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Arthroscopic Fracture Reduction With Fibular Nail


Indications

  • Patients with potential wound healing issues such as diabetes, soft tissue trauma, or older age

  • Weber C fractures in younger patients to avoid extensive dissection

  • Patients with medial and posterior malleolar fractures that are amenable to percutaneous reduction and fixation

Indications Pitfalls

  • A fibula too tight to accept the nail

  • Patients with involvement of the tibial plateau

  • Failure to recognize poorly controlled diabetes, Charcot arthropathy, or vitamin D deficiency

Indications Controversies

  • Reduction and fixation of the syndesmosis remains a complex part of the procedure.

  • Patients with a potential better result with a plate should undergo plate fixation.

  • Comminution of the medial malleolus or posterior malleolus may mandate an open plate procedure.

Examination/Imaging

  • Preoperatively the skin should be examined to determine if there is any blistering or an open wound ( Fig. 72.1 ).

    FIG. 72.1

  • Plain radiographs should be performed after closed reduction of the fracture ( Fig. 72.2 ).

    FIG. 72.2

  • A computed tomography (CT) scan is helpful in determining the position and displacement of the fracture fragments ( Fig. 72.3 ).

    FIG. 72.3

Treatment Options

  • Closed reduction and casting

  • Closed reduction and Kirschner wire (K-wire) fixation

  • Open reduction and internal fixation with plates

  • Closed reduction and external fixation

Surgical Anatomy

  • If the fracture extends above the level of the ankle, then the syndesmosis is likely unstable and requires fixation ( Fig. 72.4 ).

    FIG. 72.4

  • The medial side may be disrupted with a deltoid ligament injury or a medial malleolar fracture. Repair of the deltoid ligament or stabilization of the medial malleolar fracture may assist in the reduction of the fibula ( Fig. 72.5 ).

    FIG. 72.5

  • The syndesmosis is stabilized by the anterior tibiofibular ligament (ATFL) anteriorly between the Gerdy tubercle on the tibia and the fibula just above the ATFL.

  • The syndesmosis is held posteriorly by the posterior tubercle on the tibia and a band going laterally onto the posterior aspect of the fibula.

Positioning

  • The patient is positioned on the table with the foot at the level of the end of the table, and the ankle is slightly internally rotated using a bean bag ( Fig. 72.6 ).

    FIG. 72.6

  • Either a thigh tourniquet or a sterile calf tourniquet is used.

  • The arthroscopy tower is placed on the opposite side of the bed to the surgical limb.

Positioning Pearls

  • Ensure that the leg is internally rotated to the point that the fixation screws go in the correct direction between the fibula and the tibia. Access may also be required to the medial side and the posterior malleolus so the leg may need to be externally rotated to access the medial side or internally rotated to a lateral position so that the posterior malleolus can be accessed from behind the peroneal tendons and transfixed.

Positioning Pitfalls

  • Failure to internally rotate the limb

  • Use of a calf tourniquet may restrict the operative field and may stabilize an unstable syndesmosis

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