Well, welcome to the Fibula Nail Talk. I'm excited and honored to have this opportunity to bring to you what I think is going to be the next major paradigm shift in orthopedic surgery. But first, some important disclaimers. The relevant disclosure here is that I am an Arthrex consultant, but I was a nail advocate long before I engaged with them. I engaged with them because I saw the genius and the potential of this nail and I wanted to make the nail better. I have no royalties in these products, just an enormous amount of belief that this is a better way to fix ankle fractures. But let's start with this key message. I think ankle fractures are very difficult and I think we're all guilty, myself included, of underestimating these injuries because they are complex intra-articular injuries of not just bone, but also ligamentous tissue and cartilage. Too often, I think we just see and address the fracture and forget about the rest of the injury. Failure to address each component of these injuries leads to poor outcomes with limited salvage options. The key to success is making sure that we consider and treat each component of the injury. When we look at these injuries, certainly my x-ray vision can be a little short-sighted sometimes, I encourage myself not just to see this, but rather to see this three-dimensional dynamic bone and soft tissue anatomy. And so with this said, this is how I try to own every ankle fracture. The comprehensive game plan is the take-home message of this slide, but let's touch on each of these areas quickly. I think a pre-op CT scan is incredibly valuable and always contributes to my surgical plan. This is an intra-articular fracture. It deserves a CT scan. I think scoping ankle fractures is very important, primarily to identify and treat osteocolonial injuries and ligaments instability. I use the simple and portable nanoscope, which makes it quick and easy to set up. And with a 1.9 millimeter camera and two millimeter instrumentation, I can get in and out and get the job done with almost no surgical footprint. I scope every single ankle fracture. I can't bring myself not to look in the joint. I don't get paid for the scope and it takes me long, but I just think it's the right thing to do. But I get it, for most surgeons to set up alone is a turnoff, but this is where these nanoscopes become a solution. It's peel-packed and portable that any OR team at any time of the day or night can set this up quickly and easily. And even if you're not a scoper, this just makes it easy for any level of scope surgeon, just insert point and click and see what you're missing if you're not looking inside the joint. Even though I aim to nail every ankle fracture, I still have a comprehensive placing system available as well as peel-on plates and mini fragment plates for the more complex fractures. Ligamentous injuries, including the syndesmosis and the deltoid are frequently ignored, but might be the most important to address. And I always use flexible syndesmosis fixation. And I also have internal brace devices available, which gives me more options to repair, reconstruct and reinforce ligamentous injuries anatomically. And don't forget the growing role of biologics for accelerated and improved bone and soft tissue healings. And finally, we need to record our outcomes with some kind of surgical outcome system so that the literature can catch up to best practice because it's definitely lagging behind at the moment. So that's my first goal is to try and own every ankle fracture. My second goal is to try and do this with an all inside ankle fracture technique. And I do this using the Arthrex Fibuloc nail because it's one of the only nails on the market with proximal talons for fixation, which provide length and rotational control, which we know is paramount to control or reduction. So why did I start using this nail? Well, the truth is initially that I did not want to use the nail and I'm embarrassed to say it, but I was one of the many stubborn naysayers out there. However, I've now implanted over 300 nails. So what changed and what converted me from being a closed-minded nail skeptic to an open-minded nail lover? And I'd like to review that briefly because I think many surgeons have the same artificial anti-nail hang-ups that I had myself. Firstly, I was very short-sighted about the nail because it was nothing wrong with my traditional quick and slick praying screw technique. And there still isn't anything wrong with that, but that doesn't mean there isn't a better way to do it. Next hang-up was the lack of proximal fixation in the available nails because I doubted their ability to maintain my reduction, which we know is essential, but this issue is solved by nails with proximal fixation, which provide length and rotation control of the reduction. And my final reluctance because the nail was always presented to me with narrow indications for soft tissue compromised patients. And it really does make sense in these hosts because it comes with minimal soft tissue blood supply and periosteal disruption, which contributes to lower wound complications. And so it's quicker, it's safer, and it's better. And I think everyone in the audience would definitely agree with this. So I did