Close the doors now, get in while you can, here he is, the one and only, dynamic, incredible. Give it up, give it up. All right, so I think we'll kick off because it is 4 o'clock and all of us have to get out of here by 4.30. Okay, so Hayley Thornburg, who is a medical student working with Dr. Giannatis, is up in Yale. She's going to talk about arthroscopic-assisted reduction of talus and calcaneus fractures and how this will improve outcomes. All right, again, my name is Hayley. I'll be speaking on arthroscopic-assisted reduction of talus and calcaneus fractures and how it may lead to improved clinical outcomes. All disclosures are listed here, I personally have none. So talus and calcaneus fractures are both challenging and complex injuries, usually seen in the setting of high-velocity traumas. For calcaneus fractures, they comprise up to 20% of all tarsal fractures and are the most commonly fractured bone in the foot. And talus fractures comprise up to about 5% of foot and ankle fractures, with both injuries more commonly seen in male patients. So these injuries tend to be intraarticular in nature and, as such, are challenging to treat with a high complication rate. These complications commonly include high rates of post-traumatic arthritis, risks of ABN, and need for additional surgeries, including fusion and hardware removal. With the new advancements in minimally invasive surgery, including utilizing arthroscopy, we are able to better assess the articular surfaces, which may help us to overcome some of the challenges presented by the intraarticular nature of these injuries. So the purpose of this study is to review the clinical and radiographic findings and outcomes and complication rates of arthroscopically-assisted reduction and internal fixation for talus and calcaneus fractures and review the existing literature for these physical techniques. For the methods of our study, we followed the PRISMA guidelines for systematic reviews and included peer-reviewed publications on the arthroscopic treatment of talus or calcaneus fractures that were written in English, published after the year 2000, and had at least a minimum of six months follow-up. Any systematic reviews, animal studies, and cadaveric studies were excluded from this analysis. So for our study characteristics, the final analysis included 15 studies within each discipline with a mix of comparative and case theories. Both injuries also had a predominantly male demographic, which aligns with the existing literature as well. For the fracture characteristics, talus fractures were classified using the Sneppan and Hawkins classification system, and calcaneus fractures were classified using the Sanders and Essex Lopresti systems. For clinical outcomes, the patient-reported outcomes used to assess the clinical function included the AOFAS score, the visual analog scale, and the SF36. Weighted means were used to calculate these final results. And all studies using arthroscopic reduction and internal fixation demonstrated improved clinical and radiographic outcomes with improved post-operative clinical outcome scores and improved Bowler's ankles. Given that this technique was used in fracture cases, not in elective procedures, these findings are as to be expected. Regarding adverse events, the utilization of arthroscopic assistance for both talus and calcaneus fractures reported relatively low adverse events with the complication rate of 3.5% and 10.6% seen in talus and calcaneus fracture reduction, respectively. Radiographic hardware removal was the most common complication seen following calcaneal fracture reduction and the second most common complication seen in talus fracture reduction. No failures were noted in either cohort. Regarding surgical technique for the talus reduction, Sneppan 2 patients were often treated with an anterior approach, whereas a posterior approach was chosen for Sneppan 4 and 5 fractures. Of note, arthroscopy should be performed using the low-pressure irrigation system with continuing monitoring for fluid extravasation. The arthroscopic technique does allow for easy transition to the subtalar joint after the reduction of the fracture fragment. Special consideration should be given to the flexor hallicis longus tendon, making sure that it remains lateral. Various instruments were utilized for fracture reduction with fixation performed using anywhere between two to three cannulated screws. For the calcaneus reduction, patients with isolated injuries were primarily placed in a lateral decubitus position, with polytrauma patients more often placed in supine position. Portal and arthroscope sizes were chosen based on surgeon preference. The arthroscopes ranged in size from 1.9 millimeters to 4 millimeters, with varying degrees of angulation. As was the case for talus fractures, various instruments were utilized for reduction, with fixation performed utilizing up to five cannulated screws, and no plates were used given the arthroscopic approach, compared to plate utilization seen in the open reduction approach. So the early literature has demonstrated promising outcomes for the use of arthroscopic assistance for talus and calcaneal fracture reduction, with low complication and revision rates noted. Due to the paucity of literature, the indications for this technique have not been well delineated. And so this surgical technique may have a learning curve. The use of arthroscopic assistance allows for adequate exposure without an additional osteotomy, decreased local trauma, and assessment of concomitant lesions, while minimizing post-operative complications and improving fracture healing. The limitations of this study include heterogeneous data and the lack of the comparator groups, which is unfortunate given the paucity of literature present. However, the study does highlight the promise of using this minimally invasive technique, with the possibility of a quicker recovery rate. And future studies should be focused on better understanding the indications for this technique. Thank you so much. Perfect. And so I think what we'll do is we'll take questions now, if that makes sense, because we're going to, I think, so one of the things that my observation in this was very quickly was that I don't do very many carcanial fractures now, in part because I'm not very good at them. Neither was I ever very good at them, because most of them ended up with a fusion. So it's interesting to see the reoperation rates when you do this arthroscopically are so low. Is there any reason why you think that might be? Or was there a selection of the grade of fracture? Were they doing sort of more easier or more complex fractures? So the grade of fracture did vary. It was not typically the extremely complex cases or the highly comminuted cases. They also, one of the biggest notes is that using the arthroscopic approach does minimize soft tissue damage compared to the traditional open approach, which may help with the long-term post-operative recovery. Great. Any questions from the audience? Yes. So, is it like to take a look at the subtator, to the posterior, then it's going to be probably hard. So, how do you use this assisted approach to treat those fractures? That's a great question. And as Haley had mentioned, these were a variety of different types of fractures. There weren't a ton of tailor-neck in this cohort, probably because a lot of people need to utilize gnostiotomy to get true access, and it is difficult to do. But at the same time, going from a posterior prone approach, actually, even though you don't necessarily see all the way across and over, you're able to send your wires from P to A across the neck that way, and you're obviously utilizing arthroscopy or fluoroscopy at the same time. So, having like a, they're prone, you're going to have the arthroscope or the fluoroscopy lateral in that, and then you'll be able to get through different non-direct visualization reduction maneuvers. As mentioned here, there was a lot of K wires versus osteotomes that were, you know, although they were saying there was direct visualization, it wasn't necessarily always at the fracture site, but it was to