All right, well, thank you very much. Just to kind of close it up here, talking about hopefully things that will be complemented from the studies that we heard from earlier. And I think for the most part, they should. I don't know how I was able to zoom on that. I've never seen that happen. So here is that. And that's reversing it with the right click. Okay, great. All right, so synesthematic injury in the athlete. So as was highlighted previously, this is a relatively uncommon injury in the population. However, in athletes, particularly in cleated athletes, this is something we see with relative frequency as it relates to the lower extremity, certainly in football, certainly in lacrosse, and even in hockey. So it doesn't have to simply be a cleat. It's any time where we can get what would arguably be too efficient of an interaction between a shoe and a surface to where there creates an external rotation moment, which is not only a problem for the ankle, but certainly a problem for the medial knee as well. So this is a ligamentous complex consisting of four main parts, the AITFL being the one that we most frequently talk about, which makes up 35% of the overall strength. But importantly, the posterior inferior tib-fib ligament complex, as well as the transverse tibiofibular ligament, which makes up the majority, almost 50% of that strength. And then finally, the interosseous ligament. So the shape of this articulation varies. Most of the time it's concave, but you have to be aware of the ones that are convex or irregular, because certainly if you're trying to reduce this, you need to understand that. And the depth can vary, and the most important thing to understand is that it's a mobile joint. I think most of us are clearly aware of that now, and unless it's a case where you're trying to stabilize a length-unstable proximal fibular fracture, you may want to do a hybrid type of fixation. And certainly the ability to be able to fix this dynamically can avoid a lot of problems that we'll talk about later. So as far as the mechanism of injury, it's a foot in a fixed and stable position on the ground, most often an external rotation of the body and lower limb relative to that stable static foot. As we know, the dorsiflexion moment brings that wider portion of the talus into the mortis, and then allows then that portion to then stress the syndesmosis to be able to rupture the deltoid as we've shown, and certainly need to understand that spectrum of injury. As far as at least being able to better define this, I've had the pleasure of being able to work with the BioCorps and University of Virginia biomechanical engineers with the NFL Foot and Ankle Committee, and one of the biggest things that's come out with our modeling of this, particularly with these three-dimensional models, is that when you look at this, one of the first things that occurs, even though we're thinking the syndesmosis is the first injury, is actually the superficial medial deltoid complex that injures, and the syndesmosis then will follow it. We followed this up then with even further studies that once again, as we show this motion tracking animation, we see the first injury, the ITFL rupture, and you can either rupture and break the fibula, or then get significant injury to the deltoid, which then when we put this into a diagrammatic form, what you see is that simultaneous with the AITFL rupture, that superficial medial deltoid significantly undergoes stress and injury, and certainly depending upon the spectrum of that injury, must be addressed, or as was shown earlier, there can be significant instability that needs to be able to be understood, so it's not seeing us later as an asymmetric hindfoot valgus or ankle valgus problem. So as far as the typical scenario of this, it usually involves contact with another player, that's direct contact, neutrally flexed or neutral and everted, and an external rotation moment that then allows that planted foot to then be able to then be stressed both laterally and medially. But it can happen without contact when you get this really efficient moment between the cleat and the surface, where if it's not going to release, that moment is going to be propagated up the lower limb, and certainly can create another similar type of injury pattern. As far as diagnosis, the external rotation mechanism is suggestive as far as the history, but evaluate this entire extremity. Understand the prevalence and the potential of this masoneuve injury, not necessarily that a very proximal fracture needs to be fixed, it certainly needs to be understood and recognized though. The squeeze test where you're compressing the fibula and the tibia at the mid-lower leg as the picture is showing can certainly be positive when it reproduces pain distally and anteriorly. The external rotation stress test with the patient sitting and the knee flexed, and once again, that stressing similar to the moment of injury, causing that pain that propagates up the anterior syndesmosis. Tenderness to palpation to the medial ankle can certainly be representative of the deltoid injury, but is not necessarily specific to it, but can be somewhat sensitive and needs at least be understood and recognized. But as Dr. Amendola has published in the past, not acutely, and not as a means of being able to stabilize to get back to function, but for more chronic, subtle instability patterns, the syndesmotic taping test, which you can do in the clinic, you can take someone who on a single limb is unable to do a single limb heel rise, do this taping test, and by conferring stability by reducing the fibula into the insusura, allow them over a short period of time to all of a sudden be able to do that. They obviously won't tolerate that too long with the venous congestion that occurs from doing this, but it's a way to very quickly at least have another tool to understand subtle instability. Stability with x-rays, seeing a posterior malleolar fracture is of concern and must be identified. So at least being able to get these orthogonal view x-rays is important. The proximal fibular fracture is being seen here. CT scan, at least in a non-weight-bearing setting, it can be somewhat useful in comparing it to the opposite side. And it's obviously not a dynamic test, but at least can give you an understanding of the degree of a posterior malleolar fracture or other issues. A weight-bearing CT, as we talked about, can be potentially a way to better understand this, but obviously needs to be understood in the acute versus chronic