I guess I'll have the rest of the panel come up. We'll kind of go over some cases, but as people are coming up, I had just a couple of questions for each of them, too. And if anyone in the audience has questions, we can have them as well. For Ned, you talked about the ankle instability as well as the impingement patients who may have really chronic ones. So when those patients come in the clinic, are they presenting with instability or stiffness? And how are you kind of talking to them, and how are you going to treat that? Is it going to be a scope debridement, or are you stabilizing them? Kind of how are you having that discussion with those patients? Because I think that is a fairly common thing that I'm seeing more and more of as well. Well, that's the whole thing, is trying to figure out what's the main problem and what's the goal of the patient that you're seeing. You know, one thing is if they have extensive bony impingement with ankle instability, and you do remove all the bone around the joint, so anteriorly, intramedially, down the gutters, what happens to the joint after that? I think that that's a stabilizing procedure on its own, you know, because you get a lot of arthrofibrosis and scarring in the front of the joint. So if you have a middle-aged patient who's got, you know, bony spurs, I think that's probably all I would do, you know, in that patient. But, you know, a young football player or basketball player, they often have, you know, significant impingement. I don't want to take any chances of, you know, not giving them the best treatment possible. So in that patient, I probably would favor doing the debridement for impingement and also doing a ligamentous repair at the same time. Are you assessing that after your debridement, or it's kind of their goals, and you kind of have the plan, that's what you're planning you're going to do, debridement plus destabilization? Or is it something interoperative that you're looking at? I generally plan it beforehand. I generally don't like changing plans midstream, but I've had a few cases where you go in and it's like, wow, this is really loose, in particular, the medial side. You know, so you planned a brostrom, and then you look in the joint, and it's like, hmm, is there more to this than just the lateral side? And then you look at the medial side, and, you know, they have a little bit of ebrinated medial malleolus, and, you know, it just doesn't look good on the medial side, and you can, when you do your anterior drawer, the medial side is moving as much as the lateral side, then that's the one I would just add the medial repair, you know, like Kurt talked about, at the same time as the brostrom. And then, Todd, a question for you in terms of the internal brace. When are you using that in your practice? Is it for all the patients? Is there certain patients that you're looking at, or certain things you're looking at preoperatively to help decide when to use that? So I use it in many patients. I usually have a preoperative MRI to check for cartilage injury and also perineal tendon pathology. I find MRIs to be useful for that. On the MRI, then I can get a look at how much ATFL is there, and the CFL, too, but that tends to be a little harder, so I kind of look at the ATFL and the axial T2 cuts. If there's enough tissue to repair, I'm going to do a brostrom with an internal brace. If there's nothing there, and it just looks like capsule, and there's extra fluid, and you can't see anything to repair, that's still an allograft reconstruction for me. There are some folks who have transitioned totally to just an augmented brostrom, and they trust that. But if I don't have tissue to repair, it's an allograft reconstruction. So I look for tissue. If there's enough tissue to repair, it's a brostrom with an internal brace, unless they're truly acute. Sometimes I don't use it in the truly acute patient, because I think those folks are going to heal. But if they have open FICEs, I don't use it. Or as we've alluded to, there's this sort of ring of you have some medial stuff, you have some lateral stuff. If I know I'm going to repair their deltoid, and I'm looking at their syndesmosis, and I'm doing a lot of things, and I'm not as convinced as truly ATFL and or CFL rupture, I would be less likely to use an internal brace. I have a quick question. Can I do a question? Yeah, of course. I think that has published a lot and talked a lot, at least recently, about sort of the 360-degree ring. I have trouble with the athlete that's six weeks out, had an external rotation mechanism. Maybe they hurt a little bit over their deltoid, but usually not. Their syndesmosis maybe is a little painful, and they're in clinic, I just can't, I can't, I can't run. What are you doing in clinic? And I know you alluded to a lot of those tests, but tomorrow, you go back to clinic, that shows up. What are you doing in clinic to figure out what you want to fix? And then you have an MRI already, or no? You have an MRI. The deltoid looks fine. There's a little bit of fluid in the syndesmosis, but no obvious widening on that non-stressed image. Yeah, and so, I mean, and I think Ned alluded to this a little bit. The idea that, especially with the syndesmosis, that you're going to see something on an X-ray is not impossible, but it's rare, and the idea that, similar to a Liz Frank, that you're going to get a patient that can tolerate you really, really getting after that external rotation stress and not try to protect, or equally of importance, I think the specificity when we see widening, you see widening on an X-ray, it is what it is, but the sensitivity of it, you know, you can be