assess the joint as a whole, and it was in combination with fluoroscopic images. Once again, though, the tailor-neck fractures weren't necessarily the main ones in this study that were evaluated, but that's a great point to bring up, and I do think that this is an area that we need to look into further. And then, just to not circle back to what your question was, also, I think sometimes the rates are a little bit lower, because we are, there are some people that are now pushing for a primary fusion of these really comminuted calc fractures, where, so I think that's also probably, the data's a little bit skewed a bit, because now these patients aren't going on to have fixation, they're actually doing an initial fusion in those cases sometimes. But I know that's a little bit roundabout answer. I don't think we have a good technique yet, though, which is why we need more of this and more people to try these techniques out for that exact reason. But I think Haley's point was that these were not arthroscopically assisted, these were actually arthroscopically reduced and fixed. Yeah. So you don't need to make that incision. So the idea of doing this, it's, yeah. So it's, again, on sort of the theme of using more and more arthroscopically, arthroscopic techniques in fracture reduction. Okay. So our next speaker is well-known to me, and Dr. Giannakos, it's James Butler from NYU, and he's going to be talking about in-office Achilles' needle tendoscopy for Achilles' tendoscopy. Thanks, Dr. Kennedy. So today I'll be discussing our paper, which is a retrospective review, analyzing the clinical and functional outcomes following the use of in-office Achilles' needle tendoscopy for the treatment of chronic Achilles' tendinopathy. So these are relevant disclosures. So mid-substance chronic Achilles' tendinopathy is a very debilitating pathology that's commonly seen in the athlete. So a first-line treatment is typically conservative management, which entails physical therapy plus or minus the use of a biological augment, including shockwave therapy and or PRP. When conservative management fails, surgical intervention is then indicated, which is typically performed in the OR setting. There's been a growing use of, and there's growing interest in the use of in-office needle arthroscopy for the treatment of a variety of orthopedic pathologies. So the benefits of this procedure is that it includes the use of a very small arthroscope. It's typically 1.9 millimeters in diameter, much smaller than the typical 4-0 arthroscope that's used in the OR setting. It's done with the patient wide awake, the use of no general anesthesia, and the use of no tourniquet. There's been good outcomes reported in the settings of anterior ankle impingement, posterior ankle impingement, and meniscal debridement. So it presents a potentially attractive solution for patients with chronic Achilles' tendinopathy. But at this point, there's no data to support its use at all. So the purpose of our study was to evaluate both the clinical and functional outcomes from the use of this procedure in these patients with mid-substance chronic Achilles' tendinopathy with a minimum of one year follow-up. So we performed retrospective chart review to identify all patients who met our inclusion criteria. So these were patients who had mid-substance chronic Achilles' tendinopathy, who had failed at least three months of formal physical therapy, and had at least one year of follow-up following their procedure. We collected patient-reported outcome measurements, which were the VISA-A and the BIS scores, both preoperatively and postoperatively, and we calculated MCID for each prong. Our other postoperative outcomes that we collected include return to sport, Likert scores in terms of patient satisfaction, complications, failures, and secondary surgical procedures. So this is our technique that was published by Dr. Kennedy's group back in 2021 in Arthroscopy. So the patient would walk into the room, they would then be prepped and draped in the usual sterile fashion whilst position-prone, but then the relevant anatomy would be marked out along with the medial and lateral viewing and working portals, an injection of lidocaine, bupivacaine, and epinephrine would be given into these portals, and then a number 11 blade would be utilized just to create the portals. And this is the technique that we performed on one of our patients. So initially the trocar and scope were inserted, and a diagnostic tendoscopy was performed in order to identify any degenerative tissue, scar tissue, and any tears. Next the shave would be inserted through the working portal and be utilized to circumferentially debride and resect any degenerative changes or scar tissue that would be present. Next the freer elevator would be inserted and be utilized to free up the paratenon and release any adhesions between the paratenon and the tendon. Next the spinal needle would be utilized in order to create microperforations within the substance of the tendon to stimulate neovascularization. The patient was then put into a soft dressing and then mobilized immediately after the procedure. So in total, 12 patients were included in this case series, with a mean follow-up of 18 months. This is the heterogeneity and the severity of the MRI findings, with 5 patients having grade 1 disease, 5 patients having grade 2 disease, and 3 patients having severe grade 3 disease. So in terms of the subjective clinical outcomes, there was a statistically significant improvement in both the VISA-A and VAS scores across this cohort. The MCID was achieved for over 90% of the patients, and the mean Likert score in terms of patient satisfaction was 4.2 out of 5. There was excellent return-to-sport and return-to-work data in this cohort. So of the patients who played sport preoperatively, 90% were able to return to sport at a mean time of six weeks following their procedure, and all were able to return to the same level. All patients were able to return to work, which occurred at approximately four days following the procedure. So two complications were noted. First was a transient sural neuropraxia, which resolved after two months, and the other was a patient who had persistent pain, stiffness, and swelling following their procedure. They had to have formal physical therapy, shockwave therapy, and additional peritendinous PRP injection, but unfortunately were refractory to these measurements and were ultimately deemed a failure. They ultimately went on to have a repeat procedure at 20 months following the initial index procedure. So there's numerous limitations with this study. So first, it's a small sample size and short-term follow-up. It's a retrospective study with no comparative cohort, and there was significant heterogeneity between the patients, particularly with regards to the severity of their pathology. So in summary, we were able to demonstrate that Achilles in office neonatoscopy is an effective diagnostic and therapeutic tool for the treatment of mid-substance chronic Achilles tendinopathy. There was a significant improvement in both the functional outcomes and the subjective clinical outcomes scores in this patient. However, this occurred at short-term follow-up. Overall, the complication rate and failure rate were low. In terms of the athletic population, there was a really high rate of return to sport at a rapid return to play time of 5.9 weeks. However, given the number of limitations of this study, further high-quality studies with an adequate control cohort are needed to determine the optimal utilization of this technique for patients with chronic Achilles tendinopathy. All right, James, that was great. Thank you very much for presenting that. Does any of the audience have questions from this? This technique, who do you, is this your standard for all these patients, or do you choose some go in the OR, some in office? And if you do different kind of procedures, what's your indication for the in office? Is the patient population different? I think as we expand the role of in office tendoscopy or arthroscopy, we need to pick a lane for our patients and those that will