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

Summary

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

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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.

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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)

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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)

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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 |

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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.

Transcript

[A]

Welcome to AOFAS Ortho Podcast, where leaders in foot and ankle orthopedic surgery discuss the issues that affect you and your practice. Please note that the views expressed on this podcast do not necessarily represent the.

[B]

Views of the AOFAS or its members. Welcome to the OFAS podcast. Thank you for listening. We have with us Dr. Caitlin Neri, who's out of Idaho, who I've got to know over the last five years. Maybe Caitlin.

[A]

Yeah.

[B]

Who's probably one of the best surgeons and obviously great friends that I've met and lucky to get to know and I've learned a lot from her. Today we're going to talk about ankle fractures. We had a discussion with Dr. Malloy looking at the United Kingdom perspective, but. But I'm going to bring her on here to talk about her view of ankle fractures. She does some phenomenal, minimally invasive techniques and see how she's going to represent all Americans how we treat ankle fractures compared across the pond. So thank you, Caitlin, for joining us.

[A]

Yeah, thank you, Aneesh. It's an honor to be here and I know you've been doing this for quite some time. I've been an avid listener and I always wondered if I'd get an invite. So I'm honored to be here. This is a wonderful thing you guys do and oh my gosh, I've gotten so much valuable insight and information from these podcasts and just like I said, I'm honored to now be a part of that.

[B]

You're wonderful. So this is my pleasure to have you here. Thanks for taking the time.

[A]

Of course.

[B]

So first thing is when you think of when you see an ankle fracture, present a scenario to you. Young, healthy, 49 year old male, physically super fit, brown bald beard, wants to stay active, breaks his ankle. How are you? So we're going to give you a. It's a lateral mal. So for example, Weber B, lateral mal, displaced, no question. What is your first thought? You got X rays, there's a 10 millimeter medial clear space widening. Weber B. Fibula is gone. What's your first thoughts? Like? I'm going to address what.

[A]

Well, my first thoughts are, I think you just tried to describe yourself but then you said athletic and fit and I thought, no, never mind. That can't be, can't be a niche. I'm teasing. I think the biggest thing that when I'm looking at an ankle fracture, they come to your clinic, you get those first X rays or you look at their ER films, it's of course you're looking at the fracture, but it's understanding the entirety of the injury. And I think that for a long time, that was our biggest downfall with treating ankle fractures is we looked at the fracture. I mean, we call it an ankle fracture because that's what we're looking at, the bones. But the truth is these are global 360 ankle injuries. And if you look at especially with believe in the Laughi Hansen classification, if you believe in the different ser and pronation, abduction and adduction and all those mechanisms for ankle fractures, there is just as much ligamentous injury as there is osseous injury. And 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. So when I look at that X ray initially, I go, okay, there's a fibula fracture. We know it has to be fixed. It's displaced. But the bigger thing is the mortise instability. Why is that mortise unstable? Why is the talus translating laterally? Why is the medial clear space wide? I mean, the two main ligaments, of course, that we're thinking about are the syndesmosis and the deltoid.

[B]

So you're going to go after this. You're going to walk in the room. Mr. So and so I'm going to fix. You've got a bad ankle fracture, you've torn your ligaments. As you said, I'm going to fix your. Before you even walk in the or, I'm going to fix your fibula, you, your deltoid, your syndesmosis, hands down. Or I'm gonna fix the fibula. And then people talk about a valgus stress test and your intraoperative. I'm curious what your intraoperative syndesmonic stress tests are you going in. I know what I do. I fix everything. I don't do any intraoperative decision making. But are you more. I'm gonna kind of see or is it these are broken. And I'm gonna stabilize everything.

