All right, so now for the fun panel discussion, I appreciate all the excellent faculty weighing in on all the different topics of the foot and ankle that we all experience as team physicians being on the sideline. So I'm gonna have some probing questions. So Dr. Lau will be first. So with the risk of post-traumatic arthritis from recurrent ankle instability, when do you tell an athlete it's time to get a reconstruction done? Do you have certain criteria that you can review with us? Yeah, so I mean, a lot of it depends on where we are in the season and how frequent. So if we're in the beginning of a season and it's the first ankle sprain, then that's obviously a different scenario than at the end of the season you've had six or seven. I think for me, kind of the criteria are they've had to have recurrent ankle instability if we're gonna tell someone they can't try. So I mean, at least more than two, but often it's gonna be like three or four and whether or not they feel safe getting back. So can they run? Can they do hill lifts? Can they do any kind of agility type exercises? And these are for like in-season decisions. And if they can't do any of those things and their MRI is indicative of a high ankle sprain, then I'm gonna be leaning more toward surgery. If it's just a pure low ankle sprain, it's gonna be a lot of how well they can be able to adjust within a couple of days and if they can do that. If it's at the end of the season and someone's had recurrent ankle instability and they can't get back, they tried the bracing and taping and all different functional rehab and they can't do it, I'm a little bit less, a lower threshold to do surgery because they're in a season and try to get them back for the following season. So a little bit depends on a season and then how frequent they are and how well they can return. But interesting how other, when people pull a trigger to do a bra strim. Excellent. And so at times you can't do a standard bra strim. And so you have to consider a different reconstructing technique. What is your, what are your pearls for the surgical technique and what's your favorite way to do it? Yeah, so I do an allografts, MBT similar to I think how you do it as well, screws on both sides. Those tend to be more for revision cases. I'm not doing them a whole lot in primary cases. If I'm in a primary case, if I'm worried a little bit, I'll add in an internal brace. I don't do that for my standard bra strim. So if I'm worried for doing a primary case, add that. So more for revision cases where I consider doing an allograft kind of reconstruction anatomic. Excellent. Also in cases that have Bayton criteria that have hyperlichromatous laxity at times, or if they've had 10 ankle sprains and the tissue is pretty thin, then it's more difficult to do a standard bra strim. Excellent. All right, next up is Dr. Waldrip. So what areas of the talus cannot be reached very well with arthroscopic technique? And if you can't reach those areas, how do you get there? Well, I think most people have the most concern about the posterior aspects of the talus. I do think you can get there arthroscopically, but typically it requires, if it's big enough or far enough posterior, a third portal. So it's getting comfortable being able to go posteriorly and using either do the case prone or use a third portal posteriorly. So it's not so much that you can't get there arthroscopically, it's that you'd need to use some sort of adjunctive measure like an extra portal. So there generally aren't places that you can't get, you just have to be able to use more than just your standard two portals. And let's say you have to do some sort of grafting for a lateral lesion versus a medial lesion, what type of techniques can get you access to put the grafts in the appropriate, for a particular lesion? Yeah, so for a lateral lesion, sometimes I don't hesitate to open. If it's a true lateral shoulder lesion, a lot of times you're there doing the ligaments anyway, and in a lot of those cases. So you can do the scope, you can evaluate the entirety of the joint, and you can get a good view of the lesion and know whether you're gonna be able to access that through an open incision. So I tell people not to hesitate, fellows, et cetera, not to hesitate to use an open incision laterally. Medially can obviously be a little more of a challenge, and that's where just pending the size and how much graft, et cetera, you start thinking, do I need other techniques like osteotomies? I rarely use like a bone block laterally for an osteotomy, but medially I don't hesitate to do it if I have to, but certainly prefer to avoid the morbidity of it if I can. Yeah, definitely. There's also some retrograde techniques you can do to try to get to the lesion if you can from the other side. Yeah, I mean, I do, I would say I do more retrograde stuff in the tibia. Certainly, occasionally, maybe once a year, we'll have to do something retrograde underneath the talus and get creative. I tell our fellows all the time to try to think creatively on how you're gonna get there. And I think the tibia certainly is one, if