Welcome everybody to the multi-institutional Sports Medicine Fellows Conference. Please keep your microphones muted though. There'll be opportunity to ask questions. We're very fortunate to have Dr. Ned Amendola, past president of the AOSSM and professor of orthopedic surgery and director of sports medicine at Duke and chief medical officer of Duke Athletics and known to everybody for his expertise in particularly lower extremity injuries. And he's gonna, a little bit different format today, talk about sinusmosis injuries in athletes first and then we can take some questions and then to talk about Liz Frank's injuries. Again, this is being recorded and it will be transferred to the AOSSM learning management system, the playbook, if you will. At the end of this week on Friday, it'll be transferred over, so it should be available next week if you wanna hear it again or wanna let some of your friends and some of the other programs know about it. Again, submit your questions on the chat function and we'll get the questions to Dr. Amendola and if the faculty wanna also chime in, please chime in. For those of you that are, because there are some names on here, people that I know we've met in the interview process, hopefully the match went well for you all today and for the faculty, hope the matches went well for all the faculty as well. So without further ado, a man who needs no introduction, somebody that Coach K is too intimidated to ask to talk on his SiriusXM show, Ned Amendola. Okay, Mark. Thanks for the introduction and thank you for organizing these lectures. I think this is one of the bright spots during this COVID thing is I think we're continuing our education and continuing to do some good things and hopefully this will continue on even after COVID in terms of education and spreading the word. So I'm happy to participate. I was gonna talk about two problems, syndesmotic sprains and Lisfranc sprains in athletes, which I think are two common problems that we all deal with as team physicians. And so I would just kind of share my experience and dealing with these injuries and open for any questions. Anything is questionable that I present. So, first of all, I am a consultant for Arthrex and I've developed some products, but I have not developed anything with respect to the syndesmosis and just wanna make it clear that I don't get anything for, and I think the tight rope, again, just to be frank is an Arthrex product. And obviously I just wanna make sure that I'm not trying to be conflicted in this presentation. So anyways, I'd start with this. This was a couple of years ago in the AFC Championship game where Gronkowski had a syndesmotic injury there. You see him getting up, he can't weight bear. So here's the play and makes the catch and gets tackled. And this really demonstrates the mechanism of injury. You can see the external rotation. There you can see his foot and ankle going in that position. So the deltoid and the syndesmotic ligaments were injured. And if you remember, it was the AFC Championship game and he did not practice and then he tried to play in the game and really was unable to function. He went in for the first play, came out and was not able to participate. And that was the question at the time. That was a few years ago. Should he have had surgery right off the bat? Would that give him a chance to play? Which brings me to this event that happened last year. And I think the fixation of syndesmotic injuries got a lot of attention. I think Alabama became the institution that knew the most about syndesmotic injuries, as you can see here, and it was on TV and it was before the championship game and how to fix those. And he made it back on the field. And so, I think we've been dealing with syndesmotic injuries a lot longer before then. And so that's what I'm gonna talk a bit about is what we know and how we deal with these injuries. And I'm not sure we know everything yet. And so it's a common injury. It's often misdiagnosed. And the misdiagnosis is, is not appreciating the severity of the injury. And so often it's diagnosed as a mild injury and then it prolongs and takes a long time to recover. And we don't really have a great way to tell exactly how severe it is. And just to go over the anatomy of the injury, the ankle and the syndesmosis, which I think is important to understand. So, you know, you have the, you know, it's a very strong and stable joint, you know, with basically the deltoid and you hear the, so do you guys see my arrow there where I'm pointing? Yeah, Ned, we can see the arrow. Okay. So, just, you know, I want everybody to understand the proximity of everything. So here the fibula has been removed where the green arrow is. And you can see the anterior inferior tibiofibular ligament, the anterior talofibular ligament, you can see they're very close together. So it's very common to have an injury to the ATFL and some injury to the AITFL. So sometimes it's a little bit confusing if you have an inversion sprain and there's a little bit of a syndesmotic component. And the anterior inferior tibiofibular ligament is a lot smaller and weaker than the posterior inferior tibiofibular ligament. So you can get an injury to the anterior one and the posterior one, as you can see here, it's a very stout, wide ligament. If that's intact, it'll maintain stability and it won't allow widening of the syndesmosis. And so people can still function even though they have a sprain of the anterior ligament if the posterior ligament is intact. And so it's definitely a spectrum of severity. And then in addition, the injury to the deltoid will determine the severity as well. And again, all these ligaments are visible on the MRI and we'll talk about the imaging for these. One of the things to know is the talus gets wide anteriorly as you can see here. So as you dorsiflex, the fibula has to accommodate the talus and that's a sign of a syndesmotic injury. If you dorsiflex or you're trying to get an athlete to push off, they can't do that because pushing off causes the talus to push the fibula out. And so if there's any disruption of the tibiofibular ligament, it'll cause pain. So again, it's important to know the deltoid. And again, in terms of surgical treatment, this will come up later. So you have the superficial deltoid. You can see here it's a very wide ligament off the medial malleolus. And then deep to that, here you have the superficial deltoid has been taken down. And here's the deep deltoid attaching to the talus and at the tip of the medial malleolus, which is very difficult to access surgically with an open incision. So it's hard to repair the deep deltoid, but I think it's important to understand where it is so that you can repair it anatomically if it's off the talus. And I think you can repair it almost anatomically if it's off