we were told today. So we'll be leaving around 11, 15, but the other guys will certainly make up for our absence. So we're going to start, actually, with Rick Frokel giving his talk. I requested that he give this talk. Rick has a wealth of experience treating foot and ankle injuries in professional athletes, and I thought it'd be interesting to hear a talk about treatment of those athletes and how that can correspond and influence how we treat our regular patients in the office. So, Rick. All right, good morning, thank you. Can you turn the lights down a little, or is that not easy? All right, we'll get going. All right, I'm going to talk about stress injuries in the foot and ankle in athletes, lessons learned from treating a lot of professional. Those are my disclosures, excuse me. So again, just so everybody understands that stress fracture is a partial or complete fracture that results from repetitive application of a stress lower than a normal stress to break the bone. It never occurs from a single loading. Now, who gets stress fractures? There are only three animals that get stress fractures. Humans, greyhounds, and racehorses, and we're responsible for the other two. What do we do in the evaluation? Acutely, of course, we look at the vitamin D, parathyroid hormone, calcium, all the things you normally do. With delayed union, you look at a few other things as well. Now, I'm going to talk to you about some of the bone healing helpers that we found helpful. We use a lot of Replesta, which is 50,000 units of vitamin D, calcium, of course, different ultrasound devices or exogen type devices. Forteo, I want to talk to you a little bit about Forteo. So, if you look at this study, 5,200 female Navy recruits randomized to the use of calcium and vitamin D or placebo. 20% reduction in stress fractures in the treatment group. So, I think that's significant. Every patient that I treat that has any kind of fracture, stress fracture or acute, I get a metabolic workup on them immediately. I want to know where they're at, what their baseline studies show, and what we can do to improve that while they're healing. Now, what's the advantage of Forteo? Well, it increases trabecular bone volume, increases the bone connectivity, sorry, increased cortical bone thickness. So, it has a number of advantages. Now, I have to tell you, still the use of Forteo to treat stress fractures is off label. Other things, you shockwave treatment frequently on virtually any stress fracture, any recurrent fracture, or even acute fracture sometimes. We do use BMAC. I don't find PRP particularly helpful. Now, let's talk about a couple of the difficult ones. Navicular stress fracture, we all know it sits in the middle there. It's the keystone, but it has a lousy blood supply, basically. And look for pain at the end spot. And you also look for patients with cable varus feet. Now, here's that beautiful picture. That's the loss of the blood supply. Let's see, does this show up on that? I think that shows up. So, you can see that pretty well. That's the area of the void where the blood supply is a problem. Now, it's often missed on regular x-rays. I will first do an MRI if I do not see the stress fracture, but I always get a CAT scan as well. The CAT scan classification is helpful. Just get a sense of where it's at, how you're gonna treat it, and how severe it is. All right, 21-year-old NFL football player, four-month history of right foot pain after increasing his training. Has some actual valgus, has pain at the end spot, normal motion, and his vitamin D is 12. So, here's the situation. Now, you can predict this guy's already had a problem. He's already had one stress fracture. So, you know there's something else going on, and you can see the stress fracture on the CAT scan. He had open reduction intervexation. We used iliac crest bone graft. We use a little device to take these slivers of bone graft and mix them with BMAC. We then excise the fracture area, put this bone graft in, then we use two screws from viral to medial. That's his x-rays in April 29th, and follow-up x-rays were fully healed and returned back to play. Now, Jones fractures. This is the fracture at the level of the fourth and fifth metatarsal articulation, metaphyses, or metaphyseal-diaphyseal junction. Now, the same darn problem. Why do we get problems? Well, Judy Smith did this beautiful study that shows, again, the problem with the blood supply in this bone, and why we have so much difficulty getting these to heal. I still use the classification zone one, two, and three. Zone two fractures usually will heal non-white, bearing in the cast. The displaced ones need surgery, and of course, in all athletes, we're gonna put a screw or a plate or something across it. Same with zone three. It's very important with stress fracture to distinguish whether they're acute or whether they're acute on chronic. Most of the ones we see in professional and college athletes are acute on chronic. They've had some pain. They don't wanna tell anybody about it, or they played through it, or they had a problem a year ago, and they didn't tell anybody. So zone three, be very careful to evaluate them with history, physical, x-rays, MRIs. They're all gonna get surgery as well in an athlete. They're gonna usually, it's true in my experience, I will bone graft pretty much all of them nowadays. I used to not bone graft some of them, but I've gotten more aggressive because you can't afford to have them lose another season by not healing. So a 20-year-old NBA basketball player, chronic right foot pain, felt a pop six months previously, was treated with a boot for four weeks, partial weight bearing when he was in college. Then shows up in the NBA combine. He has pain in fifth metatarsal, pretty good alignment, his vitamin D is 12. This is what his x-rays look like, November 24. You can see there's a lot of reactive bone around that fracture. Clearly, he's had acute on chronic situation, and he actually still got drafted, but immediately the plan was to fix his foot right after the draft. So take down, you have to take down the non-union, put BMAC, iliac crest bone graft, and squirt some down the shaft. They put the bone, also bone graft around the actual fracture, put a screw on, put them on a bone stimulator, vitamin D, and also Fortale. So that's December 24, April 8th. You can see he's returned back to play five months, no pain, in an orthotic. I use a special orthotic to unload the fifth metatarsal. I call it a Duke orthotic, because Jim Nunley kind of taught me how to use it years ago. So Jones-Vaxxer result in the NBA study, 26 players, mean age 25, 85% return back to previous play level, but 90% had recurrent injury, and 12% had a second procedure. In the NFL, 93% of the players were able to return back, re-fracture rate was 7%. Now it's interesting, rookies had 44% problem, and 74% problem during the first three seasons. Another thing I wanna mention to you is that if I get a re-fracture of a fifth metatarsal, what I'll try to do is, I'll take a little BMAC, I'll squirt it in there, and I'll needle the fracture site, and then I'll also put them on Fortale, and a bone stimulator, and a Chalkwave, and not re-operate them in the sense of putting another screw in. We've had a good luck getting those to heal. How we doing on time? Okay, one other thing I wanna mention, we've identified at UCLA, we have three players that rebroke after getting fixed, and we did some studies on their metabolism. We found they had some unique variant of healing, and they had a defect in their calcium and vitamin D situation, and by kinda trying to alter that, they all got, went on to heal eventually. But you have to be aware, you have to do some workups, metabolic workups with an endocrine specialist, and some of these people are getting recurrent injuries to make sure that they don't have some of these defects. All right, in summary, high innocence of suspicion, careful history, physical exam, appropriate imaging, do not forget about the metabolic workup, the rehab's critical as well, and avoid recurrent injuries if possible. Thanks. Thank you. Thank you. Congratulations. We'll hold questions until after the next two presentations