Okay, good morning, everybody. We're going to just start to save some time here. So first of all, I would like to thank all of you for coming here. I feel like we're survivors of this meeting finally wrapping up. We appreciate your attendance here. So we're going to start with the first paper. It's going to be presented by Alex Brady. Alex is a mechanical engineer at the Statement Philippine Institute, and he will be talking about tibial-tolerant augmentation of the deltoid ligament. Alex, welcome. Yeah, so today I'm going to be talking about tibial-tolerant augmentation of the deltoid ligament, a robotic investigation of ankle stability. I'd like to thank my co-authors. You can find our individual disclosures online. A little bit of background on the deltoid. So the deltoid is essential to maintaining proper joint contact and mechanics of the ankle. Despite being frequently ruptured in association with syndesmotic injuries and ankle fractures, the deltoid ligament is not always repaired. The thought there is that non-weight-bearing during fracture healing can actually allow time for the deltoid to heal on its own. However, conservative management has shown poor outcomes both acutely and over time with the development of arthritis. These traumatic injuries happen most often in a sports setting, putting athletes at an elevated risk for instability. So we're dividing up the deltoid, which is comprised of many ligaments, into the anterior deltoid, which is the tibiocalcaneal, tibiospring, tibionavicular, and deep anterior deltoid ligaments. So this one typically ruptures first, this anterior part of the deltoid, and it is the most common deltoid injury. The posterior deltoid is comprised of the superficial and deep posterior deltoid ligaments, and tears to the posterior deltoid occur in more severe injuries. So this study is actually a follow-up study of a study we presented last year. So on this side, I want to briefly summarize the results of that study and look at the remaining questions that inspired the present study. So in the previous study, we started by testing native ankles, and then we cut the anterior deltoid first, and what we saw is that increased external rotation and eversion instability. Then we did an anterior repair using suture anchors, which restored external rotation but not eversion. Then we performed an augmentation using suture tape between the calcaneus and the tibia, which further improved eversion stability. And finally, we did another augmentation between the talus and the tibia, which showed no improvement. The one important result that we noticed while we were doing these surgeries is that that first augmentation we did, the tibiocalcaneal one, was technically difficult to perform. The reason for that was that there was a risk of damaging a neurovascular bundle on the medial ankle, and we thought that the tibiotalar one would be easier to do arthroscopically. So one question that we had remaining was that the tibiocalcaneal augmentation is more technically difficult, so could the tibiotalar augmentation alone be enough? Since we did that one second and we saw no improvement, we weren't sure if it was just sort of redundant to the tibiocalcaneal one or if it was just not very helpful. So we wanted to know about that, and then we also wanted to know about the case of a complete tear and to see if these augmentations could be helpful. So with that in mind, we designed our present study. Looking at our first state, we looked at nine states. Our first one was native, and then we cut the anterior deltoid. And then we performed an anterior repair using a double-loaded suture anchor, so just taking those ligaments and tacking them back down to the tibia there on the medial malleolus. Then we did a tibiotalar augmentation. So for this one, we used suture tape and we anchored it at the insertion of the deep anterior tibiotalar ligament, and then we pulled it up to an anchor on the anterior colliculus of the medial malleolus, halfway between the origins of the tibiospring and tibiocalcaneal ligaments. So we reinforced that. Then we did the same thing here on the calcaneus, using an anchor point that was on the center of the sustentaculum tali, and then pulled it up to the same insertion on the medial malleolus. Then we cut the posterior deltoid. So the point of this was to see what would happen in the case of a complete tear with the anterior repair and both augmentations. And then we took away the tibiocalcaneal augmentation, so this would be a complete tear with just the repair and the tibiotalar augmentation. Then we took away the tibiotalar augmentation, and finally we took away the anterior repair to get a complete cut state. So the way that we tested these, we mounted them to a robot. We tested 10 specimens, and we did two tests on the robot, which were eversion and external rotation of five newton meters, with the outcome being the amount of range of motion in the ankle under those tests. And we performed each test at zero and 25 degrees of plantar flexion. So moving on to our results, you can see this slide shows the anterior tear results in external rotation. So the y-axis on the graph shows degrees of external rotation, and the x-axis shows our two tests that were run at zero and 25 degrees of plantar flexion. And then each colored bar represents a successive state of the specimen. So we can see that the anterior deltoid cut in orange there caused an increase of external rotation, which was significant with the blue star there. And then the anterior deltoid repair actually returned that to normal, which was great. And so the simple suture anchor repair restored the native external rotation, and there was no benefit of either of the augmentations in external rotation. So that confirmed what we saw in our previous study, that the repair restored external rotation. So now looking at the complete tear here, we see a larger increase in external rotation with a complete tear, which is kind of as we expected. And then we saw that the anterior repair actually also restored native with no significant difference from native. So there was also no significant benefit of augmentation in this case. We do see a slight benefit in terms of the magnitude getting closer to native, but no significance there. Now looking towards eversion, we have a much larger increase in eversion in the anterior tear here. And looking specifically at the 25 degree plantar flexion test, we see that the anterior deltoid repair actually helped. It was significantly decreased from the cut, but it did not restore native, it still has a blue star there. We also saw that the tibio-taylor augmentation unfortunately showed no benefit whatsoever, which was kind of a bummer because that's what we were hoping for. But the tibio-calcaneal augmentation was effective at restoring native biomechanics in eversion. And then finally looking at the complete tear in eversion, here's something to note is just the magnitude of that red bar compared to the blue bar. We saw a really, really big increase, over two-fold increase in the amount of eversion. So this was a very unstable ankle in the complete tear. And then similarly to the anterior tear, the anterior deltoid repair helped quite a bit, but it didn't quite restore native. And in this case, both augmentations were helpful for restoring native. So in conclusion, to answer the questions of this study, the tibio-calcaneal augmentation is more technically difficult. Is the tibio-taylor augmentation alone enough? The answer was no. Tibio-calcaneal augmentation was found to be more effective to stabilize eversion in this study. So it would be helpful to develop maybe like a guide or a strong technique for doing this in a safe manner. In the case of a complete tear, are both augmentations helpful? Yes, but the tibio-calcaneal augmentation was more helpful. So how to use the results of this study? I would say that in a deltoid, it is helpful to repair it. And if you were going to do an augmentation with suture tape, doing the tibio-calcaneal one would get you more bang for your buck there. Further questions for future research? We know that the deltoid is rarely torn in isolation, and it's most commonly torn in conjunction with ankle fractures and syndesmosis injuries. So we want to know what the optimal pattern of treatment would be in the setting of these combined injury patterns, which is more important. And then I'm happy to answer any additional questions at the end of the talks. Thank you. Okay, now we're going to continue with Bradley Lumber. Lumber is from Houston, and he is the Human Subjects Research Director at Houston Methodist Hospital, and he's also a professor at Rice University in the Department of Kinesiology. We're going to have Bradley talking about the effects of blood flow restriction in Achilles tendon repairs. Thank you for having me. Our disclosure on the AOSSM website. So Achilles tendon ruptures, particularly debilitating injuries, where we can see recovery or return to sport times often exceeding a year. Following Achilles tendon rupture repair, unloading and disuse typically elicit losses in whole limb muscle and bone mass. This also