my first fibuloc in such a host and it worked perfectly. But during that case, I thought to myself, why am I reserving this more minimally invasive respect for biology for only my high-risk, lucky patients? Why am I not applying best surgical principles to all of my fracture patients? And thus my first fibuloc became my last plate quite literally. And in 2022, this is how I manage all of my echo fractures. They all get a CT scan. They all get a nanoscope. I look hard for and aggressively treat ligament sensitivity and all get a fibuloc unless contraindicated. Again, all unstable fibular fractures in my practice get a fibular nail. And in case you missed that, my indications are all unstable fibular fractures. And whilst that always raises eyebrows in the audience, I challenge everybody to ask themselves, why not apply the same respect for biology to all your fracture patients? The nail allows a much more minimally invasive biology respecting approach, thus avoiding stripping the entire fracture and adjacent fibular vital blood supply and respecting biology, allowing much smaller incisions and a much smaller surgical footprint. But it's about much more than incisions and cosmesis. It's about biology. Add to this the biological mechanical advantage of bone grafting the fracture with our reamines and the load sharing bearing properties of the fixation. It's now a much quicker surgery in my hands. Patients have much less post-op pain and swelling, which is leading to early restoration of comfort, motion and strength and anecdotally much less consumption of narcotics, which is very important as you know. It allows earlier weight bearing. This patient is walking without his boots six weeks out from a nanoscope, fibuloc, tightrope and the deltoid repair. This is an athlete that we cleared to play at three months, but apparently he felt good enough to clear himself a month before that. So it is completely revolutionized how I manage these injuries and it's completely changed my practice. So it's all well and good me getting up here and telling you how good this technique and devices, but where's the proof? Well, I have it. Fibular nailing has been out there for a long time. These were all the devices that were motivated by the soft tissue complications frequently encountered with plating techniques, sticking a big place under a very subcutaneous distal fibula. And even with these devices, without proximal or distal fixation and using closed techniques for better than the comparison nail groups, particularly in terms of lower complication rates and the advantages of the nail were gaining traction. This paper in 2012 looked at a larger group of Acumed nails, but this paper demonstrated something very important because they reported early failures due to the lack of proximal fixation in that particular nail. And these failures occurred because of the inability of this nail to hold the length of rotation reduction. Now they prepared various pseudo fixes for this. Firstly, as we see here with a screw above the nail, but we see in this next picture how that worked out. So they suggested another pseudo fix, which was using the cinder mastic screw holes as pseudo proximal fixation, which improved their outcomes. However, this is not a fix because firstly, this screw has to be above the fracture line to act as proximal fixation, which is often not the case. And secondly, because it then forces the surgeon to put rigid fixation across the cinders mosas, which has clearly been shown to be inferior to flexible fixation in most cases. But the real value in this paper is it proved that proximal fixation is necessary. And even with these failures, they still reported superior results of their paper and their cohort of nailing compared to placing with lower complication rates. And there's much more literature out there learning favor to nailing, so sorry, learning favor to nailing over placing with lower complication rates, faster healing, faster recoveries, and that's with old techniques and old devices that don't have proximal fixation. So if these old devices outperform placing, then it stands to reason that more modern devices may further improve on that superiority. And this 2016 FAI paper looked at the FibriLock nail, which affords proximal fixation used in this small series of patients with 100% union and no wound complications. More recently, Sam Adams from Duke presented an AOFAS paper looking at his series of 41 FibriLock nails with very good results in a low complication rate, concluding this is a very safe and effective method of fixation. And we have two randomized controlled trials out there that support the superiority of the nail over placing. And there's much more out there, all of which supports and favors the nail compared to placing with similar or better outcomes and lower complication rates. And this is what I experienced, why I abandoned my comfort zone with placing, and we're excited to finally be sharing our results. And we looked back at our first 110 consecutive nails with a mean follow-up of greater than 12 months. We excluded 10 nails for the standard reasons we see here, primarily to keep our cohort simple and comparable, nothing unusual in our demographics here. Most