All right, so 8.30, we'll probably have some people that will still be kind of walking in from some of the other early ICLs, but just to stay on time, we'll go ahead and get going. I'm Dr. McCullough, Dr. Rick Ferkel, who needs no introduction. So foot and ankle innovations, appreciate everybody being here. We'll have some case presentations and questions at the end, but in order to try to get through everything, we'll try to work through. So if you can, try to save your questions until that case discussion. And so without further ado, the first talk, if we can go ahead and pull that up and back, is going to be Soft Tissue Repair 101, Brostrom Repair in 2024, and that's going to be Dr. Eric Ferkel. So Eric, thanks. Is there a way to put it on presenter mode on the screen up here? Is there a way to put it on presenter mode on the screen, or no? No. But you've got a laser. The green is a laser. Got it. Do you want to point to that? Cool. Yeah. All right. All right, well, good morning, everybody. We'll get started on ankle instability. So, ankle instability in 2024 epidemiology. As we know, ankle and sprains are one of the most common injuries we see in our sports, medicine, practice, whether you're taking care of college athletes, high school athletes, or just the weekend warrior. It's about two per thousand person-year injuries. So, anywhere between 20,000 to 25,000 ankle sprains a year we're seeing in the USA. Most commonly in basketball. Also seen in volleyball players a lot, and also the leading cause of loss of time in American football. Epidemiology. Typically, there are lateral ankle ligaments. We don't want to forget about the medial side, which we'll be discussing later on. Multidirectional instability does exist in ankles as well. So, ankle sprain anatomy, just to review for the audience real quickly, ATFL is the main internal rotation restrictor of the talus. And this is what it looks like on the anatomy here. Primary to inversion, internal friction, and anterior drawer. And then we look at the great anatomy from Dr. Hitmik in Klan's lab in AJSM, in JBGS back in 2019, 2015. CFL, looking at the ligament there. The main hind foot adduction. A little stiffer than the ATFL. And you can see its anatomical landmarks right there. And then it's a primary restraint to inversion and neutral and dorsiflexion. We also don't want to forget the perineals. This plays a major role, I think, also in ankle instability. And oftentimes in our clinic we'll see patients present with perineal tendon pain, perineal tenosynovitis. Oftentimes, it's because they're functioning as a dynamic stabilizer when the ATFL and CFL have been injured and are weaker. And so even after our post-operative patients come back in, you'll oftentimes see lateral retromalleolar pain because of the fact that the perineals are working overtime to help stabilize your ankle. So again, making sure that you're working on strengthening the perineals and also addressing the perineal tissue tendon pathology at the time of the surgery. Let's look at the algorithm for ankle ligament instability at this time. So it goes all the way from functional instability, which you may want to think about as micro instability, a concept Dr. Jordi Vega has come up with, managing possibly arthroscopy or arthrobrostroms, presenting all the way to full and severe instability, where maybe we can consider an allograft. So thinking about the chronically unstable ankle, how do you manage it comes in your clinic? Of course, physical exam is primary management number one. Going on to stress x-rays, especially in your workers' comp patients, where you need to maybe document more significant instability to get the surgical options approved. I think MRI is really important. Look for cartilage pathology as well. Also, standing alignment. I always teach our fellows, have your patients stand up, take both their shoes off, stand from behind them, and in front of them, watch them walk. You can't be a full orthopedic surgeon, I think, in foot and ankle surgery without watching them walk and watching them stand. Looking for cavus alignment, that's really critical to evaluate as other causes possibly of chronic ankle ligament instability. Of course, preoperative or nonoperative management is the main state of treatment. I get my patients into physical therapy right away after injury. I think it's improving over time and time again to working on kinetic chain strengthening. And of course, when considered non-ops failed, move on to surgical management. So when do you fix these? Recurrence sprains, cartilage injuries that are concomitant, perineal tendons that are going on to cause continued pain. We want to avoid what we see in the bottom right there, which is further development of late-stage arthritis. Other causes, perhaps chronic laxity or hyperflexibility, hypermobility, tarsal collision, neuromuscular diseases, such as Charcot-Marie-Tooth, perineal tendon pathology. And then think about functional instability, too. Functional instability, whereas difficult in biomechanical or ligament instability, is more of this joint instability, but the sensation of joint instability, possibly due to neuromuscular deficits, which, again, thinking about kinetic chain strengthening is really critical to help treat that in the nonoperative setting. So we think about the surgical technique options. There's anatomical techniques. There's the non-anatomical techniques, which are moving more towards a historical manifestation, but I think something just to think about when you're looking to do a review on this. So let's talk about the arthroblastom first. Pete Mangone and Jorge Acevedo have been really essential in kind of laying out the landmarks for the management of this. Not all CAA patients are candidates for this, but I think that you can think about when you are going to approach this, who do you want to do it with? For me, it'd be more of a micro-instability patient, addressing specifically more of the ATFL. And so those are your landmarks. Of course, you want to look at your intranervous safe zone here and mark that out to avoid an injury. This is what the landmarks look like, and this is what it looks like when you're passing the sutures. You can also address the CFL as well, but of course, you want to make sure the perineal tertius is not getting injured by your sutures there. The Brausch and Gould, for me, this is scoping your ankles, number one, first and foremost for any surgical management of these patients, looking for chondral pathology, loose bodies, and document them and treat them if necessary. So for me, this is the setup, which we'll get to, I'm sure, a little bit later on in the talks here. Ankle distraction with a thigh holder, marking out your SPN, of course, and all your landmarks. And then doing your approach here, I like to do a curvilinear approach as opposed to an upside-down approach. I think it helps you address the perineal tendon pathology more easily as well by doing it this way. And also, like a total knee surgery, you're thinking about your neck surgery perhaps down the road as well, so knowing how to address those. So you see a tissue in the bottom corner up there as well, and then adding augmentation if necessary. So you think about augmentation as an option, it can either be biologic or synthetic bracing is an option here. There's been some studies that are showing that it does increase the ultimate load of failure, and perhaps skin-backed patients do return to play more quickly. For me, my patients who I do this with would be larger athletes, longer-sustaining chronic instability, perhaps a varus heel or a cable varus alignment may be a patient who I'd add an augmentation for. For me, it's not an every-time patient who I do augmentation on, but I do think it's a good option to have in your armamentarium. So for augmentation, it did show 58% return to pre-injury level activities and lower activity level, and only 16%. So we think about literature review, better outcomes are being shown in the anatomic versus the non-anatomic reconstructions. Arthrosclerostems are, I think, emerging, still needs better data as to when and how we best use this as our surgery. Don't want to forget about the allograft reconstruction procedure. And so when do we do this? This would be somebody who's had multiple surgeries. The ATFL-CFL tissue is perhaps too thin. And I think for us, at least for me, augmentation is not going to be a viable