the medial malleolus. And so again, you have this circular construct with the deltoid medially, anterior and posterior tibiofibular ligament, and then the interosseous membrane. And so you can see that you can have an injury to all these structures depending on the severity of the injury. And again, I'm trying to drive home the same point is that it's a spectrum of severity. So you can have the, this is an arthroscopic view of the tibiofibula and talus and the distal tibfib ligament here is intact. So you know that that's intact. And if that's intact, the posterior one will be intact too. Here's one where just the distal fibers of the tibfib ligament are torn, but the relationships are maintained. Here, you see it's a much more severe injury. Now you're seeing some widening between the tibia and the fibula and there's space here between these structures. And then with complete disruption, you get the translation of the talus and the fibula with respect to the tibia, as you can see here. So you can use arthroscopy to your advantage to confirm the severity of diagnosis and also confirm what you need to do surgically. And after you're done, you can confirm if it's reduced. Now, I became interested in these a long time ago. I started my practice in 1991. This was my first syndesmotic sprain that I fixed. And this was what I use as a screw, three cortices. You can see the mortise is intact, but this was a PhD investigator in the lab and she had her own lab. And she came to me after she sprained her ankle, came to me several months after saying that she had difficulty pushing off. And so she had tested herself in the gait lab before the injury. So here you have heel strike and push off. And here after the injury, she was never able to push off. So she got heel strike, but couldn't push off. So then we did surgery, we did arthroscopy and we fixed the syndesmosis with a screw. And then we took the screw out after eight weeks. And then she tested herself in the lab again. And you can see four days after screw removal, seven days after screw removal and 11 days after screw removal, you can see that now she's gone back to the way she was pre-injury. And this really kind of taught me a lot, this one particular case. And she was bright enough to, she was a volunteer for studies before the injury and then she happened to get injured and studied herself. And it really kind of explains what happens when you have a syndesmotic injury. You can't push off, you can't pivot and you can't generate force because it's not completely stable. It's not unstable that you get widening. You just have a little bit of instability. And so stabilizing that little bit of instability here with a screw or with any other type of fixation will restore that ability to generate force. So moving forward, if you look at the literature of syndesmotic injuries and return to play, and here's a number of studies, these are case series. You can see the return to play is very variable. Here's a Rick Wright and NHL hockey players, six to 137 days. This is a military study, 17 to 115 days. Nussbaum was a NCAA division athletes. And again, I think there's a little bit more modern study. The variability is not as much, but you can see that there's a variability in the diagnosis and the ability to return to sport with conservative treatment. So the point of this is if you could figure out the hockey player that took 137 days and the military people that took 100 days, you might be able to fix those quickly and prevent that amount of time off their work and return to sport. So that's the whole point. And that was the Alabama thing, that basically did early surgery. It was a mild in terms of severity, didn't have widening. However, it stabilized the amount of instability that was there and allowed the athlete to go back and play. So here's an example of that. This was an 18 year old, his last year of high school, he had a sprain in his ankle. He was able to get back and play after several weeks after the sprain, but he never got to 100%. And then when we got to Iowa his first year, he was still not 100%. And here's the initial x-rays we did when he came to Iowa as a freshman. You can see the calcification. So he had a sprain that was relatively stable. In other words, there's no widening of the mortis. So he's got two relationships here and he's tried to stabilize this ankle on his own with the calcification. You can see the CT scan. Again, the relationship is normal here, but here's his arthroscopic view. You can see the anterior ligament is disrupted and there's a little bit of widening arthroscopically. You can put this probe up there very easily. Normally it's a little bit of, you should be able to put your probe up there, but it should be a little bit more difficult than that. So his anterior ligaments were disrupted, his posterior ligaments were intact. And so this created that amount of instability that he couldn't get to 100%, but he was good enough to play up to 70 or 80%. So the question is, if this one was fixed originally, would he have done better? So we ended up cleaning this up, freshening up the injury and stabilizing it like this. And so I think in these cases, and that's what I'm talking about, is cases where you have a sprain, the X-rays are normal. Even a stress X-ray is normal. They can still have some instability. I think if the stress X-ray shows instability, it needs fixing. If the stress X-ray doesn't show any instability, what do you do with these? And so this is the point. We don't really have a perfect test to determine what to do. So you have to look at the injury mechanism. You have to look at the examination and re-examination, and you might examine them every day or every couple of days to see if they're staying the same in terms of the findings. And we'll go over the findings. You can do imaging, including an MRI, and we'll go over those. And then you look at their functional progression. So if you have an injury and it looks like it's severe, it is probably severe. You should consider maybe early stabilization in these injuries. So the typical test described in the literature, tenderness along the syndesmosis, pain with external rotation. I don't think a squeeze test is that good, and I wanted to show you this stability test using tape. And you can't do this right the same day, but after a few days, you can do that. So here's, again, the examination. This is a subacute or chronic injury. So it makes them tender. All right, so tenderness is important, and I just wanted to show you the taping. As you go from behind the fibula anteriorly and you pull the fibula anteriorly like this, and it's a very tight stabilization taping job. This is only temporary, just for a couple of minutes. And you basically do that, and then you test the athlete and see what they can do so