be suitable for that and those that won't. And I would say that probably 95% of our patients are suitable. And the reason for that is you've already got to know them because they've earned their operation. They've gone through PRP. They've gone through shockwave. And throughout that period of time, then they will get an idea or you'll get an idea of what type of people they are. We've been doing this since 2019. So we've got probably 300 or 400 of these that we've done in office. And there's probably not been one at all that's had any adverse effect in terms of their feeling any pain or anything like that. In fact, I will tell you that when you look at the outcomes of this, patients buy into the surgery much more when they're awake and looking at it. So because they get a sense of truly what's going on and the likelihood of them being recounseled in terms of their physiotherapy or otherwise is reduced because of that. So I think for my purposes, we're going to be doing sport surgeries in the office like dentists do. We like going to your dental visit. Go and have it done and you get off there and you walk home. That's the way it's going to be. And insurance companies ultimately are going to mandate that because the savings for insurance companies are massive when you don't have an anesthesiologist or an operating room. So, that's a great question, and it is, and we haven't come up with a true algorithm, but just anecdotally, there's a gestalt that if you look at the axial view, and it's greater than 60% of that is truly pathologic or degenerative. I think at that point, the likelihood of success in this is low. But I will tell you, I don't think we're regenerating the tendon. I think as Nick Van Dyck, as you know, you worked with him, and he's worked with you on this, I think we're really just denervating that area, exactly. And I think so when you look at these under ultrasound, I wouldn't advise it because you won't be happy. The ultrasound doesn't change that much, but the patient is asymptomatic and able to get back. So, I suppose we need to look at this two or three years downstream to see if they end up with ruptures of these or what happens. But it doesn't seem that they do. They get back and they're relatively painless. And I think because we're adding in the MFULI technique, that may create sort of a neovascularization in the area that may help them heal, but it's not radiologically apparent early on. I was actually going to follow up on that question that Dr. Stone had. That was actually one of my questions as well. But with the MFULI technique, obviously you're doing like kind of the peppering where you're trying to stimulate some neovascularization. I imagine when you're doing your PRP injection, are you doing that same technique? I mean, for me, when I do a PRP for Achilles non-insertional, I do use a peppering technique in order to do what you're describing. Are you doing something differently for your PRP? Or is it the same? No, I agree with you. I do both, in fact, because, again, we don't have good data. There was a great debate about this a few years ago. Should you do an intrasheath injection or should you do an intratendinous injection? And the reality is we don't know. And so, I think by doing multiple, small intratendinous injections, you're creating an inflammatory response. You're also creating neovascular potential. And then by putting it into the sheath, you're creating an anti-inflammatory well over there. So, I think you should do both. And then to follow up on that question that Dr. Stone had as well, with the intersubstance tearing, is your shaver going inside the tendon at all or is it also a peritendinous? No, that's the point I was making to Dr. Stone that I don't think that's the pain generator. I think the pain generator is all this neovascularization that's occurring on the surface between the peritoneum and the tendon. And that is where you have this uptick in pain generators there. When you release all that, there's a caveat that I should have included in these slides and James Calder alludes to this. He looked at premiership rugby players. I know we're going to talk about soccer players in a second, but premiership rugby players, this was common. And so he looked at a series of three or four of these or more and they did well. And then they put an ultrasound on them. And they found in fact that those that didn't do well had a piriformis muscle that was operating slightly out of phase. It was almost like a jiggly saw running against the edge of the tendon. And then he would go in and he would resect those. So in all of these, wherever we find that there's a piriformis, we resect it or at least we'll clean it up if we find that it has that attritional wearing on the side. No, I really try and avoid taking the parotenone away. It's such a diaphanous layer at this stage that oftentimes you may actually shave it inadvertently. It doesn't need to have a big problem. You have to be super careful when you see fat on the lateral side because you're really close to the nerve there, and that's why we really use the freer elevator on the lateral side. We use the shaver more on the medial side. But no, I don't. And so when you see a tear on this, you don't typically see them on the surface. You'll see a change in the morphology of the tendinous appearance. It'll look more glistening than the true striations. And in those areas, we will go in with the shaver just to get that degenerative stuff away. But we don't take a great amount of it away. That's a great segue into our Premier League study that Dr. Weiss from Galveston will be discussing. Take it away. So this will be far less technical than what we've discussed. This is actually a medical student project I'm presenting on behalf of Sabrina and Sterling who cannot be here today. I'm Bill Weiss from Texas, Canadian, living in Texas, and not really a soccer fan, to be honest. I have no financial disclosures, but I am the communications chair for the Canadian Orthopedic Association, and I do work on the editorial board for Arthroscopy and also the Bone and Joint Journal in Britain. So soccer is the most popular sport in the world, and there are increased physical demands and intensity resulting in higher injuries among the elite players. And there are prior biomechanical and epidemiological studies that suggest that cleats may play a role in the role of injury. So these medical students had an idea to look at the English Premier League in the 2021 to 2022 season and analyze the number of injuries and classify them, and then also look at the cleat patterns of the players, and the goal here was that this may help provide information for clubs and players to choose cleats effectively. We analyzed 15 cleat models, included 510 players, and there were 221 injuries during that season. This data was all collected from the internet, which is a limitation that we'll discuss, but there is a website that you can look to see when and how these players were injured, and there's also a website that will tell you about the shoes that they wear and what the models are. And we basically classified the stud patterns and then did an odds ratio analysis to determine if this was associated with injury, and this is something that we didn't come up with, but we classified the cleats as either very aggressive on the far left, which is kind of your pointy, I would call them almost baseball-like cleat pattern. The mildly aggressive is a mix of the stud and the aggressive cleat, and then the non-aggressive was just basically your typical studded cleat that you would see in many other sports. And what we found was that the highest injury ratios and odds ratios occurred in the very aggressive and the non-aggressive cleat patterns, and they were significantly different from the mildly aggressive cleat patterns, which still had injuries, obviously, but were not to the same extent. And the odds ratios, we looked at a number of different injuries, including ankle, hamstring, knee, and calf, foot, or lower leg injuries, and found significant odds ratios for the very aggressive cleats in terms of ankle, hamstring, and