results in a loss in function, mobility, and tissue strength. While resistance training is commonly used to stimulate muscle strength and bone strength, it's often contraindicated in the early post-op period due to physical limitations. Blood flow restriction therapy utilizes a specialized automated pressure cuff applied around the proximal limb and restricts blood flow by direct compression of the limb when it's activated. It's modified from a popular form of resistance training referred to as Katsu training. BFR therapies have been shown to acutely stimulate muscle anabolism and chronically increase muscle mass and strength in clinical trials when combined with low-intensity exercise. We've done a lot of work on this over the years. Last few years, the work we're presenting today most similarly mimics what we've done in ACL reconstruction, where we had two groups performing the same rehab program. One group had select exercises where we augmented with blood flow restriction, where we saw significant preservation of whole limb and thigh-specific muscle lean mass, bone mass, and site-specific bone mineral density preservation at the distal femur, proximal tibia, proximal fib. We also saw reduced return to activity timelines, and this is following ACL reconstruction. We wanted to do a similar study looking at Achilles tendon rupture repair, where we hypothesized we would find some similar effects. We had patients undergoing Achilles tendon rupture repair by one of two surgeons on our team. We did DEXAs at pre-op, 8 and 16 weeks post-op, functional assessments at 4, 8, and 16, and patient-reported outcomes were recorded throughout. We had typical exclusion criteria, no previous injuries to the area, several comorbidities, and all of our participants, in order to be eligible to complete, had to complete at least 85% of their rehab sessions. We had similar group demographics, no re-ruptures, no infections, no PT-related complications. So for rehabilitation, they started at four weeks post-op. Patients performed the exact same rehabilitation program, regardless of the group they were in. The only difference was our BFR group had blood flow restriction applied to three to four exercises per PT session, based on our standard clinical practices. Repetition range for the exercises was set at 20% one rep max, assessed in the contralateral limb, four sets of 30, 15, 15, 15 repetitions, 30 second rest periods. For isometric-based exercises, they just hold for 30 seconds. For exercises where we did use blood flow restriction, the standard for our lower extremity blood flow restriction protocol is 80% limb occlusion pressure, individualized to the individual. So following rehab, we saw some similarities to our ACL findings where we saw, but to start, when we look at total body mass, we actually, our no blood flow restriction group experienced an increase in total mass, primarily attributable to an increase in percent fat. Unfortunately, that indicates they were probably eating in a caloric excess. But despite that caloric excess, in our BFR group, we showed preservation compared to the no BFR group of lower extremity lean mass, calf region lean mass, and lower extremity bone mass. So some similarities to our ACL findings. For functional outcomes, with regards to work capacity, our BFR group had some improvements compared to the no BFR group for single heel raise, repetitions to failure. Although we had some trends for single leg squat distance, Y balance, and calf strength measures, we did not see any difference between groups. For our patient-reported outcomes, we did see some improvement in our BFR group relative to our no BFR group for our promised physical score. Obviously, there's some limitations here. It's limited statistical power, we have a small sample size. We have a lot of difficulty recruiting for these types of studies because our patients are in surgery within 72 hours. So our research coordinators are kind of pulling their hair out, monitoring the caseload and when we need to identify a patient, recruit them, and then get them to come over to the lab and do all this testing. We didn't monitor nutritional intake, which is something we're taking into consideration for further studies. Certain functional tests were not permitted until eight weeks. DEXA, while it's repeatable, it's accurate for looking at regions and we can't necessarily isolate muscles. And we're limited to the early post-op phase. But in conclusion, for the results that we have so far, when utilized in conjunction with a standardized rehab program, BFR therapy continues or contributes to both lean mass and bone mass preservation, paired with some improvements in function, mostly work capacity related, less so in maximal strength. While continued studies needed to evaluate long-term patient outcomes and explore physiologic mechanisms that may have contributed, findings indicate that BFR may serve as an effective adjunct to standard rehabilitation in the early post-op phase following Achilles tendon rupture repair when high activity exercises are contraindicated. Thank you. Okay, and for our last paper, we have Jeremy Silver. Jeremy is PGY-4 at the University of Rogers, Robert Wood Johnson in New Brunswick, New Jersey, and he's going to talk about high ankylose brains and 18-plus year follow-up. All right. Thank you for having me. I appreciate it. We have no disclosures here. So a little background. We all know high ankylose brains are very common injuries. Most often, they're treated non-operatively, but there's no standardized treatment methodology that's currently accepted widespread. Operative intervention is generally reserved for higher-grade high ankylose brains with radiographic diastasis, and there's a number of different surgical options to treat these injuries. However, there's really a paucity of data for long-term outcomes, both non-operative and operative management of these injuries. The purpose of our study is to look at the long-term follow-up for non-operatively managed high ankylose brains with a standardized treatment regimen, and the hope is to use this data as a comparison for different management techniques in the future. So our hypothesis was that a conservative treatment of high ankylose brains without radiographic diastasis will result in good long-term outcomes. The methodology of this study is based really on two studies that had been completed prior, the first one looking at Division I college athletes from 93 to 97, and then a similar study in high school athletes from 01 to 03. Inclusion criteria for both of these studies were high ankylose brains without radiographic diastasis in treatment using a standardized treatment protocol. This is the protocol that was used, it's called the conservative-aggressive approach, conservative in that the phase one involves four days of non-weight-bearing in a neutral posterior splint that's removed daily for modalities to limit swelling and pain. Ultimately, it's aggressive for the next two, three, and four phases where you start progressing weight-bearing is tolerated, phase three is more sports-specific cutting exercises, and then phase four is a gradual return to sports. All patients in this study were contacted via social media, and in about a six-month span, they were asked to complete a red cap survey that included demographic information, subsequent injuries, two different patient-reported outcome measures. If they were able to, we also got them to obtain weight-bearing x-rays to look at KL scoring, as well as any notation of HO or spurring, and then Rubies is our in-house statistician team that helped us out. So there were 74 patients identified from those two prior studies, 40 were contacted and 31 completed the survey. 24 were college athletes, there was a total of 33 ankles as two of the patients had bilateral high-ankle sprains. The vast majority of them were football players, male, the mean age at time of follow-up was 35, the mean time from injury was 25 years, and the mean BMI was 32. So these are the results from that initial studies, they encompassed a wide variety of high-ankle sprains. Mean initial tenderness length was measured at 8.6 centimeters on average, that's measured from the tip of the lateral mal, average return to sport was about 13 days. All patients in that study had high-ankle sprains without diastasis or fracture. About a third of them had medial tenderness, 100% returned to full sports, 0% had HO at six months after that initial injury. All but one rated their outcome as good to excellence, 45% of collegiate athletes played professionally and 43% of high school athletes played in college. In terms of the red cap questionnaire, 42% suffered subsequent ankle injuries on that same ankle, 16% had ankle surgery but none of them required stabilization of their syndesmosis, none did require HO removal however. 