Can The Fibula-Pro-Tibia Technique Have An Impact For Diabetic Ankle Fractures?

By Christopher L. Reeves, DPM,Alan A. MacGill, DPM,Amber M. Shane, DPM, and Joseph A. Conte, DPM Clinical Editor: John S. Steinberg, DPM

Is there a biomechanical tradeoff? Delivering multiple transsyndesmotic screws across the distal tibiofibular articulation theoretically eliminates its natural motion. Controversy exists on whether syndesmotic fusion interferes with restoration of normal ankle joint anatomy and motion. Studies have shown that 6 degrees of rotatory motion and 1.1 mm of mediolateral translation occur at the distal fibular interosseous site. Lack of this motion is not a significant detriment to a patient’s normal walking ability.16,17 This finding was similar to the report by DeOrio, who noted no deleterious effect on gait after five patients underwent fusion of the distal tibia and fibula via a fibula-pro-tibia technique.14

Navigating The Potential Complications Of The Fibula-Pro-Tibia Technique

This surgical approach is not without its own inherent complications.4,6,7,11,12 Additional hardware may lead to prominence and subsequent wound complications, or the need for second surgery hardware removal. If one uses a relatively longer lateral incision to deliver the proximal fixation, wound healing issues may arise. To avoid this longer skin incision, one may deliver the fibular plate subperiosteally through a smaller incision. One may then deliver the proximal screws percutaneously with the aid of intraoperative fluoroscopy.

There is always the potential for complications with surgical treatment and one must determine if the benefits outweigh the risks. This decision is no different when implementing the fibula-pro-tibia technique for diabetic ankle fractures. With appropriately selected patients, we believe this operative technique can provide a stable, braceable limb, reduce the risk of late stage joint breakdown and return patients to being community ambulators.

Final Words

Ankle fractures in the patient with diabetes involve a large realm of potential complications. Factors such as ambulatory status, quality of bone, glucose control and vascular status, just to name a few, are imperative for the foot and ankle surgeon to consider.

The fibula-pro-tibia technique has been adapted to treat high-risk ankle fractures, specifically in patients with neuropathy, diabetes mellitus, and/or Charcot arthropathy. This technique involves delivering multiple transsyndesmotic screws through a fibular plate and into the distal tibia to form a “one bone” lower leg. The goal is to create a rigid construct in the face of osteoporotic bone in order to neutralize the deforming forces that lead to a Charcot joint event in the high-risk patient population.

Dr. Reeves is an Attending Physician at the Florida Hospital East Orlando Residency Training Program in Orlando, Fla. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. MacGill is the Chief Resident of Foot and Ankle Surgery at Florida Hospital East Orlando.

Dr. Shane is an Attending Physician with the Florida Hospital East Orlando Residency Training Program. She is an Associate of the American College of Foot and Ankle Surgeons.

Dr Conte is an Attending Physician with the Florida Hospital East Orlando Residency Training Program. He is in private practice in Orlando.

Dr. Steinberg is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. Dr. Steinberg is a Fellow of the American College of Foot and Ankle Surgeons.

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