knee. And then the non-aggressive cleats seemed to be more associated with hamstring injuries. You know, as to what all this means, it's hard to say, of course, at this point. It's an interesting little paper that showed some interesting findings and I guess is the impetus for increasing research into these kinds of things. So an interesting medical student project, essentially, with significant limitations in terms of, you know, the data was collected from the internet based on these websites and who knows how reliable they are. And our classification of the cleats was somewhat, I mean, it was completely something we invented and or referred to, so it's hard to know. But interesting in and of itself, especially in the day and age of talk about in football, and there's a paper coming about this as well from our group about artificial turf versus grass and stuff like that. So our conclusions were that there were significant associations between cleat patterns and lower extremity injuries during that season in the English Premier League, particularly the very aggressive and non-aggressive cleats showed increased levels of injury. But these are very preliminary findings and are interesting at best at this time, but certainly require more investigation. So that's Sabrina and Sterling at the top, and me, and we thank you for the opportunity to present this and yeah. Good. Thanks. Thanks so much, Phil. So it is an interesting topic and, you know, many years ago Scott Rodeo wrote a paper on turf toe and how it affected or how it was affected by the playing surface. And shortly thereafter, we had a patient come in and he was from Chelsea Football Club and he had a sesamoiditis and we thought, well, it's got to be because they just changed over from natural turf to a synthetic type thing, so that's what it is. We did all the usual conservative things. We even gave him PRP because he came all the way over and he'd been seen by other people there. And we sent him off and we thought we were great because when he was training, everything went great. When he played a game, he kept on coming in and he kept on having the same problem with his medial sesamoid. And one of our fellows and residents who was far smarter than I just said, that's really strange because it almost looks like a bruise rather than a sort of a sesamoid. And so we looked at his, he was sponsored by Adidas or Adidas, and their cleat right underneath or right on top of where the cleat was, as it was fixed into the boot, there was a little washer underneath that. And that was getting the transfer of the pressure was going through that. And so it created all that problem. So I think it is something that we need to look at a little bit more carefully. But it's, and I think not just in, you can look at it across all injuries and I think as you were doing it, I was sending out urgent texts to my staff to say, you need to get onto these webpages. Yeah. Well, they're out there for football, hockey, I mean, we have a paper coming out about patella fractures in football players, like American football players. There's a lot of data on hockey out there too, if you want to look at something in skates. And then obviously there's soccer as well. And I guess the problem and the limitation is you have to rely on these websites to be accurate, which usually they are, but you know, who knows, they might change up cleats in the mid season or something. It's interesting because the quest for information is not just coming now from doctors and this sounds silly, but fantasy football is really interesting. Yeah. I know, I've played three teams. They're really interested in this stuff. And there's a lot of money involved. When there's a lot of money involved, then we start to get a lot of questions. And so, you know, one of the things that James and his group have published recently is looking at COVID, how it affected injury patterns in the NFL, in terms of Achilles and so forth. There was an uptick in Achilles from deconditioning. So I think all of these things are going to be looked at much more. These data, you know, data is worth money no matter where you get it off the website for free. It's great because they're typically a little bit reluctant to, the teams themselves, they're reluctant to release it. This is true, especially during hockey playoffs. Yep. Lower extremity injury is all you hear. Right. I was just going to, I mean, I think you brought it up, but the, you know, the discussion also about Jones fractures and the interesting thing about the picture you showed from the aggressive to the least aggressive, it looked like it was more of the actual type of cleat as opposed to the location of the cleat. Yeah. I'm also wondering if there's, you know, any evidence about, you know, like Dr. Kennedy kind of brought up with the test point injury, like if the actual position of that cleat has a role in injury as well. So it may be the spread or kind of the clustering of the cleats can play a different role. I would think you're right. And we have a spinoff project we may do in the, we have a biomechanics lab at UTMB and we wanted to do, you know, put them on an artificial surface and then try to slide them and measure how much friction are they, like how much grab they have and use that potentially to, you know, improve the quality of this data. But I agree. I mean, there's no standard and depending on where they are, they may cause pressure points. They may cause pressure areas in various areas of the foot that might be detrimental. Yeah. Good stuff. All right. Thank you. Thank you for coming all the way. So our... Edmonton via Galveston? Yep. Edmonton to Galveston via El Paso. Where Brian is delayed his airplane. Yeah, he just arrived. Oh, there we go. Perfect. All right. You go first. Okay. So we now talk about... I just checked in the... You guys want to have a chat? Oh, yeah. Brian, you go first. Okay. So we're going to talk now. Unstable distal peripheral fractures. Whether we fix the... Once we fix the fracture, whether we should fix the syndesmosis and the deltoid or just the syndesmosis and leave the deltoid alone. When I was training, leave the deltoid alone. That's what we were told. Don't touch it. So there's more and more and more evidence now that we probably should. But we're going to hear both sides of the argument now. Thanks very much. Thanks for having me. So I was assigned to... Oh, looks like your files just showed up there. Eric, do you want to go first again? I think we're going to lose. Yeah, I know. Okay. All right. So we're going to talk now. Unstable distal peripheral fractures. Whether we fix the fracture or leave the deltoid alone. When I was training, leave the deltoid alone. That's what we were told. All right. So we're going to hear both sides of the argument now. Thanks very much. Thanks for having me. So I was assigned to... Oh, looks like your files just showed up there. Yeah, I know. So this is a Duke UCLA talk. Yeah. Typically UCLA wins. But we'll see. So I'm going to talk today about why in a typical Weber B distal tibular fracture with a syndromic injury, that you should be thinking about fixing both the sinuses and the deltoid. These are my disclosures. I also just want to call out some of my colleagues and mentors in the room for your guidance through the years. So I think with the deltoid anatomy, just to kind of gloss over that, I think we all know about it. The superficial, the deep components. In the superficial deltoid, you have the tibial navicular, tibial spring, tibial coccyneal, and the superficial posterior tibial tailor, resisting external rotation with a valgus stress. In the deep deltoid, you have the deep anterior, posterior, which is the primary restraint for plantar flexion, resisting both external rotation and lateral displacement. So the role of the deltoid in the complex repair of ankle fractures has been really borne out a lot with Dr. Hinterman's group. Going back almost 24 years ago now, we're looking at how almost 40% of ankle fractures they found had associated deltoid ligament injury involvement on orthopedic exam. Now, preoperatively, it's