13% utilized an ankle brace for athletic activity and 0% used assistive devices for ambulation. The patient reported outcome measures of the CFAS score was 42.68 on average, which was within the normal range in the literature, and the promised 10 was 53.4, which was also within normal range. In terms of the x-rays, we were able to get 11 patients to complete their x-rays, nine were collegiate and two high school, all were male. The average age at time of x-ray was 48, the mean BMI was significantly higher than the overall cohort at 37, and the average time to follow up in this group was 27.3 years. So 36% demonstrated some evidence of HO, 91%, so all but one, had suffered a subsequent ankle injury after that initial one, including one that underwent HO removal, 73% had some osteophyte formation, all but one had some evidence of OA, but 8 out of 11 of those were less than grade 3 with no joint space narrowing. So this was the longest follow-up of non-operatively treated high ankle sprains in athletes, showed good clinical outcomes, initially they represented a wide spectrum of injury, at follow-up imaging on that initial study there was no HO at six months, all but one had good to excellent results and all returned to sports. In our study, the long-term follow-up, the CFOS and PROMIS-10 scores were within normal range in the literature, four out of 31 used a brace for activity and nobody used any assistive devices for ambulation. About 42% of patients did suffer a repeat injury, which is roughly in the ballpark of the reported rates in the literature, five out of 31 required surgery but none for syndesmotic stabilization. In terms of the x-ray data, there were four out of 11 patients had HO, which is a common complication of high ankle sprains shown in the literature, but there is limited data on how that presence of HO affects the patient reported outcomes. In terms of arthritis, 91% had some evidence of OA, but the clinical significance of that is unclear and there was only joint space narrowing in 27%. OA, if the ankle is not necessarily thought of as a normal part of aging, it's most often post-traumatic in the incidence in athletes is significantly higher, but it's not necessarily correlated with ankle pain or disability and the risk increases with greater BMI as was the case in our cohort. The limitations of this study are many and obvious. It's tough to do these kinds of study for having such long-term follow-up. It's tough to get patients to complete surveys, tough to get patients to have x-rays and you certainly have some recall bias, but I think they're important, especially as we're moving into an age where we treat high ankle sprains with a number of different methodologies. So in conclusion, this was the longest follow-up study in literature. The use of the conservative aggressive approach demonstrates good long-term outcomes at 18 plus years among an athletic study group and should be thought of as a viable treatment option for high ankle sprains without diastasis or fracture. And hopefully our data may serve as good long-term comparative data for other management modalities in the future. I'd like to thank Eric Nussbaum, who really spearheaded this project, and the references. Thank you. Thank you. So at this point, we'd like to open it up to the audience for questions of the paper presenters. I mean, I would certainly like to start, if anything. So Jeremy, you know, in thinking about high ankle sprains, I mean, it's fascinating considerations as to the potential viability of non-operative treatment. Can you tell me a little bit about the radiographic assessment of diastasis and how that was done? Was that single leg and with weight bearing? Was it dual leg? I mean, I think that's the biggest struggle we all have is the identification of what's the stable and what's the unstable. What's the grade one? What's the grade two? What's the grade three? So can you go through that for me a little bit? Yeah. Absolutely. That's a hugely important consideration, especially as we separate without diastasis and with diastasis. But this was two leg, weight bearing x-rays, AP, mortise and lateral. You know, so I mean, as a critic, you know, or critiquing it, my concern becomes is that potentially no different than the Liz Frank? You know, when we think about Liz Franks and we do single leg compared to dual leg, is there going to be a natural desire to want to stay off of it? Now the argument could be, well, hey, if we're doing this well in the short term, does it really matter? I then go to then the long term understanding then of osteoarthritis of the ankle. Are we talking about osteoarthritis of the ankle? Are we talking about capsular calcifications that are occurring within stability? And then ultimately assessing that and or the formation of HO, are they as stable as we think they are? It's all good questions. And I don't know that I have an answer for that, but certainly something to consider. I think perhaps, Kurt, it doesn't matter if they do okay in the long run. They sound like they're really doing pretty well, right? Which was interesting. So hopefully we're finding the ones that need instability. I had a quick question for Dr. Lambert, Tom Haytmanek from Vail, Colorado. Super interesting study. You guys used 80% occlusion, which I think is pretty standard for, I don't know, I gathered maybe a third of your exercises or something like that. Is that standard within? And I don't know kind of what is usually done in that pretty standard protocol. So we had not done this in Achilles tendon rupture before, so we mirrored it a lot off of our ACL stuff. For ACL patients, it's pretty standard to take three to four exercises where, to describe it a little bit more, within a given exercise, the whole time they're doing a given exercise, they are under occlusion. So you are occluded for about a five minute period, including the rest range. The whole point is to kind of get this buildup of metabolites and stress factors in the muscle to kind of initiate the anabolic process. From some of our other work and comparing to other studies, it does seem that there may be an effect of doing multiple exercises compared to just one. Most of the studies we've seen where we don't see much effect of blood flow restriction, it's limited to like maybe just a single exercise compared to other studies that are doing multiple, getting kind of multiple stimulus across exercises. And we generally progress those, our PTs and our physicians kind of progress those exercises going from lower intensity activities, things like quad sets out to more intense activities like doing single leg stuff, where they're kind of doing more balance oriented activities. So yeah, it's pretty standard for a lower extremity and 80% limb occlusion seems to be fine. For some of our older patient population where that's a little bit harder to tolerate, they'll start them down kind of at 40 or 50 and kind of progress. We have the lit shows that you get a pretty good effect above 40 or 50% as well, but it kind of tops out at 80% where you don't gain any additional benefit. For the upper extremity, for example, max that we typically will go is 50% because over that it just becomes too uncomfortable. Dr. Lambert, I have a question for you, actually two questions for your paper. I think it was a very interesting paper. When you start blood flow restriction, you guys started four weeks and did you do it up to the 12 week of the protocol or do you find that you will do it only for certain amount of time like phase one? Right, so we take it all the way out to the 12 weeks just to standardize it. Again, the exercises will change to be progressively more difficult, so we'll just apply it to kind of the next set of exercises that we move into, but we've done it out the whole way. I would like to see if there, we have a lot of data on early post-op. I'd like to see more stuff on kind of longer term, but then it comes down to the challenge of what's insurance gonna pay for and how long can we get our patients to keep showing up to PT? Will you be able to have like a longer follow-up in these patients, like after you do the therapy, you know, if there's any impact, like what is the longest follow-up that you have in these patients? So in these patients, we're still going through a lot of that data, so we'd like to get out to six months follow-up where we're at least getting patient reported outcomes. We did that in our ACL group and we were also able to get, in our ACL group, we were able to follow them long enough to get clearance for return to activity. We tend to have a little more of a challenge with that for some reason in our Achilles tendon patients and I think just the cases are a little more rare, but those are data we're trying to go through and collect right now. Ideally, at least getting patient reported outcomes out to six months would be nice for us, particularly for some of the bone stuff that we're trying to look at. Thank you. Hi, Eric Virgo from Los Angeles. I love that you run BFR. I think there's some great opportunities for us to figure out how to better utilize this. To offer Lorraine's point, for me, I'm getting them in BFR around day 10 post-op while they're still maybe immobilized and I know you guys didn't start until four weeks. Do you think that perhaps there'd be different outcomes if you started them right away? And then also, if they're immobilized and doing upper chain strengthening, not necessarily calf strengthening, but