subtly off rotationally and completely miss what you're trying to look for. So, getting back to your question, you know, I think it depends on what the MRI shows. I think it depends upon what degree of tenderness do they still have. Do they still have tenderness four centimeters, six centimeters up? Do they still have pain at the syndesmosis with a mid-tip-fip squeeze? Do they still have a positive external rotation stress? You know, a lot of those things will, you know, as you start to educate the patient, and certainly with these collegiate athletes, examiner athletes, it's not just going to be the patient. It's going to be their family. It's going to be their kind of handlers, and you've got to have everybody on the same page, That's one where I'm going to have a lot more concern about, is there something seeing us that we're not seeing, and do we need to look in on this? I think the other thing we mentioned, I think when they can tolerate it, that supramolecular tape test can help a ton, because if they can tolerate that, and all of a sudden they can't do a single limb heel rise, and they can then, that's a very different thing. Now if they, you know, if you didn't, if they simply couldn't get up on their toes, but all those other stress tests were negative, then that's a situation where an ultrasound guided FHL injection, they may just have a little bit of residual FHL symptoms that just need to resolve, that can resolve simply with an injection, but certainly I'd like to defer to Ned, because he's spent a lot more time than I've even considered about this, about how to manage these. No, and I, you know, Tommy, I think that's a common question, and again, I think it depends on the gravity of the situation, and Kirk alluded to that, if you have, you know, one of our starting key players on the team gets a high ankle sprain, and, you know, a few days have gone by, and there's really no resolution or any demonstration that they're getting better, and they've had an MRI, they've had, you know, some element of syndesmotic injury, personally, I think the only way you can tell for sure is to do an arthroscopic evaluation. So I think in those cases, I, you know, I speak to the coach, I speak to the athlete's family, I say, look, we can continue non-operative treatment and continue rehab, it might be two weeks, it might be three weeks, it might be four weeks, and we're continually, you know, evaluating, waiting, and then we might be doing this surgery in four or six weeks. I just say, well, why don't we just do it right now, take a look at it. If it looks stable, we can progress with rehab without, you know, any worries. If it looks like it needs a little bit of help, we can stabilize it and then progress the rehab as quickly as, you know, and put in a, you know, suture button and, or, you know, maybe, you know, maybe you're doing something different now. I don't know, Kirk, I was going to ask you, is there a place to just do an internal brace of the AITFL only? I think there can be, I think the issue becomes, in order to get that internal brace over the AITFL, that's a decent amount of dissection. So the idea that you're going to do that and then all of a sudden you're going to have somebody snapping back in two weeks, that's probably unrealistic. But certainly we can do it. The problem becomes, though, if you look at the studies and what's the majority of the stabilization, if you have enough of a disruption of the syndesmosis to where, you know, it's not simply just AITFL, which is what the internal brace is only going to do. Most likely something that you're going to operate on is going to have some element of posterior and if you do an AITFL repair alone without the tightrope, I worry that you're not completing the ring of stability as it relates to the fibula and you're certainly not fixing 55, 60% of what you need to fix. Well, I found that interesting because both of you, it's a little difficult still, right? You know, and I think that's what's hard about syndesmotic injuries because we all see some high-level athletes who have a lot of resources, but we also see some high school kids who don't have a lot of resources, right? And so doing a surgery to check it out, right, and that's what Bob has always said, Dr. Anderson, and that's great if they have the resources, but sometimes we're stuck in those situations and I think we still need to figure that out a little bit. I was wondering if weight-bearing CT was playing into that yet. I don't have one and so I'm not using it yet. Perhaps there is some, you know, Cesar Neto looks like he's looking at that. We'll see, but that's hard and I think the NFL guys who you deal with a lot because I'll see sometimes a second opinion and they'll say, well, how do we know, right? Can we just get a weight-bearing CT? Can we do something? So it's hard. I find the syndesmosis to be hard. So there's still a little gestalt, it sounds like, in both of your clinics, which makes me feel better anyway. Yeah. Brian, can you ask the group about arthroscopic stabilization? Yeah, I was going to ask you that, see if anyone else is using it or thinking about using it or how you guys are incorporating it in your practice. I've talked about it in an older patient where I worry about wound healing, not like 80s, but, you know, older. I've done it in the lab. I've not pulled the trigger on it just yet. Yeah. I mean, in complete disclosure, I have not. Because for me, the idea is twofold. One, well, so one, compared to Ned, I'm not facile in tendinoscopy or tenoscopy, however we pronounce it, to be able to understand what perineal pathology is there that the MRI missed. And so