[A]

I mean, for the most part, every patient's a little bit different. There's some nuances. So that conversation does differ a little bit patient by patient. But you can tell a lot by just looking at the inj. I don't stress. I'll do valgus stress. I haven't stressed a syndesmosis in years. I think you can because you can a, you can look at the X ray, and a lot of times it's pretty obvious the syndesmosis is wide. So why are we doing cotton or external rotation stress Tests or these things, you already know it's out. So for me, if it's obviously wide, that's one reason to not stress it. The second reason is if you have an unstable ankle fracture and you believe those mechanisms that we watch, those videos we watch of how the fibula breaks and how the forces travel around the ankle posteriorly from lateral to medial, the forces have to go through the syndesmosis. So if you have a torn deltoid by default, you also are going to have a tear through that syndesmosis. So to me, I'll still look, especially if I have a small lateral incision. I happen to be right at the incision, I'll still look, but I don't do any crazy stress. I assume automatically if it's an unstable ankle fracture that the likelihood of a syndesmotic injury is incredibly high. So to answer your question, I tell patients, if it's very obvious, really unstable syndesmotic injury, a lot of diastasis. If the medial clear space is really wide, I tell them you're getting fibula, syndesmosis, deltoid. If it's subtle, and I'm not quite sure, I just tell them I work lateral to medial. I do this fibula first, then if needed, I fix the syndesmosis. And then the one stress test I will do is a valgus stress test to test the deltoid. And I put some stock in that. But still, if you look at the injury films and they've got significant medial clear space widening, the deltoid is out. So even so, if you, what would.

[B]

You say to the surgeons in the audience that say, look, I haven't done a deltoid in my career, all my ankle fractures do fine?

[A]

I'd say they don't, they may. And I think that we all get three month follow up and then you don't know what happens to your patients after that in a lot of cases. But what we do know from the literature is less than 80% of patients report good to excellent. Less than 80% of patients report good to excellent outcomes following operative fixation of an ankle fracture. So that means more than 20% of people are out there not doing well. And I think that we may know about some of those patients. We may not, but there's a reason, and some of that may just be inherent to the injury. Some of these are really bad fractures. They're going to be prone to arthritis, stiffness, whatever else. But I do think some of that's also us neglecting to fully address the injury and neglecting to address it appropriately. As least invasive as we can, as we're going to talk about today, and also not getting them rehabbed fast enough. I think if you lock somebody up in a boot without moving their ankle non weight bearing for six weeks, you're asking for ankle stiffness. So I think those are all things that we have to consider in terms of getting patients back to life and giving them as good of an outcome as we can.

[B]

I think those are great points. I think the key thing that I learned from you is that you don't accept mediocrity and you look at more introspection. So we can do better. And I think the standpoint of, well, these are just bad injuries and it is what it is. There's truth to that, it is what it is in a lot of cases, but we can do better. And 20% not doing what they wanted for an ankle fracture. Rotational, not pilons. We're not talking about pilons.

[A]

Right, right.

[B]

We for sure can do better than that. And I respect the fact that you're talking about the deltoids and mostly trying to make them stable because the argument is that there's some downside to it and infection, et cetera. But, you know, that's kind of with anything that we do. And it's a stable ankle is better than an unstable ankle. I don't know how you can argue otherwise.

[A]

Absolutely. And you look at these injuries, there's obviously a huge range. There's a very different, a big difference between a moderately displaced Weber B with a deltoid injury compared to like a fracture dislocation, trimalleolar fracture, dislocation with a big posterior mal. I mean, those are very different injuries. Low energy versus high energy, what type of hit the joint takes at the time of injury. And there's a difference in outcome between those patients. But I think my goal is to give everybody a stable mortise. If you can give them a stable mortise that's capable of being stressed with range of motion and weight bearing early, you're going to give them the best chance at a good outcome. And I think that's what's important.

[B]

So you got fellows who listen to our podcast Residents, you've got some general surgeons, orthopedic surgeons, you got all the foot and ankle people. So for the young ones who may be doing boards, getting out of boards, getting grief by their partners, what would you tell them when they look at this ankle fracture? And how would you convince them besides what you said? But is there any Way to tell them, like, look, don't hesitate to fix the deltoid or syndesmosis. And despite what your partners say, because and it's not a ton of data saying that they're going to do great if you fix the deltoid and they're going to do terrible if you don't. But what would you tell them is kind of the most like, why, why should they start thinking about it and fixing all the ligaments like you're doing?