setting, what is it like on the injured compared to the uninjured, and we're still trying to define how exactly that can be utilized. As far as MRI, it's sensitive to injury to the complex and acutely you can look for things, particularly that medial-sided injury that you must be aware of. Chronically, it's going to be a little bit more difficult. I think it's a tool, but it certainly, as we know from some of the literature, is not a way to be able to predict return to play based upon involvement. Just once again, becomes a tool in the spectrum of being able to understand how to manage these injuries. Arthroscopy, without question, is the gold standard to be able to understand this. Not that everyone with a high ankle sprain needs it, but certainly for the ones that are in question, this is going to be the one to be able to definitively understand that. And even when it comes to basic Weber B, Weber C fibular fractures, it can be a way to be much more sensitive and specific to understand what's involved compared to just doing a stress x-ray alone. And as far as even just things such as the drive-through sign, this is a 4-millimeter shaver. You should never be able to put a 4-millimeter shaver into the medial clear space if you can. Without question, there's probably damage to the deltoid in addition to the syndesmosis. And these are ways where, once again, even being able to drive into that anterior portion of the distal syndesmosis, if you can do that. It's representing pathology that needs an instability that needs to be addressed. So as far as the current algorithm, for me, an inability of an athlete to bear weight, pain with external rotation stress, particularly if that propagates pain greater than three to four centimeters up, tenderness to palpation directly along the syndesmosis extending four to five centimeters proximal to the mortis, positive mid-lower leg squeeze test, deltoid tenderness to palpation. All of these things are clues and cues to where you need to probably look at this further. And that look at it further, I think at this point as an MRI, it's not jumping automatically to a scope. If it's an AITFL-only injury as Amendola has shown us, no diastasis or symptomatic instability, you certainly have to set the stage for understanding that this is going to be longer than just a simple sprain so that everyone is on the same page, whether that's the patient and the player's kind of support structure and handlers, or whether that's the coaching staff. They can come out of immobilization, at least in my opinion, once that provocative stress of external rotation is negative for pain. You have to realize that as it relates to these type of ankle sprains and boot immobilization compared to an inversion or an eversion injury, that boot is not going to confer necessarily rotational stability. So trying to be able to support the deltoid with an insert in that boot, and also understanding that even early on, just even two, three, four, five days of non-weight bearing, being in the boot's not going to necessarily confer an automatic stability to that. And you need to recognize it, and that's why some folks, even like Bob Anderson, will advocate to training staffs to cast them so people will keep their hands off, they'll be stabilized, and it tries to limit their weight bearing early on. Too early return to play can restart this entire process, so you've got to be aware of that. But an athlete's ability to do a single limb hop test, 15 to 20 consecutive without pain, is a very good, simple, structural and functional test to understand there's probably enough stability to progress. And 86% to 100% return good to excellent outcomes with full return expected. No question the most controversial are the two ligament injuries. The 3 plus ligament disruption to fractures, we know those need to be fixed. But it's these two ligament injuries that are the tough ones. Used to recommend just an EUA and a stress. Now whether it's needle-based arthroscopy or a scope, if there's a concern and we're needing to get a definitive answer, arthroscopy is the way to get that definitive answer, especially if there's notable MRI findings such as superficial deltoid irregularity and posterior malleolar edema, which at least if nothing else was showing a significant stress to that PITFL complex, which once again is about 45% of the overall integrity and strength of the syndesmosis. That squiggly line that's being shown there, once again, that's an avulsion of the superficial deltoid that must be appreciated if you get lucky enough to see a coronal cut that shows that. That's clearly a problem. Obviously, looking posteriorly and seeing some of that posterior malleolar edema can be a consideration of some stress and concern as well. That's what it ultimately ends up looking like arthroscopically, where you get this almost chondroosseous avulsion of the PITFL complex. Must be able to appreciate that. Now as far as fixation of it, how are we going to fix it? Historical treatment talked about screw fixation debates. What size screw? How many cortices? Are there one or two? The concerns are obviously hardware breakage. When do you remove it? It's not a static joint. It's dynamic. So how do we manage that? Does fixation matter? We know from the classic Ramsey and Hamilton study, it does. And malreduction is incredibly important as it relates to the risk of post-traumatic and post-injury tibio-taylor osteoarthritis and chondromalacia. So why suture button fixation? There's no need for routine removal. We've shown in numerous studies, even from our trauma colleagues, about how this can ultimately be successful. Of note the Sanders and Anderson studies and JOT and JBJS respectively. If we look at these, once again, the understanding of how this stabilization can confer not only an ability to appropriately and more appropriately reduce, but also to avoid recurrent diastasis. That's what we want to at least be able to understand. And that's been borne out in those two studies. What about one versus two tightropes? Obviously it depends upon the injury and the spectrum of injury and whether or not you're doing any other concurrent procedures such as fixing the deltoid. Certainly being able to make them divergent can confer a little bit more rotational stability, but so can direct repair anteriorly where if we think of this as a 360-degree ring, if you're fixing the anterior directly and stabilizing it, then posteriorly being able to stabilize it even better, you can confer that stability and potentially