All right, well, can you guys hear me okay? All right, well, thanks, Norm, for that talk. Anybody with any questions in the audience? I think I don't see anything on the app, but anything, a hand raise or whatever you'd like to ask? Norm, what's your go-to on full-fixed part of the Phoenix.log animation? Yeah, so quickly, when I do them, intraoperatively, I actually don't put them in the leg holder, because the ankle has a lot of instability. I actually tie a Curlex around my waist and just use my body weight. It makes it easier set up, makes it easier for everybody, and if you don't find anything in there, you can quickly get out of it. So that's number one. I didn't put a picture in there, and I should have. I've gotten away from microfracture in general, on the whole. I do what I term an abrasion chondroplasty, which is I usually take a burr and or a very aggressive shaver once I've cleaned up the lesion, and I scallop the bone to attempt to create that healing environment in an environment that's already in a good position to heal without injuring the subchondral plate, which I have concerns can lead to cysts. Any other questions? I've got one. Going with Norm, again, great talk. Your thoughts are how many rates of second-look arthroscopies have you had to go back with, and what things look like after those fractures? Yeah, so my rate is a lot lower since I do them initially. My criteria, there is no scientific data for this, my criteria is 50 years and younger, I pretty much scope them all. Over that age, if it's a fractured dislocation, I scope it. That's age bias. I understand that. I don't really, there's no data out there, so I kind of have to cut it off somewhere. And it's pretty small. It is, off the top of my head, it's usually for arthrofibrosis more in stiffness and impingement stuff than it is for osteochondral lesions, though that does happen. So it's pretty small. I would put it less than 5%. Yeah, and I mean, I think it'll be interesting also to get Dr. Stone's input on this when he comes up kind of for the second half of this, because one of the issues, I think, as we mentioned, with a lot of this trauma is the unrecognized chondral injury and then what happens down the road and then how we're trying to then salvage those things then. I don't disagree with Norm as far as what we try to do in the acute setting, and you'll probably get a lot of different opinions about this, but going in and inducing more subchondral edema and trauma at the time of an initial traumatic event, sometimes then if they have struggles getting back, you don't know if it's because of what you did or what the trauma did to them. So sometimes in those cases, getting the loose body out, I think less is more. I think the key, though, whether it's from Dr. Bhimani's talk or Dr. Waldrop's talk, the key is the identification of the subtle instability patterns that otherwise are means by which looking at them radiographically, fluoroscopically, or preoperatively, I think fail to meet the sensitivity criteria. Certainly they can be specific when we see them, but those are the ones that are grossly obvious that we're probably going to fix those anyways. It's the subtle ones that we miss, and then the fact that the ankle, at least as far as some of the other joints, most arthritis in the ankle is post-traumatic and unrecognized ligamentous instability, and so the key is to identify that. To that end, Dr. Bhimani, so in thinking about the talk that you gave in the paper, so taking that from the experimental standpoint to the clinical standpoint, and this maybe gets a little bit to Norm, what's your recommendation as far as the clinical setup? Is it with a thigh distractor to let the gastro-soleus complex relax and have the knee flexed? Is to do it in extension? What's the thought at least with Urol's group? Any thoughts on maybe even how to intraoperatively, is there any thought about doing it with the knee straight? Because it looked like in the experimental model it was relatively straight. At our service, usually people do it with knee extension and without a distractor. And then just manual distraction? Just manual distraction. I think that the setup, at least for me, as Norm talked about, it's a challenge. But I'll tell you, there are some pretty tight ankles that if you don't get that knee flexed a little bit, it is really hard to get a scope in. If it's broken, it's not that hard. No. I'll tell you, I don't disagree as far as the tilt, but sometimes as far as that ability to distract, sometimes even it's, especially in the ones that are more like a Weber B. Dr. Hesburgh, I'd like to ask you a question. What was your hypothesis going in? To me, that was pretty fascinating. It's a very small, certainly a small number of talus that you looked at, but that was pretty shocking to me how little of the cartilage that you could see. Even though I argue that you should scope them and it allows you to evaluate them all, that was even less than I thought. I know in research it is what it is, but what were your thoughts going in, and did it surprise you? See, I think you hit the nail on the head about the limitations. Obviously, we would have loved to do this in 30, 40 cadavers, but it's just a matter of availability. We'll try and add to it as we can and bring those confidence intervals down a little bit. It actually spun out of a sort of interdepartmental question about variance of opinion between two specific surgeons about how much they thought that they could see. I tried to do a literature search to answer the question, and I could not answer the question through the current literature, and so we decided to try something to give us a foundational basis. We just picked the most common type of ankle fracture that you would expect to see, and then you can see even optimistically you're seeing a fifth of the weight-bearing surface. Now, the question about if you have an injury, where is it more likely to occur? It's on those shoulders where you're going to have, you know, where you did have visualization, but in terms of your ability to address it, I think also we didn't even attempt to talk in about how much you could address it through the fracture versus just identify. Dr. Stone. Dr. Stone. Can I ask you a question? I know you're going to be up here later, and you may address this. On those ones that do have the fracture, this is just a shear that's a peel, and you have it. Do you microfracture, or do you... Yeah. Right. Mm-hmm. I agree with that. Agreed. Well, I think you don't follow the master with opinion. Well, I'm one of the masters, but I'm right in line with you. I mean, when you look at the biology of what's going on there, and specifically to, we won't go too basic science here, but I mean, a number of individuals and a number of studies have shown the concern for microfracture is that bleeding and how angiogenesis can essentially prevent chondrogenesis. So the smaller holes is better. So I'm very particular about the instruments, not just the ones that show up because they forgot to flash the foot and ankle tray and the knee tray and shoulder stuff is always available, and that's using my approach. And if the subchondroplasty is intact, I do like to poke some small holes there, but I do not go all in as much as I do if it's a deeper lesion, to the point of the more osteochondral lesion, as you alluded to. You're right. I mean, it's nothing like when you do that, particularly with one of your trainees, and they say, hey, this thing is already bleeding. We haven't even poked any holes in it yet. And you're like, yeah, because you've already passed the subchondral plate and it's a good bleeding bone. Let's not make it worse. And first, do no harm. But, and then what I was going to say in support of what Kirk was mentioning earlier, it's also nothing like when you get in a case and you assume you're going to be able to show a drive-through sign of syndesmosis, and because they're so tight in extension, you cannot get the shaver there, but you know they're unstable because you've confirmed it from an MRI. They're subtly unstable on your pre-op imaging. And the resident's like, oh, I'm really trying to get this thing in here. And you're like, you know what? You're not going to get it in. And sometimes having them in that knee-leg holder is showing, like you said, a little traction around the waist, and it opens it up. And I do believe that ties into what you mentioned, Dr. Bhimani, in that when the AITFL is out, that posterior hinge component, we really don't know what it means. And those are the ones that we watch the closest. We say, you know what? I think you're unstable. I don't want to come back six weeks from now and you're worse. So a lot more to still learn from one another about. So great session. We'll give some applause to that.

ankle fractures

treatment options

surgical techniques

ligamentous instability

research