I want to be able to at least get in that sheath and I would say eight out of ten, nine out of ten times, there's an element of inflammatory tenosynovitis that I want to get out. So that's the first thing. The second thing for me, the idea that I'm going to do this repair and I, maybe I'm drinking the Kool-Aid too much, but I augment all these, not because I feel that their degree of instability mandates it. The fact that they're unstable is why I'm there. For me, it's a rehab thing because I want this thing moving ASAP and I do not want it to stretch out. Whether it's the Achilles, whether it's the ATFL, whether it's the patellar tendon, whether it's, the death knell of any of these is pathologic elongation within the period of time while it's trying to heal. And so I want them moving to keep everything going so that they can get back fast and I want them weight bearing and I just don't want it to elongate. So I still open. Ned? Yeah, me too. That's why I have a, you know, a more facile, adept, younger partner doing the arthroscopic. No, I think it's something that's definitely an evolution. There's a lot of people doing it and there's a lot of people doing it in athletes, you know, in Europe and, you know, we have a few North Americans doing it, which I have the same concerns. You know, I want to have a nice, warm feeling at the end of surgery that this is done, nothing else needed to be done, there's nothing going through my mind. You know, we've, you know, used all the tissue, we've stabilized everything, we've looked at the perineal tendons and, you know, and so I think what you do in an open surgery, I don't think we're quite there yet with the arthroscopic one, you know, so if you're using anchors on the fibula for the ATFL, for the CFL, you know, you put the anchors in, you put those, you know, sutures through those and you augment those with, you know, with the extensive retinaculum and then you augment that with an internal, I mean, we're not doing all that with arthroscopic treatment, are we, Brian? No, I mean, so there are techniques to, there are some newer guides that you can do an internal brace arthroscopically with an incision more distal. So there are techniques, I have not personally done that, I've, you know, done it in the lab, but yeah, I mean, I think all those questions you mentioned are very valid and I think we're still understanding it and so. My opinion is similar to Ned's, I think you're going to make someone tighter and there may be some high level athletes who don't need to be really perfect to perform, right? I think we've all learned that about our athletes. These guys are going to, and gals are going to perform sort of regardless, right? You know, and if you can get them a lot better, but I agree, you're not doing nearly as many things arthroscopically. It's, it's, I do a lot of foot and ankle surgery, I do mostly, I do all foot and ankle surgery. So you know, there's this arthroscopic or excuse me, minimally invasive chylectomy trend to where you kind of stick this new MIS burr in there and knock the spur off the big toe. I feel sort of the same way. There's a lot of things I do in a chylectomy, taking the bone spur off, looking at the cartilage, evaluating the ligaments that you can't do in an MIS fashion with just x-ray and I feel sort of like that about arthroscopy. But I think it's, it'll get there, I think, eventually. I think, you know, as you mentioned Ned, about the functional, like static versus dynamic. So a lot of these high level athletes have a lot of resources, they didn't get a lot of rehab early, got a lot of work and maybe some, maybe some of that dynamic portion can compensate for maybe a little bit less of the static component to it. What about the audience? Any, I mean, we've done a lot of talking, anything, any questions from you all before we get into cases? Not putting anybody on the spot, but just want to make sure we're not up here having a four person conversation. Are people doing arthroscopy for their stabilizations or doing a lot of ankle arthroscopy? Or better yet, how many people, when they see an ankle fracture, are scoping their ankle fractures? I do some. I still don't do all. No, I get it. I mean, we're not talking about like a trimal that's a fracture dislocation, the whole thing's blown up. Is that a question? Yeah. From a rehab perspective, have you guys seen a lot of your therapists use drag angling for acute ankle injuries or post-op care? I, I mean, I don't personally think that I've had that, done that, but. Yeah, I mean, I, we work with our therapists really closely and our athletic trainers. So for where we work, we have three physical therapists that are part of our athletic training group, take care of all our teams and, and they're all trained in dry needling. And you know, I think, I think it's just kind of a form of acupuncture. You know, I think you can use it for swelling, you know, for nerve, nerve pain control and just, you know, getting things comfortable. I think it's, it's good. I think most people use it and we use it for chronic tendinopathies, you know Achilles tendon, patellar tendon, you know, plantar fascia, stuff like that. But we, we tend to use it at our place for helping as a rehab modality and reducing pain and swelling. When, when do you use it? Yeah, similar issues with the college team we work with. So we've been seeing a trend that dry needling is helping the swelling go down a little faster. So just wanted to see if you guys thought the same thing or. One thing, we use it some in Vail, but I will say my therapists are very excited about BFR and blood flow restriction therapy and using it