Name: Management of Ankle Fracture/Dislocation Utilizing Titanium Anatomic Distal Lateral Fibular Plate
Uploaded: 2017-06-20T00:00:00Z
Channel: Arthrex
Description: Justin Fleming, DPM, (Philadelphia, PA) provides a case presentation on an ankle fracture dislocation repair using the Titanium Ankle Fracture Plating System, the Ankle TightRope ® fixation system, and the AITFL InternalBrace™ ligament augmentation.

<p>Justin Fleming, DPM, (Philadelphia, PA) provides a case presentation on an ankle fracture dislocation repair using the Titanium Ankle Fracture Plating System, the Ankle TightRope<sup>®</sup> fixation system, and the AITFL InternalBrace™ ligament augmentation.</p>

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VPT1-00885-EN | D | Management of Ankle Fracture/Dislocation Utilizing Titanium Anatomic Distal Lateral Fibular Plate

Justin Fleming

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Management of Ankle Fracture/Dislocation Utilizing Titanium Anatomic Distal Lateral Fibular Plate

Hi, I'm Justin Fleming from Philadelphia, Pennsylvania. And today we're going to talk about the management of ankle fracture dislocation utilizing the titanium lateral fibula plate. So this is our patient. She's a 32 year old female. She had a mechanical fall on ice. She sustained a closed trimalleolar ankle fracture dislocation. These are the injury films taken at the time of her injury. I think it's quite obvious she has a pr4 fracture dislocation. She has a small posterior malleolar fracture. And the thing that really sticks out to me is really there's a high volume of soft tissue disruption, including the syndesmotic components and the deltoid component as well. And so for me, in my practice over time, this is one injury that requires additional stabilization for the long term maintenance of the reduction. So this is the preoperative film. And then you see the intraoperative reduction of the the length and rotation of the fibula. You can see that the mortise now is symmetric and that we have a good working length on the plate. So we have six cortices above in multiple cortices below. Again a high high density high volume of screws in the lateral malleolus. And then as typical for all of these rotational ankle fractures we assess the syndesmosis. And you can see through a rotary stress test that the mortise is grossly unstable, a large increase in the medial clear space and the tib fib overlap. So this is the intraoperative video just showing the amount of instability that exists. Again, just a small amount of rotary force really decouples the distal fibula and the distal tibia. And then additionally in something we don't really talk about very often really, is the sagittal plane instability that exists in some of these more unstable injuries. And that can make syndesmotic reduction difficult. So this patient has been stabilized with a single TightRope at the level of syndesmosis. And I think for a lot of us, for a long period of time, this has really been the typical end point in the surgical reconstruction. But as we noted before, really there really, there was a high volume of soft tissue injury. And so I want to show you potentially some some different thoughts on how to create more stability at the level of the syndesmosis. And so this is just showing the improvement in stability after the TightRope has been placed. But you can still appreciate there's a small amount of of rotary instability and a small amount of sagittal plane instability that exists even after stabilization. And so I want to point you to this study done by Doctor Clanton in 2017. This was a study evaluating the individual contributions of the syndesmotic ligaments to the overall strength of the syndesmosis. And they sectioned the ligaments from front to back and then back to front. And they use a physiologic loading method. And what they found was that the TfL really provides the majority, up to 25% of the rotary stability and the posterior translation that exists in the syndesmosis. And so their conclusion was really that we should think about repairing the TfL, because it is necessary to improve the external rotation stability in a small subset of of rotational ankle fractures. And so this is the lateral plate. And it really is the first plate that allows us to couple soft tissue reconstruction with fracture stabilization in foot and ankle. And so if you look at the distal cluster of the plate, there are some small screw holes where an internal brace can be passed through. I've done this before application of the plate. And it allows us to directly repair the anterior syndesmosis and an anatomic fashion. And it really improves the stability of the syndesmosis overall. And hopefully we'll help these patients in the long term. So on the right you can see the intraoperative c-arm shots just really demonstrating the placement of the anchor, but also to make sure that it's extra articular as well. And you can see that through the plate we're able to stabilize the anterior syndesmosis. And it's really anatomic. And it really is at the level of the of the true anterior syndesmosis. And then this is looking at rotary and anterior posterior testing after the TfL has been repaired. And you can see this is a very, very stable construct, certainly more stable than, than previous. And so the last stage of the reconstruction, and certainly the deltoid is not part of the syndesmosis, but I think you have to couple these two structures together simply because it does provide the overall stability to the ankle joint. And it's my belief that the deltoid is disrupted in a small subset of patients. It really does increase the amount of stress on the syndesmosis. And so on the left hand side, you can see a valgus stress exam that's been done after lateral column reconstructed and syndesmotic stabilization. And this is the technique that we've been using to repair the deltoid. It's essentially an outside in technique. The drill bit terminates at the level of articular cartilage. And then a 3.5mm anchor with internal braces, then passed through the medial malleolus at the level of the inner cochlear groove. And then we're using a 4.75 SwiveLock as an interference screw to stabilize the medial structures. The posterior is And stabilized, and we repeat all the stress exams to make sure that all the components are covered. So the majority of time in our surgical protocols, we've really only been addressing the interosseous ligament, which essentially is responsible for up to 30% of the syndesmotic stability. And so I think at this point in time, we're really looking at the individual components of the syndesmosis, including the deltoid, to provide an overall increase in the strength construct. And again, it's about the maintenance of the reduction in the long term to reduce the risk of, of post-traumatic arthritis. And so I think the indications for a TfL repair are these patients that we've just showed you the PDR for injuries that are largely ligamentous. They have a one portion of it is the fracture. But really the bulk of this injury is ligament itself. And then certainly any fracture dislocations through a series of stress exams that prove to be unstable. And those patients that have medial ankle instability, as I mentioned before, I think if the deltoid is not constraining the talus in the medial position, then it's going to increase the load on the syndesmosis and potentially cause premature failure. And then lastly, if the TightRope is placed up above really a three centimeter region. So we know that if we get above that level, it does decrease the effectiveness, the stability of the TightRope. And we may look to supplement as well. So this plate is really exciting for me because it allows us to couple soft tissue reconstruction and fracture care, which simply hasn't been done in foot and ankle. And hopefully this will also raise awareness of the the importance of kind of the completeness of syndesmotic reconstruction. The distal cluster has polyaxial locking screws, which I think are very important, especially in segmental injuries. And again, the the design of this is low profile and anatomic, which certainly makes it easier on our part to help our patients. Thank you.

Management of Ankle Fracture/Dislocation Utilizing Titanium Anatomic Distal Lateral Fibular Plate

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