All right, good morning, we'll have you all take a seat. I'm sure we'll get some people wandering in after we get started, which is great. Wonderful having you all here. I'm Bob Anderson, formerly of Charlotte, now of Green Bay, Wisconsin, and I'm moderating this session. I think it'll be a really fun session. We've got some great speakers. The title of this session is Sports, Getting Back to the Game, and we're gonna go through a variety of different anatomic parts and how it relates to sports, and we do wanna save plenty of time for case discussion. I've got a lot of cases to present to the panelists that I think will help answer some of your questions and your situational concerns with your athletes of all ages as well. So without further ado, I do want to, one thing, please silence your cell phones if you would. Number two is when you do ask a question, we get to the discussion period, please come to the microphone. This session's being recorded. We need to make sure you speak into the microphone so we can all hear the question at the same time. So without further ado, we're gonna introduce our first speaker, which will be Dr. Kent Ellington. Dr. Ellington here in Charlotte, North Carolina, is gonna talk about ankle instability, when enough is enough. Ken, you've done a lot of work in this area, so bring us up to date. Thanks, Bob. It's a little nerving to give a talk on sports stuff in front of Bob Anderson, but I'll try my best. Anything that I say, I probably learn from Bob, so. And, yeah, and half the slides may have been recycled for something you gave me years ago. So here's my disclosures. The relevant to this talk would be Ardalan that we'll talk about. I'm not gonna go through some of the basic anatomy stuff that you guys are all too familiar with. It is interesting that there's 25,000 ankle sprains a day, number one reason for a visit to the ER, and so it keeps us busy. And one of the most common procedures I do is a Broyston procedure, and that's evolved over my 11-year career. And how many for you, Bob, 30-something? Wow, that's incredible. Yeah, so obviously there's functional and objective instability. And one of the mantras is that people have been, I kinda learned, at least I thought, that all Broystons do well. And then, like everything in orthopedics, if you do it long enough, you start realizing that not everything goes the way the textbook says. And as you follow patients after ankle instability, you can see that short and long-term, there's issues that evolve over time. And eventually, if unrecognized, chronic instability leads to end-stage ankle arthritis. So back to the basics. Make sure you order an H&P and evaluate the instability frequency and do a proper physical exam. I don't do this routinely. I don't know if there's much utility to doing this, but every now and then you feel someone that's really loose and you take them to Floro, and I just did it so I can have a cool X-ray for the talk. And another one here showing the entry and drawer. And then back to the history part, hyperlaxity. So this is a patient of mine that had Ehlers-Danlos, and so you can ask them if they can do any cool circus tricks and pinch their skin and evaluate that, because I think that is relevant and goes into your surgical decision-making. So there's the classic lateral reconstruction and surgical options is the Brostrom, and then the Brostrom-Gould, and then I call it the Brostrom-Augment. So that's using some type of another layer or additional technique that is anatomic, meaning from the origin and the footprint of the ATFL. And then there's the non-anatomic repairs. Brostrom-Evans being popular. Bob, I was saying to someone earlier that we should probably call it the Brostrom-Anderson, since you've kind of made that such a popular procedure. And then other surgical procedures, and DG looked at patients with instability, and just about all of them had something else. So anytime you see this patient with chronic instability, you just gotta think about the bigger picture. We know what the goals are, and sometimes motion can be sacrificed to achieve stability, especially in revision cases. A little of this quick history, 66, you know, Brostrom described this technique with a direct anatomic repair using suture only and with a good success rate, but there's other things to consider. So just a few things real quick. Don't forget the camera. I don't scope all my Brostroms, but I do scope most. Everyone can have their own algorithm, and that's debatable, but some people do scope all their Brostroms, and that's fine, but there's something just to remember, again, with instability. Think about the scope, think about the perineals. Don't forget the syndesmosis, and this is something that Bob has taught me a lot about. Patients that have not just lateral instability, but syndesmonic instability. This is a patient I just did actually two weeks ago, a 24-year-old pro soccer player, and if you look on the axial MRI, you can see edema around the FHL and the PITFL, demonstrating a partial tear, and their symptoms are subjective. They can't really tell you what's exactly going on. My ankle aches, I can't push off, I can't accelerate, I can't pivot. Their tender of the syndesmosis, you know, when you put the camera in, you see a partial tear and a drive-through sign, and a little bit of chondral damage there on the lateral talus as well. And don't forget alignment. I'm not gonna talk about anything about this, except just, you know, take that into consideration, but here is a patient that I did a few months ago that scope micro fracture, brushed him with augmentation perineal repairage. She was back because, or he was back because of a Jones non-union, but did have cavus alignment, so Jones screw and then a dorsiflexion first, metatarsal osteotomy to address the cavus. So just something, again, don't forget about that. And then the medial