Name: Lower Leg Fracture Management for the Sports Medicine Surgeon
Uploaded: 2018-05-11T00:00:00Z
Channel: Arthrex
Description: Andrew R. Hsu, MD, (Irvine, CA) presents the Arthrex ® solutions for lower extremity fractures. Dr. Hsu highlights the FibuLock ® fibular nail, ankle, and pilon fracture plating systems, Syndesmosis TightRope ® XP implant, and the ArthroFX ® external fixation system.

Foot and Ankle

Andrew R. Hsu, MD, (Irvine, CA) presents the Arthrex® solutions for lower extremity fractures. Dr. Hsu highlights the FibuLock® fibular nail, ankle, and pilon fracture plating systems, Syndesmosis TightRope® XP implant, and the ArthroFX® external fixation system.

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VID1-01343-EN | C | Lower Leg Fracture Management for the Sports Medicine Surgeon

Andrew R. Hsu

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Lower Leg Fracture Management for the Sports Medicine Surgeon

So as a foot and ankle trained person myself, when I think about what makes an ankle fracture more of a sports case versus a traditional trauma case, I think there are three main things. The first is this idea of fragment specific fixation, fixing all of the fracture fragments in addition to soft tissue specific fixation, and fixing the ligaments and the tendons around the zone of injury. The second is the use of ankle arthroscopy as both a diagnostic as well as a therapeutic tool to address articular cartilage injuries, as well as ligamentous damage at the same setting as the actual fracture fixation itself. And the third is biologics, bone marrow aspirate, bone void fillers, wound dressings, amniotic tissues, things that maybe typically are traditional trauma surgeons don't use, but that we can use to provide more of a comprehensive care for our ankle fractures. So why do I use Arthrex for all of my lower extremity injuries? Really? Well, it's very, very helpful to have one rep that has everything that I need from an external fixator to pilon on plates, small frag plates, amniotic tissue, biologics, BMA. Everything that you can have, especially with a lot of these cases being add on cases, things that you're kind of adding on at the last minute. It is very helpful to have one company that can provide you everything that you need to take care of all the soft tissue as well as the bony fixation. So these next couple of cases are really just real world cases that you may encounter showing off just kind of the variety of different ankle fractures that you can see. It's not really just a one size fits all type of paradigm that many of the residents that we teach. There are so many different injury patterns you can have, and some of the tools that you can use to treat them that Arthrex has. First case is a 35 year old avid cyclist. He was involved in a motorcycle crash. You can see here he has a closed distal tibia as well as fibula fracture extending into the plafond. And these situations I'll use the Arthrex ArthroFLEX. This is a very quick, easy to use external fixator. It's very cost effective. It's really targeted a lot towards surgery centers as well. My typical configuration is the one seen on the left. Really just a standard delta frame. If I know I'm going to be putting them in that for maybe 1 to 2 weeks, I'll add a few more bells and whistles, like a kickstand, as well as additional bars, just to kind of help reduce that soft tissue swelling. We get a CT scan and we see typical shaped fragments. We see proximal extension as well as articular comminution as well. So the approach for this is anterolateral approach using the two seven and three five lag screws, as well as the Arthrex distal tibia plating system, which fits very nicely over the anterior lateral plafond. There are also some good medial locking plates that exist as well. I also have a Quickset calcium phosphate bone cement ready, in case there are any bone metaphyseal voids that want to fill in. Alternatively, I've also used bone marrow aspirate mixed with cancellous chips to fill in those voids. Fix the plate. Make sure that all of the screws are outside of the joint itself. And then we work on the fibula. In this case, I didn't want to make another incision over the fibula. I just wanted to do it percutaneously to have to avoid that tenuous skin bridge that may occur. So just a single cannulated screw through the fibula itself. And then again, you can add in any bone void fillers you may need to at the very end Case 225 year old female avid soccer player who was involved in a slide tackle soccer injury. This is one of those cases you can get burned pretty easily on. Just based off of the X-rays. It looks like a pretty benign injury. Small medial fragment, small posterior fragment. You think maybe you can just get this with a percutaneous PTA screw? But