[A]

I think the hardest part, especially coming out of training, is you are a product of your training and your mentors. And I was the same way just to use intramedullary fibula nailing as an example, when I first got shown that, I mean, I was a true AO technique disciple because of my training and my mentors that I respect very, very much. And the first time the rep brought this fibula nail and said, let's try this, I said, absolutely not, I will never do that. And now, six years later, I'm doing it for the majority of fibula fractures. And that's what happens with paradigm shifts. You have an initial period of resistance and then you slowly start gaining adopters and people come around to the idea and finally you see the. And I think that I would just encourage all of the fellows and surgeons early in practice to respect your training, respect your mentors, they're all very wise and know what they're talking about. But at the same time, none of us are always right. And I think that we're really gaining a lot of knowledge in terms of these not just being ankle fractures, but being ankle injuries. And I think that even if you've been told your entire career not to fix the deltoid, just know there's two sides to every story. And I think there actually is. I mean, you're right, there's not powerful literature one way or the other, but there have been good studies that show, especially in combination with the syndesmonic injury, if you don't fix the deltoid, patients actually do have increased medial clear space widening years down the road. There have been long term studies showing that. So I think that, and of course us as foot and ankle surgeons and Those young surgeons, 10 years into practice, they will have seen these deltoids and these syndesmoses that aren't fixed and they'll see, they will get patients in their clinic and 10 years after an ankle fracture who didn't get their deltoid fixed and now they have a big rigid flat foot that you have to fix. Because the deltoid stretched out, the spring ligament has stretched out, their hindfoot's fallen into valgus, their arches collapsed. And those are actually really hard. Those don't behave like a typical flat foot. So it only takes seeing that once to go, you know what? I'm fixing every deltoid if it's torn.

[B]

I think it's a great argument. And it's kind of what Andy actually said a little bit about that because he, he said the same thing. And you guys didn't talk to each other at all. Obviously, that in your experience and his experience are the same, that you get that deltoid spring and they get a flat foot. That's a horrific actor. So I'm biased. I agree with you. But your argument's fantastic.

[A]

I mean, you think about ankle injury. Yeah. And if you think about a bimalolar ankle fracture, we would never hesitate to fix the medial malleolus if it was unstable, displaced, anything, even when it's non displaced. If I'm already there fixing a fibula, I'm probably putting a screw across the medial malleolus just to make sure it heals or doesn't displace. So we would never neglect a medial malleolus or in the setting of a bimalar ankle fracture. So why are we neglecting these Ser4Deltoids? It's the same thing. It's just you're tearing the ligament instead of the bone. And you think about every textbook you read, it starts with. In the deltoid chapter, it says, the deltoid is the primary stabilizer of the ankle.

[B]

100%.

[A]

I can't tell you how many times I've read that sentence and gone, if it's the primary stabilizer, why are we never addressing it? Not only in fractures, in ankle instability and everything. We just. I don't know, for some reason it's been neglected. So it's a syndesmosis.

[B]

I had oncology many years ago where they said, don't do it.

[A]

Yeah.

[B]

Okay. So there's no question you fundamentally believe that the ligament should be addressed. And these are true ankle injuries versus ankle fracture as an isolation, which I think is a very good way for us as foot and ankle surgeons to think about these injuries, because that's what we do. It's a shift in thought. And I think a lot of people around that, not everybody. So we've decided to fix it all. Now, the fibula, you are definitely a minimally invasive. And what I've seen that you can do is beyond what I can do. With that technique. So what, besides just trying to do something new and different, what would I say is why did you choose? After trying it out on patients and seeing its benefit, why are you now a major minimally invasive fibula with a nail versus an open? Because the argument is when I see a patient, I do a lot of open ankle fracture stuff and they seem to do fine except when the wound falls off and then you're crying about it a little bit. But in a young, healthy patient where the wound is probably not your biggest issue, I want the audience to understand, why do you still prefer the nail? And for full disclosure, both of us are consultants for a company that makes the nail arthrex, obviously. So that's. People should know that a little bit. But. But you know, Dr. Nary is you're very ethical and you want the best outcome. So why did you switch to most? Because I know you don't get any. There's no skin in the game for you directly from this. So why did you now become a nailer?