good to have kind of your antenna up to see if they're going to have an injury there. Medial side of pain, echemosis. You can possibly examine for anterior medial drawer if they'll let you. And then thinking about kind of what's the role of managing this in this cadaveric study by Dean Lawrence's group, looking at the syndesmodic screw and how to compare when you treated both ankle stability and instability with fibular external rotation, noticing that there was increase in external rotation when there was both PITFL and deltoid involvement. So managing these have been shown to have really a significant improvement. Dr. Anderson, when I was a fellow in Charlotte, did show that in a study of NFL players who had an acute superficial deltoid injury in the setting of a syndesmodic injury, that there was treatment of the medial sided structures led to better return to play in almost 86% of the patients with no significant differences when you do not in their return to play experience. So we know that primary deltoid repair has significant involvement in post-traumatic arthritis. And this study that Dr. Hinterman and Dr. Bronow published showed that in patients who did not address the deltoid injury that was when untreated led to 20% patients going on a PTOA. This is a really important study. I think it was kind of a landmark in kind of shifting the way we thought about how to manage deltoids and ankle fractures. 20%, you can't just walk away and say that's an OK number to leave alone. So shifting the mindset from where the trauma surgeons may have left us in the late 90s, early 2000s, saying, all right, let's think about how to manage this. In fact, it even presses further. Is there a role for maybe even treating just the deltoid and not the syndesmosis? Obviously, this talk is about treating both, but it's something to be thinking about. So in this study right here, it showed that repairing the deltoid ligament at the time of the lateral malleolus fracture actually had comparable results to treating both syndesmosis and deltoid. Another study out of the Journal of Korean Foot and Ankle Society, again, showed the deltoid ligament repair actually seemed to restore ankle stability when the syndesmosis was not addressed. And then again, this study showed in the deltoid ligament repair study, deltoid ligament repair using both anchor fixation of the deltoid with those comparative with syndesmonic scrufication with the anchor group. The anchor group actually had a lower malreduction rate of the syndesmosis, interestingly. So Dan Guss had a paper that Kevin Martin alluded to this morning looking at the role of the deltoid ligament in the syndesmonic instability. This is a cadaveric study where they isolated the detection of the deltoid ligament and then again, did a combination of the deltoid ligament with the AITFL. What they showed is that when the deltoid ligament was disrupted in the setting of a syndesmonic injury, that the syndesmosis became unstable. However, the syndesmosis was not unstable when it was just the deltoid ligament that was injured. So what it showed is that deltoid ligament destabilization led to coronal plane instability when associated with syndesmonic injury. So how do we assess for medial ankle instability? Well, certainly you can get an MRI, you can get a CT scan, but I would advocate for diagnostic arthroscopy as our mainstay of treatment and how to manage this. And so this is a really great stuff that Tom Harris did out of the UCLA Harbor Group showing that when you see a patient who has a medial clear face widening of greater than 5.5 millimeters and then correlated with a visualization of a posterior tibial tendon under arthroscopy, well, believe it or not, they probably have both deep and superficial deltoid ligament involvement. So going into your surgery, you're measuring 5.5 millimeters of widening. Boom, let's think about planning for it surgically, and then let's put the scope in. And then what I would actually recommend you guys do is evaluate the scope because oftentimes you'll have a posterior tibial tendon interposed in the medial gutter, maybe preventing your reduction, or a deltoid ligament interposed in the medial gutter preventing your reduction. So if you don't reduce those, you're going to malreduce the ankle fracture. So it doesn't matter how good of a job you do, it's not going to reduce properly. So indications in these patients were persistent widening and then high injury patients. So have a high index of suspicion. Also have a high index of suspicion in mason nooves and Weber C ankle fractures. So this is the interop assessment. You can see the deltoid tear there. And again, what I'll do is after I scope it, I'll fix the fibula, fix the stenosmosis, and then stress it. You can see what it looks like pre-injury on the stress x-ray there. So then you go and you do your opening immediately. So surgical treatment, well, I think you can, it's dealer's choice. But for me, what I'll do, like I said, is you fix the ankle fracture laterally and then address the side medially. So a medial brostrom, like Dr. Anderson has described in his text, you can do this with both deep and superficial if you want to address them separately. I'll show you in a moment. I consider adding augmentation. But I do believe that adding medial stabilization can allow you to begin weight-bearing them sooner, which I'll show you in a moment here. So let's look at a patient of mine. This is a college football player who had an external injury. There's actually no fracture. So it was an acute, synesthematic injury with deltoid injury here. And you can see the significant medial clear space widening, slightly greater than five and a half millimeters here. What should you do first? Well, I think hopefully all in this room will agree we should scope it first. And I showed these pictures earlier, but again, distraction, marking out your landmarks. I like to wash it out and then addressing the common pathology. And you can see here what the medial gutter looks like there on the inside, completely widened on the inside there. So you fix the syndesmosis, stabilize it, and then you address the deltoid with a medial-sided brostrom. In this case, I did a superficial medial-sided brostrom. And then you see post or pre-deltoid repair and then post-deltoid repair. This is another patient who kind of more aligns with what our question was in the debate. This is a 52-year-old male, not a wrestler, but wrestling with his son, which can, as dads in the room probably know, can lead to injury perhaps sometimes. And you have Weber B ankle fracture here. And then you get significant medial clear space widening, again, greater than five and a half millimeters of medial clear space widening. You can see the Guyton ball, or at least in our case, is a three millimeter probe, showing about four millimeters of medial clear space widening there in the medial gutter. And you can see both the deep and superficial deltoid have been torn here. So in this case, we decided to address both the deep and superficial separately here. And so what I'm doing there on the far right view is finding the deep inferior colliculus of the medial malleolus. And you can put an anchor into the talus at the kind of the equator of the talus. And then you can then bring that ligament fixation, whether it's going to be a tape or whatever kind of suture you want to use, and then bring it through the deep component out and into the inferior colliculus. And that addresses the deep and then separately address the superficial component as well by doing a medial gutter, sorry, a medial side of brostrom. And here you can see the gapping before. And then let's go back and show that again. Thank you. And then you can see now how that gap has significantly closed down. And you can really assess how well your reduction is that medial clear space. So I think all the studies here that I've shown prove is that if you don't close that medial gutter down, not only are you going to have the risk of significant post-traumatic osteoarthritis, but also probably a stage four flap that will develop down the road that maybe