and then we'll entertain a couple of questions. Next I'd like to invite Guillermo Cardon from Buenos Aires. He's gonna present a paper, Arthroscopic Correlation of Syndesmotic Lesion with Predictive Findings of Instability on MRI. Guillermo. Thank you. How can I put the next one? Yeah. Okay, thanks for the invitation and the opportunity to share our research finding today. Pure syndesmosis are generally under diagnosis or misdiagnosis. However, at the leading cause of disability of chronic pain and the incision range from one to 18% of all patients. The important is to make an early diagnosis and a proper management for the treatment are essential to prevent some development of a scar, tissue impingement, chronic instability, atherotopic calcification and deformity of the ankle joint. And it's important to highlight that one millimeters of widening of the ankle mortise reduce the contact area for tibiotelar joint in about 42%. And this will be the lead to instability cause of consequently early osteoarthritis. The objective of our study was to propose a new MRI basic classification for predicting syndesmotic instability and validate this against arthroscopy, the current gold standard. And why it is important? Because it's accurate the preoperative planning and better patient counseling may reduce the need for diagnosis arthroscopy in selected cases. Let me be briefly with this. I'm going to show our proposed classification with some image to clarify the concept. This is a patient with a symptomatic syndesmotic lesion, but we ordered an MRI and there was not evidence of any ligaments involucrate. So we consider as a stable. So this is not needed for an arthroscopy. And this is a great one. This patient have a lesion of the anterior tibiofibular ligament. And we consider to a stable and we don't think it's necessary for an arthroscopy diagnosis. And why this? Because we think we are disproving that the diastasis of the tibiofibular is given for the ligaments of the syndesmotic complex. And as we know, the anterior tibiofibular ligament represents a 35% of the diastasis. The interosseous is 22% and the posterior 33%. And the transverse is very small, less 7%. So if only we can evidence an anterior tibiofibular ligament injury, we disminute the diastasis for F35. It's not sufficient to consider as unstable. So in this kind, we consider stable. A grade two, in these cases, you have an anterior and interosseous ligament. So approximately 50% of the complex, the percentage of the stability of diastasis are with these two ligaments. So in this is the more important to use the arthroscopy for a diagnosis of instability. A grade three, in this, we have three ligaments and the more three important ligaments for the stability of the diastasis of the syndesmotic complex. That is why it's about 90, 95% of all the ligament to resist the diastasis. So these are considered unstable. We can make the arthroscopy, but we know we have to repair it. A grade four is more severe injury with the complex that the deltoid ligament is compromised. And the grade five is more severe and more instability because with this mason nerve or medial malleolus fracture. And this is a retrospective study between 2018 and 2023 at our hospital. The inclusion criteria were patient with syndesmotic lesion, with preoperative MRI and diagnostic arthroscopy and stress maneuvers. And the exclusion criteria was previous ankyloarthroscopy, fracture, infection, charcot, severe psoriasis of age over 70. We collected our classification in MRI and arthroscopy findings about the instability of syndesmotic and lateral ligaments and complications. And we make a descriptive static analysis to summarize the data. And we make a correlation between MRI and arthroscopy. The results, we found 16 patients. The mean age was 40 years. And these are the grades that we find in our MRI classifications. So we found in arthroscopy that all the patients were unstable about the syndesmosis and all have an external lateral ligament instability. And 18% of the patients have a medial ligament instability. The MRI as a sensitive for detecting instability was 100%. There was a perfect agreement with arthroscopy but the statistics kappa was not defined. And we can found a statistical association between MRI and ligaments instability. As complication, we found only three patients with a minor complication like a superficial infection, stiffness and discomfort. There was no major complication or recurrence of instability. And in three athletes required hardware removal. The limitation was a small sample. So the limits of the formal power analysis is small. So as a conclusion, MRI is a reliable tool for classification of persons with motor injuries as stable or unstable. There's a strong correlation between MRI classification and arthroscopy findings of instability. And while fluoroscopy and arthroscopy remind the gold standard, it's invasive and not always necessary. MRI can get clinical measurement and surgical decision-making minimizing both the diagnostic invasiveness and risk of underdiagnosis. The study support the use of MRI as a primary non-invasive diagnostic modality but it's a small sample. So the result are promising but require validation and a prospective comparative study is needed. Thank you very much. Thank you. Next paper presentation is gonna be by Austin Wetzler. He's gonna talk on augmentation of the Achilles tendon repair with reinforced bioinductive implant. Austin. Hello everyone and good morning. My name is Austin Wetzler and today I'm gonna be talking about Achilles tendon repair augmented with a reinforced bioinductive implant. Before I get started, I would like to thank all my co-authors listed below and give a special shout out to Rachel Keller. And I would like to state before I get started that I have no financial disclosures or conflicts of interest. In recent years, there has been a much greater emphasis on enhancing healing and early return to sports and athletics following Achilles tendon repairs. Previous literature has explored the use of various different dermographs and xenografts for an Achilles tendon repair. In this study, we look at a reinforced bioinductive implant that has recently been developed with the goal of augmenting soft tissue in tendon repairs. This RBI is an off-the-shelf implant that requires no special preparation or storage prior to use. The dimensions of this implant are 23 millimeters by 30 millimeters. The structure of the RBI is composed of highly porous type one collagen material as well as biocompatible poly-L-lactide microfilaments. This structure forms a scaffold that both augments and strengthens the reconstructions as well as promoting the induction and maturation of host cells to help heal tendon injuries. A common issue that is encountered when repairing an Achilles tendon is a deficiency located on the anterior side of the tendon. This deficiency essentially just represents a lack of tissue. To reinforce healing and enhance recovery, the RBI was applied to the anterior surface of the repaired Achilles tendon. The purpose of this study was to evaluate the outcomes of a consecutive series of Achilles tendon repairs augmented with this implant. In this study, all patients were diagnosed and underwent a standard open Achilles tendon repair within four weeks of the inciting injury. All cases were completed in the prone position and all patients received general endotracheal anesthesia as well as a popliteal block. A tourniquet was placed in the upper thigh and inflated in all cases. During the procedure, the ends of the Achilles tendon were debrided and crack-out stitches were placed in each side of the tendon and passed to the opposite side where they were then tied together. In this slide, as highlighted by the green arrow, the deficiency can be visualized. On the back table, the RBI was hydrated and sutures were placed into the opposite corners of this implant. The implant was then centered over the site of the deficiency and using the sutures previously placed, the RBI was secured to the anterior side of the tendon. The remaining two opposite ends of the RBI were sutured to the tendon. And lastly, a suture was