All right, so I'm going to try to get through both deltoid and syndesmosis, so 10, maybe 15 minutes. But once again, thanks for being here. So syndesmotic injury in the athlete. So as we look at this prevalence-wise, and there's certainly going to be some overlap from what Ned and Tom talked about, but this occurs frequently in athletes, most commonly in collision sports, particularly cleated athletes. It's a relatively uncommon injury in the normal population, but rises quite a bit in cleated athletes. So the ligament is complex. You know, it's the AITFL, 35% of that overall strength, which you're seeing right there. The PITFL and the transverse tib-fib ligament, which make up the posterior aspect, and then the interosseous ligament, which is about 22%. As far as the biomechanics, the shape of the articulation varies. 75% of the time it's concave, but it is not always concave. So it's incredibly important when we tighten this down and when we reduce it, to reduce it anatomically and also to understand that it's a mobile joint and not static. So this is why, at least in the majority of cases, there's significant concerns about fixing this statically when it's dynamic, particularly as you start to weight bear. And also realizing that in addition to that, you know, front-to-back motion and proximal distal motion, there's also rotation of that as well. Typically in the injury, it's a foot in a fixed stable position on the ground, particularly with a cleated athlete being stuck in the ground, and then the body then rotates around that. And it is not uncommon in this chain of injury that occurs for this to be associated with medial-sided knee injuries as well. And once again, when that talus is dorsiflexed, it takes that wider portion of the talus into the mortis and then further allows for that ability to be able to stretch and potentially disrupt, as we will see, not only the syndesmosis, but also the significant concern as far as thinking about the ankle as a 360-degree ligamentous stability complex, the deltoid, which we need to be aware of. So as we've started to model this, looking at it in the NFL, the front and ankle subcommittee, what we started to realize working with the BioCorps engineers at UVA, one of the first structures that actually is disrupted as we get this external rotation stress mechanism is the superficial deltoid, particularly the tibio navicular and tibio spring portions off the tibia that you can see in at least that three-dimensional rotational diagram there on the left. One of the first things it's disrupting is that before you even disrupt the syndesmosis. You can further see that here in some of the both cadaveric studies that we've done in addition to this three-dimensional modeling. And then as we look at this and as we load it, this is a very unique kind of three-dimensional understanding of this to see that, once again, these rotational injuries are not simply just the syndesmosis, but it's the idea of what this does to the deltoid. And as we talk about how we're going to intervene with these and such as the TUA effect as far as everybody wants a tight rope for their high ankle sprain, you must understand whether or not there's medial instability present and how severe that is in order to address it appropriately. Because simply fixing the syndesmosis when you have a bad deltoid injury is not going to be enough. So it usually involves contact with another player in a neutrally flexed or a neutrally everted ankle and external rotation relative to the injury. But it can happen without contact too, particularly as the cleat does not disengage from the surface. So certainly be aware of that. A lot of times these are more anecdotal or reported injury mechanisms from the athlete unless you have a high visibility injury that had a lot of TV angles on it or the trainer was able to witness it. But as far as diagnosis, external rotation mechanism is suggestive. You must evaluate the entire extremity and understand if there's that proximal mesonew fracture. The squeeze test that's being shown there is something that can be certainly specific to this, somewhat sensitive. But one of the really great things, Ned Amendola described this in one of his papers before that if you're dealing with someone not acutely but more subacute or chronic and trying to understand whether or not they have subtle syndesmotic instability, this tape test, this is certainly not a way to be able to functionally treat an athlete. You're not going to be able to do this and then throw them out onto the field of play and them tolerate it. But just for a few minutes to be able to do this super malleolar tape test, by doing that and creating that circumferential stability, you can allow somebody who otherwise has pain with single limb healer eyes to be able to be stabilized in their syndesmosis and be able to do it. So this is a way to be able to pick up on subtleties of that. And then also just understanding if there's medial injury. Obviously when there's a posterior malleolar fracture, that's of concern, must be identified and must be addressed. And then also obviously the proximal mesonew fracture that we're showing here. Non-weight-bearing CT, it can be somewhat helpful, particularly if you're trying to evaluate the posterior malleolus. But obviously weight-bearing CT as far as a true stress is certainly increasing in utility. The issue is just whether or not you have accessibility to one of those. But it certainly can be helpful. MRI is sensitive to injury to the complex, and you've got to look for the deltoid injury immediately in addition to what's going on, identifying FHL edema. Because from a functional standpoint, one of the last things that I see that is difficult for these patients is the sense of them being able to get up on their great toe. And a lot of times that can be because the FHL is sitting along the syndesmosis distally. It will be one of the last things to be able to recover, even if they're