[A]

So I'll tell you my story. As I alluded to earlier, when I first saw the nail, I said, absolutely not. It doesn't mesh with all of the AO principles that I've been taught. It's not in line with my training. Why would we ever do that? I mean, I was an absolute, I was against it. And eventually you start to hear more and more people talk about it. I was of course reading the literature, looking at other surgeons who were doing it and I started to see the indications, at least for like the unhealthy diabetics that are going to be non compliant, that are high risk for wound complications and those types of things, I thought, all right, well if I have a diabetic and I know they're going to walk and I don't want their wound to break down, maybe this makes sense. So I started using them in those types of patients and in that cohort. And I wasn't necessarily monitoring it, but over time it just sort of dawned on me like, wow, they're actually all doing reasonably well. Their ankle didn't fall apart, their fracture healed, they absolutely walked early. They're insensate, you know, they're non compliant and this held. And it just, I just kind of had an aha moment one day where it was like, I'm using this in the most unhealthy population on the planet and they're doing fine for the most part. So why would I not do this in healthy patients? Why? And that was my when sort of the thought process switched and as time went on, I think the advantages are threefold. And I don't think there's anything wrong with plates and screws. For the record, I don't necessarily think we're like doing something bad for patients by doing an open approach with plate and screws. That's how we've done it for years and it works. Works fine. But I think the benefits of intramedullary fibula fixation are threefold. One, it's a load sharing device. We all know the difference between load sharing and load bearing. And there is no question plates and screws are going to take a lot more stress and strain, especially with early weight bearing, than an intramedullary nail is because plates and screws are load bearing. So it's a load sharing device, which I think for me allows me to comfortably walk patients sooner and not worry about my fixation. Secondly, it's an intramedullary device. So you're preserving all of that periosteum around the fracture, which we know brings in a lot of the blood flow and the biology. It also decreases the rate of symptomatic hardware, which, you know, good for patients, bad for us. But my hardware removal rate has probably decreased by no, 95%. So like I said, anecdotally it's kind of hard to give up an easy 10 minute surgery taking a fibula plate out. But short of that, it is the right thing for the patient. And so I think that that's a big deal. And then finally, the smaller incision, I like to call it minimally invasive. If I'm being honest, it's probably not minimally invasive. I'm not doing this through arthroscopic portals, but the incision is probably 75% shorter than I would for a plate and screw. And I think when you have those smaller incisions, you are completely preserving the biology of the fracture site. You're not stripping the periosteum, you're not going to get a ton of swelling from your incision. You're not getting the pain that's associated with longer incisions. All of those things lead to faster fracture healing and patients are comfortable moving their ankle sooner and all of those things. So I think it's a lot of small things that add up to a big difference. And that's why when I talk to people who use plates and screws, I just say, listen, I'm not saying this is like groundbreaking, I'm not saying this is 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. And so that's my story.

[B]

That's a great answer. And it makes a lot of sense, what you're saying. Having my own plates and screws in my own arm and having it taken out in the symptomatic heart or any healed fine.

[A]

You think about our incisions for a fibula fracture, it's huge. The incision is huge just to get the metal in, and that's what you're doing. The incision is not for the fracture. The incision is for your hardware. You have to make an incision long enough to put a plate. I mean, the worst incisions are those little bit higher Weber cs. Not true shaft, but, like, the higher Weber CS where you got. And there's a syndesmonic injury. So you have to bridge, really, from the tip of the lateral malleolus all the way up past the fracture. And it's like, oh, my gosh, that incision's like 20 centimeters long. You know, it's too big. When instead, you could do it through 4 centimeters. And. And that's where I think I've really sort of shifted my thought about. It was like, I just had this moment where it's like, oh, my gosh, this incision is for the hardware, not for the fracture.

[B]

That's a big thing. You're not doing this percutaneous. You're doing what you got to do to get the fracture reduced. The implant is where we make the rest of the incision. Listening to you and watching you talk is kind of where I realize that's the difference. Like, we would make these incisions not for reduction but for fixation. And you're not compromising the reduction. You still get it perfect. And then it's just. The hardware is just different.