option in these patients. Here's some good data Dr. Richerford has published as the kind of indications. When you're doing a stress-extracting clinic, 10-degree difference on tailored tilt as opposed to contralateral limb, failure of previous surgery, ligament dyslaxia, BMI above 30, higher demand laborers or athletes, and then poor tissue quality, which again may be a game-time decision in the OR. So preparing one versus the other and have that contended for both in the OR setting. So is the ATFL similar in an allograft setting? This is a great study that I thought points this out nicely here. That did show the native ATFL in allograft had similar stiffness and strength, although allograft was even stronger in this one study in the cadaveric model. And then when do you use tendon allograft or auto-allograft? So you think about failed prior reconstruction, like I mentioned, and then the larger athletes and hypermobile patients. And then so what do you want to use, either allograft or autograft for these patients? So this did show here that allograft was similar strength and stiffness to the native ligament. And then this is a great meta-analysis I thought came out of KSST in 2022 that did show that allo and autografts, whether you want to harvest a hamstring from the patient up above or use an allograft, were actually at very similar outcomes in post-operative patient scoring and satisfaction. So surgical techniques for these patients. This is showing clinical x-ray findings here. And then stress them again in the OR to confirm this is what you want to do. You can see how your tunnel placements are going to be for the fibula as well as, and then you make a secondary incision in the calcaneus, passing your graft, and ensuring that both ankle and subcutaneous motion is not restricted but is stable. And of course, adding the brash and gould on top of that as well is also critical. And then you can see what it looks like with the final repair and construct in that situation there. Dr. Ferkel Sr. did this study in 2015 showing that post-operative patients did return to 71% of their pre-injury level when using a semitendinosus allograft augmentation. In this study out of KSST, also showing good return to sports in patients using an ankle ligament reconstruction with tendon autograft for chronic lateral ankle ligament instability. And in this study showing that allograft in some ways, in some studies, were actually better than a brash and gould for the patients with multiple recurrent ankle instability. So this is something to keep in your armamentarium for patients who have chronic failure, recurrence, instability. Allograft is a great option when repair is unlikely to be successful or has failed. For me, post-operative management for these patients, typically non-weight-bearing in a splint for 7 to 10 days. I'll switch them into a boot usually around the 2 to 2.5 week mark. If they're allograft, I'll keep them a little longer non-weight-bearing. But I think weight-bearing is tolerated, can be gained between the 2 to 2.5, 3-week mark in a boot. And then usually switch them over to a brace around the 6-week mark. Really critical for my patients is blood flow restriction therapy. It's been a game-changer, I think, in our clinic to help prevent post-operative atrophy. I get them to the therapist usually around day 7 post-op to help begin BFR. And then you think about functional testing down the road. And let's look at that a little bit here. And so how to return to play in these patients. And so you want to think about different options about how to assess your athletes, whether you want to use the needle-wall weight-bearing lunge test or vertical test, box-op test to determine if they're ready to go back to sport. I think if we're going to put them back to sport, bracing them and taping them for at least the first 6 to 12 months, post-op is going to be critical for your patients as well. But I think as you kind of think about the different options here in 2024, really assessing what is going to be the best option, not only in your hands, but for that patient. So I look forward to answering questions at the very end. Thank you very much. All right. Well, thanks, Eric. Next, I guess I'll introduce myself. I'll talk about Achilles. All right. These are my disclosures. So we're going to focus on non-insertional rupture. Obviously, insertional rupture can be a part of this. And insertional tendinosis, tendinopathy can be another management thing that we can potentially discuss in the cases. We know it's a devastating injury. We know that classic non-operative compared to large open operative treatment, there's clearly risks with both, and that we're trying to mitigate that with the more recent technologies. So why are we talking about it? We know from the Cochrane Review that open versus non-op, the issue are wounds, but that open repair significantly reduces the risk of re-rupture compared to classic immobilized for six-week or greater non-operative treatment. But the complication can be reduced with smaller incisions, but that we still need to be able to understand what the difference between functional non-operative and those less invasive techniques can be. But we know that complications are a problem. We know that when you get a wound here, this is high-dollar real estate as it relates to skin and soft tissues, and that once that there's an infection, it is skin and you're right down on tendon and you do not have a lot of muscle as a protective overlap to try to easily cover. And instead, you have to rotate from above, and that it's a significantly difficult issue. So how does it have any repeal in athletes? Well, we know that even professional athletes deal with this, and this is a significant derailing event as it relates to the trajectory of their careers. So it can be a problem. When we look at function of this in historical, whether it's the National Football League and Selene Parikh's study that is frequently quoted, talking about how at least in looking at this from a public database standpoint, one-third of athletes never return to play, and of those who do, they play at a less optimal level functionally. The same is true in the NBA. When we look at 18 athletes over the 88 through 11 seasons, where once again, a third to almost 40 percent never returned, and of those that did, once again, didn't do very well. So with classic treatments, we simply just have not done very well as far as return to function, arguably not unlike some of even our knee colleagues as far as ACLs and the fact that there's a lot of failures with that or suboptimal return. So as we look at this, so what's the drive then for nonoperative treatment? What's these articles from JBJS and from our colleagues to the north? The reality, though, is if you look at these, the problem is that the Willits article was powered to be able to look at re-rupture, not function. So if you get down into it, it was actually underpowered to really understand that the fact that the differences in strength ratios at one to two years that they saw, well, they have unknown significance that they weren't really powered to look at that function. The same is true with the Sorosano article, that they understood that randomized trials are needed to compare the less invasive or percutaneous to nonoperative because their surgical patients return to function, return to work faster. This is true even of the most recent article that's been out that got certainly a lot of press, especially it was being picked up by the national kind of PR. So this is a randomized multi-center control trial looking at nonoperative open and a mini-open. But this mini-open technique was different than what we will discuss. And the conclusion they had was that nonoperative treatment, open repair, and minimally invasive led to similar outcomes at 12 months. The problem is that if you look at how they did it with their mini-invasive technique, first off, they tensioned the operative side to the nonoperative rather than over-tensioning it. And we know that all of these Achilles repairs stretch out, so if the best you do is as tight as it is at time zero, all it's going to do is stretch out from there. And so, as they mentioned, the sutures were tightened so the ankle demonstrated an acquiescent position comparable. The other issue that they saw is there was a 10-time risk of re-rupture with nonoperative compared to operative even in their trial as