quite a bit and really are, are excited. And you know, the concept being that you can kind of get some muscle, you know, some lactic acid buildup without loading the joint in that early phase. And so that, that they are excited about and we've seen some good results with as well if you have people with that. Yeah. I mean, I think some, some key highlights just because I was running out of time with mine, but you know, early immobilization, even if it's just for two to three days, but getting them fully weight bearing sooner rather than being in a brace and limping around on crutches for a week. I think those things are huge. Appreciations when you have medial sided or syndesmotic things of once again, these flat boots, adding an insert to the boot to help support that medial side, I think is incredibly important. Third, devices kind of like the Firefly, you know, things that we're trying to use to try to get just this low grade kind of muscle stem that's trying to help promote edema, you know, movement. I think we do that. We do that quite a bit, at least with the teams I'm involved with and then also compression. So a lot of compression socks, whether it's initially tuba grip stocking initially that then we either move to a true formal compression, that the more edema we can control, particularly retromolearly, retromolearly, medially and laterally, it's going to get those tendons firing faster. And there are some braces even out there that do that. So those are the keys for, for us, for me. Yeah. I had a question. So what do we see arthroscopically? Like why would I scope? Yeah. You know, it's certainly in the high level athlete, I think the key is what's the state of the union, what's seeing us that we're not seeing. So it's the chondral injury as far as that. But more so than that, whether it's that Lou article that we referenced, the idea that is it simply just a lateral malleolar fracture or what's the syndesmotic involvement? What's the deltoid involvement? For me, I'm scoping to understand what the spectrum of injury is, realizing that unless it's a high level athlete, I'm not getting an MRI preoperatively, I have an x-ray. What I need to understand is the syndesmosis involved. And what I have found at least is that it's involved a whole lot more than I would expect. And then if I don't stabilize it and I want to weight bear this person quickly in their boot with their fracture at three to four weeks, if I haven't stabilized it, it's going to compromise the structure and that there's more deltoid than we would appreciate. So that's what I'm looking for. So to you guys and also the group, what I see a lot is a distal fibula fracture with displacement, maybe medial clear space widening, maybe not. And I'm still trying to figure out the optimal treatment. I think if the fibula broke, you have either a deltoid ligament injury or a syndesmotic injury or often both. And then how much do I need to fix? Because I went on in an unacademic fashion, unfortunately, I started opening all the deltoids and looking at them. And I did it for a little while and most of them were torn. And then I found one or two that appeared untorn. And then I was looking at it on the medial side and that wasn't very appealing. So do you ever just played, I guess question number one is, do you ever just plate the fibula and then stress it again? Because the trauma guys would do that. Or do you say, I know the fibula is broken. So something else to get into that position, to push the fibula out the back with external rotation of the foot. Something else happened here. And so I'm going to treat something else. So I guess I'll start with an easy question. Do you ever just plate the fibula? And I would ask you guys and perhaps Brian as well. Yeah. Did you want to answer? I'm going to tell you, I can't remember the last time I ever just plated the fibula because there's always a level of syndesmotic involvement and I want to get them weight bearing on it as soon as possible. So even if it's just one simple tight rope, I am putting that in with most of these, what we would classify as simple SCR injuries because there's a whole lot more than meets the eye with it. But for me, as far as the deltoid, I do not think the deltoid is always involved enough to a degree to where you have to go in and do that medial brostrom. Now if you go in and you can drive through medially or you go in with a probe and you can follow all the way around the tip of the anterior colliculus, that's a problem and that's an avulsion and that needs to be addressed. But that is not- That might heal. You even alluded to that. So if you can stabilize the ankle and you plate the fibula and you fix the syndesmosis and it's not going to widen, it's now a normal mortis, that deltoid might be okay. I think- Within deltoid. Agreed. I think if you can drive around the anterior colliculus, that's the tibial spring and tibial navicular that need to be fixed. If you cannot and there's clear intact fibers running from that anterior colliculus down to the medial talus, I do not think you need to go and open every single one of those. Ned, what are your thoughts? Well, I don't think there's anything wrong with plating the fibula and then stressing the ankle. So what do you do for an undisplaced low fibular fracture? If it's undisplaced? Maybe they just need a boot. Well, I'm going to stress that. It's a great clinic, so we'll get to that. But I'm just saying, so they broke their fibula. So did they injure the other structures that you talked about? Correct. They got into some position that broke their fibula. Now it recoiled, right? And it went back. But yes, at some point