The AOFAS Orthopod-Cast

Episode: How I Treat This: Ankle Fractures - Part 2: Not Just a Fracture

Date: November 20, 2024
Host: Dr. Aneesh (AOFAS Podcast Committee)
Guest: Dr. Caitlin Neri

Episode Overview

This episode dives into modern approaches to treating ankle fractures, emphasizing the importance of viewing them not just as isolated bony injuries but as complex, multi-structural ankle injuries requiring a comprehensive, biology-respecting treatment plan. Dr. Caitlin Neri shares her evolving philosophy, insights on ligament and syndesmosis management, and innovates with minimally invasive surgical techniques—advocating for a shift in surgical paradigms that goes well beyond traditional fixation methods.

Key Discussion Points & Insights

1. Rethinking Ankle Fractures: More Than Broken Bones

(02:06–05:54)

• Ankle fractures should be seen as 360-degree injuries involving significant ligamentous damage.
• Dr. Neri stresses the need to address both osseous and soft tissue injuries for stable mortise restoration.
  • “For the bones to break, some ligaments have to tear, too. And I think that that's what we failed, we neglected for a long time.” – Dr. Neri (02:06)

2. Surgical Decision-Making: Fix the Ligaments?

(04:04–07:12)

• Dr. Neri explains her standard approach:
  • Fibula first, then assess/readily address deltoid and syndesmosis.
  • Relies more on imaging and mechanism than intraoperative stress tests for syndesmotic injury.
• She argues early, full stabilization leads to fewer poor outcomes than simply addressing the fracture:
  • “Less than 80% of patients report good to excellent outcomes... So that means more than 20% of people are out there not doing well.” – Dr. Neri (06:03)

3. Convincing the Skeptics: Why Address the Deltoid?

(07:12–12:22)

• Many still neglect deltoid fixation, assuming fractures do fine.
• Dr. Neri challenges this: long-term studies show medial clear space widening when the deltoid isn’t fixed.
• Neglect leads to rigid flatfoot and complicated secondary problems.
  • “It only takes seeing that once to go, you know what? I'm fixing every deltoid if it's torn.” – Dr. Neri (11:21)
• Emphasizes respecting tradition but staying open to evolving evidence and better outcomes.

4. Shifting Technique: The Why and How of Minimally Invasive Fibula Fixation

(14:05–19:05)

• Initially resisted intramedullary nails; became convinced after success in high-risk patients (diabetic, non-compliant, wound-prone).
• Advantages of fibula nailing:
  • Load-sharing allows earlier weight-bearing.
  • Minimizes periosteal disruption (preserves biology)
  • Dramatically lessens need for hardware removal
  • Smaller incisions, less pain, less swelling, faster healing.
  • “The incision is not for the fracture. The incision is for your hardware.” – Dr. Neri (17:56)
• Argues AO founders would have endorsed modern MIS if available.

5. Posterior Malleolus Approach: MIS, Open, or Both?

(21:06–25:05)

• Posterior malleolus requires individual assessment:
  • Large, displaced: open (posterolateral approach, sometimes prone, still MIS nail for fibula).
  • Small “lateral lip” avulsions: prefer percutaneous reduction/fixation using arthroscopy or nanoscope for reduction confirmation.
  • Avoids open posterior approaches when possible to limit scarring and dorsiflexion loss.

6. The Role of Arthroscopy/Nanoscope

(22:40–24:47)

• Uses “disposable arthroscopic instrument” (nanoscope) to verify reduction through minimal portals.
• Places screws from A–P for posterior malleolus, using CT scan to meticulously plan trajectory.
• Checks reduction stability intraoperatively via direct probing.
  • “I'll stress it with either a freer or elevator, you know, probe something like that to make sure it's stable.” – Dr. Neri (25:04)

7. Looking Forward: The Future of Ankle Fracture Care

(26:56–29:29)

• Anticipates MIS and biologic approaches will become the gold standard within a decade for suitable fractures.
  • “If all of us bury our heads in the sand and just do things the way we were taught... we're never going to go anywhere.” – Dr. Neri (26:56)
• Compares to transition seen with tibia fractures and arthroscopic rotator cuff repairs; predicts similar evolution in ankle fracture management.

8. Syndesmosis Fixation: Suture Button vs Screw?

(29:29–31:50)

• Prefers suture button fixation for flexible, durable stabilization—unless rare, highly unstable situations (e.g., high-energy or neuropathic fractures) demand multiple screws/plate.
  • “Flexible fixation across the syndesmosis is more beneficial for long-term functional outcomes than a screw.” – Dr. Neri (29:52)

9. Summative Pearls and Final Thoughts

(31:50–32:52)

• True “ankle injuries,” not just “fractures”; treat the joint biologically and comprehensively for the best long-term results.
  • “We treat all aspects of the injury and we need to start treating it with more biological respect and we can do better than we did five years ago.” – Dr. Aneesh (32:24)

Notable Quotes & Memorable Moments

• “Why are we doing cotton or external rotation stress tests or these things, you already know [the syndesmosis is] out.” – Dr. Neri (04:04)
• “I was a true AO technique disciple...and now, six years later, I'm doing it for the majority of fibula fractures. That’s what happens with paradigm shifts.” – Dr. Neri (09:16)
• “[MIS fibula nail] is not groundbreaking, but at the end of the day, there’s a lot of small benefits that actually end up adding up to a much better outcome for patients.” – Dr. Neri (17:47)
• “It doesn't happen. Those [posterior malleolus] things heal so biomechanically...Of course in a perfect world we'd all prefer more biomechanically stronger fixation. But does it really matter in this case? And I don't think it does.” – Dr. Neri (23:07)
• “If you look at an ankle fracture, it's really technically like the most beautiful marriage between sports and trauma.” – Dr. Neri (28:53)
• “We're the masters of the ankle and I really think if it's an ankle injury is the best kind of the summary I would have today.” – Dr. Aneesh (32:24)

Timestamps for Major Segments

| Time | Topic | |-----------|------------------------------------------------------| | 02:06 | Global injury perspective: ligaments and bones | | 04:04 | Syndesmosis/deltoid debate & patient counseling | | 07:12 | Literature and long-term outcome discussion | | 14:05 | Minimally invasive fibula nailing advantages | | 21:06 | Posterior malleolus approach and individualized plan | | 22:40 | Role of nanoscope/arthroscope in reduction | | 26:56 | Future gold standard: biologic/MIS fixation | | 29:29 | Syndesmosis: Suture button vs. screw | | 31:50 | Final pearls and the push for biological respect |

Conclusion

Dr. Caitlin Neri’s approach champions a patient-specific, thoughtful treatment of ankle injuries, integrating advances in minimally invasive techniques and a comprehensive focus on both bone and ligament healing. This paradigm aims not just for fracture union but for optimal, lifelong ankle function—an evolution she believes is both inevitable and essential in the foot and ankle surgery field.