stable. And you certainly have to be able to differentiate between simply FHL irritation and syndesmotic instability. But a lot of times, even in the subacute setting, an ultrasound-guided injection to that FHL tendon sheath can relieve some of that residual FHL symptom and get them back. Arthroscopy, however, compared to these other things, it's the gold standard. Whether that's needle-based arthroscopy or arthroscopy in the OR, the ability, as Lou showed, to be able to identify when you've got increasing instability beyond just the tendon scene fractures, when you have a fracture present, or certainly when it's just a ligamentous injury as well. This is the way to be able to truly understand what's involved. Is it simply AITFL only? Is it that and the posterior complex? Is it medial? Or is it a combination of all of it? And so the key there is to be able to address this. This is a medial-sided, that's a 4-millimeter scope. You should never be able to drive a 4-millimeter scope into the medial gutter. If you can, there is clearly instability of the syndesmosis, and most likely the deltoid as well, because otherwise that should be a fairly tight and congruent structure. That's once again showing the ability to be able to easily drive through in that AITFL insertion area. You should never be able to drive up into that anterior tip-fib joint. So as far as the current algorithm, inability of an athlete to bear weight, pain with an external rotation stress, tenderness to palpation that extends beyond that 4 centimeters, because as Ned discussed, I mean, because of the integral nature of how that inferior aspect of the AITFL and the proximal aspect of the AITFL are right there, sometimes you can have folks with a little bit of tenderness right over the AITFL that is simply just related to a bad lateral sprain. But if that tenderness extends proximally, you have to be, certainly have a heightened awareness of instability of the syndesmosis. And then obviously concerns if you have tenderness medially, and then knowing if that mid-tip-fib squeeze creates pain, obtaining an MRI to at least understand what's going on. When it's just an AITFL-only injury, you have no diastasis or symptomatic instability, you just have to set appropriate expectations. Realize it takes longer, can come out of immobilization once that external rotation stress is negative, but be very sensitive to the fact that just because you have a high ankle sprain, being in a boot compared to an inversion sprain does not automatically confer stability. Realize what's happening medially. A lot of times I will put inserts into these boots to try to help support that anterior portion of the superficial deltoid. But also realize if they're still getting a lot of pain, even just a few days of strict non-weight bearing can help them quite a bit. And when they're able to perform a single leg hop, that tends to be pretty prognostically encouraging and positive for them to return. The two-ligament ones are the most controversial. The three-plus ligament ones with fracture, those are the ones that are getting fixation all the time. That's an example of an MRI showing that serpiginous-looking superficial deltoid. That is never normal. Similar to seeing that in the medial collateral ligament to the knee. If you're seeing that, there's significant disruption and instability, and you must address that and identify it. That's what it looks like when the PITFL starts to have a chondroosseous avulsion off the posterior aspect. Once again, something that's easily seen with arthroscopy. As far as treatment, screw fixation, do you go three cortices, four cortices, one or two, 3.5, 4.5? What do you do when you remove it? Do you allow it to break? The issue with this has obviously been talked about significantly now, even talked about quite a bit in the trauma literature. We certainly know from the Ramsey and Hamilton study historically that getting that congruent as far as the talus and the mortis is incredibly important as far as minimizing the risk of post-traumatic arthritis and functional instability. So you must reduce it appropriately. The important thing about suture buttons is you don't need to remove them, and they do help to reduce it. And as far as literature, there's been a lot of literature now, even in the trauma literature, supporting the idea that we can use suture buttons and do not have to routinely use screws. And we can go over some of this in some of the cases a little bit later. One versus two tightropes, I think it depends upon how you want to fix it and what the degree of instability is. Is there a posterior malleolar fracture that you fixed? Is there not? Certainly a suture tape can be used anteriorly to where the suture button, and it can more stabilize the posterior aspect. And that's what that looks like. For me, my current treatment algorithm, arthroscopic evaluations of this, fixation of fractures at present, if the posterior malleolar fracture is relatively large enough, I think you have to be careful, particularly in athletes going and doing a posterior exposure and putting a plate, because getting their FHL to scar down quite a bit on that can be detrimental to their function. So I try to fix most of these with an A to P screw if possible. Two tightropes with a majority of them, but a hybrid construct can be used if you feel like you have instability of the fibula. But the key is being able to identify the instability and also understanding, at least for me, certainly with a contact athlete, although with almost any patient now, I tend to use a four-hole plate, just like that, not only to center the button on the fibula, which is triangular and it wants to shift front to back, but also to protect against the deaded stress reaction that you can get, particularly with a contact athlete, that is a very difficult problem to manage if that occurs. So I look at that plate, if nothing else, as a big washer, just to be able to keep it centered