placed in the middle of the implant in order to securely fix the implant to the anterior surface of the repaired tendon. Following surgery, all patients were placed in a short leg cast in gravity equinus. At week one, the cast was removed and patients were placed in a walking boot that contained heel lifts. And a physician-directed exercise program was initiated which encouraged non-weight bearing range of motion exercises. At four weeks, the heel lifts were removed and the patient began full weight bearing in a boot. And at six weeks, the boot was discontinued and concentric exercises were initiated. Shortly after this, eccentric exercises were slowly incorporated as patients returned to baseline regarding strength and range of motion. In this study, 15 consecutive Achilles tendons were repaired and augmented with this reinforced bioinductive implant. The average follow-up was 2.7 years. The average age of each patient was 35 years and the study consisted of 10 males and five females. All patients returned to full activities five months post-op. No complications, re-ruptures, or adverse reactions were reported with the use of this implant. The Achilles tendon rupture score on average was 91. The recent focus on Achilles tendon repairs has really emphasized on how to improve outcomes and facilitate early return to work and athletics. The patients in this study who underwent repairs augmented with this RBI all reported excellent outcomes in early return to work and athletics. Anterior deficiencies encountered during Achilles tendon repairs are commonly caused by loss and debris of tissue at the proximal and distal portion of the Achilles tendon. Also, compression of the tissue itself leads to deficiency due to the crotch-out lock-in stitches. Some advantages of this implant that need to be emphasized are that Carter and Walsh in animal models showed that when suturing this implant to the tendon, it increased the initial strength of repair. The implant itself also enhances the healing of the tendons as well as increasing the strength over time. This RBI is off the shelf and very easily applied during surgery and does not increase substantial time in operation. The most glaring disadvantage of this implant is that it's costly, costing about $3,000 per implant. It is recommended that Achilles tendon repairs with deficiency located anteriorly should be augmented with this implant. However, a data point that should be explored is the overall incidence of this anterior deficiency occurring. Further studies are also needed comparing this technique with other traditional techniques as well as comparing this bioinductive implant with other implants. Further studies should also explore the effects and differences of aggressive rehab protocols and how they relate to outcomes. I would like to wrap up by saying that Achilles tendon repairs augmented with this RBI had excellent outcomes and these outcomes were reported subjectively. This RBI is easy to use and easy to implement and enhances healing and strength of the tendon which allows for more aggressive rehab and facilitating early return to athletics and work so patients can get back to their normal lives. Thank you so much and I hope you all have a great day. Thank you. Want to come up? Take a couple of minutes for questions. Any questions? Kevin? Yeah. So, Dr. Korkul, lately I've seen a ton of the Vickler. What's your take on that? Excuse me. Well, my change in opening them all is that I had a couple NBA players rebreak, and I felt they rebroke because I probably didn't open them and bone graft them. So I've gotten a lot more aggressive over the years after you have a couple, you know, rebreak of opening them all, bone grafting, and it's been more aggressive in terms of doing it. Now, in terms of which ones you operate on, the big thing is what do you do with all the edema patients? They got navicular edema, they have a little pain, and then what are you going to do with those? With those, you can shockwave, you can do the other things and just see if they'll get better and watch the edema resolve. Obviously, the edema is going to stay a lot longer than their symptoms, hopefully. Those I won't operate on. I'll try to not operate on those. But anybody with a fracture that's a high-level athlete, I think you have to be aggressive in operating on those because otherwise they can lose two seasons. They lose one season just getting better nonoperatively, and then they lose another season if you have to operate on them. So I think you have to be fairly aggressive in treating these patients to try to get them better. I use two screws. I have seen people use one screw and heal, but I feel two screws is better because I try to get one screw across the fracture site a little higher and one a little lower. The idea is kind of rebar, trying to prevent the fracture from propagating as well. One more quick question? better clinically, they're able to return to sport, usually football, something like that. But if I CT them, it's still there. So would you fix those guys in the off season? Would you let them continue to play as long as they're asymptomatic and it's not progressing, follow closely? Yeah, I would follow them closely. I wouldn't operate on them if they're asymptomatic, even though they have a line. Frequently, as you know, stress fractures will still have some lines, even though the patients are completely asymptomatic. So that's always the art of the treatment is when do you make a big deal out of the line when you don't worry about it? So I think if they're clinically asymptomatic and it looks like the majority of the fractures heal, but not all of it, I watch them and just keep a close eye. Thank you. Thanks, guys. So we kind of keep someone on time. I'll call it here. Thanks to- Okay. Thank you. Thank you. The next talk is gonna be by our other FERCLE, Eric FERCLE. He's gonna talk about management of Achilles ruptures, appropriate given the last talk, fixation strategies, when to augment. What a good lead-in. All right. Good morning, everybody. Thank you, Dr. Stone, for the invitation. So this morning, we're talking about management of Achilles tendon ruptures and when to augment in my approach to managing the surgical fixation of them. These are my disclosures. So as we know, Achilles ruptures are fairly common, always coming out in the media. More recently with Aaron Rodgers, patients come in the office asking, you know, I want what he had. It's commonly seen in basketball, probably more than any other sport. However, I wanted to bring up the gymnastics element of it. In the Olympics last year, two gymnasts tore their Achilles. It's quite a devastating injury, and these more often occur in floor exercises. As we know, the mechanism, plantar flexion with an extended knee, sudden dorsal flexion, or a direct blow to the connective tendon. Often patients come to your office and they'll say, doc, I feel like someone hit me in my calf. Turn around, nobody was there. So you can see here, it's usually a non-contact, maybe a trivial event, and boom, right there, pop. So why do they occur? We know the hypovascular region usually inserts just about two to six centimeters above the insertion, where the blood supply is typically reduced, especially over age, repetitive microtrauma, eccentric loading. Occasionally, tendinosis can play a higher risk. However, the big thing that we worry about and why augmentation may come into play are the missed ones. I'm not sure how yours are in your community, but in my community, it's not uncommon. People come in three, four weeks later, they're told by urgent care, oh, it's an ankle sprain. They're put into a boot or a brace, and then all of a sudden, whoops, that was missed. So in clinic, you don't wanna miss that divot, have them sit prone. Sorry, do you mind just turning the lights on a moment? And then one thing I'm also constantly looking at is looking at the symmetric resting tension, and that's also a good way to look at how they're evolving during the course of their recovery too, and making sure that the tension is maintained, because it is really critical to make sure you don't under tension them, and then also they don't expand