well. So do not be fooled by the titles of some of this stuff. It is not the same. And also, when you look at this and you look at the reasons why they may have complications, this is what a Dresden hook looks like. This is not the way that we talk about doing this less invasively as far as the risk of serral nerve aggravation or irritation or capture. So what about the real story? If we look at the Lanto article in 2016, surgery restored calf muscle strength earlier, up to 24% difference at 6 months and 10% to 8% strength difference at 18 months. It also resulted in a better health-related quality of life domain in the domain of physical functioning. So we have to understand that a loss of power is also a complication. It's not just simply a wound. We must tension these appropriately, let them rehab appropriately, and realize that that's just as much of a complication as a wound is. So if we look at this, the Mond-Griffith technique, this is what was initially published. Certainly, Maffulli has shown this to be able to be successful as well. Originally, Bradley and Tavoni talked about it. The problem was is they saw two re-ruptures early on and said, well, you know, this just isn't good enough in an elite-level athlete, and we've just got to open it up. The Achillon is certainly a percutaneous technique option. It just doesn't lock, and so the problem sometimes is capture of the tissue. And also that in the U.S. it's a plastic jig, and it's a little flimsy compared to the European metal-based version. But even with that, they showed that complications were less with that Achillon technique. The percutaneous Achilles repair system that we're showing here, it creates locked fixation, it's metal, it's reusable, and it's just a simplified means of creating a non-locked or a locked suture percutaneously. That's it. It can actually be used on the quad tendon, the patellar tendon, depending upon where the location of the tendon is. It's simply just a means by which to pass a percutaneous locked suture, period. So is it strong enough? We know from the HSS group that it is, that as they looked at this compared to a Krakow and a PARS lock technique, it is similar at those high cycle types of biomechanical tests. We also know from the NFL study that Bob Anderson and I originally did that all of these athletes that we initially looked at returned to play, the fastest of which was at 5.4 months. We also know that it's applicable to the general population from Andy Hsu's study when he was a fellow at OrthoCarolina as well, and that it also related to fewer complications. Multiple different ways to do it. You can anchor it to the heel, you can do suture to suture, depending upon what your preference is. The key is just to understand from the non-operative literature that the Achilles wants to heal. The problem is that you must do it in a less invasive manner and you must tension it as much as possible, particularly if you're going suture to suture, because the key to function long term is muscle tendon unit tension, period. We just have to try to do it less invasively so we don't create wound issues or create other problems from the fact that we are intervening. As far as meticulous skin closure, I think you need to be careful with this. I close it in layers. I close the peritoneum and then the deep dermis. But then for the skin, you can either use nylon or I actually use glue. As the incision, you can make it vertical early on. I try to make it horizontal because that's where the longhorns lines are. That's the way the skin wants to heal. So as you look at this, that's before even closing the skin. With the glue, that's at 1 week, 2 weeks, 6 weeks, and 12. So it wants to heal. Now, there are some people that have more sensitive skin, so I still think for the first 2 weeks, this isn't someone you should immediately weight bear. You need to still try to respect the tissues, but you just have to manage them in a way to where you are less invasive. Once again, construct tensioning. You do not want to match the other side, especially when it's suture to suture, I argue, to maximally tension these because we know that a lack of tension will equal a lack of power, and that will be a complication. And the Eliasson article in AJSM discusses this, and that regardless of how you initially immobilize them, they all stretch. So just be aware of that and maximally tension. You can accelerate rehab. You can use an Ultra-G. I agree, as does Eric, with as far as the use of BFR. That has revolutionized the ability to do this, particularly to get early knee-bent range of motion going on to try to stimulate the soleus because a lot of times the soleus is neglected with this, and you must get that built up not simply with knee-extension heel raises but also knee-flexed heel raises. So I think standard treatment is still falling out of favor. Be very cautious about large open incisions. I think minimally invasive is going to be the way to go. Choose your technique of choice, but just remember some of these key things about it. And our goal, once again, is to restore the tension, to maximize that tension during the first three to four months. And the early studies demonstrate that percutaneous means are a way to be able to do that, to get that tension with avoiding the complications of large open incisions. Thanks. And so next we're going to hear about deltoid repair in 2024 from Dr. Kevin Martin. Thanks, Kevin. All right, thanks for having me out here today. Let's get started. Some deltoid. So here are my disclosures. I think everybody now at this point makes everything, so please use whatever implant you like or what you need in your department. So we already talked a little bit about the anatomy, but when you start talking about the deltoid, you know, sometimes in teaching, it's like one huge structure, it's got multiple bands, but in reality, you really need to understand the difference between the superficial and the deep deltoid. Again, Dr. Clanton did a nice job describing this, and being able to look at that image on the far right and be able to see the difference between the spring ligament, the tail and the vicula ligament, and where you're at. And I think sometimes at foot and ankle, we get a little willy-nilly. We just kind of put our anchors where we think they are, but we really need to stick to the anatomy, especially on the deltoid. So having this in your mind, you're having your residents review it, review where these spots are actually located anatomically. And now draw your attention to that deep anterior tibial tail or ligament location on the talus and on the tibia. Keep that in mind as we go forward. And then again, looking at what that looked like in a real cadaver, where we're actually at, and how often times we talk about, hey, we're just going to fix the superficial deltoid. And where it's at, their insertion is basically in the same spot. And you're going to see on some of our incisions, you're actually repairing both. And it wouldn't be a good deltoid talk if you didn't start describing some of the syndesmosis. We know the syndesmosis has to be addressed simultaneously. You can't really address one without the other. So appreciating that the AITFL is truly three bands. You have your proximal, your inter, and then the distal, the bassus ligament we often take out at the time of surgery. We often debride that out. But just knowing you have three bands and then where the CFL and ATFL insert is also important. And then looking at this, this will become really important in the future. If you're an arthroscopist, like everybody in this room is, understanding where your anatomy is and how do we restore it, and can we do it arthroscopically? Can we do it safely arthroscopically? Knowing that you're about seven millimeters off where the AITFL comes in and where that capsular ridge lies. And I'll show you why that's real important in a second here. Looking forward, again, like Kevin, why are you talking so much about syndesmosis? We have to understand the syndesmosis and how it affects range of motion. So we know by Dr. Clanton's work, when we resect the AITFL, we do get substantial external rotation. I was at a meeting a couple weeks ago and someone was talking about how the deltoid had failed, but they hadn't even looked at the syndesmosis yet. And they showed the ankle rotating and they were blaming it all on the deltoid. And they hadn't even looked at the syndesmosis. They fixed