[A]

Yeah.

[B]

So saying that now.

[A]

Just one more thing to interject. If you. And this dawned on me on a plane ride once. I was just thinking about it, and I was thinking about, like, the AO founding fathers, you know, they. And that was my big resistance to intramedullary nailing up front was this always violates AO technique. They never failed. Fix the fibula this way. But number one, every other long bone, we've transitioned to intramedullary nailing, and that's considered AO technique. Number two, if you think about, like, if you open, you know, one of the OTA books or read the true principles of the founding fathers of AO technique, it's preserve the biology. Adequate fracture reduction, careful Soft tissue, handling, all of those things that you achieve, fracture healing, and we're achieving all of those with intramedullary fibula fixation. So I actually think if they were sitting at this table with us today, they would be endorsing a minimally invasive approach to the fibula.

[B]

They didn't have it at the time.

[A]

They didn't have it.

[B]

That was. They had a Krishna wire long screw. These didn't exist. So you can't even say that just because they didn't have it.

[A]

Yep.

[B]

All right, so now you've made a very convincing argument to do it minimally invasive. And it's not just because of ease, I think because a lot of people, like, say, oh, it's faster, whatever. That's not the point. The point is it's a biologic way to look at a fracture. And you're opening it small. Get it reduced nail goes in. Choose your implant as you desire. We know what you use, obviously, the fibulock, but now you have that. So how are you looking at, like, a post male then? So, you know, post males, traditionally I would flip them prone, do all this stuff, open, everybody. So how do you now I give you a trimal. How are you doing the trim? Are you doing it? Are you doing your minimum invasive? Like, are we all fancy Americans now with our arthroscope or nanoscope looking at it, doing some perk fixation, and we're not opening fractures at all anymore. Well, how do you deal with that? Because you seem like you want to maintain the MIS for the fibula, but the struggle then is, what about the post mal? How do you deal with that?

[A]

Well, I think the first thing is you have to truly understand the fracture pattern, because every posterior mal or trimal or whatever is different. I get a CT on the majority of them unless it's really obvious what that fracture pattern is. And I think there's a big difference between a posterior malleolus fracture that's just an avulsion of that posterior lateral lip versus a true posterior distal tibia fracture. If it's a true posterior distal tibia fracture, transverse all the way across the joint, displaced. I'm going to open that. I'm going to do a posterior lateral approach prone. I actually can put the intramedullary fibula nail in prone as well. It's not as hard.

[B]

You can do it prone, too.

[A]

You can do it. Yep. But I do think those still require an open approach. So I think that's a point that's important to make. But for the true poster lateral Lip fractures, even the really displaced ones. I think of that more as a PITFL avulsion and I will do my very best to not do a posterior lateral approach for those because we do know, I mean literature has shown that posterior capsule, even if you don't violate the capsule, just all the dissection, the soft tissue handling everything at the back of the ankle there scars, it leads to a lot of scarring. And I have found with that approach that patients really struggle to get their dorsiflex. So for me, where I'm trying to preserve the function of the ankle, I actually think the poster lateral approach, even though I love it, I think it actually can be really detrimental to their recovery. So I try to avoid it as I can. But of course you still do the right thing for the patient.

[B]

So listen, sure you're a minimally invasive and we know some. I'm sure Dr. Kevin Martin has been doing nanoscope and all this and he has nice pictures of it of doing a post mal with a scope. Why have you. I'm curious. I know your skill set and it's phenomenal. Why have you not tried or maybe you have or transitioned to is probably the best answer. Like a nanoscope look in the joint or arthroscopic look in the joint. So I do perking the postmap.

[A]

I mean that's exactly what I do. So we don't biomechanically plate and screw fixation is stronger than A to P screws. But my argument's always if you get the reduction right, why do we care about the biomechanics back there? I mean I've never had a poster malleolus non union. Have you? I mean it doesn't happen. Those things heal so biomechanically. I mean 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. So I will.

[B]

And hitting the piece of both.