and lengthen over the course of their recovery. So in terms of the non-operative approach to this, papers always quoted, I have Canada, of course, about the non-operative management and people do well, and I always joke with my patients, well, you can go to Canada and get non-operatively managed. However, in my opinion in the United States for our young athletes, and even our middle-aged warriors, our weekend warriors, like this topic of this whole session is I think treating them is really the way to go. And there's this great paper that was done that actually won the AOFAS Goldner Award last year, doing what's called a Monte Carlo analysis, which showed that re-rupture is actually almost exclusively a complication of the non-operative group, right? And so the non-operative group in that study actually showed had a higher 6% re-ruptures as opposed to the open or MRIs had a 0.6%. And so in the New England Journal study, by excluding those re-rupture patients from their further data collection, the protocol actually eliminated the worst outcome. And so it actually was a very flawed study, and you do a deep dive on that. So this is a paper out of Canada, and then the one in JBJ showing that Achilles versus Opris-Nanop, how meta-analysis, surgical patients had a higher return to work quicker, but more randomized trials were needed. So why do surgery? Well, faster return possibly. In this study of OJSM, surgery, again, faster return to work. Also, in this study out of Finland, I think this is something I always quote my patients, we can get restoration of your calf strength earlier, and also more physical function, so more power. And then also muscle atrophy and strength. So surgery versus non-op. So non-op had increased length, decreased strength. So in terms of the approach, you can do an MIS or an open approach. My opinion, this is not always necessary. So how do I approach it? Typically, I'll do a horizontal incision, although occasionally I'll do vertical, depending on the type of tear pattern or how long they've been out since their injury. These are different options. Endoscopic is also an option as well. The Maugh-Griffin or Mifuli, I don't have as much experience with. So in terms of the percutaneous technique, use a jig and you pass the ridge of needles through it. This is a study by Dr. Delam's group out of HSS, looking at the construct had similar forces with early rehab compared to non-locking construct. Dr. Anderson's study looking at no ruptures and return to play at 8.9 months post-op. And this study was done when I was a fellow in Charlotte, looking at open versus mini-open and how the percutaneous technique had a higher return to baseline at five months and 6% fewer total complications. So this is how it looks proximal, so up to distance up. You can also do anchors in the calcaneus if you like. That's not typically my approach. I'll do that for my distal third, but it's not an all for me on those. I typically prefer to do, not put anchors in the calcaneus and they're gonna avoid putting a drill hole in the calcaneus, especially in my athletes, where you can create heel pain. So you just gotta be careful of that. Because the Achilles really wants to heal. So that's why, in my opinion, doing minimal detection is really key. I do a no touch technique. The fellows, the residents who are with me, no, do not retract on the skin. And if you can, avoiding putting anything around the skin, because you want to really preserve that peritonin and the soft tissue. And so the Achilles is very sensitive, less is more. This is what it looks like in the OR. Check the Thompson afterwards and make sure. And I feel you're really maximally tensioned because the Achilles definitely has some creep elongation over time. And so you're gonna stretch that out. And so get at time zero, you want to have maximal tension there. And then eventually it'll stretch back out. Because the concern obviously is over elongation. And that's what the fear is if you don't tension them enough there, especially when using this technique. So that's what it looks like in the OR, at week one post-op, at week three post-op, at four months. From a marketing strategy as well, therapists see that, they're like, wow, who did this surgery? It looks beautiful, right? It looks like a sock line at the end of the day for patients, right? It's a really good approach, I think in my opinion as well, but people are in the community seeing that. Again, soft tissue technique and management of that. Wound closure is key. I joke in the OR that I spend as much time closing than I do on the actual surgery. So my average turnover time for surgery is about 28 minutes, maybe 32 minutes, depending on what it is. But then another 30 minutes are almost spent just on really meticulous closure. I do an epitendinous suture, I do a peritoneal closure, and then I do two more layers on top of that. It's really important, I think also, you can do some venting of the anterior tissue or the deep fascia that allows for the peritoneum to then close more easily around it. And then you can close at the top, you can do, I do a forerun monocle, or you can do dermabond as well. And then post-operative protocol. This is so critical, as already was alluded to as well. So I begin blood flow restriction usually around day five to seven post-op. When they're in a cast is Johnny Owens' group, and then also Mark Dracos has shown in Achilles Rehab, significant improvement in returning the hypoxic state, and then reducing muscle atrophy while they're immobilized. And then eventually, for me, I'm a little less aggressive than was shown in the previous study. But for me, I'm gonna have them walk until usually around week four. Week five, begin the heel-lift protocol, and I don't get them out of a boot until week six. I'm sorry, out of a boot until week eight, and then into a shoe by that point. And it's really critical to tell your therapist, for me at least, no dorsiflexion past neutral for the first 12 weeks, because the therapist can be really, really aggressive. And so you wanna have great communication with them, give them all your cell phone. And so they can really get stretched out way too quickly. And we may or may not have seen that in some of the players who've had that in the professional sports, where the therapists are just too aggressive, and then you're limping, you lose that power. And so this is a study by Dr. Dracos I was alluding to, looking at BFR after Achilles. Increasing strength of operative leg and facilitating recovery. Skip through this, just to make a time here. So tendon augmentation, the reasons you may need this poor tendon quality, increased repair strength needed, chronic or neglected ruptures. What are the types of augmentation you can use? You can use Autograft, Planteras, free, right there. An Acellular Dermal Allograft. Xenografts, as alluded to, although the one that was brought up is actually a combo Xenograft with a synthetic. And then benefits of augmentation. Increased repair, stiffness, strength, bridging that goalie or that gap, or to reduce gapping actually as well, utilizing this bioinductive implant strategy. So for me, I like to do kind of the burrito style. AI gave me that picture, I typed in Achilles burrito, and that's what came out. So I like that picture there. Or you can do a coverage or an inlay. For an avulsion technique, you can also think about doing actually, placing at the emphasis where the Achilles attaches below it, or you can do it above it, or above and below too. And this is the rotator cuff study, looking at augmentation, how dense, mature, parallel bundles of collagen, and then eventually over time, progressing. A couple of studies to point out real quickly, looking at Achilles specifically with bioinductive implants, and how it can help increase ankle strength and motion with increased tendon thickness on MRI. Another study out of Spain, looking at reduced comorbidities compared to FHL transfer. Just a quick presentation here. 52-year-old male with a distal third Achilles tear from pickleball presented at six weeks. And so for me, it's that distal third. It's a really hard thing to do, I think, with doing this end to end, there's