the deltoid and ignored the syndesmosis, which made no sense to me. You really got to look at both. You can't treat one without the other. Since we're in Boston looking at Dr. Gus's paper and the guys out here, the disruption of the deep deltoid really affected it when you transected the AITFL and the interosseous ligament together. You really had to have all three to get instability. So please, if you see one, you got to go looking for the others to make sure you're not missing some acute pathology associated with this. And that's why I would look at this. So this is a patient I would argue that that's the medial gutter that's looking through that. You can see that deltoid has had better days, right? You can see it's unstable. It's rotational. It's valgus. And you can see it directly there with your scope. Again, this is using a 1.9 millimeter nanoscope. So you can really see down that gutter very clearly. And then you swing over and you see your AITFL is torn. That's what I'm talking about. You got to look. If you see one, you got to go looking for the other one. And so deltoid anatomy back to the actual what does it actually do? And what's interesting in preparing for this talk, I probably pulled three different papers that describe the anatomy in different ways here. So this is one out of Dr. Clanton's work just recently in 2022. He talked about the superficial resists eversion, deep resists external rotation, and then the valgus tilt, you have both involved. But it's going to be somewhere in the middle. This is not going to be a one or the other. And authors are still arguing about this. I think we need to continue to resect, dissect these out, and continue to do better biomechanical studies so we know exactly what we're doing and why we're fixing it. Looking forward, this is a good JAOS paper. Really tries to guide us. When do we fix a deltoid? If the paper has historically told us we don't fix any of these, why would you fix any of them? But these papers were all written in the late 80s and early 90s. So I think we really need to revise when and why we fix these. So the medial gutter is blocking your reduction? Of course. Medial clear space is still wide. Got it. High energy rotational energy? Sure. Weber sees. We know it's going to be out. All great reasons. You look at the first line in their paper though, what do they say? Their repair is still controversial. We need to get rid of that line. We need to start establishing that, yes, you do need to fix the deltoid. And that's everybody in this room's job to get out there and fix the deltoid. Dr. Hinchman went through and described in his patients and his method of repairing it and why I pulled some of these papers is how they fix the deltoid. So most of these authors, he used one suture anchor and he only fixed the superficial layer. Going on further with another Hinchman paper, he talks about direct arthroscopic visualization. And that's going to be paramount throughout these literature review. They went in and they looked at it directly with the scope and that's what allowed them to see it. And they said 40 percent of their ankle fractures had a deltoid injury. Forty percent. So if that number is high, think how many were missing by not looking at it. The scope is paramount in your ankle fractures. This is another reason why. Then looking at a good outcome study. This paper they went through with a high energy and they repaired half of them. They said, well, the functional short term isn't that much difference if we fix the deltoid or not. Not that much difference. But you read the next line, the medial clear space was still much wider with a group that they didn't fix. And we know that that tip, that translation of the talus out of place is going to catch up to these patients sooner or later. It may not caught up to them initially on the first short term data, but years down the road that is going to catch up with that post-traumatic ankle arthritis. So that, again, is a reason to fix your deltoid. If you look at our paper we published in JAOS, going through the full review, taking step by step how do you examine the syndesmosis? How do you actually tackle these athletes that have a high ankle sprain? What do you do step by step breaking it down? And so now let's get to kind of how I attack this in my clinic. If I come in and I know they have a high ankle and a deltoid, they're getting a scope. The scope washes out MMPs. We know from the Duke paper we know that's going to reduce the post-traumatic arthritis. We're going to fix the fracture. We're going to do a dynamic exam of the syndesmosis and the deltoid. I want to see both of them, how they're working in my hands when I'm doing a direct arthroscopic examination and I'll fix the deltoid last. So what do I do first? For me it's going to be a percutaneous suture button construct. Every company is making them now. Use whatever you want. For me that's percutaneous. Screw across.. Rope across. Secure it. That centers my fibula in the incisor first, okay? And the coronal plane is now stable. But often times we're still off in the sagittal plane. So what I'm doing now in the sagittal plane is I'm drilling, tapping, and placing a 4.75 swivel lock in the anterior lateral distal tibia. Again, that paper I talked about being off the capsular ridge, you can see we're anatomic. We're off the articular cartilage. We're right at that ridge. Then we go over to Wagstaff's tubercle and we drill to Wagstaff's tubercle. We drill, tap, measure, and place our 3-5 directly into Wagstaff's. You can see here I take a little knit and awl wire and sound my hole ensuring that I'm actually where I think I am. Didn't blow out the wall or miss. And then we stick our 3-5 directly into the fibula. And then I would argue this is as anatomic as you're going to get for the syndesmosis. After this is placed, we take it through a range of motion. We are not intra-articular on the cartilage. People are worried that we're too low. If you put it too low, yes, you can create a bassus ligament and that would be horrible. Make sure you're up and out of the way. And we published that technique a couple years ago as well. Do an all arthroscopic AITFL internal brace. Looking for what you want to look for, you want to look for that Mercedes sign. Did you restore that Mercedes sign? Swing back over to your anterior lateral portal and look. If you don't see that good Mercedes sign, it looks more like my Dodge Ram that I drive, it's the wrong answer, right? Make sure you got that Mercedes in there. It looks like that. And what does it look like post-op? So my high-end athletes, this is what they're getting now. They're getting one rope above. I think two ropes is too much. Dr. Clanton's paper showed that two of them can overstuff the joint. So now instead of doing two, for me, they get one rope and one internal brace across the AITFL. And now let's look at the deltoid. These little simple ones. I think sometimes we've got to look back, and again, Dr. Anderson and Shu did a great job looking at 70% of these can be seen with a scope. Again, that's the whole point of the talk today. You can see these with a scope. You've got to be looking for them. And then they fixed errors with one to two suture anchors and superficial only. So here's an example. I've already fixed the lateral ligaments and already fixed the syndesmosis, and I still have this external rotation, though. You can still see this ankle has a little bit too much rotation in it for me. You can see it just barely evolving off the tip of the medial malleolus. So for me, that's too much. So I take them. They're in the OR. We place our two knotless fiber tacks directly at the footprint of the deltoid medially, and then I take the two different interlocks and I actually pass them through each other to make like a ripstop formation where the two knotless anchors now are intertwined, and they pull up the whole cuff. You can see we're just kind of shuttling the sutures through. I hope that's coming off better on your end. Okay, it's coming up. And we shuttle the sutures back and forth, and then I place the ankle in a good neutral position, take each end of these, and now as you're shuttling it pulls up that whole cuff of the deltoid all percutaneous. Oh, that's bad. Oh, that's bad. That's too bad. It looks really cool in real life. I swear. There you go. So really just doing that nice cuff, it pulls the whole cuff back and restores. And to be