the trauma surgeons won't see, but us in the room may see. So this is what the final fixation looks like there. So Dr. Hunt's group had a great study looking at the various surgical constructs and return to sport protocols in these symptomatic injuries. And what it showed is that preferred fixation in these groups were with a complete deltoid injury, all the way from a moderate to a high impact and very high impact, either flexible, screw or hybrid fixation. And then most people use a suture button construct. And what they showed is that the trans-synesthematic repair versus deltoid repair, similar outcomes, but no re-operations in the deltoid ligament repair compared to those who had only trans-synesthetic fixation. Norm Waldrop shared some of his information with us here, which I'll show you in a moment. And then in these patients, how do you manage them? Well, I think if you're fixing the deltoid and the syndesmosis, for me, I like to keep them non-weight-bearing for the first four weeks. I'll put them in a splint for the first week, switch them over to a cast, into a boot by week three, begin active dorsiflexion, plantar flexion, limited eversion, inversion for the first six weeks, begin partially weight-bearing by week four, with fully weight-bearing by week six. So I think the old adage may have been non-weight-bearing for six weeks, but if we can begin fixing the deltoid, I think we feel more confident about letting them put a little weight on it sooner. Patients are going to then kind of manage themselves, obviously, of course, but you can have them start beginning motion earlier. As mentioned earlier today, begin BFR, possibly pull-alter-G therapy, and the goal is return to play in a brace by 16 to 20 weeks post-op. This is a Norm Waldrop study that he shared with me. Looking at 21 of his NCAA players at Alabama, they had grade two, three synesthematic injuries, and treating them the way described here, with average return to play at about four weeks, and the earliest at two weeks in these patients. Obviously, superhuman players at Alabama, that's why they win the championships every year, but a little different model than probably most of us are seeing in our population. Okay, and so thinking about this going forward, is there a benefit to deltoid-specific fixation? I think we all need to be thinking about this, addressing the deep superficial, whether you want to do them separately or concomitantly. I think we've got to still have better research on how to optimally tension them, and then what is the best fixation construct, but it's really in our bimalleolar equivalent ankle fractures, fixing the deltoid is absolutely critical, and I encourage all of you to do so. Mic drop. Thanks, Eric. I think you're convincing a lot of the audience, and so now it's up to Brian to put us back on. So first, I thought we had five minutes, so that was long in the five minutes, so I might be a little bit shorter. I thought it was supposed to be a debate, so we'll see. We can still debate. All right, so I was assigned to give a set of notices about deltoid repair, and I will give the due perspective. So these are my disclosures. This is Eric, and I thought that he might say a couple things here for us to think about. Deltoid repair is stronger, I showed some biomechanical data, which he did. He's going to say it's less complications, less re-operations. But is there really a clinical difference? So let's talk about that. So biomechanical data, here's the biomechanical data starting from Duke as well, looking at these different stages of section and repair. And, you know, anterior displacement, isolated deltoid repair, restored at simmer, but so did isolated stenosis repair. And then they did say that you add more stuff to it, has stronger constructs, which makes sense. Any kind of cadaver stay, I think that's a flaw. As you add more and more anchors and more sutures, you can always have a stronger construct. And so, you know, the things that are missing from that, you know, you have skin, you have muscle activation, you have healing, all of those things are not included. So those are things, this is all time zero data. So yes, it's stronger, but does it really matter over a time period that you're going to get it back? So I am a sports surgeon, I also do knee. So let's think about this in another way, in another perspective. So we think about ACL and MCL tears, how many times do we have to operate MCL tears? Not very often, right? Most MCL tears, we don't. They can heal on their own, you fix them, a primary problem, the ACL, and then the MCL has the ability to form a clot, which will heal itself, right? So let's think about the ankle, right? So if you fix a fracture, can the deltoid fix itself? It's also extra-articular, it can form a blood clot, it can heal itself too. So yes, there are, as Erica mentioned, frequently an injury to the deltoid, but how many times does it have to be repaired? So clinical data, so this is some classic data research, fixing a fibular non-op deltoid, these are 36, 27, 28 patients that are looking over a period of different times, not repairing a deltoid, showing that those can heal on their own without having to repair it and do surgery, make an incision there or add any anchors. So anatomic reduction is a key, the deltoid can heal. Some comparable studies here, these are a little bit older data, and again, all these, again, the conclusions, you can read them yourself, showing that they can heal on their own without having to be explored or repaired, as long as you have the anatomic reduction. Here's a, I knew that Eric might bring out some Duke data to show that maybe I'm contradicting my own colleagues. So this is a sinus nosis group, deltoid-only group, both anatomic reduced at the final X-ray. Clinical outcomes were the same for both, he didn't mention that. So all these outcomes were the same for both. The reason why they said to do, and they recommended deltoid-only was because of hardware removal. In this study, they used screws, not flexible fixation, and which most of us use nowadays. So really, you could say either one, you don't necessarily have to do both. Another one, he brought this study up as well, I thought he might pull it out because it's also another Duke study looking at the same question, deltoid repair versus sinus nosis repair versus combined. So the sinus nosis repair, key to the moment, they mixed that up with metal, some of them did metal screws, some of them did flexible. 108 patients, no difference in clinical outcomes. Main difference was the metal screws required a re-operation. No patients to isolate suture buttons required hardware removal. So key to look at that. And so, and then, so why are we, most of us are in this room probably doing flexible fixation. There's just some studies to show that this is an RCT looking at post-op CTs, rigid metal fixation resulted more likely to be mal-reduced, reduced physiological motion. And so flexible fixation is my part, my, you know, what I typically would use even in our high-level athletes. Again, so is that the right thing to do? So here's a systematic review that was done very well with Dr. Hurley, which Dr. Kennedy knows as well. And this is all showing that suture buttons are favored. So outcome scores, mal-reduction, other, any kind of complications, implant removal, broken implant, and then again, more clinical data. So again, as long as you're using suture buttons, it's going to give you that, not result in kind of hardware removal. So is it clinically better? So if you fix the fracture, you use flexible fixation and you have the anatomic reduction, the deltoid can heal on its own. So Eric, I thought about why you might be saying you want to use anchors. So I know you, I visited you in SCOE, you're from California. I felt like the median home value there was pretty high. So I don't know if there's some secondary motives here. Here's a study that's showing the systematic review of the average cost of deltoid anchor, okay? So somewhere between 500 and upwards to a thousand. So I don't know if maybe there's some secondary gain for your health that's out