not much tissue left. And so that's what it looks like. And then all together at the very end with the implant there. So operative managing of Achilles tendon, at least in my opinion, is the gold standard. Decreased risk of retear, ability to regain and redefine the muscle tendon unit reliably, increased power, use meticulous soft tissue techniques, and then using MIS also allows for possibly a lower infection with an equivalent nerve complication risk. So again, this is not what I think you should do, is if you can avoid it. And thank you very much. Thank you. Thank you. Thanks, Eric. Next, I want to call up Brian Law. Brian was one of our hosts in the Traveling Fellowship and got to spend some quality time with him. And he's going to talk about operative management of Hadlen's deformity. It's nice to see you again, I said. Thanks, Jim, for the opportunity here. Let me just make sure I get this right. All right, so today we had the opportunity to talk to you about operative management of Hadlen's deformity. Let's see, how's this? There we go, okay. So Hadlen's deformity is a constellation of things. So it's an insertional Achilles tendonitis, as well as bursitis and retrococcalneal bursa. And then that deformity here, it's kind of the bump on the bone there, but you can also get this pump bump, which you also hear about. So different ways to kind of diagnose it and where they describe the pain, which is a little bit different than Achilles tendonitis, which is described in the bottom right here, which is not quite the insertion, but a little bit higher. So on physical exam, a lot of times they just, where they point, they point right to that where the Achilles inserts, it kind of gives it away. But you can see kind of a, they talk about this two-finger test, squeeze test, where you can feel right around that area. You can look on x-ray, which also can give you kind of indication even before you walk in a room, of what they might have. The mainstay of treatment for this is conservative management. So I know this talk is about operative management, but I do want to spend a couple of slides on conservative management because that is the mainstay. Doing courses of PT, some heel lifts, some anti-inflammatories, and operative management is really only after extensive non-operative treatment. A couple of things with your order of physical therapy, what exactly you're ordering. You can order some eccentric loading, but there's also heavy slow resistance. And they're both effective, and obviously it'll depend a little bit on your therapist and what they're comfortable with. But it shows at least if it's heavy slow, to sometimes have more compliance with it as well. This is what the study that was done in 2015 was showing that it might be a little more compliant to the heavy slow, and patients seem to like it more. So I know that in our boards, a lot of times it says eccentric loading for these Achilles injuries, but there are other alternatives that patients might like more. So when you're ordering your physical therapy, describing kind of what you want, it can be important too. There are also some other non-invasive treatments. So not quite just physical therapy, but not quite surgery. We can do shockwave therapy, PRP injections, and then you can do these topical nitroglycerin patches. If you are gonna order that, it's obviously off-label. So you gotta make sure you're putting it specifically in the prescriptions, what you're asking them to do. And typically you're cutting them into fourths, and actually for the first couple of days, you actually come into eighths to titrate that. I think that is an option, and I think patients do well with that. I typically do it as like a second line if PT itself doesn't work. But it is an option, but you just have to be careful how you're prescribing it. Now, going on to the surgical indication. So it's obviously a failure of non-operative treatments, and typically it has to be for at least a couple months of really going through it. A couple options, you're gonna endoscopic or open, and this is obviously the arthroscopy association, so we're gonna talk a little bit about endoscopic. But it's a prone position for both. Posteroscoping if you're gonna do it endoscopic. And it's really for younger patients or if they have no tendon degeneration, which is often determined by MRI or if they have swelling on an exam. And then there's good results of that, of chiropractic function and satisfaction. And then open is probably also commonly done, which is like a central midline approach or a lateral approach where you can actually debride the tendon a little bit more. But you do have to split the tendon one way or another, which can have risk of avulsions, and also make an incision there, which we just learned about can be a high risk for wound complications. And so here's a study looking at biomechanics in terms of endoscopic versus open approaches. This is a cadaver study looking at endoscopic versus midline. And you can see in terms of overall pull-out strength, which you might suspect since you don't have to take down achilles at all, that endoscopic you have much higher pull-out strength, where you have to split, even if you're very meticulous, you are gonna have to take at least a portion of that tendon off. And when you do that repair, it's not gonna be quite as strong. They didn't have any difference in their resection amounts. And then the thought was that you could potentially return them back to earlier because you have a higher pull-out strength, less likely smaller incisions, less likely infection, and less likely to avuls it if they move quickly. So what is this? Is this a posterior approach? And I'm just gonna go over a few slides of exactly how I like to do this. But it's a posterior, so if they're prone, you're kind of using the lateral malleolus as a marker, what level you wanna be at. You can also use fluoroscopy to kind of triangulate where you wanna be to start. There is obviously the posterior tibial under vascular bundle here on the medial side. And so I'm gonna kind of a little bit of how you might wanna do this too. And this is how I do it. I think other people have slightly different approaches. But if we take this slide here, and I tend to put my camera in first from the medial side and I'm angling toward lateral. So I'm staying away from the posterior tibial bundle. And then I'll come in with that other incision and I'm actually trying to hit myself on purpose. Okay, and then I'll slide down that and then kind of working back and forth and kind of create a little space, a little bit of working space for my shaver. And then as I can develop and see that space again, I'm protecting myself from going to medial. I'll pull that camera back a little bit. And now I've got a little more potential space to work with that shaver and be able to see everything. And then you're working more and more back as you come back and then be able to eventually see your Achilles. You can also just for us, try growing them as a similar, same technique as well. So here's an example of this. So this is 57 year old, had a contralateral side open and didn't like the incision and stuff. So actually we ended up going to endoscopic for her. You can see that on her MRI, and I don't always get MRIs, but she unfortunately came with one, but that's something, if you're thinking endoscopic, I think it's important to get. But you can see in her Achilles, there isn't really much signal there. A lot of it's in that bursa. And so we clean up that bursa, we use fluoroscopy to triangulate and make sure that we're getting a good resection. And she was actually, you know, felt much better. She had, for end of one comparison of open endoscopic, she enjoyed her endoscopic much more. We were able to get her moving much quicker. Here's a gentleman, a female who actually had a prior open debridement at an outside hospital and either reformed or forget how long the timeframe was between the surgeries, but she obviously has that bony prominence in the back there. And we didn't want to risk going through the same incision and wound complications. And so we ended up going endoscopic for her. And you can see we