critical of myself, my one anchor was too high. I'd go even lower currently. So I'd adjust where those go, and as we get better, I hope we will get better as well. It's one small incision right there, and I'd argue for my grade ones that's what I'm going to do. Now look at this one, though. This is a different animal. Looking in that gutter, you can see that deltoid has had a lot more injury to it. It's torn at least to the middle, so I'd call that a grade two. And then we go over to our Guyton ball. We see that three millimeters easily fits into syndesmosis. It's unstable. I love the fibular translation test. It's underutilized, under-talked about. Slide that thing back and forth and see what it's doing. And then do your dorsiflexion external rotation stress test under direct visualization. Why are we using fluoro? Look at it with your scope so you can look directly at it and see what it's doing to know if the syndesmosis is unstable and the deltoid is unstable. So what do we do? We fix the syndesmosis. And for this one, though, when I have that unstable deltoid, I still feel it's an open procedure for me. So I make the incision, two knotless fiber tacks, and then pull up that whole cuff of tissue and do what Dr. Anderson described. He called it his medial brostrom. So I still do a three-layered with vicro suture giving this a nice, solid repair for these grade twos. And you can see you can pull this up. You can do whatever anchor you want. It doesn't really matter. It's just to avoid the pathology associated with knots. And then I'd argue that you've restored the anatomy there. Now the gutter's closed. Laterally, you've got your Mercedes sign. I would argue this worked really nicely. And this is in line, too, with Dr. Kadakia's information that with repair, we can actually restore that joint line symmetry. They used bone tunnels, but again, they only repaired the superficial, which we did on this paper as well. Now, what about this one, though? This is another different animal. If you can look all the way through your medial malleolus, this is gone. That is your superficial. That is your deltoid from front to back. The whole entire thing is gone at this point. So on these, I feel like this needs more robust repair. You get done. You fix your ankle fracture. How many of us stop oftentimes and don't do this stress test? This stress test, I think, is important to do. You get this? This needs to be fixed. So we move in, open up the medial side. And you can see this deltoid is completely evulsed off. It is completely incompetent. So then I open up the front, expose the medial malleolus, take it down to bone just like we do our brostrom. Find the location of the deltoid insertion on the lateral talus, medial talus, drill, tap, anchor in. Then I take the suture tape. I don't leave it inside the joint, though. That tape's got to be passed. Then I pass the suture tape through the deltoid and out so that it's not inside the joint. And you can see, as you shuttle this through, it gives you a really nice cup of tissue. The deltoid is very robust. And then what it does, if we can get this video to keep glitching here. There you go. You can see they have really nice control of the ankle with that 475 in your talus. Then I still put a suture anchor on either side of it. Again, just basically doing the brostrom like Eric described. Same thing. And then the internal brace lays on top as a seat belt construct, not holding the whole entire tension of the construct. Then some Vicryl to clean it up. And that's my grade three. So do I have a lot of evidence for how I do this? But this was just my approach on how I attack these one, twos, and threes, and how you go from the simple repair to the more complex, depending on the amount of injury. We published that paper a couple years ago as well. And then, of course, it wouldn't be a Martin if I hadn't been out, I don't know, a couple years ago. But anyway, it's time to move out. All right. All right. Well, thank you very much, Kevin. And so next, we've got Dr. Giannakos. Is that correct? Is that how you spell it? Yeah, okay. Pronounce it. So ankle fractures for the arthroscopic surgeon. I scope every time. And here's why. Arianna, thanks. All right. Thank you for having me. Thank you. having me here today. So I'm going to be speaking about ankle fractures for the arthroscopic surgeon. I scope every time and here's why. Oh, there we go. Here are my disclosures. So a more pertinent disclosure is that I scope every athlete ankle fracture, and here's why. And even more so, I needle scope every athlete, and here's why. So we know that ankle fractures are incredibly common injuries, and unfortunately, the majority of these can go on to develop post-traumatic ankle arthritis. So what should we be concerned about at the time of injury, and why am I scoping these fractures? What am I looking for? So in general, particularly in my athletic population, I get concerned about prognosis for these patients. I want to be able to tell my athlete that they had a cartilage injury, they had something else potentially going on, so that we know what we have to look forward to in treating and managing them long-term. In addition, as had mentioned in the previous presentation, Adams did a nice study in 2015 demonstrating that during an ankle fracture, there's a pro-inflammatory synovial environment, and that there's an increase of pro-inflammatory cytokines and matrix-degrading proteins in the synovial fluid, which ultimately, even up to 10 days after the fracture, creates an intra-articular catabolic environment. And this, unfortunately, can lead to the development of cartilage injury, and then ultimately post-traumatic ankle arthritis. So an ankle lavage, which is very simple, can actually help reduce this risk, and hopefully prevent this development, or at least slow it down. What else am I concerned about? Well, osteochondral injuries and cartilage injuries. And you can see here, and these are just a select few studies, but there are numerous studies that demonstrate anywhere from 45% up to 80% of patients who sustain an ankle fracture actually have an osteochondral injury or a cartilage injury. And this is something we want to know at the time of injury, particularly in our athletic population. And this can ultimately lead on to loose body formation as well, which is really concerning, because if that stays in the joint, obviously these patients are at a higher risk for cartilage wear and tear. This nice study by Aziz in 2021 was a retrospective review article, and they actually looked to see what patients were coming back and needing some sort of second-look arthroscopy procedure, and found that almost 20% of patients had some sort of loose body in the ankle joint. And this is something that can't be detected on imaging, you know, with a CT scan potentially or your x-rays initially. You can often miss this loose body, which can then once again increase chondral injury post-operatively. What about the undiagnosed syndesmosis? So this is something, particularly in our athletes, that we need to be more concerned about, because these patients, if we don't fix them at the time of injury, can develop pain and instability and really can't get back to sport at the level that they want to. Lu in 2005 conducted a retrospective study as well and looked and demonstrated that the cotton test only picked up 30% of syndesmotic instability, and that patients who couldn't get back to sport and who came back for a second-look arthroscopy, up to 60% of them did have an instability of the syndesmosis that needed to be repaired. So this is something we don't want to miss. And I included this as well, which is ankle impingement. Not quite as important, because this is something that is more development, usually long-term following an ankle fracture. But it is nice to be able to not only do an ankle lavage, but actually take down any scar tissue that's already developed, clean up any potential bony prominences, particularly in our athletes, because most of the time these patients have sustained some sort of trauma in the past, whether it be an ankle sprain or an ankle fracture. And so they probably have a higher risk of impingement and scar tissue in the front of their joint, particularly that anterolateral gutter. So if we're able to clean that out now, we have a higher chance of reducing this risk of developing postoperatively. And that also comes hand-in-hand with getting