quad, hamstring? Right, yeah, so if you ask our sports med docs that are doing the ACLs and a lot of the hip stuff, they'd rather get them in starting sooner. I can say that because with our ACLs, they start at two weeks, but it's kind of like the back and forth between your sports med knee folks and your foot and ankle folks who the kind of the compromise on it was to start at four weeks. But I think getting them in earlier, even if they're just doing things like quad sets and stuff like that would be beneficial. If nothing else, to get them kind of acclimatized to just the device itself because it is not the most comfortable thing to do. So even just for that, I think there'd be value in doing that. And functionally speaking, just if you're able to get the quads and the hamstrings and upper chain stuff stronger, even earlier on, how do you think that would affect overall like functional outcomes on the road, even though if it's not- Right, so again, functional outcomes, when you're talking about things like single leg squat distance, well, it's not just necessarily an Achilles activity, right? Same with Y balance and all of those. So I think you might see, I can't, based on our ACL stuff, I think you might see some similar benefits there. And so far, the effect seems to be not so much a, on a function standpoint, not so much a maximal strength effect because you're still not able to train at high load, maximal loads. But we do see some improvements in work capacity. So if we could start them earlier, I think there might be some benefit. And also just generally speaking, just for, I think a lot of people out there are seeing BFR in the community. However, it's not necessarily Owens Recovery or Delphi or Katsu. There's other like more generic models out there. How do you think those would differentiate? So yeah, so Jeremy Linecke is another researcher on this that I talked to a lot about this. And the only worry there is when you're, when you're working with unknown pressures and you're working with just kind of like these strap devices, there's kind of, we're cautious about that. I'm not saying that if you're able to achieve occlusion, in theory, you should be able to achieve some of the benefit. But to have a non-auto regulated device where you don't know the pressures you're working at, some of the concern might be you get an overzealous athlete who, or somebody who's kind of has a less is more or a more is better attitude. And so I can't really speak beyond that, but we have concerns about that. That's all I can say. Alex, just real quick from your paper, just for the benefit of the audience, myself, and maybe even with recruiting Tommy and to kind of help with this. So the clinical correlation here is obviously with the major deltoid disruptions, there can be the consideration for the augmentation of that posterior arm to try to prevent eversion. But that the point of that study, not unlike your AITFL study that you all had done previously is that's a time zero consideration. So most often with these, we're not gonna be stressing them maybe in that same way because they're gonna be in a splint or gonna be in a boot. And could you take the correlation or the clinical application of this to say, hey, even if you just fix the anterior, you're gonna do a good job at preventing the external rotation, which a boot can't really prevent. But because a boot and a brace can prevent eversion, inversion, that hey, because of the technical challenges of that posterior limb, you can focus on the anterior and let that be your process. But just wanted to ask that to you. And if you wanna pass the baton, certainly do it. Hi guys, Tom Hatemanek. So I'm also on the study. I work in Vail with Alex and he does a great job with the robot, but doesn't do a lot of surgery himself. So to your point, Kurt, it made it make sense, right? That posterior limb is really important in eversion, but we can control that, right? You're not doing a whole lot of eversion in that immediate post-operative period. So clinically, we're still repairing the anterior part because that's what's right there. It's pretty accessible and we're doing it. I know you're a big 360 guy and you wanna fix everything and we do too, but it's hard to get down to that succintaculum. The idea of using the internal brace or whatever device you want to augment it is cool. We've been looking at it because I think for me, that augmentation's almost later on doing the allograft reconstruction. There's multiple different ways that are described. They're all hard. There's big holes in your tibia. I think that that augmentation's probably more in that chronic setting. In the acute setting, it's still an anterior repair. I think we should be doing that more. I agree that it's hard to get further back. And I don't know how much that posterior stuff is injured in your SCR or ankle fractures. So we wanted to study it so we know and we can look at the data and Alex did a great job designing these things for us. I'm gonna give him a lot of credit for that. And then we're trying to still just figure it all out clinically. Yeah, no, perfect, thanks. Well, I wanna thank our presenters for a great job. I think it was a great variety of topics that during a lot of discussion. We would like now to invite our panelists to come up here. And now I wanna introduce our last speakers for the day, Aaron Ferkel. Dr. Ferkel is a dual trained orthopedic surgeon, sports medicine and foot and ankle. And he's coming from the Southern California Orthopedic Institute talking about managing achilles tendons in the athlete. All right, good morning, everybody. Thanks, Lorena. And thank you all for spending the last remaining moments of your meeting here with us. So I'm talking a little bit about management of achilles ruptures in the athlete. These are my disclosures. So acute achilles ruptures, we know they're a fairly common injury here. And the elite athlete has, in the NCAA sports, you're typically seeing it in 40 to 80% of athletes. Basketball's number one sport. You see here Kevin Durant on the bottom and most recently Aaron Rodgers up there. But something I also wanna point out recently that's been in the news is in gymnasts. This is a great study that came out of Sports Health a couple years ago showing that 17% of NCAA female gymnasts had achilles tendon ruptures. Recently two Olympic gymnasts had achilles ruptures as well. And most of the people are noticing it on their floor exercises when they're doing their back tumbling takeoffs. So why is this happening? It's a plantar flexion moment with the knee extended, sudden dorsiflexion, plantar flex foot. Typically a patient will come into your office, hey doc, I was kicked in my calf, turn around, nobody was there. And that's the typical presentation when someone's come to your office. So you see this, it can be a non-contact. Oftentimes it's usually more common than contact, frankly. And you can see right there where his achilles is rupturing that moment where the calf is contracted with a plantar flex moment there. And boom. So why are these occurring? Hypervascular region, usually the most common area in the mid portion, two to six centimeters above the insertion. The blood supply is reducing with age. Can we prevent this? Maybe with a repetitive eccentric loading pre-injury. Obviously stretching. Perhaps there's a nutritional element that Dr. Lambert will teach us about down the road in terms of how to prevent these kind of injuries and tendon injuries in general. Scope of the problem. This is something that I'm sure we all see in our office. This is a missed injury oftentimes. 25% by primary MDs or in the urgent care setting. Doc in the urgent care told me it was an ankle sprain. They told me to wrap it up and walk it off essentially. So they come into your office two weeks later now in a plantar flexed, sorry, not in a plantar flexed situation. And they're now been stretched out and essentially missed. And what would be worse is that they're coming to your office two to three months later. So making the diagnosis in our office is pretty common and we all know this, whether it's a Thompson test. I like to also measure their resting tension. You can see on the bottom section here where you're looking at they're in the prone position and really looking at how the loss of resting tension is different than the contralateral side. And then looking at that during the postoperative period and really just making sure that's restored. So when you think about treating these injuries, there's a paper that came out recently in New England Journal of Medicine that really advocated for not really treating it. And I would argue that that paper is discovered by the Leonard Goldner winner last year's FAI in the AOFAS meeting by Dr. Guyton's group, really did a Monte Carlo analysis, which is basically taking all of the patients who are in that study and then basically re-randomizing in a way that actually took out, the problem was they excluded re-rupture patients from further data collection analysis and they limited actually their worst outcomes. And so in the New England Journal study where they showed, okay, you can