they can push off, they can pivot, and they can do everything functionally. With the tape job, it kind of confirms that they have some mild syndesmotic instability, and you might want to stabilize that with doing an arthroscopy and stabilization. How about the imaging? Here's one of the linemen that I treated had chronic syndesmotic findings five or six weeks after an injury. Here's the MRI, shows the edema at the posterior aspect of the tibia at the attachment of the posterior syndesmotic ligament. So it doesn't have to be torn, but it shows chronic stress in that area. The anterior one is torn. You can see the anterior one is not visible. So the anterior tip of the ligament is torn, and there's stress in the posterior tip of the ligament. So this posterior tibial edema is a sign of more significant instability. Here's some x-rays in an injury at time zero. Here's some x-rays at six weeks. And when you see this calcification at the back, it usually correlates with that MRI finding that there's some stress posteriorly, stressing the posterior inferior tibial fibula ligament. Northwestern. Okay, it's got what they wanted. They got an interception from Stancy, but they could not- This was in 2009, and the quarterback got tackled. Maybe a net predictability. Lead at 10-0. Wooten with a big hit. And then just bending back down. So here's the- Trying to secure the football. Wooten make a great play. One of our impact players at the beginning of the game. Same injury as- Knocks it loose. Same injury as Gronkowski. Only three passes. A great play. One of our impact players at the beginning of the game. Got tackled. Had an external location injury. And he can't weight-barrel. So you can see there, he can't put weight on it. And his x-rays just showed, you know, it was easy decision for this one because you can see there's some instability there. But here, I just wanted to show you the MRI findings correlate with that. Here's the edema. The posterior syndesmotic ligament is intact, but there's edema there. And he obviously has some injury to the deltoid there. So we did immediate surgery. You can see the findings at arthroscopy. There's space there between the tibia and the fibula. Easy to get there. And the anterior ligament is disrupted. The posterior ligament, it's incompletely disrupted. There's a slight avulsion there. So it kind of goes along with what we were saying that the anterior one is torn, and the posterior one is avulsed. So that's why he's demonstrating some instability. So we did immediate fixation, and he ended up playing five weeks later in the Orange Bowl, and we ended up winning the Orange Bowl. Here's another case, again, to demonstrate all these things we've been talking about. This was this year at Duke. One of our linemen sprained his ankle. He's one of the tough guys on the team. We don't have too many tough guys at Duke, but he was definitely one of the guys that, you know, he played the whole game. After the game, he says, you know, I think I twisted my ankle. He had some mild findings, no medial tenderness. Did have some mild pain with stress in the ankle, but he could weight bear, and he said it wasn't that bad. So we ended up imaging him, and here's his MRI. He had normal X-rays, and basically you can see the posterior syndesmotic ligament. There was no edema on the back of the tibia. The deltoid ligament was intact, and essentially the important structures were intact. The anterior ligament looks like it was probably injured, but essentially we were pretty happy with this MRI, so we decided to treat him non-operatively. And again, so we went through the same thought process. Should we rehab and continue to play as tolerated and mobilize and treat it more like a severe injury or do early surgery? So this one, I didn't think we needed to do early surgery because I thought it was more of a mild injury. So he played five games. He was never 80 or, he was never 100%. He was playing at 80 or 90%, and then at the end of game five, he re-injured himself, and I have a video of that. After this injury, he had definitely more swelling, more tenderness, and significant pain with external rotation stress and loading the joint. So here's the injury. So here's the center right here. Again, he's blocking and he gets landed on again there and has the same similar external rotation mechanism of injury. And so we did x-rays. So we hadn't done any x-rays in five weeks, but here you see five weeks later, you see the calcification. And now he's got widening between the tibia and the fibula. He's got complete disruption of the of the stenosmosis. And now here's his MRI. And you can see now he's got basically some edema at the back, disruption of the posterior syndesmotic ligament. You can see the edema. He also has some anterior edema here. So much more severe findings. So the question in this one was, did we manage it correctly or manage it incorrectly? He got back to play and then he got re-injured at five weeks. So again, you can see the difficulty even knowing about the injury imaging, trying to make the right decision. So we ended up doing surgery after the second injury and here's the arthroscopic findings. You can see the widening between the tibia and the fibula here and the posterior syndesmotic ligament. So that's before and after reduction. You can see here it's nicely together after we fixed the syndesmosis and we fixed it with this small plate. And you can use a little plate there, but you can use two buttons. Get a little bit more protection of the fibula and compression of that syndesmotic disruption. So here he had disruption of the syndesmosis, but the deltoid ligament was intact. And six weeks post-op, you can see that he's maintained his ankle mortis, maintained the reduction, and here's back to training for the winter program before we got into this COVID thing. So again, to emphasize... Yeah, a couple questions. So in retrospect and looking back at this, and I know you and I have talked before about sometimes early, you know, particularly early surgery and getting it back faster. In retrospect with this case, you know, if you saw the same thing happening again next year, would you go in and just and try to stabilize it even though it wasn't displaced with the hopes that it might prevent this re-injury or aggravation of the injury, progression of the injury? That seems like from what you're suggesting was after when you after operating him, that was the end of the season for him even though there was probably five games left, right? Well, I think if you would have done surgery early, you know, you can rehab it like it's a stable injury. That's the whole point. I think if you have an injury where you can rehab and try and get him back without surgery, if you do the surgery and do the syndesmotic fixation, it actually makes