kind of did the same approach, kind of doing that debridement with her bur, slowly coming down and using fluoroscopy to confirm that. And she had a good result, and that she's much happier with this. So we did this endoscopic approach and we didn't have to worry about the wound, and she healed up quickly. Now you can go open, and there's a couple approaches. If I were to go open, I do the midline split. And there is also a lateral approach you can do as well, but I like the midline. I get really good visualization of it. I feel like I can decrease that risk of any kind of nerve injury. But we do have to worry about wound healing. And I do obviously stress to my patients that they have to protect, especially for the first month. I have them in a split for two weeks to really protect it and kind of keep that covered. It's something you do have to counsel your patients about. Here's just a study comparing the midline versus lateral approach. And it basically shows that they have, both show improvement, and that they both have similar amount of complications. There wasn't specifically amount of difference between either one. Here's a 35-year-old. Here again, this is MRI. You see there is some tendon degeneration. I think that might be harder to do endoscopically. I'm interested to see how other people on this panel might do. But for me, if I see that, I think it's a little bit harder to do endoscopically to get in there and kind of do a good debridement. And so this is just kind of an approach. You have your tractors in there. You can have a saw. I have the mini fluoro in there to help me see exactly where my resection's gonna be. And I take that part off. And then I do a double row kind of speed bridge approach in terms of the repair. Special considerations, I have to admit that I have not done this in practice. I find that the endoscopic and open approaches do very well. But if you have a refractory to a good resection, good debridement, and that can construe during osteotomy, using this phallophillip angle as kind of your indication for that. I'm interested to see if people on the panel have done this. But I have not personally done this. I feel like the other approaches can do very well. So in summary, conservative management is the mainstay, and I want to make sure you start with that because you can do well. Endoscopic treatment, posterior approach can be very safe. It can decrease complications, has much, much greater, pull out strength and often facilitate early return to activities and play. However, you have to make sure there's no Achilles and intrasubstance disease if you're gonna do that. If you are going to open, I tend to do a midline approach, but you can do a lateral open to decrease that avulsion risk and osteotomy is for special cases. So thanks again. It was great hosting Jim and the rest of the Childhood Fellows this year. Open to questions when we get there. Thank you. Thanks, Brian. Next up, we're gonna have Kevin Martin from The Ohio State. The Ohio State. Talk about lateral ligament reconstruction. All right. Yeah, well, good morning. We're gonna lose some of our senior members here. They're gonna check out us. We're gonna keep rolling though. So looking at Brostrom in 2025, what the heck am I doing? First of disclosures, we are the national champions. This should be noted in the disclosures. So I'll rub that in for one full year. Going forward, my background is a paratrooper in the United States Army. Three deployments. We sprain our ankles and when we do, we do it well. In this West Point study by Brett Owens shows that when we have that higher rate of recurrence and we have that rate of instability, when our guys are going out, we hit the ground hard and we hit it with equipment on. So we're also very common to have these. So when these young soldiers, young athletes come in and we have this kind of gross instability, how are we treating this? And how do we get them back to the field or back to duty quicker? And that's really the answer. So Kevin Kirk is a friend and is a mentor, another military service member. Looked at his study showing that these actually can stretch out if you accelerate them too rapidly. Just like your Achilles, if we get going too fast, too quick, we can actually elongate them and they'll also have significant less strength to our repair with about 50% the native repair strength. So that's something to note when you repair this and you say, hey, I can do my Brostrom standard and I can rehab them really fast. The answer is maybe you can't, right? So let's look at what some things. So Chris Coetzee's paper is very nice. This is a randomized, actually it's not randomized but it's a prospective study looking at return to play was much quicker when they augmented with suture tape and how fast it got these athletes back to the field. And then what I did is I essentially copied that same study when active duty service members. So we looked at our service members and our return to play and our return to sport and we got it to 96% of these patients could do a single leg hop and single leg heel rise at six weeks with unprotected, no brace on at all. So this is a pretty high number. What they did though, the reviewers kind of beat me up. They said, hey, if you tell a soldier to jump out of a plane, he'll jump out of a plane. So if you tell him to hop, they'll hop. So we redid this, right? So we redid this study at Ohio State and we're pending publication on that. And our numbers dropped from mainly males to mainly females and we dropped to about 89%, but still 89% hop in a six weeks with civilians is a very good number. So let's look at what I actually do in practice. Cause sometimes we talk about a brostrom and if we all raised our hand at how we actually did it it's crazy how much different each one of us in the room will do it. So this is the way I'm doing it in 2025. This right here is what I wanna avoid. I do a lot of revisions and this is what, this makes me sick when I see this patient come in, there's knots everywhere. So how do we get rid of that? So for me, I do this incision, it's pretty relatively small. You know, it's not minimally invasive, it's pretty small. We take down the whole cuff of the ATFL and into the CFL and I look directly at the barrier area in the ladder wall of the talus, make a small burn mark. So I know right where I am, I have a residence, they're doing this part, they're drilling, they're doing all this, but I'm looking right at it. Then I drill and tap and then I make this nice, beautiful flap and I go right through it. This is a technique that I'm using and that way we get the tape or whatever augmentation. There's so many augmentations out there. We saw the BioBrace today. Whatever you want to, you get that off of the soft tissue. I don't think that should be on the cartilage. So I'm passing this on top of it so it is truly the seatbelt. And then moving forward, we still gotta stay true to our anatomy. Sometimes foot and ankle, we get a little crazy. The ACL guys debate anatomy all day long and we get a little bit lax. So six, 12 and 18 are right around there. LePrad's paper shows us right where to put our anchor. So stay focused, you know, actually look at this and really teach your residents. Stay true to the anatomy. I do drill my hole for my augmentation just off of the face because I still want to repair the ATFL and CFL back to the face of the fibula and leave my augmentation off a little bit so it lays on top of it, truly like the seatbelt. So it's not just sitting there blocking my actual real repair that I want to do. I'm now using all suture knotless anchors because I want to avoid those knots. So this gives us a nice way to avoid our footprint and I do so many revisions that this drill hole is very small and there's almost always real estate, even on your third revision to go in and actually do some repairs. Simply do a horizontal mattress at the ATFL and a horizontal mattress at the CFL. You can cut, pass. This is actually some suture management. So those of you like me that, you know, the shoulder guys do all this cool complex suture management. For me, this is new. So just keep track of your sutures, where you're going and then it's simply a pull, kind of pulling this thing through and it actually works to seat that in there, it's very nice. And then looking at this, this is what got me is that it avoids me tying knots and my residents tying knots. So this is great. So as I'm pulling that, you can see that reduce it very nicely with a completely knotless system and that's what we're looking for. And then on this, you can see, you can use the internal brace, you can use the bio brace, you can use Artalon, you can use whatever you want to. But I think this is the point. Why I'm showing this step is because people ask you, how do you actually tension to prevent over tensioning? 