there was some significant injury. So I mean, that needs to be immobilized for a little while, at least in a boot, because something happened, right? To get them into that position to break the fibula. But those are the hard parts. I know, but I'm just, the point I'm bringing that up is if you believe that with every fibular fracture, they've had additional injury, so then even an undisplaced one, you need to fix and fix everything. Yeah, I would say I don't do that. I would get a stress x-ray on any fibular fracture that's not like an injury. No, I think it's a spectrum. And again, I think that's why I don't think it's wrong to, if you have a displaced fibular fracture, you have indications for surgery, you fix it. Like I would scope it first of all, you know, to check everything and then fix the fibula and then stressing it. I don't think there's anything wrong with that. And if you don't get any opening on the medial side or any valgus tilt, I wouldn't do the deltoid. Agreed. But I think your point about doing the tie rope, I think is a good point. Yeah, and are you guys okay with the suspensory fixation device? I use one. So there's, Dr. Klant did a study that two is more, is more appropriately strength, has more appropriate strength than one, but I still use one because I think there's some healing that happens. That was a time zero kind of study. Yeah, absolutely. You look like a two guy and a plate. Well, I am. So once again, I think it determines, it's if there was a fracture to the malleolus, the lateral malleolus, and that's a syndesmotic injury associated with lateral malleolar fracture when it's distal is a one for me. And it's put the button right in the middle, like Mike Gardner talked about, where if you look one centimeter up on your true lateral view, the center of the incisura is halfway between the anterior cortex of the tibia, anterior cortex of the fibula. Put it right in the middle. That will reduce you and hold you anatomic. The two is when it's pure ligamentous injury or it's a length stable proximal fibular fracture and you need more rotational control. It's either that or you can do one and you can do an AITFL suture tape kind of augmentation internal brace. Yeah, I think the AITFLs, I like the internal brace for AITFL, which I think Ned was alluding to because there isn't a lot of tissue to repair. It's kind of this wispy thing. Okay, last question, then I'll be quiet. Sorry, go ahead. I have had two in the last two months isolated what I think is a PITFL injury on MRI imaging can't do the things they want to do. One was a skier who kind of like got caught and I think, you know, it's hard to, it's kind of an internal rotation mechanism. And the other one was like a jump off a wall. And so I fixed those. Have you ever seen that? I didn't, I wasn't quite sure what to do, but I fixed it. No, I think you did the right thing. I don't think it's a very common injury. I must say, I've not just seen isolated posterior injury, but, you know, skiers have also been described as having a, you know, a posterior, isolated posterior malleolar injury just because of their position and where they're getting, you know, so it may be a similar type of mechanism. Curious, how'd you fix it? So one, there was some bony fragments. So I took the bony fragments out, which is sort of like that posterior mal injury. So I took that out, anchored it, and then I used an internal brace construct. The other one, I just kind of squeezed it, and it was like a little bouncy. And then I put PRP in it because it was more acute, and I used an internal brace. I don't know if that was right. Internal brace, you're talking about for the PITFL? Yeah, I put it into the tibia and into the fibula. Posteriorly? Yeah. Yeah. I don't know. I went between peroneals and- Yeah, so you did a posterior. Yeah, I do it, I do that a lot. You alluded to the fact, you know, like I do it a lot. Yeah, and so you went prone, scoped posterior. I didn't scope it. Okay. I didn't scope it. Yeah, yeah. Oh, it's hard to see from back there. No, no. Yeah, yeah. So I went prone. Interesting. Yeah, yeah. Interesting cases. That's why I brought it up. No, no. We do want to get into cases, but are there any questions from the audience? Anything? So, okay. So we'll just get a couple quick cases here. So this is one of my cases. 17-year-old male soccer player, ankle injury four weeks prior to visiting and seeing me. He had this when he was jumping down seven stairs and laying on his foot, inverted injury. Said he heard a loud pop. He's had one prior ankle sprain just in the last couple months, in the past year. He has been wearing his boot, trying to for the last four weeks. Describes him having some grinding, uncomfortable with it. He's heading to college in two weeks. His parent, he's going to be playing club soccer, not the one college, but club. His mom and parents are anxious about trying to get something done. What are you guys telling these patients? Start with Tommy. I would check his SPR. I want to make sure that he didn't fire violently and dislocate his perineal tendons because you can get fooled when the fellow tells you the story. And you go, oh yeah, it's not really me. So I would check an SPR. I'd probably get an MRI to see if there's any cartilage injury. At four weeks, I'm not really, I mean, you're kind of halfway through your non-operative protocol. So I would probably give him a little, I'd get an MRI, try to give him a little bit more time and fix it at the Christmas break. So ordering MRI right now, are you waiting for some concerns? No, I would do it now. Well, I'm sitting and looking at your next slide. So yeah, I