you're comfortable localizing it with your advanced imaging, that you can get to, because the bone's soft enough that you can access the lesion from above and pack graft behind before you have to do something of that nature. Excellent. And for the people that don't do a lot of osteotomies, you're gonna reflect your medial malleolar osteotomy on the deltoid. I usually use a K-wire to hold it back, so I don't always have to retract it. And then for the anterolateral aspect, you do anterolateral put osteotomy. That's a biplanar. That gives you great access for putting in osteochondral grafts, if you have to do that. That's correct. And I always tell, I always instruct our fellows when they're drilling their screws on the medial side before you make your osteotomy, that take your time, do it right. I occasionally even don't hesitate to put an anti-glide plate over there if I have to make a steeper osteotomy to access it, because I have had the medial malleolar non-union when my OCD healed. And if you haven't, I don't think you've been in the game long enough. So that's a frustrating thing. So that's something we all want to avoid when what you're there for heals and the osteotomy doesn't. That's very true. So let's say you have an athlete that's a 20-year-old football player, comes in, has a grade two congenital malatia of the tibia over a full thickness osteochondral defect of the talus. It's about nine millimeters. What are you going to do in that situation? Cross my fingers, because if they're an athlete, that's a tough problem. But from an operative standpoint, certainly want to address the talus lesion. And most of the time in today's world, we have some of the newer things, like some of the cartilage scaffolding techniques where we can drill and then put, some of the juvenile cartilage matrix or bio cartilage, et cetera, whatever you choose to use on top of the lesion. I have gotten away from a lot of microfracturing because I worry about some cystic changes. I'm not afraid to be very spare with it, but I don't do a ton of it. I would say more judicious in the amount of holes I'm poking. And then above that on the tibia, I would, a lot of times I would anti-grade drill that from above and try not to violate both sides, above and below from the joint. So I might use a K-wire under fluoroscopy and drill that in more of an anti-grade manner. Yeah, those are a little bit challenging, the tibial OCDs, but you can use a guide similar to an ACL guide that's made for the ankle that can help you pinpoint and get to where you need to go. A lot of times what I do is I just, I basically make my own homemade guide. So I'll two-point or pass point two K-wires. And once I get those on top of each other in two separate planes, I'll use a third to drill to that point. And basically that's a poor man's version of an ACL guide. I love it, I love it. All right, Dr. Dussantz, you're up. So I'm on the sideline or in the office and I have an athlete that's saying, I'm ready to play, I'm ready to play, doc. Let me back in the game. How do I tell with the athlete that has an injured ankle if they're ready to go or not without having them sprint to my office? Because you know, there's not enough space and that'll cause injuries. Sure, sure. You know, I think that's a great question. Depending on the athlete, a lot of times they won't necessarily tell you the truth as to how symptomatic they are. And it kind of depends on the time in the season and what's at stake. And so one of the things that I like to hang my hat on, and I would say it's number one, can they squat without any issues, right? So can they squat? Number one, do they have to lift their heel up to squat really nicely, right? So that gives you one giveaway. And when I ask them to do that, I will often like look at their face just to see if they're trying to hide something. The other easy thing is I'll have them do like a hop test, right? So double leg or single leg hop, have them do it maybe 10 to 15 times and see where they are, see how difficult it was to do that. And if they have no issues with that, then oftentimes I'll say, all right, you're ready to go back to play. And to some degree that goes along with not only ankle injuries, but let's just say an avicular stress or something that you had to fix. It's a good sort of telltale sign. If they can do it, then usually they're ready to go. Excellent. Building on the stress fractures, what stress fractures in the ankle are you going to need to have your antenna up that I need to follow this athlete closely or need to restrict their weight burn or maybe we have to do surgery right away? Yeah. Frankly, the ankle doesn't scare me as much as the navicular, right? So I know, I mean, this is an ankle form, but let's call it foot and ankle. And so if I see a navicular problem, then I have a low threshold to do something about that. And thankfully, if it's incomplete, I may have a prolonged period of non-weight bearing, but if it's near complete or obviously complete, then it's something that I would open up bone graft and put some hardware through to try to stabilize it. And