I always encourage you to get a CT scan if there's anything that's just a little bit worrisome with the overall injury. Sure enough, we see that her syndesmosis is out. We see that the post male is actually in two separate pieces, and there's actually some interposed articular fragments as well. So a little bit more of a complex injury than what the X-rays would have you believe. You look at the 3D CT recon and sure enough, these post mal fragments, there's two separate pieces here. This is a young, healthy, active soccer player. We really want to fix everything as anatomically as possible. We start her prone and really we want to get a great fixation of those two pieces in the back. I break out the Arthrex CFS tray. These have 2.4mm plates and screws that I can use. I place two of these plates along the back with these smaller screws, so they don't occupy as much space as a 3.5 screw. I get that anatomically reduced. I add in both plates and this is what you see. And then we flip her over supine. Again her syndesmosis is out. So what I do here? A four hole, one third tubular plate. I like to use the knotless TightRope in a divergent pattern. I like to use it with a cannulated technique, especially when there's hardware that's in the way. I want to make sure that they're 30 degrees divergent. I want to make sure that they're not going to run into those screws, especially if there's not that much working room. So you can see here on the lateral view I have the exact trajectory that I like. I check that clinically always to make sure that just as a gross perspective, I can see that these guidewires are going in the right orientation and they're not necessarily just going parallel. That could internally or externally rotate my syndesmosis. Again, we have that little medial mal fragment. So with her we excise that fragment. But at the same time we were surprised to see that we had complete avulsion of the superficial deltoid complex off of the anterior medial malleolus. So we prep that out completely with a small rongeur. And we use two of the three millimeter SutureTak anchors and just use a horizontal mattress type of configuration to bring that back over. This can be very, very helpful to provide a more anatomic reduction. Sometimes this medial superficial deltoid can flip into the gutter and actually block your reduction. So we get this out of the way before we actually tie down our syndesmosis. So finally we get our syndesmosis TightRope flush onto bone, we get the trajectory that we want, and we finish the case by imbricating and tying down that superficial deltoid complex. We've repaired the superficial deltoid complex, the syndesmosis and the bony fixation all at the same time. Next case is a 21 year old male who was involved in a football injury. Bad injuries. You can see here. Syndesmosis is wide open, big medial, clear space, proximal comminuted fracture, but it appeared to be length stable. Young patient I want to start with a diagnostic arthroscopy of a high suspicion. In these high energy types of injuries of articular cartilage damage. I want to know exactly what's going on. If there are going to be any articular fragments, free floating bodies, osteochondral lesions. This is my typical scope set up on the left five minute scope. You want to get in and out. You don't want to insulate the tissue too much, especially with the soft tissue damage. Thigh holder quick, in and out. Look at it. Sure enough, what you see in the center image there that's looking laterally, you see the syndesmosis as well as disruption of the syndesmosis. You see these osteochondral lesion. And sure enough, there were some free articular fragments which we had to fish out. I don't typically tend to microfracture these in the acute setting. I'll just debride them down to a healthy stable base. And then looking medially you can see the superficial deltoid complex flipped into the medial gutter. A more modern take compared to the previous case I just showed I like these 1.35 FiberTak anchors. These are all suture anchors. They occupy a very small footprint. They're loaded with number one FiberWire. And they're very strong. So you can see me holding up the entire leg by just the sutures alone. So they're very, very good tool, especially in a tight working space. If you don't want to use a three millimeter SutureTak in this case, rather than using the four hole, one third tubular plate, we use the new two hole syndesmosis plate that's designed specifically for the TightRope. This fits very nicely, occupies a very small amount of space. We get that 1.5cm above the joint. Pin it into place again. And in this case we use the new Knotless TightRope XP devices. These are These are pretty clever devices where you don't have to make these medial stab incisions anymore. You