mean, I'd get the MRI. If they're anxious, we need more information. You know, the fact that he'd had one sprain prior, I mean, I think a physical exam, I would obviously be curious about to know kind of what's the degree of asymmetric instability, or is it symmetric? Are they still significantly swollen? If they're still significantly swollen at four weeks, I'm certainly a little bit more concerned that there may be more than meets the eye. And then what therapy have they done? Because four weeks without any therapy is not like four weeks, it's almost like one to two weeks for me. Whereas four weeks where they've been doing some diligent stuff to try to get it better and it's not getting better is a very different scenario. So he had not had therapy yet. He did have a lot of bruising. You can still have some significant amount of swelling on that side. So in that case, I don't think an MRI just to get more data is unreasonable, but I would not be automatically jumping to something surgical. Ned? Yeah, I'd do a full evaluation, I think to make the mom happy and the athlete happy. So I think an MRI definitely, and I think all the comments were made were good. And it depends. If he has something on the MRI other than lateral ligamentous sprain, then that's a different story, so. So that is what I did. These are his x-rays, which we didn't see anything significant. We got the MRI. We started, we went from the boot, started his physical therapy, and got the MRI at the same time. The images are show up here, but mom calls two weeks into the rehab reporting that no progress, really sharp pain when he tries to really weight bear without the boot on. Sorry. And then after that call, we get this? Yeah. Well, he had scheduled it, but hadn't gotten it yet. So this is his MRI. No gross chondral injuries. Injuries, he's still got hematoma there as well. But nothing super crazy that stands out. But really having difficulty weight bearing, feeling the grinding. Now you're at six weeks? Yeah, closer to six weeks, six, seven weeks. What do you mean grinding? That's what he described. It's exactly how he described it. He said he feels something's grinding in there. Grinding posterolateral, because he's feeling like- He points to his anterior joint line. So he said that's really limiting him from doing PT. Anyways, again, I think from the beginning, you didn't do what the mom wanted. She's upset that you didn't get the MRI at the beginning. Right? We ordered it. It just took a while for them to get it. Two weeks? Took a while, yeah. And then to come back to clinic and stuff like that. Sounds like Canada. Canada, probably a couple of months, right? Yeah. I mean, I think you talked to them. I wouldn't mind getting that hematoma out of there and scoping it and put a couple of sutures in it. It doesn't, I don't think it's going to matter much one way or another. It could probably do well with either. So he's done adequate rehab now? I don't think he'd be, he hasn't been able to participate in rehab because of the, there's so much wafer. There's a wafer in the boot, right? Or coming out- Coming out of the boot. Well, anyways, I, you know, it's a common scenario, right? I think you have to come to peace with the family and, you know, like, I don't think you need to do everything a patient wants if you don't think it's the right thing to do. Like, if you think this is going to get better with non-operative treatment, conservative treatment, you need to use your, you know, clinical acumen and wisdom and convince the mom that this is the way to do it and that it's going to get better. And I mean, I think it's wrong to just go ahead and do surgery because they want surgery at six weeks. Yeah, I think the key here is what's been the evolution of the exam. What's the asymmetry or symmetry? Is there significant, you know, is this a spectrum where it's the lateral hinge but now it's becoming the medial hinge and you're starting to get more global instability? Based upon that MRI, I do not think it's significant medial-sided instability because I just don't see the avulsion edema. The superficial deltoid looks okay. The deep always kind of looks a little bit heterogeneous like that. This is one where if there's a significant amount of posterior, and I examine them for this, lot of pain with FHL firing, this is one where not unlike the syndesmotic stuff, I would consider an ultrasound-guided injection into the back to relieve their FHL. So if they're walking abnormally because they can't get on their toe, that helps to proceed them through the physical therapy they otherwise need. Because unless this thing's grossly unstable, I still think that this, based upon what I'm seeing, should do okay with non-operative management. All right, what'd you do, Brian? So- So I brought this up because it is a common scenario where patients are pushing for things. The thing that got me worried was that they're grinding in that anterior joint-line pain. I wanted to make sure it wasn't something I was missing. So I scoped, okay, with the plans of... And what there was was actually, we were scoping. This is the hematoma as we came in. Everything looked normal otherwise. In the medial gutter, this is what we saw peeking out. I had one of my trainees was scoping and it was kind of going through kind of quick. I was like, wait, what is that? And we went in there and it was a loose body. Sure. So this came from off the distal tibia, off the anterior portion. But I bring this case up because I think it's important to highlight why it's important to do arthroscopy at a time of surgery. So MRI was negative. He's not that far out from his injury. So I think