treat these non-operatively and they do similarly to the operative group. And when you actually re-randomize, it actually showed that re-rupture had exclusively the most complication rate in the non-operative treatment group. So the question is, were they data censoring or it's just maybe they didn't do the study perhaps as the way we would have done in orthopedic side. So looking at the studies that have been coming out in the past 10 years or so, the JBGS study came out in 2012 showing that patients who had surgery had return to work quicker and a faster return to sport. Also in the study in OJSM, that was a award winner that year, showed that systemic review, operative treatment decreased re-rupture rate and also again, faster return to sport. This is a great study out of Finland in 2016 AJSM that showed that patients randomized control study looking at non-surgical, resurgical management in patients surgically treated had improved physical function and pain, restoring calf muscle strength earlier over the entire range of motion and also a better health related quality of life. So more power, better quality and patients were happier. So I think this is a really fascinating study that really kind of I think invoked us to really push further into doing surgery. And this is a follow-up study the same Finnish group did that came out recently looking at how on MRI studies, there was a significant longer tendon length in the non-operatively treated group, decreased gastroc and soleus and plantar flexion strength and increased compensatory FHL size, which I think is really impressively showing that atrophy is setting in in people who are treated non-operatively. So non-op, increased tension, decreased strength, increased length, decreased strength. So how do we approach these if you're gonna choose surgical management? You can do a percutaneous mini-open method, you can do an open method. Is the mini-open strong enough to perform aggressively early rehab? What are the complications? So let's look into this more. I think if you're looking at this incision here, this is the typical open incision. You're really doing a lot more devascularization of the soft tissue and in my mind, that probably is not the best way to approach it. So what are our options? You can have that incision or you can have this incision. I'll go into reasons why I think MIS may be a better option for us. We looked at MIS options. There's the older method of the oculon, which I think is less commonly used today. There's the PARS, which is a more commonly used method, the MoC-Griffin, the MFULI, and there's endoscopic method as well. Just touch real briefly on endoscopic method. This is Dr. Fisikul's video that he shared with me looking at an acute Achilles tenderrupture fix endoscopically. This is the portals they use. This is technically very challenging, I think, for the majority of surgeons out there to do if they've never done one of these. There's a few different studies showing that patients have good outcomes. There's transient and serial hypesthesia and postoperative in two of those studies. Talking about the percutaneous Achilles repair method. This is an anatomic jig. I think people are using more commonly now than the Aclon, which is the previous percutaneous jig, and it has the ability to have a lock fixation in the more reusable, stiffer construct. Here's a study by Dr. Delan's group back in 2014 showing that using this PARS versus the Aclon, which is a non-locking method, had a greater load of failure compared to the non-locking and resists forces simulating earlier you have compared to non-locking. This is Dr. McCullough's study when he was a fellow with Dr. Anderson, showing that in NFL players, no ruptures, no serial nerve complications, and average return to gameplay was at nine months. This is a great study that also was done in my year when I was, and she was a fellow in Charlotte, showing that PARS versus open repair had a higher return to baseline at five months in the PARS group, lower complication rate, higher return to baseline function. So an Achilles repair mini-open is the construct. There's a few different ways of doing it. You can do insertion into the calcaneus, or you can do PARS to PARS, or end-to-end if you want to call it that way, and then using a tape instead of a suture may actually have stronger pull-out with no outer coating on it, which may decrease patient complication. So the Achilles wants to heal, so you want a minimal dissection. Paratenon, for my fellows know, that was basically a no-touch technique, barely ever touching the skin, touching the soft tissue, with just using retraction with sutures if you need to, or a rag now. Less is more, and so for me, I will do a horizontal incision if they're more acute. For me, if they're about three weeks or longer, I'll do a more vertical. I do recommend, if you're starting out, using more vertical in case you don't want to, you need to switch or open a longer incision technique. Here's what it looks like in the operating room. They're placed on prone with a bump, and you can insert the PARS jig, for me, proximal and the distal, and the deer ear construct and passing suture techniques that way. So this is what it looks like when they're leaving the operating room. Is that one week, is that three weeks, and then at four months. The patients come into your office, they're like, doc, my therapist thinks that it looks like a sock line, and it's so, you know, it's kind of impressive looking. It's right in Langer's lines, and so it's not only, I think, a great way to do it, but also, from a marketing standpoint, the therapists are like, whoa, who's this person who's doing this? And so I think it's helpful from that standpoint. Patients are very happy with how the incision looks, obviously, there as well. So to that point, Achilles repair wound closure is key. So I also add an epitendinous suture with a PDS, meticulous peritoneal enclosure. Occasionally, I'll try to do a deep release that allows for a better peritoneal enclosure, and more of a vent for swelling. And then you can add your, I do a 3L monoclonal and a 4L monoclonal, and you can also do Dermabond as well. So that's what the closure will look like there. Post-operative protocol for me, I do a well-padded plantarflex splint for seven to 10 days. Dr. Lambers, I mentioned earlier, I usually will do a BFR beginning at five to seven days post-op while they're in the splint. Get them into a boot around week three to week five, and do progressive weight-bearing with the heel lifts. And out of the boot, usually around week eight into a sneaker. Alter-G will begin, and on the field court running, usually around four to six months. For me, my return to running is usually if they can do a single limb heel rise on that injured surgical side. So Dr. Lambers touched on this a little bit. Mark Dracos out of HSS had a nice paper looking at BFR and Achilles, which did show, similar to your study, that absolute calf strength was increased in BFR group over the control group in this study. Another study in the Journal of Applied Physiology showed that at 14 weeks using a heavy load, had a low-load BFR, there was demonstrated that low-load blood fluctuation actually had inducing of muscle and tendinous adaptations, which are similar to the high-load resistance training. So I think as we kind of move forward for our athletes in managing Achilles ruptures, what we're seeing from all the studies that were presented today, there's significantly less operative associated risk combined with surgical management. So you have decreased risk of re-rupture, ability to reliably regain and redefine their muscle tendon unit, you have increased power, and then with these newer techniques, a lower infection rate, possibly equivalent, or lower complication with the nerve risk compared to the open and the MIS technique. So I think as we move forward, it actually is a question is, not do we not do surgery, it's how do we do the surgery? Is it do it open or do we MIS? And our athletes. So in my opinion, is this incision necessary? No. I think we wanna have it looking like that for our patients coming to the office there. So operative treatment, in my opinion, is the standard of management of Achilles ruptures in athletes and active patients, preferably MIS, but certainly further study is needed. Thank you all very much. Thank you. I'm gonna turn to the panel. Any questions or comments about that? So Eric, I have a question for you. That was a great talk. That was a great overview. You showed a slide of the PARs to speed bridge, which is that running the sutures down, anchoring them into the back of the heel. I found that to, on occasion, create some longer term heel symptoms. What are your indications for that? The theory's great, because you can be more aggressive with rehab and you have more confidence it's not gonna stretch, but in your practice, what are your indications for that? Thank you for that question. I think this is actually a very timely question, considering, obviously, with Aaron Rodgers, and it's certainly not a new technique. It was not invented last year. It came out, actually, in 2015 by the