can use it all through the hand delivery device to get that button seated flush on the bone, so you don't have to fidget very much over on the medial side. Next case 18 year old male who was involved in a skateboard fall. Kind of a strange injury. Can't really tell what's going on here. All I can tell you is, every time we kept trying to reduce him, he kept trying to fall out the back. So he put the ArthroFX on him and get a CT scan just to get a better idea of what's going on. Why is he so unstable posteriorly? Sure enough, we see this little rim fracture along the back with a somewhat comminuted fracture. So I don't abide by this idea of, well, oh, if it's 20 to 25% of the joint, then I have to fix it. The posterior malleolus. I fix it if I feel like it's unstable. And this gentleman was clearly unstable, falling out the back during reductions that we had to put an ex-fix on him. So you see this posterior rim fracture here? Arthrex has these two millimeter contoured rim plates that you can use out of the distal tibia set. We also put on a distal fibula locking plate as well. We fixed the distal rim fracture first to make sure that all of those screws are outside of the joint before we move on to the fibula. Now, if you're worried about peroneal tendons, any tears, any synovitis that you see, Arthrex also makes an amnion amniotic tissue, which can be very, very helpful in reducing scarring over the perineal tissues. Jumpstart their wound dressing as well, which has also been shown to help reduce infections as well as improve wound healing. Taking one step away from the sports fracture, what about just your general practice? Your on call. You have a geriatric, somewhat more morbidly sick patient. This is a 65 year old female with diabetes who just fell down some stairs. Bad comminuted fracture. The medial mal is in multiple pieces. It's not just transverse or vertical. It's kind of both very, very bad lateral skin. You can see that after we put on her ex-fix there's this soft tissue defect over on the AP plane. So for her I don't want to put on a plate and screws. I don't really want to put much lateral hardware at all. So I use the FibuLock nail that Arthrex has, which is a very nice solution to this. Basically just an intermediary nail for the fibula. So make a little incision over the fracture site, and I pinned that into place. And just like any nail, you want to get your guidewire start point exactly where you want it so you don't blow out laterally. We get it at the tip. We check it on AP and lateral views. We insert that start the start reamer and then we introduce the long ball tip wire as well. We ream proximally and then you insert this nail again. It's typically about a three by 130. And we deploy the proximal talons to get our proximal fixation. And then we can add in our 2.7mm interlocks distally. One of the nice things about this nail too is if you need syndesmotic fixation or just anything as an extra backup, you can place a TightRope through the nail itself. In this case, we elected to do that just to have the strongest construct possible. And then we added on a little 2.4 plate again from the CFS straight with some three millimeter lag screws to fix the joint together. So a nice solution if you're not necessarily looking to put on a traditional lateral plate, you can use the new FibuLock nail. So what are the main takeaways? So why do I use Arthrex again? As you can see from these cases, there are many different types of these injury patterns. They're not all the same. They're not all going to be amenable to a one third tubular plate or a lateral locking FibuLock plate. So you want to have all the tools in your inventory and have them ready to be able to address all the different types of fractures that you may find. I'd always recommend a pre-op CT. As you can see from some of these cases, you can get fooled by the initial x rays and a quick diagnostic scope not only for diagnostic use, but also therapeutic as well. Being able to tell the patient, hey, you have a big osteochondral lesion. This may be symptomatic after surgery. And recent literature has also shown that there is some benefit of removing that initial hematoma, those inflammatory cytokines from the joint, just washing it out just for under five minutes at the beginning of the case. And lastly, you don't want to just get focused just on the bone, just on the fracture. You want to remember what's around the fracture, the syndesmosis, the superficial deltoid ligament complex, the cartilage itself. And you want to have biologics at your disposal as well, so you can provide comprehensive care for these injuries from all facets. Thank you very much.

Lower Leg Fracture Management for the Sports Medicine Surgeon

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