these patients moving relatively quickly within the first one to two weeks so that they don't get stiff. And then lastly, as Dr. Martin also alluded to, being able to identify other injuries inter-articularly, whether that be the deltoid, whether that be assisting with fracture fixation like the posterior malleolus, and being able to directly visualize your reduction, as well as visualizing after you fix the syndesmosis that that is reduced appropriately and anatomically. So just a benefit summary of arthroscopic interventions is direct visualization of the joint, removal of any loose bodies, and addressing any osteochondral or chondral injury, ligamentous injury at the time of that initial surgery. Being able to have some sort of prognosis in the findings so that you're able to tell your patients what to be concerned about in the future. And then also doing this in a way that is very minimally invasive, small incisions where you're able to have preservation of vascularity and reduce risk of complications. So why do I use the needle scope? So this is a 1.9 millimeter diameter camera. It's very small, and it's semi-rigid, so it's more flexible than your traditional arthroscope. I like this because most of my training in the U.S., I had used ankle distraction with a, well, leg holder. We saw that actually a picture, a nice picture in Dr. Ferkel's presentation a little bit early on. When I trained in Europe, though, no one was using any ankle distraction, and I actually really liked that better. And so utilization of a smaller scope allows you to not use any distraction at the time of ankle fracture treatment, which I think is really important. So no one wants to be fumbling around positioning the patient, getting their distraction on, and then having to take that down in order to potentially malreduce the fracture. So that for me is one component. Also I can use very small poke hole incisions where I usually don't need to have any type of suture. I can use a steri-strip to close. It allows me to have very clear visualization, particularly if I just want to go in, make sure there's nothing going on, clean out the joint and ensure so that I feel better leaving the operating room, that I'm not missing another injury that ultimately may contribute to my patient not getting back to sports. So this was a nice study by Jordy Vega, and this basically demonstrated that there's a pretty high risk of iatrogenic cartilage injury using larger scopes. He reported up to 30% just in iatrogenic injury. And that's why utilizing a smaller instrument may actually benefit and reduce the risk of this injury, particularly if you're working with residents who are in the OR and playing around with the scope. And you can see that this is how the setup is with the needle scope. It's very simple, very easy to use. And these are some cases just demonstrating the use of the needle scope during fracture fixation. You can see for posterior malleolus reduction. You can see, I don't know if this video is going to play. There we go. You can, once again, assess the syndesmosis, see how unstable it is with direct visualization. You can clean up any bony impingement or soft tissue impingement that maybe the patient had developed prior to the injury. You can address any osteochondral injury as well at the time of injury and remove interarticular loose bodies, whether they're fractures or just cartilage loose bodies. It's really important that we get that out. So any concerns with arthroscopy? Well there is some concern that maybe you're adding time during your case. But a nice study by Ken Hunt actually demonstrated there was only an increase by 10 minutes of tourniquet time when utilizing arthroscopy. Now once again this might be variable depending what you have to do after you do your arthroscopic procedure. Maybe it's technically difficult. Most of us are scoping a lot of our athletes anyway, so usually if you're comfortable scoping this is a real quick look for you. There is concern about soft tissue fluid extravasation. If you're using a low flow such as the needle scope, this actually is very low risk. And iatrogenic neurovascular injury, once again, very low risk as you're using very small portals. I wanted to include this to you to see are there any additional complications by incorporating arthroscopy in your procedure. And this nice study by John Kennedy's group was a pearl diver study and looked at ankle fractures and compared with and without arthroscopy. And they demonstrated that there was no difference in reoperation rate and that actually complication rate was lower in the arthroscopic group. And then there is variable literature looking at the benefits clinically and functionally if including arthroscopy really does anything for that patient. And while it's variable in the literature, this was a nice study by Ken Hunt. It was a retrospective review looking at bi and trimalleolar fractures. They found that, once again, tourniquet time was an extra 10 minutes, which is really not that long if you're able to perform all these procedures. And they found very high rates of full thickness osteochondral lesions, loose bodies, and partial thickness cartilage injury. And what was unique about this study was that they actually demonstrated that the arthroscopic group had better clinical outcomes as well as better patient satisfaction in the long term. So in conclusion, arthroscopy can be utilized to address intraarticular pathology. Studies by Adams in 2015 demonstrate that this may actually improve the overall synovial fluid environment for your patients and therefore hopefully help reduce the risk of developing post-traumatic arthritis. There were no increased complications rate incorporating arthroscopy. A needle arthroscopy allows a more minimally invasive approach where you don't have to use ankle distraction, which is really helpful as far as time and just ease of the surgery. Thank you. All right. I'm going to try to get through this really quickly so that we can at least have some time for some questions because we've only got about 18 minutes left of this. So unfortunately Ken Hunt couldn't be here. He is traveling with the Denver Nuggets to try to see if they can get a win against the Timberwolves tonight. So I am going to stand in for him on this. So when we look at osteochondral lesions of the Taylor Dome, once again this is going to be a very quick kind of hash through it because we could spend an entire session just on the management of these. But we know that there's over 200,000 surgical procedures annually as far as chondral lesions, severe dysfunction in active people, very commonly associated with lateral instability. So as we're talking about these instabilities, syndesmotic, medial, lateral, got to be looking for that to also then understand what the implications of that are long-term as far as chondral injury, especially with fracture. Frequently posteromedial and anterolateral, but obviously we know they can be all over. And this, when we think about instability, this is the important thing to understand about chronic lateral instability, whether it's that anterior translation hitting on the anterior tibial plafond or it's that tilt out of the talus. These are sheer injuries that will occur and we must try to avoid these because especially these shoulder lesions, as we all know, are very hard to treat. So a lot of different surgical options going from small to larger and more open. So bone marrow stimulation, allograft, cartilage scaffolds, autologous cartilage implants including now MACI with a matrix, and then obviously OATS. So as we look at these and we kind of try to go through this, if we look at microfracture or bone marrow stimulations, debridement, keratogen, microfracture, bone graft if indicated. Obviously compared to the knee and the initial Stedman studies with this, a lot of these lesions are chronic. They're already down into the subchondral plate and it has to deal with a lot of sclerotic bone. I don't know that automatically microfracture, as Stedman discussed it, when it was a full-thickness chondral lesion rather than an osteochondral lesion, they're the same animal. So realize that the debridement as it relates to the talus and the bony change is a much different beast, but it needs debridement. But be careful with these large microfracture picks. A lot of times what you need is you just need good curatage and first do no harm. But the ability to be able