there in California there. So, or maybe you need another car. So take-home points, not all deltoid injuries are the same. Just like your MCL, a lot of them are more mild and may not even require fixation. As long as you can, any time we fix the deltoid, fix a fracture, then it can heal. So the verdict is in, fix dysmosis, not the deltoid. In all honesty though, in most cases. I do advocate as Eric recommended, doing the SCOE first, evaluating and checking to make sure your deltoid is stable afterwards. But this is what I was assigned, so. Yeah. Thank you. So, what's your question? You guys do a lot of these, so do you scope them afterwards as well? You said scope it before, but then you fix, send the SMOSes, then scope it again, keep everything at all time? I do, yes. I keep everything up from my scope standpoint. I scope it first, clean it out, fix the fracture. I use the scope to help assess my reduction of the syndesmosis as well, and then fix the deltoid, and then reassess the deltoid to be sure that I don't close the medial clutter down in clear space. Yeah, so I do the same. I set up for, like, ankle fractures, so I don't use a traction for other, like, more cartilage stuff, I use traction. I just use, like, put the, you know, the device on there and pull manually. So it's a really easy setup. I don't put them back in traction or anything like that, so I would just go back and take a look. Again, look for the syndesmosis, and then go for it, too. And just to clarify, I don't put them back in traction either for the secondary looks, either. I put them in traction for just the opening part, and that's it, yeah. So when you, Brian, when you do look inside and you do a stress test and it opens up medially, how would you fix them? It's a media blossom, so you're not really going after the deep portion. No. So, I mean, obviously, if there's a huge displacement throughout the vector, you're more suspecting of that, and you see that off the top of your head, then that makes a bigger interest for you. Because that's terribly hard to do, isn't it? To get in there and identify those two ends, and then you might think, well, I'm over-tightening it if I'm putting in a suture. So, I think you have to be careful. I do think there are occasions, like all good debates, probably the truth is in the middle. I think there is a reason to do it when it's unstable. And for healthcare costs, and also, unless you're truly making a great clinical benefit, perhaps you shouldn't be doing it in all cases. But I do think it's nice. And I think, and I don't want to be paraphrasing you, but do you, you would just do the Brostrom type repair rather than trying to do the deep portion or other occasions when you would try and address the deeper health risks? I mean, I think, to your point, if you're looking at it and it's completely blown out both sides, and the quality of the tissue from the deep may not be very good, there may be a role, you said, we still need to learn more about this for specifically addressing the deep. In general, I would say the majority of our repairs are kind of grabbing it all together and bringing it up as one cuff and then repairing kind of a pants over vest. The one thing I would just also just add is, I love your paradigm kind of comparing the MCL and ACL, but I do think just as we kind of move ahead in kind of our understanding of the deltoid, it may actually shift and actually the deltoid may actually be the ACL, and the synodmosis may be the MCL, where some studies are showing that, like, maybe we don't initially need to always address the synodmosis if it's stable on the coronal plane, but the deltoid actually need to be fixed for sure. So, something to think about. Good, good. So, I suppose we need to have a straw vote then, or a poll to see who won. That's a tie. Because there's some money in on this, you know, outside there were some bookies out there. So, do we have a vote and a show of hands of who would always repair the deltoid, because that was the title of it? Who would always repair? Ooh, oh dear, oh dear. Well, who would occasionally repair if it was unstable? I think that's a fair question. So, that's about half. So, I do think that it's a draw. Nice. All right, and now we have, we all came here to listen to the granddaddy of orthopedics in America, my friend and colleague and wonderful mentor at times. And he's going to talk to us about his own Jones fracture. And we're going to talk about a Jones fracture. And the first question I'm going to ask him, as he knows, is who was Sir Robert Jones? So, I hope we can answer that. Sure, you probably know more about Sir Robert Jones than I do. All right. All right, so we're going to finish up. So, Sir Robert Jones, we're going to talk about Jones fractures. I'm going to concentrate on an athlete, because I think it's a little different. We don't have enough time to talk about both. So, what I'm doing to get it healed the first time, and again, what are we doing for all these high-level athletes and high school and weekend athletes too, to get this thing healed? Those are my relationships. So, Sir Robert Jones, 1902, first described this, a series of six. He actually had one himself. There's always been a little bit of debate of what type of fracture he had. It appeared that he had more of a zone one, or zone two or zone three fracture, probably a zone three. And I'll go over that in a second. So, to define truly a Jones fracture, it's a fracture at the level of the fourth and fifth metatarsal articulation, in the metaphysis or metaphyseal-diaphyseal junction. Now, we all know there's a couple of different etiologies. One is this firm capsular attachment at the metatarsal cuboid joint, and the force at the metatarsal-diaphyseal junction can cause this interruption in the blood supply. In the vascular blood supply with avascular acrosis, it's probably a combination of both that contributes to the problem. So, multiple classifications, I like to use zone one, two, and three, although more recent articles seem to merge zone two and three into one, although I still think they're a little different. So, zone two fracture right at the junction of the articulation of the fourth and fifth metatarsals at the base and the inter-metatarsal ligaments. This is more of a distal fracture, more of a zone three. DeVos wrote an article many years ago, and some people use this, called it a DeVos fracture. Now, in the NFL, it's interesting, they did a nice study on looking at NFL players and their morphology. They found that the long, narrow, and straight fifth metatarsals with an adducted forefoot were most at risk for metatarsal fractures at the fifth. Now, the surgery, you make an incision at the base of the fifth metatarsal and extend it a little approximately. The key is you have to lift up in the peroneal brevis, pull down the lateral band of the plantar fascia, and you must get in the exact right position. Where a lot of mistakes are made is that the position isn't correct when you insert your guide pin. So, high and inside, almost like a baseball pitcher, that's the key. There's a narrow entrance, and really the true key is that you have to have your drill dead against the skin on the lateral heel, or you're gonna go too medial. I prefer to drill it and tap it with a cannulated system, and then I like to use a solid screw. So, this is the setup. Typically, I always use the fluoroscope, of course. Now, there's a couple problems in doing this. One of them is that in these CAT scans, in this particular study, showed that there's a lot of problems with cuboid impingement. In fact, one of the future Hall of Famers in the NBA had a cuboid impingement, and it had to be removed, and subsequently, he broke it again. So, 95% of patients have potential cuboid impingement. So, you have to countersink the screw, or what I like to use is a chamfered screw so that the chamfered portion is near the cuboid to avoid that impingement. So, other things that can really help are bone healing helpers. Vitamin D, oftentimes, I always check everybody's vitamin D. I oftentimes put patients on Replesta, which is a 50,000 units. I either