15 degrees on a nice bump, not holding it in any strange positions. And that's where I think going forward, if we're gonna start using these other devices, we're gonna have to figure out what position we tension them in, how much tension do we apply and each device is gonna have its own elasticity that needs to be involved. So this is what I do for the internal brace, keeping it pretty simple and just kind of following the manufacturer's guide. Put the internal brace in, then I still pull the IER up and over, so that's my final picture there on the right. Usually you cannot see the internal brace when we're done. And then the big thing, like we're talking about today is rehab, rehab, rehab. It's not so much we do in surgery, what do we do after surgery? We start the blood flow restriction therapy, we start alter G, we have different balancing mechanisms, we start these acutely, start them right away. So what I do the first two weeks, they're in a boot and they're walking. The crutches are gone by post-op day five and the boot is gone at post-op day 12. So at post-op day 12, they go into an ankle lace-up brace and they stay in it the whole entire time, right? They're rehabbing in that. They start blood flow restriction at 72 hours if possible. Some of that our players can start 72 hours, but the general public is usually around that 10 day mark. They wear the ankle lace-up brace until they get to the eight week point and they're using that for all activities. My athletes are going back to sport around eight weeks and that is full back to sport. And then people that talk to me about, hey, my brochure can do what yours do. This is our six weeks. This is a typical patient of mine at six weeks. And if your patient's doing this at six weeks with a vicral repair, we've seen that at the academy this year, somebody was touting their vicral repair versus internal brace. I wanna see them do this and then have some confidence. It's pretty, you know, these guys and gals are really beating up on these repairs. So at six weeks, that's what we're expecting. And that's very similar with my military population. This is some of my special operations that I guys that I took care of. This guy's at about five and a half weeks, ignored everything we told him, went out and was jumping from 40,000 feet and did 40 jumps at 40,000 feet. And then I had no idea what Irish dancing was. Who knew Irish dancing was? I had no idea. She said, can I go back at six weeks? And I'm like, sure, it's Irish dancing. What could that possibly include? If you watch this young lady, oh, it's kind of, yeah, if you watch her dance, you're like, oh my gosh, I had no idea this was a Brostrom test. Cause they were on their toes the whole entire time. She won worlds at about six and a half weeks post up. And then revisions, I think this is the way to go for revisions as well. We're taking them, we're getting rid of all these knots, we're rehabbing them. This is actually an internal medicine resident. So you know the internal medicine, they're not really the most agile people, but look at them, hop up and down does well, right? All right, so there we go. And then again, for revisions, this is great for revisions. No one wants knots. If you're that patient that had the whole handful of knots in your ankle, you don't want those. So this is also, like we said, it's not a serious sales pitch, but hey, I have a knotless repair for you. Let's get rid of those knots and let's move forward. And again, just kind of watching that mechanism. Some of us aren't used to the knotless stuff. I know our shoulder peers are way ahead of us. So we got to kind of catch up in the foot and ankle world. And then up and coming, the flexible fixation. How flexible is good? Absorbable, like that PLL thing we saw a few minutes ago. How fast should it absorb? Should it be six months, six years, who knows? All suture constructs, is that going to pull out of the tail? So I'm not sure. And then the all inside, that's the way we're going. We got to get this arthroscopic. The people in this room are the ones that are going to be doing it first. And I'm not sure if I'm good enough, honestly, to do it yet. And that's the true point. And then this picture right here is what I keep seeing with these flexible fixation devices. We won't name any names. This is what I keep seeing from a group in town. It looks like a kind of a ball of snot in there. And I'm not really sure what to do with it. So I'm taking it out and revising it. So we should bring that up next year, how to revise certain products in different ways. So the all inside arthroscopic technique, these guys reported in your high activity patients, it does worse and then results in reoccurrence and instability. The 28% reoccurrence rate with arthroscopic repair. So I'm a big arthroscopy guy. I'm here with you all, but I'm still not ready to do it all arthroscopic yet. And this is a surgical variation technique that I did. I surveyed about 70 of you. And I asked you how many knots you tie during a brochure. It was anywhere from zero. One person did bone tunnels up to 55 knots. Some people were doing three double loaded anchors. That's crazy, right? Seems crazy to me anyway. But that's why we as a team, when we talk about stuff at clinics or at these kinds of conferences, we should show what we're doing. So we actually know how to actually talk to our peers, what we're actually doing. And then what do we do with these syndesmosis injuries? 17% have a syndesmosis and so high and low ankle sprain simultaneously. How are we addressing this when we go in to do our brochure? So we got a good paper here that shows if you can get a four millimeter measuring, you get that nice probe, you can stick your shaver in the syndesmosis, measure it. If it's four millimeters, your patients are going to do worse. These athletes are going to do worse. And I think we know that. And lately I've had this huge run of hyperlaxity. These Earler Stanlow's patients that are hyperlaxed. What are we doing with them? How are we treating them different? So we came up with this technique called the flying V. So if you look at Wagstaffs, it's a very anatomically placed. It can be your point where you go from ATFL to AITFL laterally. So this is an athlete came in for the low ankle sprain, the MRI wasn't too impressive, but then I did the dynamic exam and that's a broken Mercedes sign. That's the syndesmosis I'm looking at. What do you do then? Do you quick pull and put a tight rope in? Do you put a screw in? What do you do for these athletes? And that's where now at this point, I'm ready to bail. And I do this and that's my flying V. So I'll take the anchor from the talus to Wagstaff and Wagstaff up to anterior lateral tibia, all through the same incision. And basically you don't waste anything. You use the tape that you already had there, whatever technique you want to use. It costs you one more anchor. This is a revision of a revision, but kind of showing how we repair that AITFL down on top of the anchor. And then this is what it looks like before and after. This is the arthroscopy association after all, we should be looking at this. So use your arthroscopy as part of your tool for your brochium. So this is before and after. This is that same athlete now. Don't you think they deserve the image on the right? Now that Mercedes sign is restored and their syndesmosis is restored. And that's what we have to be ready to do when our syndesmosis is out during surgery and have a bailout, have a what's next. And I'd be like, I'd love to hear everybody talk about, hey, what are we doing with these syndesmosis injuries? Am I crazy? What are you doing? Would be great. So this is one of our division, our four time all American wrestler, 23 days post-op to flying V sends me this video. And then four weeks later, he sends me this video, right? So at four weeks, he's going live. He tells me it's hand fighting, but hand fighting and wrestling basically means you're going crazy. You're going full go. And then we jumped to six weeks. He got his hundredth win. So a hundredth win in wrestling is pretty impossible to get. And he got his hundredth win. So he's doing really well. Thanks. And I'm a military background. Anyway, it's good to be here. A lot of SOMOS members out there. So thanks for having me. Dr. Stone had scheduled himself to do a quick osteochondral lesion talk right now. And they had to go to the meeting. So just like a little bit question and answer for this, who in the room looking forward, you have an osteochondral, Eric, I'm looking for you and all these guys. So if we have an osteochondral lesion in a high level athlete, when you do your Brostrom, if it's 10 millimeters, are you putting in autograft? Are you putting in some graft? 