stabilizer, the deltoid, there's all types of things to consider and think about, and not to go into too much detail, but just, again, remember the anatomy and keep that into your surgical decision-making process. The difficult exam, you know, the patients can feel really loose in a lateral stress test, but when you're trying to evaluate the medial structures, it's kind of difficult to get this objective finding. So a lot of it is based on history and the MRI, showing a lot of a signal change on the T2 coronal. So back to the classic brostrom, this is how he described it, and you just do a simple repair with some ethabond, and that's the classic way. And what I like to do, for not all of mine, but with some, depending on what's going on, is an anatomical repair with the brostrom plus augmentation, again, with the same origin footprint of the native ATFL. Why I like to do it, it gives me immediate strength, fast recovery, and kind of a belt and suspenders to the brostrom. Just for historical reference, this is the Evans procedure, taking a slip of the brevis into the fibula, and then a snook, bringing it back around to the calcaneus. So here's a patient that performed a brostrom peri-ulnar reconstruction on, and then augmented with a fiber tape product on top, and this is what I used to do, and patients did quite well, and over time, maybe some little extra stiffness because there's no flexibility in that construct. So flexibility does matter, elasticity matters, and so if you look on the left here, that's somebody jumping with a rope, and then on the right, that's a bungee jump. So a little bit of flexibility is important repairing ligament structures. So, and so what I do now is I use a more, I still use the anatomical repair, and augment it with a more flexible type of construct that has features similar to the native ATFL, and there's been a lot of cool science done by Norm Waldrop and others looking at the range of motion and flexibility and stretch of the native ATFL, and augmenting it with products that mimic that can give, I think, better clinical results. And then in addition, it can actually incorporate into the ligament, and they have really cool histological data going over years looking at its incorporation into the ligament, and actually it gets replaced with type I collagen, and here's a second look at biopsy of an ACL three years later showing normal type I collagen, and even five years later, a normal incorporation of the product. So when do you do it? Revision cases, obese patients, athletes, and you can define that however you like. Patients with cavus, again, laxity syndromes, neurological issues, peroneal dysfunction. Do we tend to lean towards doing this type of augmentation in workman's comp patients? If you're in the OR, and you do your Rostrom, and you're not satisfied with it, it's thin, you wanna do something about it, and you can have this on the shelf to improve your immediate and hopefully long-term strength results. So Rostrom is the preferred method, but there is room for improvement. Ankle reconstruction using adjective anatomic repair with strength and flexibility does have advantages, and then a thorough evaluation for global instability, including the syndesmosis and medial structures, scoping when needed, peroneal involvement, and foot alignment have to be definitely thought about in every single instability case you take care of. So old school, everybody who knows me knows I like to talk about flying, and so this is what I used to fly, and this is what I fly now. So this is like the 1966 Rostrom, and this is the 2021 Rostrom, and so this is cool photos here, and if you fly, and you use old stuff, when you crash, you die, but if you fly the new stuff, if you're gonna crash, you pull a parachute, and your plane floats down, and you walk away from the crash like this guy, and just takes a picture of your plane, and you're alive. So 300 people have crashed their Cirrus plane, which is what that plane is, and walked away safely. So a couple photos here, and then one thing that I've learned, I've been flying for seven years now, that this is a prop strike, and this happened at the airport that I fly out of, in Monroe, just about 20 minutes from here, and somebody had a hard landing, and these are the five reasons pilots die, and these five reasons are important for surgeons as well. Don't be complacent, don't be preoccupied, neglect, fatigue, and distraction. So those five features, I think, can keep a pilot alive, and a surgeon out of trouble. Thanks. Very good, Ken. Let me just ask a quick question, before we bring Ken up here. Is there ever a role for just a Rostrom, or do you think we should augment everyone? Well over half of my, can you all hear me? Well over half of my Rostroms are still just regular Rostroms, without augmentation. Just a straightforward Rostrom? Definitely, yeah, probably two thirds. And what about, is there a role for any athlete to have just a Rostrom? And if so, what type of athlete? I have leaned towards any kind of college professional athlete, if I do a Rostrom, I add augmentation. Panel, anybody just doing straight Rostroms on athletes, no augmentation? Ken, okay, all right. And I think for things like maybe gymnasts, figure skaters, ballet, enthusiasts, whatever, maybe there is a role for that. But personally, I think what we found is, and a lot of the articles do support this, when you get to the cutting athletic variety, the field sports, probably is best to put augment, some kind of augmentation in there. But Bob, the rehab matters too. I think if I have a patient with a bone spur, where I need to really mobilize them quickly, I'm gonna use augmentation, because I don't want them to stretch out their repair. But if they have time to rehab, I think the natural ligament is strong enough. So when a quick, quick rehab, more reason to do augmentation. Or like a