to debride that and then what you're going to use in it, depending upon whether it's just a full-thickness cartilage lesion or an osteochondral lesion, being able to get those marrow elements out and then being able to then progress them with that depending upon the size is important to understand. So smaller lesions do well. We know that there's 10% failure with lesions that are less than 1.5 centimeters squared or 150 millimeters squared, and 80% when they're larger than that. Also 10 millimeters has been another thing published by Glow looking at 48 patients, that is the main predictor of outcome, once again being size as we relate it to just bone marrow stimulation. So once again, size matters as it relates to that, and certainly this study showed that as well that Hunt published in AJSM in 2012. As far as looking at the long-term data, it's limited. So we need to continue to understand how these survive beyond five and six years. The key is understanding when instability is present and making sure that you manage it. As far as looking at timing of return to sport, highly variable, especially with contact sports, but there's very little data past that four to five month mark. As far as looking at the cartilage remodeling, these are the things that we need to understand as far as how you want to get motion going early. You just want to limit the amount of high impact early on while you get that subchondral bone to regenerate. As far as being able to use any type of allograft to this or augmentation of it, certainly micronized cartilage allograft that's publicly available to be able to use, commercially available, or also then being able to augment this, whether it's with a bone marrow concentrate or PRP. Certainly if you're using PRP, a leukocyte pore as far as the articular environment is what you want to try to use, but just realizing you can then do this arthroscopically. The concern always becomes cost and whether you're doing this in a hospital setting or an ambulatory surgery setting, so just being aware of that. But that allograft cartilage scaffold is a way to where we call it even microfracture plus to be able to augment beyond just simple debridement, even though in studies debridement shows to do very well. There is certainly a juvenile particulated allograft that you can use as well with this. De novo is one means of that. You can also use viable osteochondral allografts that you can form to this and you can secure down the suture. But once again, as we start to get these larger lesions, you have to start becoming more kind of thinking outside the box about how to do this short of going to a true, full osteoarticular plug. There's limited data on use of the scaffold, 48 patients, mean four-year follow-up. No difference in time return to sport, but they did show improvement at least in functional outcome measures. As we look at ACI and particularly now even MACE, it has been historically hard to get approved, although certainly with the work of Dr. Ferkel, he has certainly pioneered some of that in the ability to be able to use this in the ankle compared to the easier means by using it in the knee. But there are larger lesions. Frequently there are two procedure cases where you have to first do a harvest, grow it up, and then come back. A lot of times you're having to get a lot more exposure, osteotomies, and then they're incredibly expensive. But even from Ferkel's studies, 32 consecutive patients, 70 months follow-up, 23 out of 29 good to excellent results, and improved cartilage quality when we look at this as far as high-level MRI. As far as OATs is the last, osteochondral allo or autograft, and transplantation or even mosaicplasty, being able to use this to try to fit these harder lesions, particularly with the mosaicplasty for these curved areas of the talus, compared to if it's central and dorsal. You know, these compromised contact mechanics do make this difficult. There's obviously also the ability to do a hemi-talar allograft, which I've done a couple of that are technically challenging. These obviously create a larger exposure, a need frequently for an osteotomy, particularly medially, and can be somewhat technically challenging, but certainly a means by which to deal with a possibly failed microfracture or less invasive procedure, or when you have a really large cystic lesion. So just be aware that that's an option. There's newer techniques that may prove equivalent or superior, but once again, the key to this is understanding the algorithm, that that algorithm is based on size. Whether it's 100 millimeters squared or 150 millimeters squared, that microfracture or microfracture plus can certainly be used with some good success. Just don't underestimate the importance of concurrent ligament instability that you must address. For the larger lesions, you need to have a certain amount of things in your bag and ready and available. And obviously with these, I think preoperatively as well, understanding beyond just MRI on a CT, truly what the bone is that you're going into to make sure you understand what the integrity of what you're trying to have grow into this is coming from. So LTs are common injuries. Microfracture works for smaller lesions, but just you need careful counseling because frankly with a lot of these, especially those medial lesions, these are unknown potential causes and certainly need to make sure that the patient, especially if they're young, understands what the potential long-term risks and benefits of those procedures are. So thank you very much and let's open it up. All right, great. Great talks. We went a little late, but so much great information. Before we go to some questions, I think one big question for me is, are we under treating the ankle sprains? In other words, we see so many ankle sprains and, you know, all right, so you go to a boot, you go into physical therapy, how many ankle sprains are we missing that we should actually operate on? Let's take the panel. Dr. Martin, should we be more aggressive in treating ankle sprains primarily? I think I definitely have been over the past three years just because when I talked to my young athletes and I'm like, hey, we're going to have you in a boot this long, therapy this long, and hey, let's check it at three months. Or I tell them, hey, we could do a surgery, but you'll be out of the boot in two weeks. Six weeks you'll be doing everything. Eight weeks you're back on the court or in the game. So it's actually almost four weeks sooner with surgery right now with a fresh sprain in my hands versus not up. So their athletes are jumping on it. And because of those repeat cartilage injuries that you guys have shown, that's what we're trying to protect. We're trying to protect and avoid those osteochondral lesions. Arianna, should we be doing a needle scope and everybody in the office with an ankle sprain from then to decide what to do surgically or non-surgically? I think that ultimately that could be a future thing for all of us to do when we can incorporate in-office procedures a little easier. I know some of our colleagues, even in the audience right now, are doing in-office procedures as a look and treatment. Personally, I probably would, if I have any suspicion that I'm going to be repairing the ligament and doing other concomitant procedures, I would take them to the OR. I think for being aggressive, I think for the professional athletes, it's very reasonable because their livelihood does rely on their play. So to get them back to sport, I agree that they probably sprained their ankle before. They probably have developed anterolateral impingement. They probably have some sort of cartilage injury. So being aggressive with these patients, for maybe a high school athlete or someone that's not at the elite level, I still would try conservative measures for them first, though. The other thing I would also add to that is the use of weight-bearing CT, I think, is going to be revolutionizing also our understanding of when to treat these patients. There's a couple of good studies that are coming out now on utilizing weight-bearing CT because, to the question that's been brought up, have we not been aggressive enough and perhaps could we avoid longer-term injury, whether it's a sequela of osteochondral injuries or chronic ankle and ligament instability causing other issues, it's determining the right patient for us. So I think the takeaway is not that everybody needs surgery