Name: Weber C Ankle Fracture Stabilization Using the FibuLock® Nail
Uploaded: 2018-07-27T00:00:00Z
Channel: Arthrex
Description: Christopher R. Boone, MD, (Bellevue, WA) presents a Weber C ankle fracture repair case. Dr. Boone describes his technique for fracture reduction and shares his surgical pearls using the FibuLock ® fibular nail and Syndesmosis TightRope ® implant.

Christopher R. Boone, MD, (Bellevue, WA) presents a Weber C ankle fracture repair case. Dr. Boone describes his technique for fracture reduction and shares his surgical pearls using the FibuLock® fibular nail and Syndesmosis TightRope® implant.

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VPT1-01049-EN | A | Weber C Ankle Fracture Stabilization Using the FibuLock® Nail

Christopher R. Boone

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Weber C Ankle Fracture Stabilization Using the FibuLock® Nail

Hi, my name is Doctor Boon. I'm from Bellevue, Washington, and today we're going to talk about a case of an ankle fracture. So we have a 37 year old obese, diabetic female. She presents to the emergency room with significant pain and deformity of her ankle. She had a pretty simple twist and fall down the stairs. Heard a pop. Presented to the emergency room. She otherwise has no history of ankle pain or injury. As far as her physical exam is concerned. She had a very large soft tissue envelope. There was some significant bruising. It was a closed fracture, but otherwise, you know, the swelling was pretty significant. She did have compressible compartments and was totally neurovascular intact distally. So these are some X-rays from the operating room. And you can see just looking at the two on the left there she has a pretty large lower extremity. You also have some diabetes to think about. So in general one of our concerns is obviously the soft tissue envelope. And then over here on the right you can see she obviously has a Weber C or a distal one third fibula shaft fracture with significant widening of the syndesmosis. Some of the things that I've learned in using the nail, kind of some of the pearls and pitfalls, I guess your starting point is the key. As with all nails, you've got to get the starting point correct. If you don't get the starting point correct, the rest of the case is going to be very difficult. I typically oscillate the wire on the way in to get it around the bend of the fibula there. If you go in on forward or even reverse, you're going to start to burn a hole in that medial part of the cortex, and then it's going to be really hard to bend that nail around. And so using using the, you know, the drill on oscillate can help with that a lot. You know, I make a small incision at the distal tip of the fibula. I don't try to do this with a with just a poke hole or a percutaneous incision. I think you start wrapping up skin and causing significant soft tissue damage. So I make about a 1 to 2 centimeter incision just off the tip of the fibula. And that seems to work better. Depth and rotation of the nail. So before you set your depth or before you set the proximal aspect of the the FibuLock nail, you have to make sure it's deep enough because you're probably going to put some syndesmotic screws or TightRope in this case across the Across the syndesmosis. And also you have to get the rotation right. And so if you look at the jig you make sure you want to you want to be in the plane of the fibula and the tibia. The fibula, obviously, as we know, sits posterior to the tibia. So you want to make sure that those holes line up in the trajectory that you want before you lock the nail proximally and then syndesmotic reduction. You know, I'll show you one of the X-rays here. You can over reduce the syndesmosis easily. You know, the idea of the old orthopedic surgeon. You know, if it doesn't work, hit it harder. Isn't really necessarily the case here. You want to make sure you get an appropriate syndesmotic reduction in the appropriate plane. Typically, I put two tightropes across the syndesmosis or through the nail. I've become more comfortable with this implant over time, and I've switched to two tightropes. In general, you want to make a separate incision on the medial edge of the tibia for the TightRope, because we ShaverDrill backwards through the tibia to the medial part of the fibula as well too. So here's a couple of X-rays. We have the starting point. You can see the x ray there on the left. You have a good starting point. Make sure you take good laterals if you can be. You can be off in both planes. And then again you kind of have a difficult time with the case. At that point. You can see the small incision that we make there on the right. So here's syndesmotic reduction, kind of what I was talking about. If you look at the x ray on the left, we use I used a Qing tong or Queen tong in this case a periarticular reduction clamp. Sometimes you can get away with a point to point, but with her soft tissue envelope, the vector wasn't wasn't appropriate. And so I ended up using a periarticular clamp, which is really nice in this case. If you look at the right x ray, you can see that talus and it tilts a little bit. And if you look between the fibula there laterally in the medial space, you can see how the talus is tilting a little bit lateral there compared to the x ray on the on the left where it's reduced appropriately. So if you look at the syndesmotic fixation now so we've got our nail placed. We've got length alignment rotation of our fibula back. And so now we're going to fix our syndesmosis. And I try to get my TightRope or whatever syndesmotic fixation you're using as close to close to the joint line or as close to the mortise as you can, obviously, without going without going into the ankle joint. This is going to be the strongest fixation that you have. So with post-operative X-rays, we've kind of we've done what we came to do here. We've reduced our mortise. We have the the appropriate, you know, spacing all the way around medial side matches lateral side. And we've also restored length alignment rotation to the fibula post-operatively. I typically place these patients in sugar tongs splints for two weeks. You know when I'm using the nail it's again in kind of a bigger patient with a larger soft tissue envelope. I don't find that I have a boot that fits very well, especially with post-operative swelling. I think a sugar tong splint, you know, the old school fiberglass or old school plasters is the best, especially for the first two weeks. I leave them in their splint. I don't have them take it off. I do try to transition them to a boot at two weeks if I can get a boot for them. Simple gentle range of motion of the ankle and then depending on the fixation and depending on the patient, I typically progress weight bearing at about 6 to 8 weeks different for every patient. A little bit, but typically about typically about the 6 to 8 week mark, which I think is is something a little bit is a little bit more aggressive than we used to for syndesmotic injuries, where we kept people non-weight bearing for up to three months, which is almost impossible to do for some people. And then at four months I tell them, you know, you can return to to activity is tolerated. No significant restrictions. In conclusion, I think the nail gives you a significant advantage against for for from a soft tissue standpoint, you're making much smaller incisions. And especially in diabetic patients, obese patients, patients with venous stasis issues. We've all seen that fibula incision come back. And the worst thing that can happen is be staring at a plate at two weeks. And that's that's something that's pretty significant when you look at it. So and then, you know, again, the high risk patient I think is important, as well as a pilon where you have a terribly displaced, a fracture of the fibula, where you just are not going to be able to get anatomic reduction.

Weber C Ankle Fracture Stabilization Using the FibuLock® Nail

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