allow them to weight bear more effectively, more safely and sooner. But it certainly is a little bit more dissection. So as far as my current treatment, when we're identifying one that we're concerned about, that's arthroscopic evaluation. If fractures are present, certainly want to fix them. The posterior malleolus, it can be a whole different debate as to how you fix it, when to fix it, and when not to. I tend to try, particularly in athletes, to avoid that posterior dissection. If I can simply capture it with a screw to avoid FHL scarring, I will try to do so. And then the other important thing is, as I'm showing here, at least in my opinion, a buttress plate. It doesn't mean that you can't put these tightropes in individually or separately. But the problem is, is there's different morphologies of that distal fibula. It's triangular. On a triangular bone, this tends to want to slide more anterior or posterior. Sometimes it's really hard to stay in the true middle. So the plate not only helps to do that, but it clearly can help to try to buttress and protect this, particularly in a contact athlete, and to avoid this. So trying to avoid that, when that happens, that's a bad problem. But clearly you can do it safely in certain indications, but the use of a buttress plate is a minimal thing and can maximize protection and the ability to reduce it and hold it there. So what about the TUA effect? Obviously there's been a lot of talk, a lot of promotion of the idea of fixing these and stabilizing them early. The question just becomes, when is tightrope alone effective? Obviously from the deltoid talks that we talked about, this is a 360 degree complex. You must not ignore the deltoid. And there will be situations where there's a high ankle sprain that has enough of a medial component that if you don't do that and simply fix this with tightropes, it's not going to stabilize them effectively. I think Ned would echo that as well. So we must be aware that even though there's a lot of pressure now, hey, I've got a really bad high ankle sprain, puts a couple tightropes in and I'll be back in three weeks, that's not going to be a shoe that will fit for everyone. So we must be prudent in understanding when it's appropriate and when it's not. As far as then thinking about that deltoid and understanding that, so looking at Bob Anderson's study, looking at acute repair of the superficial deltoid in an NFL-based population, these are ones that had fractures associated with them, all players back to running in sport by six months in 86 that returned to true gameplay. And then once again, as I was talking about this concept of a 360 degree ring of stability, I talked about this briefly in orthopedics today about a year ago, but the idea that we need to be looking at this as a complete comprehensive structure and not just isolated individual structures. So as far as a final case example, a 280-pound, 6'2", Division I collegiate athlete, acute external rotation, injury was rolled up on, tenderness along the syndesmosis, approximately centimeters, 6 centimeters, pain with external rotation, all these things that pointed, all right, we've got a problem here. So as we look at it, and this is a non-weight-bearing X-ray, so not stress, but I mean, nothing obvious that's popping up on X-ray, but because of all those other parameters, we've got concerns enough to where, look, this needs something more than simply just X-ray. So as we look at it, once again, here's the MRI, and you can see that significant medial injury, if I can get the, so you see the significant medial injury that has occurred. Once again, you can see, if we go back, you can see some of that posterior malleolar edema, you can see clear disruption of the ATFL. So I mean, we know based upon our provocative testing, this is a problem. We just wanted to understand what's the spectrum. And so then you see all that, so the issue is what now? Is this going to be non-operative? Can we just cast him for two weeks, four weeks, six weeks? How long is it going to take to heal? Is it going to heal? With that medial side, is non-operative ever going to be appropriate? Certainly talk to them quite a bit, let him understand the concerns about the significance of this and that we would need to scope it. This is how we initially scoped it, showing this complete avulsion of the ATFL anteriorly. That's then as looking at it further, you can see that disruption. This is the medial clear space where you can clearly drive in, that's a concern. This is his anterior colliculus, which once again, if you go through with a probe or with a shaver, if you can take that and you can take it all the way around the anterior colliculus, that is clearly a problem and a clear disruption. Once again, the consideration of that chondroosseous avulsion of the posterior complex, if you're seeing this, this is of mechanical concern as well. And so that's what that looks like. And then once again, if we dive into this and we cut through skin and subcutaneous tissue, this is what you see. It's almost like a patellar sleeve avulsion where you can easily get in and get all the way to the medial talus and that's not going to heal, at least in my opinion, well, particularly if you want to try to get them weight bearing early because they will still invert and evert even in that boot. So it's not going to protect them well enough. So you can go and you can do a medial brostrum where you can go and repair that tissue. That's the tightrope. Here's the button, the buttress plate being able to be utilized. That's how, once again, if we look at this from the side, the other important thing is to realize, as Gardner has shown us, halfway between the anterior tibial cortex and anterior fibular cortex, one centimeter is the middle of the incisura. So if you're doing two, you want to go on either side of that. If you're doing one, you want to put it right at that centroid of those two. That's how you can know that you can use a tightrope even if you don't want to use a clamp to be able to reduce that appropriately. So once again, syndesmotic instability, it's a common difficult injury, continued improvements in diagnostic criteria as we had heard from some of our colleagues earlier. Management is still controversial. Might we use MR arthrography? Might we use more needle arthroscopy? I think it depends. But we've got to manage appropriately and do not forget the medial side. So thank you very much.

syndesmotic injury

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