it more stable so you can rehab them even more aggressively with the expectation that it's stable on getting back. So I think in this case, it's hard to say to answer your question. It's hard to say would I do anything different. I thought we worked him up pretty well. You know, again, we had the fellows there. I was there. The trainers are there. We're all examining and re-examining this kid and, you know, maybe he underestimated or he kind of hit his symptoms better because he's such a tough kid, wants to play NFL football and stuff like that. But, you know, he played and he didn't play it a hundred percent, but the coach they looked at, he's not that good. We should take care of his ankle. You know what I'm saying? Like I think looking at it, it's hard to say that we would have made a different decision, but that's the whole point of this presentation is that's what you should be looking for is if you can figure out that this is one case that's not going to get totally better, maybe you should intervene early. Okay. So, and there's two questions that have come up. One is, you know, do you still scope prior to cytosmotic fixation for cases with preoperative evidence of instability? All right. Knowing that there's instability there and you're operating on them, do you always scope them or not ahead of time? Yes. Yeah. So that's my last few slides is just to show you the routine that I do. Okay. All right. And the second one might also be answered. So sorry about that. Keep going. Okay. So this is just to demonstrate my approach when you do surgery. Again, it's an obvious case, but I do these for all the cases. I do arthroscopy and then fixation. So here's an obvious case that needs surgery. Okay. There's no arguing about that. This was a 17 year old high school player, no fracture, just complete deltoid and complete syndesmotic disruption. And you could say, well, why do you need to do a scope in this case? You could just fix the syndesmosis, fix the deltoid and just do, you know, without doing the arthroscopy. But here's what the arthroscopy does. So this is the arthroscopic view. This is looking at the medial malleolus. You can see the superficial deltoid is completely peeled off here. And then the deep deltoid, this is the deep deltoid is pulled off the tails. You can see there. And if you continue on, you can see the chondral, we just debrided a little bit of a chondral flap. So, you know, that's been taken care of. So if there's any chondral injury, you can take care of it at the same time. And now we're on the lateral side and this is like the drive-through sign. You can see the, you know, the tibia fibula. Here's the end of the remnant of the anterior tibiofibular ligament on the fibula and on the tibia. You see right here. So it gives you a nice understanding of the injury pattern and the severity of the injury. But here we're going to go posteriorly and look at the posterior tibiofibular ligament. And you can see that it's completely peeled off. So this is the ligament right here, this whole flap. And it's a second, we're just going to put a probe in there. There you can see it now. So you can see how stout that ligament is and it's completely peeled off the fibula right here. And you know that if you reduce the fibula anatomically, that's going to sit there nicely and that's going to heal nicely. And you saw in the last case I showed when you reduce the tibia and fibula, this is going to sit together nicely. But you can see that you can also fix that if you wanted. You could probably do some surgery here if you wanted to add an element of an anterior tibiofibular ligament surgically. And so that's the arthroscopic evaluation. Then we did the syndesmotic fixation, as you can see here. And there's no stress on the ankle. And now here's with valgus stress, you can see that the medial side opens up, which really kind of makes it clear that you should do something with the deltoid. And so we went ahead and made a small medial incision. We put an anchor in the talus and that flap of the deep deltoid ligament, we sutured with this suture anchor and kind of cinched it down to the talus and then repaired the superficial deltoid. So that's my routine for these cases is really do the scope, determine the injury pattern, reduce the syndesmosis, and then kind of see if you need to do something with the deltoid, which I generally do with a small incision. So you repair the deep deltoid and then the superficial deltoid on the medial malleolus. And I think the, just to finish this talk, so in terms of going into the future, you know, I think you're probably going to see in the future, probably, you know, more about complete syndesmotic fixation in addition to something holding it together like a tight rope or suture button, you know, probably something for the anterior tibiofibular ligament and something for the deltoid. So I think there's stuff coming out now about doing a complete fixation of these injuries to make sure that you got a complete stable ankle. So that's it for this presentation. It's syndesmotic sprains are a spectrum of severity. I think it's important to try and evaluate the severity. I don't think we're totally sure as I demonstrated there in that case, I think anatomic reduction and stabilization is most important. And then, you know, some people are talking about some additional synthetic and anatomic augmentation to improve the stability and allow early mobilization. Go ahead, questions. Yeah. So there is a question here that says, now, you know, I saw that you're scoping before you were fixing. The question was, do you actually keep the scope in the joint when you reduce it to be sure it's reduced? Or do you stick it in when you're done? Or are you just using CRM images after to make sure your reduction is okay? I usually put it in after I'm completed the fixation to confirm the reduction. And I use fluoro as well. You know, I think you should use all those things. And that's a very good question. How do you determine if the syndesmosis is reduced? And that's, you know, I think everybody knows there's been some papers lately written on malreducing the tibiofibular joint, especially with fractures, you know, fixing the fibula and then putting in syndesmotic screws and causing some subluxation. And especially when you use a clamp, you know, there's been a couple of papers from Iowa showing that if you use a clamp, you might cause some subluxation of the fibula. So I think, you know, I think you should do everything you can to determine if the fibula is reduced. One is, you know, make sure that the imaging, the fluoroscopy is intact. And then I think using arthroscopy after the case or even during the case would help you determine that too. Okay. So there's a question by Matt Fury is how often and what are your indications for