it would be totally reasonable to do a conservative management, as everyone said. Continue that, discuss with the family that most of these get better and et cetera, et cetera. But what got me was the grinding, that's saying how you couldn't even weight bear, and after a couple of weeks. So that's what we found. So then we did stabilize his ankles. We got some hematoma out and we stabilized him while we were there. So even though it was from medial, didn't need to do anything medially other than just debris? Other than debris and take that out. Was there an impingement lesion that I didn't see on that lateral x-ray there? No, there wasn't. The fragment came off of the distal tibia, right up in here. So good work. Good job. Absolutely. Any other thoughts from the audience? We've got maybe time for one more case or. Kurt, this is your case. If you want to come up, we don't have your slides. I think MRI, and Dr. Amendola may know, I think MRIs are three millimeter slices, right? So you can miss some things. Dr. Clinton always used to discuss that with patients and say, well, you know, if you were rationalizing why you were into the scope, sometimes you can miss things that are small. You know, if it's a four millimeter, you're only catching a very, you know, if it's a four millimeter loose body, you only caught very the, you know, tiny little bit of it and it didn't look like much, so. No, but again, be the devil's advocate. I think that's a great job, Brian, but how many patients have a loose body that big in the ankle that functioned perfectly fine without any problems? Perfect. Like a lot. So, you know, like, you know, I think it's, again, I think you're right. I think six weeks or two weeks or four weeks, if they're not progressing and there's something wrong, then you got to do something. Yep. So. All right, so this is Curtis Gates, 18-year-old male collegiate pitcher, twisting his injury to the left ankle after a cleat was caught on the base. Started a conservative treatment. Progressive attempt to return to play, able to perform some linear base movements, but difficulty with explosive push-off jumps or twisting movements. Presented as a second opinion eight weeks from his initial injury. Any other things you want to add for the history? No, I don't think so. Okay. No obvious standing malalignment. Pain with attempted single leg heel rise on the left. Secondary, subjective deep posterior interlateral ankle pain. Tender over the syndesmosis, setting up to four centimeters in approximate joint line. Pain of external rotation stress test. No ATFL or CFL laxity. So I think the key here is that, I mean, you're a long way along and you've still got all these positive issues. So, you know, they've been trying to manage it. We can go to the next one, Brian. But, you know, you can do that syndesmotic tape test. You know, you're far enough out to where you don't have the same degree of swelling. And if all of a sudden that fixes their inability to do that single limb heel rise, I mean, they're not going to tolerate that for more than two to three minutes. Like their foot starts to get pretty congested and they don't like that feeling. But in a very short period of time, you can get an answer to a subacute. And I think the paper by Dr. Amendola was fantastic for that. So I have used this. Not routinely, but in the subacutes. Go ahead and go to the next one. Yeah, I guess, Ned, you wrote this paper on this. Is there certain ways you like to tape around, like what techniques do you recommend how to use this in the clinic and when to use it? Well, I think Kirk has outlined it perfectly. It's in the subacute situation. There's not a lot of swelling and the patient can tolerate it. And usually the anterior syndesmotic area is disruptive. You know, the anterior tib-fib ligament. So I think you should try and tape from posterior to anterior. So start on the fibula, stick it on the back of the fibula, and then come anteriorly and come around in that direction. So it brings the fibula anteriorly and compresses it. And I think the key thing is the patient tells you. After you get them to go on their heels and do a toe-to-toe walk, say, wow, that's really good. You know, like they tell you that it's better. And so when you say, well, that's what the purpose of the surgery is, is to allow you to do that, I guess the patient is in agreement. Yeah, I think that's what, I remember the way you taught me in clinic how exactly how to tape it. I think that's important to keep in mind. And for a male, if they're hairy, just a technical point, try to get some like four-by-fours. Or if you got some pre-wrap good, don't put the tape right on. Otherwise it's like. Putting it on's not a problem. It's getting it off. Well, yeah. Yeah, you're out of the room by then, right? Yeah. Yeah. But the key here is just how benign the x-rays look. Yeah. So don't be fooled by the fact that things look completely normal. And don't think that with an awake patient, even if you tried to stress them, that either one, they'll tolerate it enough to not fight you, or two, that it'll be specific enough, or excuse me, sensitive enough to pick it up. Go ahead and go to the next one. So that's all. And you can see this medial malleolar edema. This is more a vulsive edema. And it can be stress. It's not because the whole thing has to be pulled off, but it's just a clue. It's a sign to where there was stress there. Not that it was pulled off, but you got to have a higher index of suspicion when you're seeing that, because that's not the precursor of a medial malleolar stretch fracture, although you got to at least be wondering about those kind of