use it once or twice a week for two months minimum, and then put them back to a lower dose. Calcium, you wanna check that. I use ultrasound. I like also virtually every high-level athlete I've put on Forteo, and I have for over 10 years. Forteo is a parathyroid hormone. It's perfectly safe. They inject it once a day, and I think it's very helpful in healing of these fractures. Other things that are helpful are shockwave treatments once a week, initially for three weeks, bone marrow aspirate concentrate injections, and iliac crest bone grafts if you need to do that. I don't think the PRP is particularly helpful in this situation. So, postoperatively, usually in a short cast, non-weight-bearing for two weeks, and we gradually increase their weight-bearing. Use anti-gravity, treadmill, swimming, stairmaster, and gradually increase as long as they continue to make progress. Now, some people will return to competition as early as seven to nine weeks, but sometimes they take three, four, five months. It's really variable, and that's the frustrating point of treating a lot of these in athletes is you can't predict always how fast they're gonna heal or if they're gonna heal. So, here's a case study, 18-year-old college football player, kicker, with acute pain, left foot, rolled his ankle in practice while kicking. Obviously has a limp, has a lot of pain over his fifth metatarsal. You look at his x-rays, he has an acute, but when you look a little closer, and it's a little hard to see on these, but he had acute on a chronic fracture, which means he had some periosteal reaction along that fracture, which means he probably had a stress fracture brewing for a long time and then broke through it all the way. So, he had open reduction of fixation with a screw, bone marrow aspirate concentrate, and Allograft paste into the fifth metatarsal, started on vitamin D and a bone simulator. This is in March. Returned to play before July, but you can see how solid it was in July, and he was back kicking for the next season for his college. So, the results of these really vary, depending on the method of treatment, the type of the fracture, and how old the fracture is. You really, I had to take a bunch of slides out because of time, but I really look at these as acute, truly acute, acute on chronic, and then chronic. They're really three separate treatment issues, and you have to modify your treatment based on what you think is the nature of their injury and the age of the fracture. So, if you look at surgical outcomes, there's many over the years. If you look at the more recent studies, Calder had 37 in professional soccer players with good results, O'Malley reported 10 NBA players that did well, and 32 other patients. But generally, the results are good, but there are potential complications, and there are definite problems in terms of, conservatively, we're not gonna really talk about today, but they can refracture or have a non-union, but surgical complications include refracture, bending the screw or breaking the screw, or a non-union. So, here's a screw breakage. This is a big problem. This particular guy was 6'8", and how do you get that screw out? Okay, big problem. Refer to Dr. Kennedy. Here's another one. June, this was an older, but this was an NBA player. June looked beautiful, looked good. Not so beautiful in September. He bent the screw. He bent the screw. He had to go back, put a bigger screw in, bone graft it, bone stimulator, the whole thing, and finally, it did heal again. So, the title of the talk was, how do I get Jones fractures healed the first time, and this is what I do. Careful history and physical, x-rays, I CT every one of them. As surgery, I insert the largest solid screw possible. I'm not a big headless screw fan, just in case it does break, or you have to get that screw out, can be very difficult. I prefer a headed screw with a chamfer on it. As surgery, I inject BBM and BMAC into the canal and around the fracture site, and then I insert the screw, then I put a little more DBM at the fracture itself. Post-operative, I'm on vitamin D, shockwave, bone stimulator, and I use Forteo if I can in every one. So, to summarize, you need a high index of suspicion, careful history, don't forget about the metabolic aspects, and avoid recurring injuries. Thanks a lot. Thank you. Thanks, and I'll ask, as you're standing here, might as well continue to do so. In terms of, I think what we've all learned today is that the two components to this are mechanical and biological, and oftentimes, we forget about that, and I think that's probably why the original screws didn't work. They've probably done a lot of work, and so it's mainly in terms of the type of screws, cannulated or not cannulated. In the old days, it's easy to put a cannulated screw down, but it wasn't that strong. So, I think the take-home point, largest diameter, and not cannulated, but how far do you go down? Because there is some contention that you only need to go down sort of two-thirds, or you should go all the way, the distance from the fracture to the proximal aspect, or is there any rules that you have for the audience for that? So, the question is about the bone morphology, and I had to take a few of those good slides out. There's been some very good studies that show the bending of the bone, and the fact that if you go too far, you're really trying to unbend the bone and put too much stress. So, I want the screw threads to be just past the fracture site, and that's it. The longer you go, the more you get in trouble with that. So, usually, these are gonna be a 40 or a 45 in most patients, not too much longer. I think another thing that you brought up that was interesting that perhaps the practice patterns are changing across this country is addressing this surgically sooner. So, I guess, what would your thoughts be on, as opposed to the college or professional player, maybe the 16-year-old high school player with an acute Jones fracture, would you surgically manage that, or would you treat unoperatively? Well, I would personally surgically treat it, for sure. But, you know, where I learned the most in one case was I had a 75-year-old lady, kind of heavy, broke it. She was non-weight-bearing six weeks per Dr. Torg, and on and on. She healed like four or five months later. She was miserable the whole time. She broke the other one the following year. She says, put a screw in the darn thing. I put a screw in her. She walked on it in two weeks, and she said, why didn't you fix the first one that way? And she was mad at me, kind of kidding me about it, you know? And I kind of learned from her, you know, you got to treat every patient individually, you know, she probably would have done better with a screw. Yeah. Good, okay, and in answer to your question, how do you take that out? And I know, because it happened to me, he wasn't six foot eight, he played for the Giants, same thing happened. We put in a five-five screw, and which is the biggest we could get in. And about two months after we fixed him we got him back to play, bent it, broke it. And so the way we got it, we had to make a fenestration, so we took a hole, we had to make a big, big incision, and then we came down and we actually took all the anterior cortex of the bone away, make the fenestration, took that off, put a massive big graft in there, plated him, and then he got back. So that certainly took him out for the season. Oh, yeah. It's a very personal story. That's a terrible disaster, absolutely. Absolutely. All right, well, I think that probably concludes. I just want to thank everybody here. This is a massive amount of work. And it's just a shame that we don't have more people. You know, four o'clock on a Friday, it's still a lot of people. So I want to thank all the audience. I want to thank all the people who put the time and effort in to produce really high-quality work, and for traveling in safe home, and God bless. Thank you.

syndesmosis

deltoid ligament

unstable distal tibial fractures

ankle stability

surgical technique

metabolic factors

Jones fractures

surgical outcomes

post-operative care

deltoid ligament repair