[A]

Yep, yep.

[B]

So a lot of times it misses.

[A]

It does. I think you have to study your CT scan ahead of time and know where you're aiming. You have to understand the anatomy. I think for me I will use the nanoscope to make sure my reduction is accurate. But a lot of times you can also just see it on your lateral. And that's the beauty of an intramedullary fibula nail. It doesn't obscure, it only obscures about 3 millimeters of your view of the articular surface on the lateral. So you can still see your poster Malleolus. So I'll use my lateral X ray. I'll use the nanoscope. It's very easy to get sometimes, you know, the back of the joint can be hard to see. But I shouldn't say nanoscope. You know, disposable arthroscopic instrument. Yep, I'll use that. I mean, it's 1.9 millimeters. It's the size of an 18 gauge needle. It's very easy to get into the joint and see in the back. And then I will actually place my screws. I will have studied the CT scan ahead of time so I can at least have a good estimate of where the trajectory is going to be. I go anterior to posterior, not posterior.

[B]

To anterior to the anterior tip lateral. Because these are like little. Which I know you know, but most of us don't.

[A]

Yeah.

[B]

How do you. Where do you start?

[A]

I just, I make a stab and I plan out my trajectory ahead of time. So every poster mal is a little different. Use a hemostat, get down to the anterior aspect of the tibia without violating any of the structure important structures, and then use a soft tissue protector.

[B]

You're not just wailing a wire in there and guessing.

[A]

No, because there's a lot of important things in the front of the ankle. But I do that. And then at the end, I will put the scope back through, back into the joint. Look at the posterior malleolus. Takes literally 10 seconds. And a, make sure it's reduced. B, I'll stress it with either a free or elevator, you know, probe something like that to make sure it's stable. And that's how you know if your screws are in.

[B]

Oh, helly. That's a no, that's actually a really. I didn't think about that. You can stress it. That never occurred to me. No, I think that that was a.

[A]

True organic aha moment. Nothing makes me happier than when I blow your mind. I've looked up to you forever. I. I sat as a fellow at the fellow course and you presented. And I said, that is one of the funniest people I have ever met. And here we are, you know, 10 years later.

[B]

Well, I remember the first time I saw you speak and I was like, I don't know who this person is. Who is this young person and why is she on the panel here? And then I listened to you and I was like, she's the one.

[A]

Oh, she's amazing.

[B]

You know, then when I went and talked to everybody, she's the one.

[A]

Yep.

[B]

Well, and you're going to Be part. Hopefully you'll be able to have the time and take away from your family practice to support IFAs. Because that, that point was huge. Yeah, because that's the part I, I didn't think about that. That you can stress so, you know, you don't have a CT to verify. And so if I asked you in 10 years, do you think most of us be doing this mis. Like the, the standard in 10 years is going to be some intramural area device, arthroscopic visualization of the joint, percutaneous fixation? Is that where you think we're headed? Where we should be headed? Maybe not where it may. Nobody can predict. But do I think where we should force our. We should be thinking that way because I think when we look at foot and ankle, it's still a very young field. Should we be like forcing ourselves to go away? Is that the right answer?

[A]

Gosh, I sure hope so. I think that, I mean, isn't that the one thing we can count on in life is change? And I think that, that if all of us bury our heads in the sand and just do things the way we were taught, however many years ago, we're never going to go anywhere. And there's no question that that's where we are going in general for not just ankle fractures, but foot and ankle surgery globally. We're trying to find more minimally invasive approaches because we've seen the benefits. And I really, really believe that, say 10 years from now, this will be the standard of care. I think it'll be the gold standard. And, and if you look at just taking tibia fractures as an example, people open plated tibia fractures for years. I mean, years, maybe even a century. You know, it just, that was the standard of care. And I think it took quite a while for the transition to intramedullary nailing, but once it's stuck, it stuck. And I'm not going to say every single fibula fracture forevermore should be treated with an intramedullary nail. There's always room indications for plates and screws. But. But I would sincerely hope that this at least becomes the gold standard for simple fracture patterns that would benefit from intramedullary fixation.