then I take them off of it for a while. So I would say the navicular is particularly very frustrating. And then when you start to see something in the talus, so the talus is another one. The fibula, I tend not to be as concerned because it's not directly weight bearing, but any stress fracture around the foot and ankle is quite frustrating for somebody in the sports world, for sure. Definitely keeps us up a lot at nighttime. The one that we particularly watch out for is a medial malleolus stress fracture, because that can be a bad actor too, can go on to non-union. And so let's say you're on the sideline again and your athlete had an ankle injury. When do you think the role of, and how does injection help you in trying to get the athlete back to play? Is it safe? Is it therapeutic? Is it worth doing? Yeah. You know, I mean, that's a great question. I mean, some of the things are pretty easy to tease out. So right off the bat, on your physical exam, that's probably the most key, right? So on your physical exam and history, if there's a deformity, I mean, right, they're done, right? But then you go on to, let's just say the Ottawa rules, you know, how tender are they in the medial malleolus, lateral malleolus, you know, navicular, et cetera. And so if they're not quite tender there, but they have a little discomfort, that's where, if you want to get them back into the game, you can do a therapeutic injection, tape them up and get them back out there. And then later on, get some, you know, sort of a more detailed evaluation. But, you know, I would say if you are concerned at all, you know, hold them back for a minute, hold them back for a minute. It'll get a repeat exam, you know, later, later on, even during the game, just to see where they're at. Because in the acute phase, I mean, everything kind of hurts or sometimes it doesn't hurt enough, right? So you want to get a secondary exam before you put them out there. Excellent. All right, next up is Dr. Chaket. So I have a question for you. Does functional rehab ever, is that ever the primary treatment for an athlete that has an Achilles tendon rupture? Yeah, I mean, I think functional rehab is so beneficial. You know, it allows the tendon fibers to heal in a more normal alignment instead of all scattered. The trick with rehabbing the Achilles is to make sure your construct is strong enough. So, you know, I usually do like two crack outs with a number two permanent suture across it. And then I pass another stitch in like a Bunnell style across and then an epitendinous suture. And it's a really strong construct, but I still immobilize them for like, you know, in the boot for like eight to 10 weeks. They're weight bearing at two weeks once the incision looks good because you can't mess around with those incisions and keep the incision as small as possible. But I really, I'm interested to see how the addition of the suture anchors connecting the proximal row or the proximal stump to the calc to set the tension to see how that plays out and how strong of a construct that is because that can actually probably change the game and allow earlier rehab. Those anchors are strong enough and get the muscle going and, you know, allow earlier return to sports. I mean, I think that's the only thing, except that I don't know if you guys have seen that gymnast from Russia who had his Achilles tendon. He was an Olympus or he was in the Olympics and he had his Achilles repaired. And within three months, he won a gold medal. And there's like a video of him vaulting and landing. It's incredible. So there's a way to even push the rehab more. And I think that's the direction we need to go in. Definitely, and also there's always a concern about elongation. So I think your point about tensioning your repair is really important because at three months they might actually elongate a little bit. So the percutaneous technique, I use anchors in the calc and actually pass the sutures through a guide that goes through the proximal stump. And then you pass the sutures through the distal tendon and then out the heel. And then I put it into the anchor. The pearl I have for you guys is not to put incisions on the back of the heel, put them on the sides, just above the posterior tuberosity. That way you don't have the wound issue and you're staring at your anchor issue, but we'll see. The serral nerve risk is much lower with the percutaneous hybrid technique now than it used to be, but the other pearl is to make sure you're always within the peritonon if you're going to use the jig. But anyway, thank you. So you did a great job on anterior ankle impingement. What are your, how do you gauge your adequacy of the resection of the spurs when you're in surgery? I think it's really challenging actually, which I always use the mini CRM. It's annoying to bring it in there, but I think it's worthwhile because it really helps you see visually how much of the spur you have left because you can be fooled quite easily. I also find myself dorsiflexing the ankle a lot to see if there's any actual impingement happening or having that, and then you get in there and