10. First of all, it depends if there's a cyst attached to that or not. No, let's just say it's this one right here. That one's kind of bad. You gonna put a graft? You should. How about this? Just any athlete. Are you gonna put an allograft in an athlete that needs to get back? Allograft? By allograft, do you mean? Allograft. So I would consider doing a, depends on the size, but if it's under one centimeter, I'd probably just do a debridement. And then for me, I would be, as you mentioned here, marrow stimulation using a one millimeter device that I don't even need to drill more. It's a proprietary tool. But do you think you can though? Can you get them back? Can you get it back in season come? If we put a graft in? Because I'm afraid I gotta do, I feel like I have to do micro fracture on high level athletes to get them back in the season. I feel like I don't have any choice. Is that false fear? Biologic augmentation too. Same season? Even, yeah. Even though, even the next season, because really these, how fast can you let them run on your graft? So these are the questions that I think we got to have as a group, is how fast can we rehab after we do a micro fracture? So I'm feeling a lot, you know, we look at some of these papers and looking at your, looking at senior Furkel's paper, looking at 10 year repair or the Rankin's paper, and then senior Furkel's paper here looking at 72%. So there are good results to do micro fracture. So some of these, my high division one athletes, I am micro fracturing them more so than going straight to an allograft just because we got to get them back. And there's so much pressure on return to sport. And honestly, you have some good talks. And then I think it was, when was that, two years ago, we had Nick Van Dyke, he gave us a huge talk on micro fracture still alive for the ankle. So I'm kind of mixed and I'd love to hear everybody's feedback on this. And then serial PRPs, like we're talking about guys. And then I'm gonna stop talking now. But anyway, so that was, thanks for having me. And so now we're kind of ran out of time and our senior members left. So I would just love to open this up for any discussion on any topic. You can ask us questions. I think we should just talk the more we get together. Yeah, come on back up and let's do some talking here. Anybody got any questions or concerns? I had a question for the bio brace pay. Oh, yeah, go ahead, sir. Go ahead. I'd just like to ask how everyone is dealing with DVT prophylaxis after foot and ankle surgery these days. Brian, sorry. I'm doing aspirin 325 while they're non-weight bearing two weeks or four weeks depending on what the procedure is. I'm doing aspirin 81 BID for six weeks. Same. Unless they have a hypercoagulable thing issued and I'll go on Xarelto or Eloquus. Yeah, I mean, maybe in a revision case, I'm not often doing that in a primary, like, you know, insertional, whether I do open or endoscopic. I'm not doing that as a primary. Maybe revision cases, if I go back and felt it was done well, and they're having some weakness and maybe, but not frequently doing that for insertional to stem disease. FHL. Oh, the FHL transfer, to add that to it. I mean, my military population kinda changed me. I, a primary just did not do well in my military population. Yeah, I have that sheet. I will put that docking barbric into the alkanes and then reinforce it on the side of the Achilles tendon. And I try to keep it interiorly, that way I'm avoiding the bulk. So with that product, one thing that I've seen is that it's really hard to suture through. The PLLA is tough. You have to have a really solid needle to stitch through it. And so I like the technique, I like the idea, but it's not quite, I don't know, it's not user-friendly for me. Do you have feedback? Either one, the shoelace or either one. I can't hardly get a stitch. I had a guy took a hatchet through his foot and it works well. To your question, I think one thing that's important that Brian did a really nice job pointing out is it's really critical to determine the cause of their pain, right? So not everybody who has insertional tendonitis has like Achilles' plane. It could be bursal-related, it could be retrocalc, I mean, Hagelin's related. And so really defining that before surgery is critical because not everybody needs to have even their Achilles' debrided. So doing escopic Hagelin's is a great surgery. Patients love it. It's two small incisions. They're walking after a week or two. And so really I think determining that is critical. And oftentimes, if they have a really, really tight gastroc, I mean, not everybody needs a recession, but that's another option as well in terms of the reason why you are having pain back there. So for me, to your point, FHL is pretty uncommon for me to do it for an IAT. You have a question? Go ahead. Yeah. Go ahead, Guillermo. Yeah. When I... This is the principal cause because you have to think in the cause. And when you are talking about a Hagelin disease, it's only the exostosis or retrocalcaneal friction to the tendon. And that is why they have the dysbursitis. So you only solve the problem, resection, the retrocalcaneal exostosis and the bursitis. It's not a tendon problem. So I think you don't need to have amputation with the flexor. And then another important thing is that you something say that I really, I'm not... The Philip technique to... Because it's how much to resect. And this is one of the more important things. And when you see that you have these X-A angles with the Philips and everything, but I really don't use in my practice because I don't think they're useful for me at all. What is the best advantage of endoscopic technique is that you can see up to where you are going to resect. That when you make open, it's difficult to do that. And in endoscopic, you have to go to the space, the retrocalcaneal space, up to the insertion, the real insertion of the Achilles, and don't leave a sharp edge, that friction to the tendon. And that is the advantage of endoscopic. It's better resolution, better approach. But one of the most important thing is that you can see where to resect because there's not really clear how much to resect. Go ahead. Are the rest of you guys rehabbing that quickly for... Those are amazing results. The rest of you guys rehabbing that quickly for monoligament repairs, whether augmented or not. And does anybody restrict plantar flexion inversion in that period? Sorry. The presidential address is starting right now, but we can... I don't want to... I'll answer your question. You can answer me offline. We can talk about it. I don't want to hold it back because Dr. Curtis is being introduced starting now. All right. Well, thanks for coming. Look forward to seeing you next year, everybody.

orthopedic treatments

foot and ankle conditions

stress fractures

syndesmotic instability

Achilles tendon repairs

Haglund's deformity

Brostrom procedures

ligament repairs

surgical techniques

recovery protocols