subtle, you know. Very good, Ken, thanks again. So we're moving right on. Next is something near and dear to my heart, that's turf toe and sesamoid problems. Those darn little bones that cause so much issues in some of these athletes. And Ken Hunt, one of our former fellows, and who's made a great name in sports on his own, from Stanford, now Denver, is gonna entertain us on this topic. Ken. I'm sorry, you just gotta double click this. There you go, perfect. Thank you, Bob. So, and thank you, Kent, for inviting me to be a part of this. It's really an honor to be here. So I'm gonna talk about turf toe and sesamoid injuries. I have no financial disclosures, but I'm gonna disclose that I too, borrowed some slides from Bob, that are still in there, and a case. So I give you full credit. So turf toe, the term turf toe was coined in the 70s. After the advent of artificial surfaces, team physician were noticing an increase in big toe injuries. And they found that it was primarily because of a hyper extension. So it's not a specific term, it just refers to injuries of the big toe complex. But they found it to be a hyper dorsiflexion injury in most cases. Now there are a lot of structures stabilizing that joint. The ones we see most commonly injured are the capsule, the plantar plate, and the sesamoids, but the tendons and the other ligamentous structures are often involved and need to be addressed during treatment. So this is a really important complex, as Bob mentioned. During normal gait, not a lot, but when you're jogging, running, and especially doing a running jump, a lot of force goes through this complex. And for more nuanced, fine-tuned athletes like ballet, it's really important for balance as well. Now the sesamoids are sort of like the patella. It's a bone that sits within a tendon. And it's really important for jumping, sprinting, and fine motor stuff like ballet and taekwondo. So I'm gonna talk about incidents, how these happen, how we evaluate them, and then how we treat them. So what's interesting is the incidence has really gone down over the last 40 years. Early on, when it was first described, we were seeing this in five or six football players every year because of that unique interaction between a flexible shoe and artificial surface. In 1990, it was described that almost half of active NFL players in this series had experienced a turf toe injuries, most of them on artificial surfaces. Fast forward 20 years, 30% of players in that series had had one. A couple years later, 11% of athletes at NFL combined. A more recent article suggests 5% incidents in incidentally athletes. So the incidence appears to be going down. Is it newer turf designs? Shoe wear changes, they're a little bit stiffer. They're shifting where the cleats are. Hard to say, but we're definitely seeing them less often. So we looked up the NCAA football data over six football seasons, and we found it actually occurred in those schools that participated less than one time per year per school. So the incidence has definitely come down. And again, we found the majority of these are on artificial surfaces rather than natural grass. The vast majority happen in games. So it's that higher impact, higher speed, higher intensity is where we see the majority of the turf two injuries. Most of them are on the offensive side. Again, that makes sense. This is a guy who's getting tackled. Now, the other interesting thing is that it was highly uncommon for these to require surgery. Now, some of them do, and those who do, you have to identify where there's a problem. But most of these are managed conservatively. So the downside to missing it is you will see long-term issues. Clannad Seifer described that 50% of these injuries have persistent symptoms. It can be pain, weakness. We see this clawing and the development of arthrosis in the MTP joints. So down the road, we often have to do more heroic procedures like fusions, et cetera. So identifying it early and treating it appropriately I think is really important. So how do these happen? I mentioned at the beginning, the majority of these are hyper dorsiflexion injuries. Borrowed this one from Bob. Look at the left foot here of Antonio Gates. The foot's planted, he gets hit by two players, his foot dorsiflexes, and that's kind of the classic mechanism. So just like this, the toes are planted, the player himself or another player falls on the foot, the toe hyper dorsiflexes, and some of those structures get injured. We can also see it when players land on another object such as another player's foot. Same mechanism, just a different way of doing it. We can also see a hyper plantar flexion injury which injures the dorsal tissues that still falls under the turf toe mechanism. And so they have a painful swollen toe, but obviously the structures that are injured are a little bit different. So most of these have a soft tissue injury where you lose those plantar restraints. The capsule ligamentous structures, the sesamoids migrate, and sometimes the tendons themselves can be injured. We also can see a bony injury where there's either an avulsion off of the sesamoid proximally or a fracture with diastasis of the sesamoids. So how do we evaluate these? Well, clinically first, you're gonna see swelling. So acutely and chronically, there's swelling of the joint. You can often feel an effusion. There's instability early on. This gets a little more challenging as the joint swells up because there's a stiffness associated with it. So it's a little bit harder to see the instability. They'll often have weak plantar flexion because of the injury to those structures. So you can typically on a table, especially when they're asleep before surgery, really evaluate the toe and see where the laxity is in all directions. We will also see this dorsal jaw test. Now this is something you can do clinically with acutely injured athletes. This is often