Title: Recovery from Fibular Fracture with Syndesmotic Widening and Deltoid Ligament Rupture: A Level 1 CASE Study
Name: Claire Meyer
Primary Presenters: Claire Meyer
College of Health Sciences
Masters
Faculty Sponsor(s): Hayley Ericksen

Recovery from Fibular Fracture with Syndesmotic Widening and Deltoid Ligament Rupture: A Level 1 CASE Study
Meyer CF*, Lane AC+, McCann JM+, Contreras JD+, Ericksen HM*: *University of Wisconsin-Milwaukee, Milwaukee Wisconsin, +United States Military Academy, West Point New York

Background: The current case is a Level 1 CASE of a fibula fracture with syndesmotic widening and a complete rupture of the deltoid ligaments of the ankle. Patient treatment plan started with surgical repair of the deltoid ligaments and TightRopes through the tibia and fibula. The permanent TightRope secures the tibia and fibula by pulling the syndesmosis back together. Use of TightRope is emerging as a potential replacement for internal screws that are typically removed at a later date and may be cause for malreduction of the syndesmosis.

Patient: A 19-year-old male football offensive lineman presented with a right fibula fracture after taking a hit during the second scrimmage of the year. The patient reported another player had fallen on his ankle but could not fall himself due to others around him, forcing his foot into excessive dorsiflexion. The patient reported immediate pain and numbness on the lateral lower leg and had a palpable deformity on the distal shaft of the fibula, about two inches above the lateral malleolus. He has a previous history of a LCL sprain to the knee, turf toe, and previous ankle sprains on the right leg. He is currently a freshman at the United States Military Academy.

Intervention or Treatment: The patient was immediately carted off the field and taken in for preliminary x-rays using the OrthoScan fluoroscopic machine by team physicians on site. Diagnosis of a distal 1/3 fibula fracture, syndesmotic widening and tear of the deltoid ligaments were made on site. The surgery, scheduled for nine days later, included a repair of the deltoid ligaments, a plate on the fibula, and TightRope to reduce the syndesmotic widening. Upon release from the hospital, team athletic trainers took over rehabilitation protocol. The first six weeks were spent immobilized and NWB while using a knee scooter to ambulate with rehabilitation limited to elevation, toe wiggles, and MarcPro on his quadriceps to remove inflammation. Upper body weightlifting began on week three. Week seven started partial weight bearing with crutches. Ankle strengthening and progression toward full weight bearing started after week seven. The patient has stated that since the surgery he has numbness along the plantar surface of his foot which should decrease with use.

Outcomes or other Comparisons: Currently the patient has a positive outlook in recovery from the initial injury post-surgery. The patient is currently in week seven protocol and is making strides towards a normalized gait pattern, regaining strength in his lower leg and ankle, and is making progress in a similar manner to other cases.

Conclusions: While there is emerging literature on the TightRope procedure, the average population studied is older than the current case study. Multiple studies have listed the malreduction rates of the TightRope procedure to be much lower than screw repairs, listing a 21.7% difference between the two, and as low as 5% for the TightRope procedure after an 18-month follow-up. This patient’s recovery and return to sport following the TightRope procedure could open the door for future studies with an athletic population to determine malreduction rates for younger, more active adults. Using cases such as this can also help identify the lifespan of the TightRope procedure and ability of this to hold up to the stresses of sport, and in this particular case military training as well.

Clinical Bottom Line: Overall, this case is good insight into the TightRope procedure and rehabilitation protocol for injuries of this nature where the ankle is unstable. Follow up information on this patient can help determine the malreduction likelihood in athletes of these demographics, as well as lead to developing a widely used rehabilitation and return to play protocol for these patients.

Word Count: 595

https://sites.uwm.edu/healthresearchsymposium-2022/files/formidable/2/Claire-Meyer-References-0b2e20.pdf