05-11T08:26:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-07T17:17:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-16T12:34:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T09:48:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-13T09:48:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-04-07T03:04:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fc518e31-fb76-4e1a-9fac-099dff7c2c88","owner":[],"postedDate":"May 18th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"78987216563966732265967177082042518542","date":"2026-05-17T13:40:40+00:00","index":58,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T08:55:16+00:00","index":40,"fulltext":""},{"type":"reviewerAgreed","content":"213381527487791323668346041869941335670","date":"2026-05-11T08:26:03+00:00","index":39,"fulltext":""},{"type":"reviewersInvited","content":"30","date":"2026-05-07T17:17:16+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T08:01:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-18 08:01:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9338710","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9338710","identity":"rs-9338710","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}