and also to protect. We talked about the two effect. You have to understand that just because you have a high ankle sprain, just putting tightropes in, you have to understand and identify the medial side, and if it's a significant enough disruption to be able to stabilize it. So tightropes alone, if it's severe enough, are not the only answer to this, and you must be aware of this. So very quickly trying to get through the deltoid, when we look at this and we look at historical studies, the idea in the trauma literature certainly is that there was no benefit to repair the deltoid, treat all of them non-operatively, they're going to do just fine, fix the osseous mortis, and everything else will be okay. The problem is, is folks like Dr. Amendola and Dr. Anderson, and particularly ones that saw high-level athletes, we realized that this would not necessarily always be the case, and that if we look at this and we look at the literature and we look at Henterman's significant studies on this, the asymmetric pes plano valgus foot, the inability to be able to get up or to be able to decelerate appropriately, and the pain that they would have is something that is not insignificant, and certainly was plaguing some of these folks that had significant medial soft tissue injuries that weren't addressed. And looking at the arthroscopy study that Henterman had done and published in AJSM in 2004, he would identify when there was deltoid elongation or avulsion and then fix it, and then looking at follow-up at four and a half years with 90% good outcomes after that repair. So the understanding that these are, there's a lot of these that are probably seeing us that we don't see and that we have to at least identify and support them appropriately. This is some of the anatomy that we could go over later, but the key here is understanding that as it relates to the syndesmosis, particularly that superficial anterior aspect, tibial spring and tibial navicular are the ones that we see that are addressed or that are disrupted in these significant external rotation injuries. These are some of the landmarks, once again trying to fly through this, but these are important landmarks to understand as far as the intercalicular groove on the tibia, that non-articular portion of the medial talus, and then if you're needing to go down to the sustentaculum tali, at least understanding that from a reconstruction standpoint. The key here is the spectrum of pathology. Most of these that are going to see us and that we need to see are the acute disruptions associated with syndesmotic or fracture. These are the ones where we can do what we would call a medial brostrom type technique. So a high index of suspicion, medial ecchymosis and pain, and soft tissue puckering, sometimes that antramedial rotatory stress instability that is asymmetric. Obviously this picture, it's obvious. We know there's disruption here. This is pretty significant disruption, but I would argue that if we go in and then we try to stabilize this and realize that there's a significant amount of disruption, this is what you see. It's not unlike a patellar sleeve avulsion of the extensor mechanism anteriorly. You have to be able to recognize this, and I think where the trauma literature is right is that if you get the ankle mortis congruent and you get the deep deltoid fibers together, I do think that those heal reliably as long as you have recreated that sling and the superficial deltoid and that you've stabilized the syndesmosis. If you do that, I do think the deep deltoid fibers heal. If you do not, though, that's where I think the deep deltoid not only stretches out and heals elongated, but certainly you start to get that elongation of the superficial deltoid, which is detrimental. So this is what you'll see, and a lot of times these will go all the way, split to the posterior tib sheath, and you will be able to clearly identify that, and it will be a straight shot if you go through skin right into the medial gutter. So being able to fix this in a medial brostrom-type repair gets all that tissue back. So you fix the fracture, you stabilize the syndesmosis, but then you equally and importantly fix that medial side. Anderson has published on this in 14 NFL players, showing that it can return to a high level of play as long as you identify this. This is a brief kind of synopsis of this idea of the 360-degree ring of stability that I did online that just kind of goes over this as well. The subacute persistent instability, this is the one where you get the asymmetric pes plano valgus or hindfoot valgus. Got to be able to identify this, the feeling of rolling in, you know, subacute being whether it's two months, whether it's three to four months. You've got to be able, if you're going to do some type of augmentation of this or repair, you still have to have good collagen. As Tom talked about, the idea of using some type of suture tape augmentation, it is not meant to replace a ligament, it's meant to augment it. If you go and open one of these cases up and you don't have any tissue there, that must then proceed to a collagen-based reconstruction and not simply a repair. But that's the considerations for it. That's how you would then be able to bring it not only to the sustentaculum, but also to the medial talus. And then in chronic, you need to be able to just simply realize that that's a soft tissue allograft reconstruction that's kind of beyond the scope here. So underappreciated pathology on deltoid, you've got to look for it. Arthroscopy can help identify acute injury. And subacute versus chronic, you just need to understand what's the asymmetry, what's the involvement, and is there good collagen to do a repair with augmentation, or do you need to then do an allograft reconstruction. And we can go over some of the cases later. I've already kind of gone over. All right.

syndesmotic injury

ligament complexity

collision sports

anatomical reduction

medial-sided knee injuries