addressing the deltoid? So obviously you showed when you stressed that it was still open on the medial side and how often are you having to repair that? And is there any other way that you're assessing whether or not you need to fix the deltoid? Well, it's so, you know, I've, I've evolved over my career. You know, I started my career for the first, I don't know, 15 years, not doing anything with the deltoid and thinking that if you stabilize the fibular fracture or stabilize the syndesmosis, that's all you need to do. Then we did some work at Iowa when I was there, which showed that there's definitely some stability There's definitely some stability in the, in the ankle when you don't do anything to the deltoid. So I started, you know, started, we started doing some, some research on the deltoid. We published a couple of papers on it, how to examine the deltoid and then started doing some surgery with ankle fractures. You know, the, the high fibular fractures, always the deltoid is disrupted. And if you do surgery, it's a nice sleeve. It's actually nice anatomy that you can repair. And then a few years ago, Bob Anderson, I belong to a group with Bob Anderson, takes care of a lot of NFL players, presented a case series to a small group of us, showing us the anatomy of the medial side. And so since then I've been doing it almost all the time. If the, if it's a fracture or if it's a complete disruption with deltoid disruption, I usually make a small medial incision and it's a nice, it's a nice injury pattern that's easy to repair. So I don't think it takes much long and much time to do it. And I think it kind of ensures that you, you maintain the stability of the ankle. Okay. Trey, Trey Aschner said, Dr. Mandola, thanks for a great talk. Does your management of the ankle with the Maison Neuve fracture change your surgical decision making and rehabs as you were starting to get into that? So you want to expand a little bit more for Trey? So if the fibular fracture is at, at the mid shaft or lower, I think you should fix the fibular fracture. If the fibular fractures in the proximal third, then I think you need to assess, you know, I think the exposure in the proximal third is a lot more difficult. I think in the proximal third, there's usually not much displacement of the fibula. In other words, you get a Mason Neuve, there's so much muscle in the proximal third around that. I don't think you get a lot of shortening or angulation. And I think that the fracture is far away from the joint. So I think you can just use syndesmotic fixation with a high proximal third fibular fracture. If the fibular fracture is short, even approximately, if it's short, like it's overlapping, you need to get it out to length. And I think in that situation, which I think is very, very uncommon, you would have to, you know, unhinge it or pull it distally with a towel clip to make sure that it comes out to length. I think if you leave the fibula short, even five or six millimeters short, it's hard to compress and reduce the syndesmosis. I think you'd be left with some instability there. Okay. And it's a question that comes from me and Murray. And I remember way back though, when you and I spoke about some of these injuries probably a decade or more ago, we would talk about putting in a screw, letting them back early, and then at the end of the season, or after a few months, taking out the screw before it breaks. And certainly you've shown some with screws and, you know, I know there's been work that shows that you're less, it's maybe more forgiving to use the tight rope than to use a screw, especially in the, if you got to make sure that it's an anatomic reduction. But what, are you using screws anymore? Are you pretty much going, staying with the tight ropes? Or if you're using some and then the others, when are you deciding when to use screws versus tight rope? I think you can still, yeah. So, I mean, just to go through, so if you leave, so when I was using screws, I used to take out the screws, you know, so usually six, eight, 10 weeks after putting the screws in, I would take them out with the, you know, with the thought that these screws are going to break. And I think it's been shown pretty clearly, if you leave screws in and let people go back and say, well, you know, they break, they break, you know, they'll break about 50% of the time. But that's really not the reason. I think the tibiofibular joint should have some normal mobility. And I think leaving the screws in don't allow that normal mobility. So I think taking the screws out will restore that normal tibiofibular relationship. Now, if you use tight ropes, I think it allows that, it allows that normal tibiofibular motion and that physiologic external rotation of the fibula when you dorsiflex and push off. So I think these, the tight ropes give you a little bit of flexibility. They don't need to be removed, but they provide enough stability that I don't think you need to use screws. So I have gone mostly to using tight ropes. I don't use screws. The only time, I mean, if you have a failed syndesmotic, like a failed fracture, like you get these malreduced fractures, where you have to osteotomize the fibula, bring it out to length and re-fix the syndesmosis, I will use some screws to really rigidly fix that distal portion to the tibia with the intention that you want as much stabilization as possible. Okay. Volker Muschall is now on the, is now on board with a unmuted mic. Volker, you got a question? Awesome. Thanks for unmuting me. Hey, Ned, how are you? I'm good. How are you? Nice to see you. I see you've started elective surgery back in Pittsburgh. Yeah, that's great national news, I guess. Yeah. I've sent it to all the administrators of our hospital here. Okay. But it's very interesting what people call elective these days. Obviously, I know that all of you on the phone have probably thought about what that all means, you know. By no means are we doing elective surgery, but the media loves that, of course. I'm so freaking bored in my house. But so, Ned, I have a question for you. You and I had the chance, well, I had the chance to talk with you so much over the last couple of years with the football teams playing each other. And I was always fascinated how quick some of these players can go back to play when they get the right indication and the right fixation at the right time. I was never able to do it as quick. So, obviously, unless you already answered the question, I wanted to hear tricks. What makes it quicker? And then the second question is for the draft tomorrow with Tua, what's going to fail first? Is hip or syndesmosis? That's a good question. You know, anyways, if I, you know, that's a loaded question. But anyways, I hope he does well. He's done very well, you know, hip dislocation, syndesmosis. Yeah. Yeah. And