[B]

I love it. I think it's an amazing thought process. And when I first saw your mis, I was like, this is for the highly skilled and this is fine for Caitlin and God bless her, but the more I see what you do, the more I see what everybody else does. I agree with you. I think that is the push that we should all strive for versus saying what I do is good enough. Now it works fine, but we can definitely do better. And I really think MIS is our arthroscopy. It's our chance to be revolutionary. That's what happened in sports, right? People would make fun of the arthroscopic rotator cuff. I can make a small incision and it heals great. Why are you doing this arthroscopically? And if you. Somebody does an open rotator cuff now, it's like a joke. Why are you doing it open? And so I think you're right.

[A]

I mean, if you look at an ankle fracture, it's really technically like the most beautiful marriage between sports and trauma. I mean, so why fight fate? You know, we really should be. And I think you get your sports folks who are very sports minded and maybe don't pay as close attention to the fracture. You get your trauma trained surgeons who maybe are paying more attention to the fracture. But really we need to be thinking like sports and trauma surgeons all at the same time. And I think that if you can really harness both those mindsets, that's the perfect way to address an ankle fracture.

[B]

Makes sense. It's bone, ligaments, mind the soft tissues, less trauma, and then last. Quickly, quickly. Because I know it's getting late, but I have to ask you for the syndesmosis. You're doing a nail. So you're putting a screw through the nail. Soft. A tightrope type device or suture button type fixation. And if it's one or the other, why?

[A]

I think. Well, I think you guys have already done that podcast. That's a whole podcast in and of itself. But for me, it's whenever I can, 100%. I will be doing suture button fixation. I think it's been proven over and over and over that flexible fixation across the syndesmosis is more beneficial for long term functional outcomes than a screw. There is the rare occasion where I will use a screw, for example, and this is, I guess it falls under the heading of fibula fractures. But like a mesa nuve that has a length unstable fracture that I don't think I can hold with one or two suture buttons, then I will use a screw. And I don't think that's a. I don't think that's wrong when you're, when you truly need it. But I think for everybody else, where it's just a coronal and sagittal plane instability, but not necessarily axial plane instability, I think we're doing our patients a Disservice if we're not using a suture button.

[B]

What about a diabetic neuropathic? Are you putting the screws in that person?

[A]

Yeah, I think there's the same answer. I know you want quick answer, yes, no from me. But a diabetic, neuropathic, it's very different. You might have a type 1, relatively active, somewhat skinny diabetic that just has a little neuropathy, but it's subtle versus the true obese, minimal ambulatory. So the true obese, the sick patient. I'll still use screws and do a technique. Two screws, I'll put three or four if they're truly neuropathic. And I'll use a plate.

[B]

You'll use a plate?

[A]

Yeah. Because I mean, how do you get screws? You can only get two through most of the nails on the market. So that is one area where I'd still prefer to use a nail. But I don't have a choice if I want put four or five screws across the syndesmosis. But for the less neuropathic. I hate using the word healthy, but as healthy as these patients can be, those younger diabetics that I think are closer to the healthy population than the non healthy population. I'll still do the nail with the suture button.

[B]

Perfect. I want to say thank you so much. The pearls that you've given your thoughts are excellent. I don't have enough time to go through all your technical tips and tricks which are, you know, if you ever have a chance to meet Dr. Neri, my advice is bother the heck out of her and ask her how to do these cases. I've learned a lot from her. We just don't have time. But her thoughts on this, I think we'll see in the next five, 10 years if she's right. But I do think the push as we come to this national meeting. We talk about MIS today a lot. I think it's a big, It's a big deal and I'm pretty sure times are going to change and it's up to us to lead the charge and not let the traumatologist or the sports doctors tell us how to do our job. 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. These are not ankle fracture, ankle injuries. And you know, 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. So thank you so much for your time. Thank you, thank you everybody listening and hope you join us for the next podcast.

[A]

Thank you for listening to the AOFAS Ortho Podcast, a Convey Med production. To learn more about joining our dynamic, dynamic community of highly skilled orthopedic specialists, visit aofas.org.