Plates? So 2000 and Late

First and foremost I hope this article find you all in the best of health and that you are safe amidst the chaos that is COVID-19. It's unbelievable how things have changed seemingly overnight from "A OK" to "RED ALERT" but we will get through this! Fortunately as we go through all of this, we can lean and rely on the amazing healthcare workers on the front lines of all of this helping in any way they can to take care of the sick and emergently injured. Working to keep some semblance of balance and order in the world. For that, I know I speak for many when I say, Thank you for this and for all that you do!

Now, globally there has been a shortage of surgical procedures occurring for a variety of reasons including:

• Managing hospital inventory of certain supplies such as masks, gloves, etc.
• "Slowing the Curve" to beat this COVID crisis
• Reducing hospital expenditure
• To keep healthcare workers safe

The list can go on and on but one piece I wanted to highlight which will lead into this week's product is that emergencies and accidents are unfortunately still occurring on a daily basis outside of COVID that simply can not wait days, weeks, or even months for surgery. Things such as cardiac arrest, cranial bleeds, certain lung and abdominal situations and sometimes even fractures. Specifically ankle fractures, which is what I want to briefly talk about.

How do we fix them now

In most OPERATIVE ankle fracture situations (Ankle fractures that can NOT be healed with a simple cast, wait and heal scenario) the Fibula is the bone in question that breaks and needs fixation. (The tibia can also be broken but traditional methods rely on a cannulated screw which we have talked about in another article). The traditional and most common type of fixation of the fibula is through a plate and screw construct. This is where one or two screws hold the bones together while a plate sits on top and stabilizes the bones as they heal over time.

As an additional note, depending on the severity of ankle fracture this may not be the FIRST step in care. For example, sometimes the ankle is broken so badly the ankle and leg are completely shatter such as in a car accident. In this case because there is no "good bones" to screw together a device known as a frame will be used to hold the ankle in "relative position". Take a look at the picture below, while they may look super complex and Sci-Fi'ish, all they are doing is place holding. These frames allow for the swelling of the skin to subside and let the position of the bones to "settle" into a normal position so that then a plate and screw can be used.

 So, putting the big smashed up ankles aside I want to back up to talk about the plate and screw construct.

Plate, screws and issues?

First let me start of by saying that plates and screws work well.

In my decade plus of working in orthopedic devices I have not seen or heard of too many issues in regards to how well this combination works. So Long as the patient is compliant and there are no other issues such as infection or poor bone quality. These fractures heal.

That being said however, there are two points of concern I would like you to consider with plate and screw constructs. First is the size of the incision. It's big, plain and simple. Ask anyone who has had there ankle surgically repaired and they will show you a scar that runs halfway up there leg. The reason for this is when putting on a plate and screw construct the surgeon really needs to dissect down under the skin and tissues so that they can visualize where the plate is going to go. This makes for a large incision, big scar and more pain at the injury sight because its more the body needs to do in order to heal!

The second issue is with the plate itself. Technology has gone very far in bringing us very thin and very strong materials, but reach down and touch your ankle. Not very much skin between the bone and your fingers right? So when you put a plate in-between that space, you guessed it, you can feel it! Not only is that not very comfortable, it can lead to having yet another surgery to remove the plate after the bones have healed and as we've talked about before. Removal surgeries are all around not ideal!

Solutions?

Would I be writing this article is there wasn’t? Maybe, but that’s not the point. The answer is yes, there is a solution. One that allows for correction of the fracture from the outside of the skin and a fixation method that is INSIDE the bone, its called a Fibular Nail.

Now at the time of writing this article there are only two FIBULAR Nails on the market that both have very similar features and benefits. One is The Fibula Rod by Acumed and the other is the Fibulock by Arthrex.

As far correcting the fracture a both companies have similar methods. A bone reducing clamp (think like vice grips) is used to hold the bones together outside the skin. This is a technique most doctors know how to do. Since the bones don't set (Stay in place) like they do in a normal fracture (When you go to the emergency room) they need to be held in place with this type of instrument until the fixation is in place.

In regards to preparing the bone for the nail itself, both systems use a K-wire and cannulated drill system to make sure the nail will be right in the center of the bone and that the "walls" of the bone are not violated (which if this happened a plate and screw situation would be in order).

Both devices also have an insertion guide to aid in implantation of the nail and its screws.

As far as differences there are a few:

Arthrex has a left and right specific nail in 2 different lengths, Acumed has one straight nail and 3 different length. Both of which have fixation in the bottom of the nail. Now arguments can be made for both as to which is the better option but in my mind what makes Arthrex the better of the 2 in my opinion is in it's PROXIMAL (Top) fixation. The Fibulock has "talons" that flair out at the top of the nail. These talons allow for fixation at both ends of the fracture which should provide a more stable fixation because now both ends of the nail are being held in place. No rotation of the bones, no sliding up or down just stable. The Acumed has no proximal fixation and if I were picking from the two why wouldn’t I want the talons? Food for thought.

Differences aside the basic premise remains the same. The incision for the nail is nowhere near what is needed for a plate and screw construct. The nail goes into the skin and INTO the bone, not on top of it. These two factors alone (Not to mention the potential time saving) makes a nail for fibula fractures in my mind an absolute game changing no brainer.

You are probably seeing a pattern. Less incision, less pain, comparable if not better fixation. The options for better surgical procedures are out there, you just need to know where to find them, or WHO to find them from ;)

So of course……. If you have been reading my articles you are probably seeing this trend of:

• Learn a bit about today's solutions
• Look at a few concerns with today's solutions
• Offer a potentially better solution

It may seem silly but that’s exactly why I started these reviews. In order to better inform the public about the options that do exist and share my two cents. Thank you for continuing to take a look and I would love to hear your feedback, positive or negative! I want to talk about what you want to hear about!

Stay safe everyone! Much Love.