internal brace group out of London, or I think it was in England, but the bigger point also to that is that this is not an internal brace, actually. It's not going bone to bone. This is tendon to bone, so there's still creep elongation through the tendon, and frankly, for me, I actually avoid putting any hardware in the calcaneus, if at all possible, and that's personally my opinion on that, and I think, to Dr. Hunt's point, I think you're actually creating another area for pain, possibly a stress riser for our athletes, so for my indication to do that construct would be a distal third tear. Not necessarily, I mean, obviously, an avulsion tear is very different, but an area where there's very little tendon to actually repair to, those are less common, but for me, those are my patients who I'll do the actual insertional Achilles repair. What about you? Yeah, I'm the same. For me, it's revisions and a very distal repair where I don't feel confident enough in what I'm able to tie together. Yeah, so here's what I would say about it. I think the way you put the anchors in matters. The most important thing is try to make a big enough incision to absolutely ensure that the head of that screw is deep to bone. I also have them aim planterly and centrally towards each other, so they converge, and then they're also aimed at the floor. I think if you can avoid edge loading and spread the force of that construct across the length of the screw and not just right at the bone screw interface, I think that can help as well. And then the third thing is that, look, I've seen heel pain in patients that are suture to suture that I primarily do and not down to anchors. Some of that just has to do with the fact that when you start to load a complex and walk, when you don't have enough calf muscle strength, they're gonna feel it right at the insertion. This is no different than the argument with ACLs with hamstring versus patellar tendon, and that patellar tendon have patellar tendonitis. Not necessarily. They may have an increased likelihood of it, but I've seen plenty of hamstring folks that get patellar tendonitis because they don't have a strong enough quad. So if you let the patient know about it, let them anticipate that when they start to load it, they may get some heel pain, whether they have anchors or not, then they're not concerned about it and immediately blaming the anchor for it. And then one thing just to also point out, when I do my end-to-end PARs, I'm fixing them in max plantar flexion. That was something that Dr. Anderson taught us, and really, he'll comment that he hasn't had somebody that he's over-tightened. They definitely do stretch out. There's some creep there. And I'm just curious for, Kurt, when you're fixing with the anchors, are you fixing them also in max plantar flexion, or Tommy, when you're doing it? Yeah, I think that's an important point, because when I was a fellow in 2013, 14, similar age group, Ken's a little older than we are, and we were checking the other side and prepping both sides out, and there was a lot of skin, and it didn't feel quite right, and so I agree, they can't be over-tightened, they're gonna stretch out and settle. That's what we're fighting for for a long time afterwards. So yeah, I would make them quite tight. With anchors, I may be back off five degrees, but it's still pretty close to maximal plantar flexion, just maybe not as much as it is suture to suture. Go ahead. Dr. Ferkel, great talk. Thank you. The PARS technique for me too, the cosmesis for the incisions, game changer, make it look nice at time zero. I've had issues post-op with the wound, and I think it's from the amount of suture, the knot stack deep to it. I hope you could comment on how to, something in my technique I'm not doing right. There's a lot of suture with the non-absorbable suture not very deep in the. Are you saying that you're having a knot stack from the repairing? Okay, so I think that's actually a good point. First of all, obviously in a skinny person, it's hard to avoid that sometimes, but I think one thing is when I'm doing my end-to-end, so it's near to far. You can obviously close the tiger, the black to the black and so forth, but I'll actually make sure that my assistant is retracting with like a ragnell to really make sure that those knots are buried, kind of almost anterior to the Achilles or at least on the medial or lateral gutters, if you will. But the other thing also is just closure over those as well. So I'll do the epitendinous closure and then I'll do a bicurl on the peritinon and then I'll do probably three or four monocurls on kind of the subdermal and then a four monocurl in some particular with tails. I don't bury the tails. I think that's important not to bury the tails too, but occasionally you will feel a little of the knot stack, but I think that eventually goes away. But I think if you can retract well enough so that the knot is tied nice and tight and they go a little more anterior, that's helpful. Eric, do you have any experience with the flatter suture that is reported to have a thinner knot stack? I think a lot of the companies make it now. I've been using that for my Achilles tendon repairs and noticed, I think there's a subjectively a little better pullout. Do you have any experience with that or not? I agree. I think that there's actually the newer, newer one, which is not coated either. So the tape that you're referring to, the flatter has, I think it is sitting a little nicer than maybe the ones we were using three or four years ago. So I think that is helpful. So I have a comment and also a question. So my comment regarding your question, so I use suture tape and what I do is you have like six ends in both sides once you tied all the sutures, right? So I get one of the ends from one side and I bring it to the other side and I tie it to one of the ends after I finish all my suturing and then I kind of dip into it and kind of like bury in the middle on the anterior part of the Achilles. That has worked for me. So I kind of put the two ends together and then I did a few more knots and then I kind of bury it with a small hemostat or mosquito. The other question that I have and it's for all of you, if we're using this system for this, like the suture bridge, kind of like the hybrid technique, usually one of the advantages of this is a faster recovery. Like the rehab can go faster. We can go up into high impact activities. What is the difference in your protocol if you do this technique instead of doing the typical parts? Yeah, and I think that's actually a really important competition because I think our patients out there saw Aaron Rodgers in a ASO brace on the field, like a week after surgery. And maybe ESPN, it was kind of being advertised as a brace construct. Again, you can still pull out easily on this internally. What we're trying to avoid is elongation here. You can't go backwards from that. And so I still think you gotta go slowly. I preach them the same as I do my PARs to PARs on these patients. I would not change that. What about you guys? Yeah, I did a study that Kurt knows about and he's laughing over there. When I was a fellow that showed that some of these percutaneous techniques are not as strong as the open technique. And so we sort of recommended going actually a little more slowly. We don't talk about it a lot because these are, I think, better. I'm not arguing they're better, but it was a biomechanical study that we do in our lab and it wasn't as strong. So I do think you have to be a little careful with these. I don't know that this is a get better faster technique. I think this is a, your blood flow's gonna stay better. You're probably better in the long run. You're gonna have less wound complications. And I think it's the right thing to do, but I don't think it is not as strong as our open repair. I think the Velcro had a study looking at those two techniques head-to-head and they were equivalent. Am I correct? There was an HSS study that looked at it, that looked at crack-out versus a locked suture and they saw no difference. I think the biggest thing you have to tell patients is that a lack of pain does not equate to a degree of healing. I think these have less pain. So this is no different than arthroscopic stabilizations compared to open stabilization to the shoulder. They hurt more, they don't wanna move more, but when it's small incisions, they wanna move faster. So you just have to set a reasonable expectation. Most people don't have an AFO that's hidden underneath their pants and their sock like Aaron had. I mean, you just, look, not seeing is believing, but you're not always seeing everything. Just be very slow early on, don't stretch it out, and then they can go. Yeah, I agree with everything that's said. I'll just add that part of why we immobilize is to protect the wound so that there's not stretch on the skin early on. But a big part of it is if they're not painful, then a lot of athletes will say, I can do more, I can advance this a little faster. And you elongate a little bit, and like you said, there's no coming back from that. And I think something that we're all in agreement on is we don't want them