you see that stripe along the anterior aspect of the talus or along the tail and from the spur. So then you can really see if you've removed it enough so that you're not getting that anymore. Excellent, so true. I also try to line it up with the medial malleolus or the AITFL attachment on the distal tibia and try to get an exam there. And you can actually take the traction off somewhat or the distraction off, and then actually dorsiflex the ankle or hyperdorsiflex it and make sure there's no soft tissue or bony impingement. So that's my pearls. And then last but not least, just the overall question. So I want everyone to give a pearl on their ankle arthroscopy technique and then comments on open induction termination of ankle fractures. Do people do arthroscopy at the same time or not? I do. I actually gave the lecture at AOSSM, I guess, two years ago, maybe, on the role of ankle arthroscopy and ankle fractures. And I do think there's a significant benefit. Even if you go look at some of the wonderful literature out of Duke that was really based out of the knee and hopefully they're taking it more into the ankle, there's some benefit for the lavage of the cytokines. Even just washing all the cytokines out that can lead to post-traumatic arthritis, there's some benefit. There's been shown some benefit for pain reduction too. So that's one side of it, much less, it allows you to evaluate any cartilage damage. It gives you the full picture as you're rehabbing the patient down the road. You understand what's going on, enter particularly with that patient to maybe help further guide them along that you may not know the full picture otherwise. Personally, I don't put them in the leg holder when they have a fracture. I actually use a curl X tied around my waist and just use body weight distraction because distraction is usually easier in the face of a fracture. So that's one of the pearls that I use. It takes less time. You don't have to, the staff doesn't have to get them up in the holder. And so, yes, I'm a big advocate of arthroscopy in the setting of fractures. So I'll go next, if that's okay. I am also a big fan of scoping ankle fractures. I remember even back in the days of residency and fellowship, we were doing it. And when I got into practice on my own, a lot of the staff was questioning why I was scoping it. But the reality is like Dr. Waldrop said, there's a lot of benefits. One key beyond washing out the cytokines and the hematoma, et cetera, is that if you think about it, there's going to be some sort of cartilage injury. And it's nice to remove all those free floating bodies, sort of all the loose bodies and joint mice that are in there. And then, if the patient isn't doing very well, you've got arthroscopic pictures that say, hey, this is what we saw. This is the extent of your injury. And this is how it's supposed to look. And unfortunately, this is the damage that was done. And it just gives not only you the sort of the big picture, but it also gives the patient an idea of why it's taken so long to recover. The way I set it up is I still put them in leg holder, and I just find that it's just easier, allows me to be a little more free. I don't use the curl-ups like Dr. Waldrop said, but I do find that if there are associated injuries, let's just say there's a syndesmotic disruption, et cetera, then I get a good arthroscopic evaluation of that as well. So there's so many benefits to scoping ankle fractures that I do it not only in the athletes, but in the weekend warriors as well. Yeah, I'll follow that. You know, a lot of the data we've talked about has come from Duke, from our division here in department. And most of us here will scope our ankle fractures based on the same ideas as washing out the cytokines and stuff, and so we're huge advocates of that. You know, for me, I tend to do the traction still, but I trained in without traction. I think one of the benefits without the traction is that if you are tested in seismosis or deltoid, if your drive-through sign, it can give you like a false negative because you've got that extra tension on it. So if you are going to do that drive-through sign, take it off traction, give you a little bit better of more sensitive tests of the seismosis and your deltoids, that'd be my pearl if you are going to use traction. I guess I'm the different one. I don't routinely scope the ankles. I find that in almost all fractures, I'm able to wash out the joint through either the medial mal fracture or the fibular fracture with a little bit less small lamina spreader. You can really see pretty well into the joint. I mean, I agree with getting cytokines out. I think that helps a lot. And you can wash out little bone fragments that way as well. And you can get a four or 5K wire and drill if there's a full thickness cartilage lesion along the medial mal. But the patients do so well after ankle fracture, they have a little bit of stiffness. And I don't know, maybe scoping it would reduce that, but it's hard to argue to add a whole extra step when the outcomes are already really good. So, so far I'm still not scoping, but I