Okay, all right, well thanks Norm for that talk. Anybody with any questions in the audience? I think I don't see anything on the app, but anything that, hands raised or whatever you'd like to ask. Yeah, so quickly, when I do them intraoperatively, I actually don't put them in the leg holder because the ankle has a lot of instability. I actually tie a curl-ex around my waist and just use my body weight. It makes it easier to set up, makes it easier for everybody. And if you don't find anything in there, you don't have to, you know, you can quickly get out of it. So that's number one. I didn't put a picture in there and I should have. I've gotten away from microfracture in general, on the whole. I do what I term an abrasion chondroplasty, which is I usually take a burr and or a very aggressive shaver once I've cleaned up the lesion and I scallop the bone to attempt to create that healing environment in an environment that's already in a good position to heal without injuring the subchondral plate, which I have concerns can lead to cysts. Any other questions? I've got one, yeah. Going with Norm, again, great talk. Your thoughts are how many rates of second look arthroscopies have you had to go back with and what things look like after those fractures? Yeah, so my rate is a lot lower since I do them initially. I, my criteria, there is no scientific data for this. My criteria is 50 years and younger. I pretty much scoped them all. Over that age, if it's a fractured dislocation, I scope it. That's age bias. I understand that. I don't really, there's no data out there, but I kind of have to cut the, cut it off somewhere. And it's pretty small. It is, off the top of my head, it's usually for arthrofibrosis, more in stiffness and impingement stuff than it is for osteochondral lesions, though that does happen. So it's pretty small. I would put it less than 5%. Yeah, and I mean, I think it'll be interesting also to get, you know, Dr. Stone's input on this when he comes up kind of for the second, you know, half of this, because one of the issues, I think, as we mentioned with a lot of this trauma is the unrecognized chondral injury, and then what happens down the road, and then how we're trying to then salvage those things then. I don't disagree with Norm as far as what we try to do in the acute setting, and you'll probably get a lot of different opinions about this, but going in and inducing more subchondral edema and trauma at the time of an initial traumatic event, sometimes then if they have struggles getting back, you don't know if it's because of what you did or what the trauma did to them. So sometimes in those cases, getting the loose body out, I think less is more. I think the key though, whether it's from, you know, Dr. Bhimani's talk or Dr. Waldrop's talk, the key is the identification of the subtle instability patterns that otherwise our means by which looking at them radiographically, fluoroscopically, or, you know, preoperatively, I think fail to meet the sensitivity criteria. Certainly they can be specific when we see them, but those are the ones that are grossly obvious that we're probably gonna fix those anyways. It's the subtle ones that we miss, and then the fact that the ankle, at least as far as some of the other joints, most arthritis in the ankle is post-traumatic and unrecognized ligamentous instability, and so the key is to identify that. You know, to that end, Dr. Bhimani, so, you know, in thinking about the talk that you gave in the paper, you know, so taking that from the experimental standpoint to the clinical standpoint, and this maybe gets a little bit to norm, you know, what's your recommendation as far as the clinical setup? Is it with a thigh distractor to let the gastroc soleus complex relax and have the knee flexed? Is to do it in extension? Kind of what's the thought, at least, with Ural's group? Any thoughts on maybe even how to, you know, intraoperatively, is there any thought about doing it with the knee straight? Because it looked like in the experimental model it was relatively straight. So at our service, usually people do it with knee extension and without a distractor. Yeah, and then just manual distraction? Just manual distraction. Yeah. You know, I think that the setup, at least for me as an orthopedic, it's a challenge, but I'll tell you, I mean, there are some pretty tight ankles that if you don't get that knee flexed a little bit, it is really hard to get a scope in. Obviously, needle. If it's broken, it's not that hard. No, don't, I'll tell you, I mean, I don't disagree as far as the tilt, but sometimes as far as that ability to distract, especially in the ones that are more like a Weber B. Dr. Hesburgh, I'd like to ask you a question. What was your hypothesis going in? To me, that was pretty fascinating. It's a very small, certainly a small number of talus that you looked at, but I mean, that was pretty shocking to me, how little of the cartilage that you could see. Even though I argue that you should scope them and it allows you to evaluate them all, that was even less than I thought. And I know in research it is what it is, but what were your thoughts going in and did it surprise you? So yeah, I think you hit the nail on the head about the limitations. Obviously, we would have loved to do this in 30, 40 cadavers, but it's just a matter of availability. We'll try and add to it as we can and bring those confidence intervals down a little bit. But it actually spun out of a sort of interdepartmental question about how variants of opinion between two specific surgeons about how much they thought that they could see. And so tried to do a literature search to answer the question and I could not answer the question through the current literature. And so we decided to try something to give us a foundational basis. We just picked the most common type of ankle fracture that you would expect to see. And then you can see even optimistically, you're seeing a fifth of the weight bearing surface. Now the question about if you have an injury, where is it more likely to occur? It's on those shoulders where you're gonna have, where you did have visualization, but in terms of your ability to address it, I think also we didn't even attempt to talk in about how much you could address it through the fracture versus just identify. Yes. Can I ask you a question? I know you're going to be up here later and you may address this. On those ones that do have the fracture, this is just a shear that's a peel and you have it. Do you microfracture? Or do you? Right. Well, I think you don't follow the master with opinion, but I'm right in line with you. I mean, when you look at the biology of what's going on there, and specifically to, we won't go too basic science here, but I mean, a number of individuals and a number of studies have shown the concern for microfracture is that bleeding and how angiogenesis can essentially prevent chondrogenesis. So the smaller holes is better. So I'm very particular about, you know, the instruments, not just the ones that show up because they forgot to flash the foot and ankle tray and the knee tray and shoulder stuff is always available. And that's using my approach. And if the subchondral plate is intact, I do like to poke some small holes there, but I do not go all in as much as I do if it's, if it's, if it's a deeper lesion to the point of the more osteochondral lesion, as you alluded to, you're right, I mean, it's nothing like when you do that, particularly with one of your trainees and they say, Hey, this thing is already bleeding. We haven't even poked any holes in it yet. And you're like, yeah, because you've already passed the subchondral plate and it's good bleeding bone. Let's not do, let's not make it worse and first do no harm. And then what I was going to say in support of what Kirk was mentioning earlier, it's also nothing like when you get in a case and you assume you're going to be able to show a drive-through sign of the syndesmosis and because they're so tight in extension, you can not get the shaver there, but you know, they're unstable because you've confirmed it from an MRI. They're subtly unstable on your pre-op imaging and the residents like, Oh, I'm really trying to get this thing in here. And you're like, you know what? You're not going to get it in. And and sometimes having them in that knee leg holder or showing, like you said, a little traction around the waist and it opens it up. And I do believe that ties into what you mentioned, Dr. Bhimani, in that when the AITFL is out, that posterior hinge component, we really don't know what it means. Yeah. And those are the ones that we watch the closest. We say, you know what? I think you're unstable. I don't want to come back six weeks from now and you're worse. So a lot more to still learn from one another about. So a great session. We'll give us applause to that.

surgical technique

ankle procedures

curl-ex

abrasion chondroplasty

osteochondral lesions