things. Do you see that a lot? I don't know that I've ever noticed. A vulsive edema? Yeah. Absolutely. Huh. All right. And I will see it on lateral ligaments that I'm getting for pre-op planning, because I want to know tendon-wise, and it's this spectrum of pathology. Because what happens is, and I remember with my own ankles playing ball, when I twisted them, I stopped hurting laterally, because scar doesn't hurt, doesn't swell as much, but I started hurting medially because I was so loose lateral that I was starting to hinge and corkscrew around the medial side. And so that's where we need to understand this as a spectrum of pathology. Not that all of them that are along that spectrum also need the medial, but you just got to at least be looking for it and understanding it, and realizing that a lot of times when you're seeing this medial stuff, if you stabilize the hinge laterally, all of a sudden you'll take the stress off the medial side. For a second, I'm just going to go into what you did. Yeah, so just basically seeing, and it looks subacute now, so it's more of this kind of rustic look, because it's not within the first two weeks. But you see this kind of bronze or rustic hue, so we're just going in and cleaning that up, appreciating that you can easily get into the syndesmosis with a four millimeter probe slash shaver. This is looking medial, nothing's getting pulled off. There's not a medial, intramedial rotatory stress. Go ahead. See, I keep going. But this, the problem is, is that this is, you're actually seeing a portion of the FHL in the back here. You know, so this is not insignificant. Keep going. And so that's what that buttress plate looks like. Yep. So, anyways. Nice. Now, you're going to place those suspensory fixation devices, but there is no direct repair of the... The ICFL? Yeah. Or anything else? I don't routinely. Okay. Now, if it's a big, huge avulsion and it's associated with a fracture, and like you mentioned, can you ever really directly repair that? No, but you can, especially if there's a small little, you know, Wagstaff tubercle avulsion or something else, you can come over the top of that and stabilize it with an internal brace. So, yeah. Anyhow. Any other questions or thoughts? Yes, ma'am. Yeah. How do you evaluate the syncytic reduction per operative day? Yeah, let's, I mean, I think we should... Sorry, what was the question? How do you evaluate your reduction? How do you know that you're anatomic when you reduce your syndesmosis? Like, do you use a clamp? Do you look at it open? Well, I think in this case, I think it's hard to mal-reduce this type of case, you know, because it's reduced already. These are like micro-instabilities, you know? They're not macro-instabilities. So, even if you put the buttons in a, you know, the angle of the button is not ideal, I don't think you can really mal-reduce it. And the buttons have a little bit of play, so it allows you to, you know, maintain the normal reduction. I think in the grossly unstable ones where the fibula is moving, I think that is a problem. And we published a couple of papers from Iowa looking at mal-reduction for syndesmotic injuries and the clamp placement. And, you know, the tendency is that if you don't put, you know, it should be almost like a 30 to 45 degree angle anteriorly from the posterior aspect of the lateral malleolus if you're gonna use a clamp. And I think in those cases, I use a clamp, you know? But again, I think the soft fixation with suture buttons gives you a little bit of leeway to avoid mal-reduction. I think if the clamp is directly lateral medial, the fibula tends to sublux posteriorly. And then you put screws in, it tends to sit posteriorly and it's mal-reduced until you take the screws out. And then it comes back forward, so I don't know. And I think one other coaching point about the buttons is you're always dropping your hand more than you, I think for me to get it into the right position in the central tibia or the anterior tibia, you really need to be dropping your hand. And that's, I think, the coaching point with the trainees and everybody is just keep dropping your hand because you want to get it. It's hard to get as far as you did on some of your images. It can be, yeah. And I mean, you know, so at least if you're using the tightrope, I don't know the other devices, but, you know, they come with the guide wires. And so I will put the guide wires through and I always open medially. I have revised a couple of folks in the city where they didn't open medially. And that button, whether it's direct kind of, you know, capture or it's indirect because the saphenous nerve adhered to it. If you don't go and open and you create that little subperiosteal window to get that button down, I worry about the saphenous nerve. The other thing I do with that open is that I'll get the wire across and then I put a little hemostat right up against the bone. And then I get a true lateral view. Because especially if I'm just doing one, I want to get that true lateral view and I want to see where I'm coming across is sitting halfway between that anterior cortex tibia, anterior cortex fibula. And then I know as I use the rope, it's reducing me into the incisura. So that's what I do. All right, I think we're already past our time. I think the general session starts in six minutes, but are there any other questions that people have? We got through a couple of cases. We have more, but, you know, just want to get you guys to the general session, so. Thank you all for coming. Thank you.

ankle injuries

treatment

ankle instability

stiffness

scope debridement

stabilization

ankle impingement

chronic pain