to go past neutral dorsiflexion, at least for me, for at least the first three months. And that's really critical to engage with your therapist on because you can get elongation early if you let them, because sometimes the therapists who don't know, they'll be pushing on them and start stretching them out, and then you're losing tendon length there, or you're actually increasing tendon length, but losing strength. Good. I have two, one first questions, just curiosity. Has anyone in the panel had experience treating a high-level like D1 athlete with non-operative management? And secondly, more importantly, do you manage Achilles tendon ruptures that are very proximal? I've seen a few of them that come right where the, like right off the muscle belly. So you feel like you're repairing tendon to muscle belly, and how do you handle those? To me, that's a very unrewarding type of repair because your proximal stitches are in red muscle. That's a great question. I think that the proximal one you're talking about is not, is common, but does, we are seeing it, and you're like, it's like placing crab meat to crab meat. A study came out recently showing that actually non-operatively managing had similar outcomes as managing a surgical with those muscle tenderness repairs. But, you know, in the day for an athlete, I'm still gonna approach those surgical, but those for me are gonna be open. I don't do PARs up there. I do those a vertical incision and open cracker. Yeah, and I agree. I mean, that's the case to treat non-surgically. If it's a proximal muscular tenderness or very proximal. The issue with the, where the Achilles usually ruptures is blood supply. And that location, proximal, has great blood supply. So if there's retraction, you have to make a little incision and suture it back, but you don't do it, you can't get PARs into muscle. So you just need to get that fascia together, make sure there's tension, and then. Yeah, it's very different than a mid-substance. Yeah. It's, you know, the issue there is just make sure who's defining that as proximal. Is it the radiologist when you're reading an MRI report, or is it you? Because there'll be some of these that are only four or five centimeters up clinically, and you go in and you're staring at a bunch of muscle, and it's like, what the hell? This is something that I would expect to be 10 to 12 centimeters up, because some people have a really low soleus. So I think it's all about defining where it is. And look, if you're using a percutaneous technique, don't feel that if you pass it up and one of them pulls out, that all of a sudden, it's like, oh my gosh, now I gotta open the whole thing up. Realize it's just a facilitation of a locked stitch. Pass it again, pass it through, and you can get it. I have a question for the panel. Maybe, Eric, you can start. What's the role for PRP? So I inject PRP in all of my athletes, because why not? And anecdotally, I feel like it's great, but the data has shown it's equivalent. Do you guys use PRP for these? No, I love that question, because in LA, everybody wants to come in, they want PRP. Can you add to my face also where they're a doc? There's absolutely no evidence that shows there's any tenosite healing. There's no evidence that shows that it's gonna improve outcomes functionally. But where I think it does have a role, number one, it helps the wound, I think, have less inflammatory reaction post-operatively. So generally, it's the anti-inflammatory meters that are being promoted. So it's binding to the IL1s, IL4s, IL6s, the TNF alphas to block those from having less swelling. I mean, there's less pain when you're using PRP. I think it prevents also the adhesion. So I'll put an angiocath below my paratenon, enclose everything, and then put the PRP in and actually activate it with calcium chloride thrombin. And I do leukocyte-poor, so I want anti-inflammatory. And so the reason why I do all that, I think, is you have less tendon adhesion, possibly, post-operatively in that area, and perhaps better wound healing additionally. But I tell the patient straight up, I mean, you're not paying extra for the tendon to heal faster or stronger or to heal differently. This is, I think, hypothetically, perhaps to help with wound healing and, like I said, those other reasons, yeah. Here's a question for the audience. We're still supposed to do cases on high ankle sprain and OCD, and we got four minutes. Do you want to talk about a high ankle and go through some of that? What would you all like to do or continue to talk about Achilles? You can stay longer, too. I'm seeing some nodding on at least going through a case. Okay, let's do that real quick. Just in case, yeah, go ahead. Yeah, yeah, and we can talk more about Achilles after. Yeah. Great job, Eric. Thank you. Okay, we're gonna do one case really quick. I know everybody probably has to catch a flight or something. Yeah, if you click outside with the mouse and then use it, yeah. Okay. Yeah. Okay, so our disclosures are on the website. I think everybody knows our panelists. I'm just gonna run really quick here. Okay. So this is the first case. This is a 30-year-old female. She's a recreational runner, likes to do kind of HIIT classes similar to the Orange Theory model two times a week. She tripped and fell off the stairs about two months ago and didn't pay much attention. Then it was like a typical ankle sprain. But however, she came having pain, so she decided to go to urgent care about a week, 10 days after the injury. She was diagnosed with an ankle sprain, placed in a boot for two weeks, and then recommended to do slow motion of the ankle. She came to see me about two, three weeks after she was placed in a boot. She removed the boot, and she kept having pain. She denied any history of prior ankle injuries, no physical therapy. During the physical exam, the patient was standardized to blood patient over the anterior syndesmosis and over the middle gutter as well. I performed a few tests, negative external rotation, tense and dorsiflexion, anterior diarrhea test, and tolerative test were negative and symmetric to the control at all side as well. I used the hop test, which I asked my patient to hop in a single leg for three or four times, and if they don't have any pain, have a low suspicion for syndesmosis, injury, or instability. So these are the x-rays of the patient. Just because of the time, I think they're remarkable. I didn't find any signs of prior fractures, not even abortions that are very obvious to this x-ray. A little bit of plesiplanus alignment. So my diagnosis was a parolimia left high ankle sprain. I started with physical therapy for six weeks, avoid high impact for four weeks, and then full up in six weeks. So the patient came back to my clinic with 20% improvement of symptoms. She didn't feel very satisfied. She was frustrated. She was unable to go to her HEAT classes for severe pain over the anterior aspect of the ankle. At that time, she was persisting pain over the anterior aspect of the syndesmosis, and that all got her. So I wanna ask our panelists, what would be the next, and we all know the next step will be having further imaging. What imaging would you like to request in this patient? Will you get an MRI? Will you get CT? We'll start down here and move leftward for the audience. For me, this is an MRI. This is a great story for chronic syndesmosis stuff. We can talk about fixation then, how that's evolved. But for me, it's an MRI. I don't have a weight-bearing CT. I don't know if I would use that here, but I'd consider it. Yeah, I'd start with MRI. I'm the same on MRI. Agreed, yeah. Okay, and then I got the MRI. So I'm gonna run some videos where there was not a lot of edema around the syndesmosis. However, as you guys can see there, there is a small avulsion, and I can try to place it again over the anterior aspect of the distal tibia. This is the coronal view. A little bit of, we can talk about a little bit of fusion over the lateral gutter, no OCDs or additional lesions. Okay. That is that little fragment over there. So I do have weight-bearing CT, and I do use a lot of weight-bearing CT. When I have suspicion for syndesmotic instability, I find that sometimes the MRI, which provides a lot of information, this weight-bearing CT allows me to evaluate the patient under a physiologic condition, allows me also to see more of the distance in the incisor as well. And our team had a lot of multiple papers published about this, so I do have the luxury of having this. I agree that if I wouldn't have a weight-bearing CT, an MRI would be useful. I also think that comparative X-rays, or initially, and even a comparative CT without being weight-bearing can be useful. So what we use, and we look at the diastasis, but also we look at two-dimensional and three-dimensional areas, where we can see here, and what we have found is that we have a little bit of variance between one leg and the other one. But that varies among subjects and individuals without history of injury. So we had narrowed down to a cut-off point about 20% difference between the two. And when we look at two-dimensional and three-dimensional measurements, the area at one