think I definitely think there's a role in, especially in like the very high level athletes in terms of documenting what the status of the inside of the joint looks like after the injury. Excellent, excellent. And one more controversial question for the panel. So to fix or not to fix a stenosmosis and how do you diagnose a stenosmotic injury? What's your favorite pearl? Fix, I wouldn't want to leave that unfixed in my opinion, but you know what I like to do, which I think is really a good way to tell if stenosmosis is out is after I have my fibular plate on, I'll put a locking tower in one of the holes and you can kind of rock back and forth on the plate that's already fixed to the fibula and see if there's more motion there should be, and see if the stenosmosis is unstable because the external rotation stress x-ray is not perfect. I find that sometimes the stenosmosis is clearly ruptured and the external rotation stress x-ray looks pretty normal. So I have a pretty low threshold to fix it. Yeah, I agree. I would fix it. And my go-to is looking at it arthroscopically so you can see if there's, you know, injection or redness in that area or you can do that drive-through sign. So that would be my pro for that one. Are you talking about syndesmotic injuries alone or in the face of a fracture? Either way. So, man, I could talk all day long about syndesmotic injuries, but, you know, in the higher level athlete, a lot of people know I tend to be on the more aggressive end of fixing them. I think it's really important to know that an MRI is a static test and it's not a dynamic test and don't make your decision based off the MRI alone. You have to also include, you know, stress fluoroscopy. If you're a weight-bearing CT person, I'm more of a stress fluoroscopy person. Some people use dynamic ultrasound, but you need some sort of dynamic test also with your physical exam. And that's where I have sort of my three silos. The ones that are still active can get on their toes, can maybe do a single leg hop, clearly have an AITFL injury, but the rest is intact. Those get a corticosteroid injection versus the ones that the MRI does not look very good, but they can kind of initiate getting on their toes but are having difficulty that I don't think need to be fixed. Those get a PRP injection. And the ones that have instability get some sort of flexible end-of-button fixation. The key there is to understand that instability occurs before widening occurs, right? So, you know, external rotation and posterior instability of the fibula occur before widening does. So dynamic instability is a real thing even without significant widening. So, you know, we're not, I still think we've got a long way to go, but I think there, I think, I do think we are improving at it. I'm, you know, I subscribe to that. I mean, I, you know, some people here would say I'm a little aggressive when it comes to syndesmotic injuries, but the reality is if it's unstable, I think it merits some sort of fixation. This is with or without a fracture. I used to fix it with a plate using more rigid fixation like screws, but I've started to lean more towards dynamic fixation. I feel that it's a little more forgiving and it's just, you know, it's a little bit more physiologic, right? It's not as rigid. And guess what? There's no broken screws that come out later. And there's, you know, I guess, I think Dr. Waldrop and I trained in the same fellowship program. So there's some overlap there in the way we treat it, whether it's injections or taking it to the OR and fixing it. But for my high level athletes, if there's any evidence of instability, I tend to pull the trigger pretty quickly. And the reason is I have found that, you know, these people are getting arthritic, they're getting arthritic earlier. And the reason is because these are some of the injuries that we've missed, right? And so if we don't fix it now, we'll have to fix it later. And the surgery later on down the road is quite an ordeal. I mean, if you're looking at, you know, suture button fixation versus a ankle fusion or a total ankle, I mean, that's, it's a no-brainer. No, definitely. I think synesthematic is evolving with respect to fixation purposes. So a lot of times I actually visualize it directly, the AITFL and actually repair it directly like a prostrum and then do a tightrope to try to accommodate for the interosseous ligaments and the posterior inferior tibial fibula ligaments. But I think the way you fix it isn't as important as you recognize it's unstable and actually stabilize it. Some people use a probe test in the arthroscopy portion of the case to make sure there's three millimeters widening anteriorly and posteriorly, that's a positive test. The drive-through sign test is also a good test. But I'd like to thank the panel for all the comments on these challenging cases and all their hard work. And feel free to reach out to any of us if people have questions and have a great night. Thank you, appreciate being here. Thank you.

ankle reconstruction

arthroscopic techniques

syndesmotic injuries

rehabilitation

surgical techniques

athletes