were low energy twisting type injuries, 84 Weber B, 16 C, broken down hit further here for the purists with the normal spread of comorbidities. Busy data slide here, an important point is that most were addressed within a few days, irrespective of swelling, which is another major advantage of the nail. Another important point here is that we opened 92% of these fractures. This does not have to be a closed procedure. And we wanted to demonstrate that a mini open anatomic reduction does not negate the advantages of the nail. I think the nail got a bad rep previously because surgeons were using it as a closed technique and not reducing the fracture. Well, that the nail does not reduce the fracture. The surgeon still has to reduce the fracture. And we collected various clinical and radiographic outcome data, and we were thoroughly encouraged and supported by results that demonstrated zero non-unions, zero wound complications, no reduction loss, fast bony union motion and weight bearing and activity, and only one single hardware irritation due to a cortical screw head that I left proud myself, unfortunately. And there's much more detail and interesting data forthcoming soon to support the superiority of the nail. And our results have recently been published in JOT. We had two fractures that were so common, we converted to a plate intraoperatively using the fibula plate to help restore length and anatomic reduction, which was still very difficult to do. However, we've now solved this problem and made these fractures much easier using a unicortical plate assisted nail technique, as you see here. And you can still accomplish that through a very small incision, as you see here, which allows us the option to place a biomechanically favored plate for the actual pilon fracture. We had one low lying SPN neuroma, but not symptomatic enough to justify further intervention. The key take home points here, this is the largest single surgeon series of consecutive nails and fibulox for all comers out there. And we had zero wound and infection issues, even when many open incision and no need for implant removal, because our construct is no profile. We acknowledge the lack of patient reports and outcomes here. And we've addressed this so we can continue to prove the superiority of this technique. And we're now collecting over data. So let's finish by looking at the nail in action. This is important. The nail is not just for elderly and soft tissue compromised patients. It is the superior implants of choice for all patients. This is the standard unstable Weber B fracture patent we've seen already with a mini three centimeter incision. Here's the same patient walking without a boots at six weeks, swinging a driver at eight weeks and water skiing at 10 weeks, all without my permission I might add. This is a, this is here it is in combination with a complete deltoid rupture in a Weber C fracture. Here's a great example of what the nail can allow you to do. This is a bimalleolar ankle fracture, which traditionally and legitimately would have been fixed through an incision like this, but now the nail allows a much better solution. Here's a trimalleolar ankle fracture stabilized by the nail, a higher common use of fibula fracture. This is a fracture dislocation with the fibula and multiple pieces nicely reduced and held with the nail transverse crushed diabetic fracture, definitely a much more difficult fracture to nail, but well worth the extra effort. Here's a nail in combination with a tibial nail. And this was actually the only hardware irritation case because I left the distal screw proud, as you can see there, and we fixed this with count sinking the screw. Cool case here, segmental fibula shaft fracture with 180 millimeter nail rather than the standard 130. And it's perfect for bilateral cases to allow early weight bearing. And I now nail all my fibula fractures through a mini incision at the time of Xpik's application. So I could go on and on, but the point is the fibula can be and should be the implant of choice for every fibula fracture. So why do I think that we should be nailing every fibula fracture? Well, the nail is quicker. It affords much smaller incisions. It's biologically and mechanically advantageous and results in less pain and less narcotic use and less swelling and stiffness and results in less wound issues, lower infection rates, less chance of nonunion, much less hardware irritation, and therefore much less need for second surgeries and overall less complications. And so I would suggest to you, the question is not why the fibuloc versus the plate, but rather why not? And this is a serious point. I ask you to think about this for a moment. I'm not sure there is a good reason, and therefore I think it's time for us to improve the way that we address ankle fractures. So in conclusion, we've proven the nail is safe and superior to plating. This will become gold standard treatment. There is no doubt that this is a better way to treat ankle fractures. So thank you for your attention. And to wrap this up, I'm going to leave you with a quick video showing you just how easy this technique is. Thank you, everybody.

Arthrex Fibula Nail

ankle fractures

pre-op CT scans

arthroscopy

fixation