the question always is, you know, was it related? You know, were the injuries related? But the, so it's not a matter of, you know, I think tips or tricks of doing, I think it's important to understand the pathoanatomy of what the injury is. And, you know, I think the point of my presentation today was really to say, look, I think we need to look at these injuries in more detail. And even though we do and we have everything, we have examination, we have multiple people, we have experts, we have MRIs, it's still not totally clear. So the question is, what do you do? So if you have an athlete and say, I think this is a pretty severe injury, but the x-rays are normal, the stress x-rays, external rotation stress rays are normal. And you think, okay, I know this is a significant injury. I know this person is going to be out six or eight weeks. I think for that person, if everybody is in favor, including the athlete, I think you should probably take them to the operating room and do a quick scope, you know, and look in and confirm the severity of the injury. And I think if the anterior ligament is torn and there's a little bit of widening between the tibia and fibula, you can get your probe in there. I think you should put a, you know, do one tightrope. Get your equipment out and then rehab them like he's a stable injury. You know, rehab them with the expectation that he's going to get back sooner. So that takes a lot of, you know, courage to do that, you know, with an athlete to say, look, here's what I think is going on. This is what I think we should do. And we should do that. And I think they did that with the, you know, the Alabama player. And I think it worked out well. And I think that's happened in many other situations. I don't think that's the only one, but I think if you have a more severe injury where you have deltoid disruption, I don't think they're going to get back quickly. They're going to take a long time to get back. Right. Great. Thank you. So here's a question from Will Workman, learning a ton from this Dr. Amendola. Thank you. What is the significance of the syndesmotic calcification proximal to the fixation site? Is that a potentially unaddressed injury? Or is that just kind of the extent of the interosseous membrane tearing and that's why it's you got the calcification there? So if you go to the NFL combine you know they do x-rays of all these and this is one of the most common findings that they see on these players is that they have calcification between the tibia and fibula proximal to the ankle but they're functioning fine. So I think it's a reaction to a syndesmotic injury. It's not necessarily indicating that it's like the interosseous membrane is torn but it could. I think it represents some blood that's that's drifted upwards from the joint injury and that blood has stimulated some calcification in that area and so I think it's a it's an indication that a syndesmotic injury has occurred. The body is trying to fix the injury and stabilize the injury and I think sometimes it's just calcification from just the the hematoma but I think it just I don't think any conclusions could be made can be made saying that if you have calcification it's a more severe or less severe injury. I think it just indicates that an injury has occurred and and that's what the how the body has responded to it. So here's two sets of questions that are based on technique and then hopefully we'll have some time for you to do the list ranks as well as this is a I mean a great eye opening to syndesmotic injuries. So first one's Alexander Brown. Thank you for the talk. How do you determine the appropriate tension of the syndesmosis repair finger tight compression? Also what is your indication for using the plate for the cortical buttons on the tightrope? I think you can use the plate anytime. You know there's no problem with that. I think there's some there's been some concern and I think there's been a one case report of a fibular fracture through a drill hole from a one it's a four millimeter drill hole through the fibula so you're putting two four millimeter drill holes and so I generally have not been a favor you know a supporter of using a plate because I thought it made the buttons more prominent. That's when we were tying knots with the buttons. Now you don't have to tie any knots and the buttons fit flush with that little plate that two hole plate it's a it's a plate made for the two buttons and so I think it's it's very simple and it's probably a good thing to use the plate and sleep at night and not worry about a stress rise or a stress fracture through that area. I think tensioning is a good is a good question and I think that's what we need. So here I was going to show you the you know there is a a device that you can actually determine you know the direction of the clamp and the clamp force so you can actually determine how how tight you want. Some people do feel you can over tighten the syndesmosis but I feel if you if you if you have the fibula reduced within that tibial groove and it's anatomic it's hard to over compress it and so I tend to you know tighten the buttons as tight as possible you know they come with two little metal things that you can grab the sutures with so you don't cut your glove or cut your your skin and I tension it as as tight as possible. I don't think you can really over tension it. Okay so last question from Mike Pullen would love to get your thoughts on diverging the two tight ropes for different angles of pull trying to better replicate the native ligamentous structures ability to aid with reduction etc. If so how much do you diverge and which do you tighten first? So I wanted to sorry I just wanted to put up a picture here. You can see the two buttons here are diverging they're not exactly parallel so I tend to pull one angling a little bit more anteriorly and a one and one going straight lateral to medial so you can see here the top button on this lateral view the top button is more directly lateral to medial and then the the distal button is more posterolateral to more antermedial you can see here and I think that's a good idea I think to but generally I put the one the button that goes straight from the fibula to the medial side of the tibia and not and try not to do the the angled one anteriorly until the second button. Okay all right let's what can you do about this Franks and well you still want to go on or do you want to end there I mean it's it's I don't want to well there doesn't seem to be any more questions I'd be inclined to see what if you can get through some of the the highlights of the list Franks if that's okay yeah that sound okay to you Volker since you're unmuted the tool is giving the thumbs up that's a go okay two thumbs up we're good all right well this is not as long and