centimeter above the tibial platform, and a volume that entails all the area, all the volume from tibial platform up to five centimeters approximately are the most sensitive for this type of pathology. So this patient, as we can see here in the CT as well, we see the small avulsion over the anterior aspect of the tibia, the ITFL, and these measurements confirm the diagnosis. So as Kenneth will mention, we're talking about chronic syndesmotic instability. Basically, I'm gonna go through what I did here in my X-ray. So I did the patient to the OR, I did an open reduction, and given that this is a chronic stage, I do try to clean the syndesmosis, and I do this construct. For these patients for chronic instability, I do an augmentation with suture tape over the ITFL. I have seen a lot of studies that when we look at these, and we look at these biomechanical studies, especially about the external rotation of the ankle, I see that it's not as stable as the native. So I usually tend to do augmentation with suture tape over the ITFL when we do these cases in a chronic basis. And after that, I just check, as Kurt is gonna mention, after that I check all the syndesmosis, and I'll check the ankle in all the views, making sure there's no residual instability, whether around the lateral ligaments or the syndesmosis as well. These are the X-rays that Juan pulls up. She's fine. She was able to go back to running and to do her activities. Thank you. Yeah, so panel, what are your thoughts? That's a great case. I think it's a very hot topic right now. They're trying to figure out what is the best thing to do for a patient like this? How do we have managed it? How they identified it sooner or any differently? Could we have avoided surgery? Probably not. Should we have done surgery sooner? I don't know the answer yet, but I'm curious from the panel, do we need to address the actual, do we need to put a tightrope across that, or can we just fix the AITFL, and that's all we need to do for this patient? Can we use just one button and do an AITFL repair? And what do you guys think about that? Well, I think it's really about the tissue that remains. As long as there's a healthy cuff of tissue that can heal back, you don't have to augment it because you're stabilizing it with the tightropes. Now, could you do the suture tape augmentation instead of, maybe, no data on that, but I think what you did looks great, and then I'd repair that cup of tissue. If it still seems like it's rotationally unstable because it's two months out, then you could consider augmenting it. Yeah, I agree with Ken, but you have to be a little careful with the suspensory fixation because you can actually externally rotate the fibula a little bit as you squeeze it down. So, I think, for me, that has transitioned to just one suspensory fixation device and an AITFL repair with augmentation. And I think a lot of that just depends upon the dissection. Because if you're gonna go and put that AITFL tape in, it's a little more dissection, it's gonna be a little bit more swelling, and ultimately, what's the pathology that you're trying to treat? Biomechanically, from what they've shown at SPRI, you certainly can do that, and it will be much more stable and you can go faster. You know, if we look at this 3D modeling that the BioCorps and UVA folks did for the NFL when we were looking at this, what you have to understand is that that deltoid complex that's over there immediately, the first thing that goes is that superficial deltoid. You've gotta understand that. Now, to the degree at which it starts to go around that and how much of that sleeve comes off, that determines, I think, whether or not you need to do medial stabilization in addition to the syndesmosis. This is another graphical representation of that where when you look at this and you see the external rotation happen, at the time that AITFL ruptures, that superficial complex goes. This is what's happening in the majority of high ankle sprains, and arguably, even the majority of SER 2s, 4s that you're going in and trying to treat, not necessarily that the whole posterior complex comes off as if the ankle is dislocated, but you have to understand that this is present. So when we think about that 360-degree ring of stability, you have to look and see it anteriorly, laterally, but also medially, and then understand how that looks posteriorly when you see this edema within the posterior mal. It doesn't even necessarily have to be a posterior mal fracture. If you've got edema in that posterior mal, there's probably been a decent enough stress on that PITFL that it's probably unstable. So you're gonna look at external rotation as far as the stress. You're gonna evaluate the entire extremity, the squeeze, but realize on these chronic ones that she dealt with, didn't mean to over, this Amendola taping test can be very helpful. You cannot tape someone to play with that. This is something that you put on there very quickly, tape above this insessura, and then all of a sudden, you can get someone with chronic subtle instability that can go up on their toes that couldn't when they're unstable. So understand that. The CT scan can be helpful. I think weight-bearing CT may have a role, but the biggest issue ultimately is when you're looking at this MRI and then understanding it's arthroscopy that's gonna be able to help you understand the subtle grade twos. The issue is just when do you scope them? But we certainly know that the scope is the way to be able to see them. And then when you do that, at least for me, identify the subtle syndesmotic instability. If you've got a fibular fracture like this, this is length and rotationally unstable. I will go in and simply fix that, even with screws. All I want is length and rotation. This doesn't have to be plated. This can be a challenge, especially in a big football player, but it's a way to be able to get length and stability. And then you can go distally and do this. If they're a posterior mal, be careful about, well, first off, before I talk about that, if you put in a hybrid, cause you're worried about its weight proximal up at the neck, you better take that screw out at about six weeks if you're weight-bearing them early, cause otherwise it will break and the heart and breakage of hardware here, even though there's data out there to suggest that it doesn't matter, you don't want it to be one of your athletes that has that. As far as posterior mals, Bob has talked about this. Ken's talked about it some, I agree as well. Be careful about trying to plate the posterior mal, cause if you get scarring of the FHL in an athlete, that's a big problem. You simply just need to control that posterior mal. You can clamp it to get it reduced, then just simply fix it and stabilize the syndesmosis otherwise. But realize that when you put that through, as Mike Gardner talked about, think about the anterior cortex fibula, anterior cortex tibia. The center of the insessura is halfway between them. If you use one, put it at the centroid between those two red lines. If you do it two, put it anterior and posterior to that, and then sequentially tighten them down to get it to fit into the insessura. And then lastly, use a plate, cause you don't want this. Now, is a two-hole plate enough? Well, at least it's a washer to try to keep it centered, cause otherwise this is a triangular bone where those buttons will wanna ride anterior, ride posterior. At least the two-hole plate keeps it relatively centered, but that hybrid fixation plate does a much better way to be able to then be able to hold them exactly where they need to be, and I routinely use that. So, as far as motion, the only other thing, you can get them going early. Just control the DEM and get your incision healed, but be careful about the boot, particularly if you have a deltoid injury. Boots do not give as much arch support as our athletic shoes do. Realize that that tibial spring is sensitive to a pronating foot, so put an insert in the bottom of it, because otherwise you are not protecting that anterior portion of the deltoid, and then let that insert follow them out. Even for the non-operative ones, do not rely upon a boot to control rotation and to control pronation of the foot, and that matters for your deltoids, your post-tibs, all of those types of things. So, that's it for that. We're way over, so any questions? All right. Well, I want to thank everyone for coming. We can talk more about OCD on the side if someone wants to, but I appreciate everyone attending this, you know, kind of last of the day deal. But if you enjoy the content, continue to promote it, say you love it, and we'll try to get AOSSM to put even more of that content, maybe not on Sunday morning, all right? Thanks.

Lorena Bejarano-Pineda, MD

Kirk A. McCullough, MD

Alex Brady, MS

Bradley S. Lambert, PhD

Jeremy Silver, MD, MS

Eric Ferkel, MD

C. Thomas Haytmanek, MD

Kenneth Hunt, MD

orthopedic surgery

Achilles tendon ruptures

high ankle sprains

PARS repair system

minimally invasive techniques

blood flow restriction therapy

specialized suture tapes

syndesmotic injuries

tightrope devices

post-operative protocols

joint stability