Drill a 2.5 mm hole, with the protection of a drill sleeve, 2-3 cm above the level of the horizontal joint line, aiming the drill bit slightly inferiorly to avoid screw pullout.
Tap the medial cortex with the 3.5 mm tap and protection sleeve.
Insert a unicortical screw, ranging from 20-30 mm in length and fitted with a washer. Leave a space for the wire of 2-3 mm between the bone and the washer.
In osteoporotic bone, this screw must be bicortical.
Prepare the 0.8 -1.0 mm wire by making a loop at approximately one third along its length.
Pass the shorter segment of the wire close to the bone around the two K-wires.
Pass the longer segment of the wire (bearing the loop) around the screw between bone and washer, forming a figure-of-eight.
Twist the free ends together.
Some surgeons prefer to use two pieces of wire, twisting the ends together to create the figure of eight loop with a twist on each side.
The wire twist is loosely prepared ensuring that each end of the wire spirals equally, forming a double helix – avoid twisting one wire around the other (straight) wire.
The wire is tensioned by pulling on the twists.
The slack is then taken up by further twisting. Repeat this until the desired tension is achieved. Both loops must be tightened at the same time and in the same direction, to achieve equal tension on both arms of the wire.
Tighten the screw carefully. Trim the twists and turn both ends towards the tibia in order not to irritate the soft tissues later.
In osteopenic bone care must be taken to avoid excessive tensioning.
Cut the 2 K-wires obliquely, approximately 1 cm from their insertion points and, with the help of a bending iron and forceps, bend through 180 degrees.
The K-wires are then driven home, sinking their curved ends into the bone to prevent backing out and skin injury.
Take final x-rays in both planes to check the results.