it's it's um anyways um you know we don't have to go through all this but you know foot and ankle injuries in sports medicine one third of all sports injuries involve the foot and ankle so again you have to understand this of your team position and again every injury is a spectrum you know and again I don't have to tell you that so you need to individualize treatment this definitely goes the same for list Frank injuries and again uh same as the syndesmotic injury you know it's important to understand the pathophysiology understand stable versus unstable and really there's there's kind of a key question you have to answer with every injury um and uh for list Franks that's the question is it stable or unstable and so um it's a spectrum of severity where in sports we're dealing with the left hand side here where you have a little bit of widening and you've got disruption of list Frank's ligament between uh the medial the uh the uh medial cuneiform and the base of the second metatarsal right right across here and so again the severe injuries will let the trauma surgeons deal with that but you know everybody knows they need surgery and need to fix those the question is is these mild sprains just like the syndesmotic ones it's important to understand the the pathophysiology again the medial column you know uh tarsal metatarsal joints one two and three are the key to stability of the foot so they have to be stable to be able to push off the lateral column is is important for mobility and shock absorption it's not as important for stability but these three have to be stable and so you know number one and two that involve most of the time list Frank's brains need to be stable uh so the same thing applies um you know as a syndesmotic injury uh they can be you know direct and indirect but usually there's some axial load as you can see here um they often they happen with high high velocity injuries as car accidents um and again it's a severity of injury that can happen with these but again we're talking about sprains where you have just widening of the uh space between the first and second so i think the diagnosis is the most important part and uh again x-rays are important and everybody should get standing x-rays to stress the foot or even stress views and assess the alignment so everything should should be in alignment you know the medial cuneiform aligns with the first the middle cuneiform aligns with the second the lateral cuneiform aligns with the third and so any view that you can see those joints you should be looking for that so in this you know fluoroscopic view you can see the second is not aligning with the middle cuneiform again normal x-rays don't indicate if there's a more severe list frank sprain and so so an mri or stress x-rays may be of value this is a good paper by steve raken and basically compared mris to stress x-rays and basically concluded that you don't always see this frank's ligament clearly on mri so you don't always see it clearly but if you can see it it usually indicates that it's it's stable and there's stability there if you can't see it it doesn't necessarily mean that it's disrupted and so therefore a stress x-ray or stress test might be necessary to determine stability again the important thing to know here would be um so this is a categoric view and the stress view that's required as an abduction stress view so this is basically abducting the foot to show the opening there and uh and so it's important to examine the patient so if they if they have a swollen foot they have the right mechanism of injury they can't wait there if they have any change on the comparison x-rays with the other side you know you're going to get an mri and ct scan if you like for more bony detail but i think the important thing to determine stability would be this stress fluoroscopy uh and i often do that under anesthesia um and we'll go over that in a minute so when you look at the classification this is a good article for everybody from jim nunley jim nunley and chris vertula from uh from uh down under um basically stating that there's a severity of injury so here we're dealing with you know stage one and stage two that's what we're talking about for this presentation is really uh these mild injuries and how you determine what to do with these and so the question is is this a stable injury so they have normal weight bearing x-rays they have normal mri negative stress test then it's stable and you can expect them to get better you can rehab these and expect them to get better and play within a couple of weeks if it's not stable then you need to make it stable and that's surgically so here's an example this was a alignment uh this was at iowa had a severe twisting injury had swelling of the midfoot unable to weight bear tender at the base of the first and second and here's the x-ray it looks pretty normal but there is a suggestion that maybe there's a little bit of widening there this is the oblique x-ray so on the on this ap view standing ap view the first lines up with the medial the second looks like it might be a millimeter off maybe not here's the oblique view the third lines up with the lateral cuneiform the lateral view shows that there's no depression on the uh in the arch you know so they're not getting a depression through the medial column so here we took them to the operating room and again this is a discussion we have with with the athlete and the family so we're going to take you to the operating room and determine if you need to have surgery so this is the stress x-ray and you can see there's a little bit of opening here but no displacement you can't displace um you know the second with respect to the middle cuneiform and the and again there's multiple views and we looked at it in multiple ways so we decided it was stable and we decided to just keep them in a boot re-examine them pool therapy and then got them back in shoes and got them back to play so this particular athlete did not require any surgery and he got back to playing i think around four or five weeks following the injury here's the same example with a with another player and here's the x-ray this looks like it's a little bit more widening but you see the base of the second lines up with the middle um and there's difference from the other side but again a little bit of rotation might show a little difference no difference on the lateral x-ray and then here's the stress view and here's the difference is that you see the displacement the lateral displacement of the second the base of the second with respect to the middle cuneiform so this one um i concluded it was unstable and we decided to fix it with a list frank screw and this is you do it under floral it's percutaneous uh it's early you know it's immediately following the injury so there's no need to open that up