right away. There's still a good role for non-operative management. But for that second-time ankle sprain patient, somebody who's two or three months out, maybe they need to get back sooner, I think utilizing weight-bearing CT to kind of differentiate who's going to be the best person to operate on it and move them a little further down the algorithm is going to be very helpful. All right. So in terms of deltoid injuries, how many people in the audience feel we should operate on every deltoid injury that has associated with an ankle sprain or an ankle fracture? Not many hands there, huh? And you said everyone? I said everyone, yeah. So, Kirk, how do we decide which ones to do? Yeah, I mean, I think it piggybacks on what Ariana was talking about, what Kevin was talking about, and what Eric was talking about. I think we need to truly understand the injury. I think we need to be—so for the lead athletes, we're lucky because most of them get MRI. And so then we can start to see differences in the striations of the deep and the superficial deltoid. We can see if it, instead of being a linear structure, becomes serpiginous. We can see if there's edema in that tailor attachment of it. So we start to get clues, but those are still clues. The key is being able to arthroscopically assess it. And then you can go in and see, and if you can take a freer or you can take the trocar and you can take it around the medium allelis, you have a big problem. You should never be able to do that. But you also have to understand what normal looks like. So you need to be scoping enough to understand normal to then understand abnormal. But I think the key is the scope and that arthroscopic examination under anesthesia. So what did you think about my algorithm? It's close? No, I do. I think the key here is the understanding of, do we need to fix the deep? Because the reality is that when you disrupt this 360-degree ring of stability, when you stabilize it laterally, fracture, and with the syndesmosis, and then you're coming over medially, you've already closed the mortise down. The problem is, is the superficial deltoid and the tibial spring and the tibial navicular that even when they stand in their boot without an insert in it and they pronate in that boot, it starts to stretch. So if you fix the superficial cuff, I think indirectly between the syndesmotic and the superficial, you secondarily fix the deep. And that's where I think the trauma folks had it right. I just think they had it wrong because they never fixed the superficial that was coming up along that medial side of the colliculus that needed to be repaired. Realistically, how easy is it really to fix the deep deltoid ligament acutely? I think, like to Kevin's point, a lot of this is going to be actually just bringing the bone to bone and addressing kind of what the deep would look like, but there's not actually a real tissue to grab. But I think it is important to be thinking about, should we be more ligament-specific in our fixation? Do we need to address deep and superficial separately? The other thing I think we have to be really, really careful about is, and if you deal with enough Liz Franks as well, like, look, some of that tissue that's in your way that you want to see through is actually the tissue that needs to heal. And if you debride too much, you're not going to have that same tissue to be able to repair. So just like you don't want to over-resect a Liz Frank to try to reduce it because you need that ligament to heal, got to be really careful over-secting the deep to be able to see to put the anchors in when actually the tissue that you need to heal is what you're debriding to put the anchor in. So that's what I worry about with fixing the deep. Any questions from the audience? Anybody have a question? Something they want to bring up or ask? No? All right. I'd be curious from the audience, how many people are fixing their posterior malleolus every single time? Even little ones? Like, how little? Like, less than 15% of the articular surface, though. For me, it depends on if you have syndesmosis, so you're trying to, you know, like with gardener's paper, you're trying to repair the posterior malleolus, so I do mine all arthroscopically now. So you lay them prone one screw sometimes. Yeah. I mean, I have two screws, but that can really fix your syndesmosis or at least be part of it. And the paper that Arianna showed, we have great results by fixing the posterior malleolus, which reduced our syndesmosis. I think the question that I'm leaning to is, should we also address the PITFL separately in addition to the AITFL? And obviously, it gets addressed if you're fixing the posterior malleolus, but oftentimes, when you're scoping, you'll see a kind of a chondral labral, I call it like the ankle alpsa, the anterior labral posterior sleeve kind of a bulge into the ankle, where you see the PITFL kind of a bulge off. How many folks in the audience are plating posterior malleolus? For a big piece, I would. Yeah. I mean, so I think if you've got a huge trimalleolus and it's blown up, maybe, but I would change you and the athletes, be really careful about plating their posterior malleolus. Because for an athlete, getting that FHL to scar down, which is really, really hard to not have happen when you plate it, that can be a detriment. And certainly, smarter folks than me, I'm just kind of taking this from Bob, but Bob has talked about how that can be an issue compared to even simply just a simple A to P screw that stabilizes it. You fix it with a tight rope or some type of suture tape augmentation anteriorly. You then close that ring and then fix the deltoid. You don't necessarily need an anti-glide plate posteriorly, but you do need to stabilize that PITFL complex, because that's about 45% of the stability of the syndesmosis. So get that posterior malleolus stabilized, fix the syndesmosis, but just be careful about too much can be too much, especially for an athlete. Great point. You just started talking about three screws is not mechanically as strong as the plate, very clivical. So that's why on that paper, two to three screws is plenty. I think that's an important point. I think some of our trauma colleagues are over-treating some of these fractures posteriorly. It's a lot of dissection, particularly in a high-level athlete. And I think, as stated, you can do just as well without going A to P. Also, just to add to that, I do try to avoid any posterolateral or posteromedial incision if I can. And while I also like the technique doing a prone scope, you can actually fix the posterior mal from an anterior scope as well, which I find a lot easier. And Chris Miller wrote a really nice technique, actually, where after you get your scope, you can directly visualize the reduction of your posterior mal, hold it with a K-wire. And then using that same portal, you bring your cannula up to the anterior part of the tibia and direct it posterolateral. There's a little safe space, so you can avoid your serral nerve. And I oscillate out the back, and that's where I make a poke hole so that you can actually grab from P to A a screw, which is a lot easier because it's a smaller fragment. If I have any concern about reduction, actually going through your fracture of your fibula and using either a freer or a periosteal, like a wood handle or something, to get back just close to the posterior malleolus, you can actually use that as a nice reduction tool to hold it as you're wiring across as well. And once again, that avoids the need to open up posteriorly so that these patients who these young guys especially, they complain of ankle stiffness following these interventions or wound problems or what have you. And so those are just some nice techniques that I think are very useful. Yeah. We've shown also that you can take a retinaculum or tenaculum very carefully and reduce it nicely and make sure it's reduced. And you put a K-wire to hold it and then put your screw in. Yeah. And if there's any foot fragments too, you can get that out of the joint fairly easily or reduce it back. Right. Well, I guess we're about done, but we'll stick around for any questions people have individually. We're here for you. Thank you very much for coming. Thank you. Thank you. Great job.

deltoid ligament injuries

ankle instability

post-traumatic ankle arthritis

anatomy

superficial deltoid layer

deep deltoid layer

high ankle sprains

fractures

surgical techniques