but you can certainly make a small incision here and open that up if it's a delayed if you're more than two or three weeks following the injury and here you see the compression and basically treat them like a list frank injury keep them non-weight-bearing for a total of six weeks and then this is a little bit different than the uh in the synosmosis they have to heal and have a stable medial column before they go back to play here's a variation it's a gymnast and you can see here there's widening between the first and second but also between the medial and middle cuneiform so the fixation is a bit different a list frank screw but also a intercuneiform screw to stabilize the syndesmosis and again the post-operative treatment is non-weight-bearing and uh and then gradual weight bearing gradual return to activity so this is takes a little bit more time and i don't think you can get them back to play quickly no matter what if you if you do surgery here's a chronic one this was a medical student came back three weeks after an overseas trip where she twisted her foot and here you can see the widening you know compared to the normal side so there's a standing ap view of both feet you can see there's a little bit of calcification here between the first and second so we did this on a delayed basis and sorry i i meant to have the surgical pictures there and uh so the you know the question is on that last case the um you know could you leave that if that was a stable injury and let it heal if it was calcifying i think you could and uh and see how they went but anyways the for list frank injuries um the question is is a stable injury and um if it is you can treat it non-operatively if it's unstable then it needs needs surgery so that's all the i wanted to show with the list frank injury i'm sorry i thought i had a surgical little surgical video of that case uh to show the uh dorsal incision between the the first and second but i'll add that um for the next time so um so again in these uh foot and ankle injuries you know there's always you know something you're trying to determine by your evaluation and i think the two injuries that we talked about list frank and syndesmosis uh basically are to determine if it's stable if it is you can treat non-operatively if it's unstable then you need to make it stable so that they end up having a stable ankle and a stable midfoot all right that's it that's great i got a question for you so you know even for the non-displaced ones that are relatively stable i have trouble getting my athletes to actually bear full weight to to do the standing x-ray to determine from stress from that standpoint do you do anything to help do you give them an injection to try to get them to stand on it to fully weight bear or what do you are you guys just tougher there in iowa and in the south than what i'm dealing with out here in california no i've no i don't inject i don't inject that area you know generally if i if i think that it's a severe injury um you know that that's going to require you know some sort of stabilization i usually tell the patient that tell the coach tell you know i think this is a bad list frank i think we need to stabilize it we're going to take it to the operating room and if it if the if the stress test under anesthesia shows that it's stable then you say okay we decided not to put a screw in it's good news you know so you change course after the the the assessment under anesthesia okay dr workman asks so for the chronic list frank you did an orif with screws yeah i know what the yeah so you basically um you know make a small incision right over the the uh area between the medial and middle cuneiform um go down and and basically uh there's usually fibrous tissue fibrous interposition use a small ranger and kind of clean all that up make sure it's mobile you're usually able you know you're able to see the joint the second tarsal metatarsal joint and the first you can put a small towel clip clamp between the medial cuneiform and the base of the second and then you can uh while you're holding it with the clamp is put an inter fragmentary screw in that same direction okay i think you did mention this during your talk um but dr hughes thank you dr mandela for the great talk do you leave the screws indefinitely for the list franks or when do you remove them if it's just a list frank screw in other words going from the medial cuneiform to the base of the second i usually leave that in unless it gives people because it's not through a joint and uh it it usually doesn't create any problems but if uh if the head is a little bit prominent or there's some irritation in that area you can easily take it out and i usually wait more than six months to take it out great do we have any other questions i know we're a little bit beyond time but any other questions for dr mandela uh do uh what do you make of suspensory fixation for the list franks injuries uh jeff abrams is asking i don't i don't use those um i know some people talk about it i just have not been happy with that you know that you get a stable enough fixation and um so i i think using a you know you can use a headless screw with different pitch threads which is what i've been using lately uh so a four millimeter uh headless screw that's uh basically a compression screw with a different pitch uh and the you know one end of the screw and the other end of the screw so as you put that in it basically compresses the medial cuneiform with the base of the second so uh even in the more severe injuries that need fixation across the tarsal metatarsal joints that's usually the first screw that i put in to make sure that that is reduced so you have to use some bridging you know bridge plate or something you know over the the second or the first i think you can do that you know but for the more severe uh type of injuries um but i have not been happy with the using a button i don't know if you guys have you guys any of you guys use a suture button for lisfrancs i have not uh i don't know steve volker you guys no yeah yeah thank you so much uh for giving the talk i know we're running into the assm webinar time that they're about to they started at four but thank you so much for phenomenal talk on the syndesmosis and the lisfrancs uh everybody's very appreciative i'm very appreciative i always learn when i when i hear you talk ned so thank you so much and uh everybody be safe and uh we'll see you all tomorrow thanks so much well thank you mark and thanks everybody and uh yeah i hope everybody got something out of it but good to see all you guys good to see your faces take it easy stay healthy good luck take care of you thank you

Dr. Ned Amendola

sports medicine

syndesmotic injuries

diagnosis

treatment

surgical fixation

Lisfranc injuries

ligament damage

classification

athletes