painful, but once it's calmed down a little bit, you can see whether there's laxity. You see on a lateral fluoro image, the sesamoids are staying put while you're manipulating the toe. So x-rays are really, really important. You wanna make sure there's not an avulsion injury. You wanna look at the alignment of the toe. Bilateral is important to see the position of the sesamoids and compare the opposite side because with the grade three terptoe injury, we'll often see migration proximally of the sesamoids. That's an important predictor for a poor outcome and therefore surgery. And also you can see whether there's a fracture of one or both sesamoids. I like the lateral dorsiflexion view. So under normal circumstances, that sesamoid should follow the proximal phalanx. With a complete injury, the sesamoid stays put while the toe goes. It can be easier to assess this with fluoroscopy because you can get multiple runs at it. And again, if those sesamoids are staying put and not moving along with the big toe, to me that's an indication that it's a complete injury and therefore in most athletes, a surgical problem. MRIs are very easy to get and sort of the standard in the athletic population. Not only will it help you identify which tissues are injured, but allow you to look at the joint to see if there's an articular injury because that may change the way you do things and sort of better help you define the ligamentous injury. And you can look at the health of the sesamoid to see if there's any vascular necrosis or a fracture that's diastased. So I like arthroscopy when there's an articular injury or a significant effusion. And you can see the sesamoid with the scope. I have not repaired a turf toe injury through the scope, but I think it's a helpful tool to remove the inflammation and further identify articular injuries. So these are classified, like most things in orthopedics, grade one through three. Grades one and two are sort of the non-op. There's a differential level of injury, but there's not a disruption in the tissues. Those can typically heal in a splint and modified footwear. It's the grade three injuries that are really important to identify. Once you lose those plantar structures, that's when you can develop difficulty with performance and long-term problems with arthrosis. For me, it's that proximal migration of the sesamoids or stand put on a lateral-floral view is kind of my deciding factor. So how do we treat these? Again, grades one and two, you immobilize them in a boot or splint. I like this toe spica cast because you can hold it in dorsiflexion for a week or so and let those tissues get sticky. We use the term police instead of rice. Police is protect, optimally load, that's the boot, and then ice compression, elevation. Rest is not a term that athletes have in their vernacular. So grade threes are typically surgical and they typically have other injuries you have to address at the same time. So the classic turf toe injury, this is one of our wide receivers, had a big toe injury, didn't really remember the mechanism, difficulty walking, so we saw him in the training room. We got this lateral-floral and we saw that the sesamoids were staying put while the big toe was moving up. A concern for a high-grade turf toe injury and his MRI scan looked like this. So complete disruption of the plantar plate, proximal migration of the sesamoids, and a lot of scar and hypertrophy in there. So we took him to the OR, did a primary repair of the plantar plate. I like doing this with an all-soft suture anchor in the proximal phalanx. Those technologies are really good and it's not a big piece of metal that Bob has to look at at the NFL Combine. And you can get a really nice repair of the plantar plate and the brevis if needed to the proximal phalanx. So here's a case example. Again, the anchor's in the bone. You can really dial in the tension of that tissue to provide that restraint not only to dorsiflexion but also to valgus. And this is a post-op. You always wanna get this post-op to make sure the sesamoids are moving along with the big toe to confirm the end of the repair. There are variants for sure. In fact, I would say there are probably more variants than the classic turf-toe injuries. This was a freshman running back, had a history of a turf-toe injury, redid that mechanism early on in his freshman year. He had that pain, swelling, and sort of a traumatic hallux valgus. So we identified this fragment. The CT and the MRI showed that it was probably chronic but there was an acute component to it. So this thing was chronically fractured but this injury had pulled it off. So we had a traumatic hallux valgus and an injury to the plantar ligamentus complex. So we removed the fragment, fixed the plantar plate, and then I released the adductor on the other side to correct that traumatic hallux valgus and he went on to do well. Another variant, this is one of Bob's cases, running back, injured his great toe six weeks earlier. X-rays were negative, didn't have proximal migration of the sesamoids but he sort of felt unstable. So on that live fluoro exam, the sesamoids are moving fine with the big toe but there's this severe laxity with valgus stress. Most of this injury was to the medial capsule of the ligamentus structures but equally as painful. So he went in clinically and identified a complete injury to the medial capsule and MCL and a rupture of the medial FHB. So he went in to repair all of those structures and this is a nice illustration of that adductor transfer. So you can use the abductor hallucis tendon to help hold the toe away from that valgus stress. And again, always good to get fluoroscopy intraoperatively to make sure that there's stability and you have proper constraints in all directions. So what are the outcomes? Well, the good news is that most turf toe injuries can get back to sport. This is rarely a career ender. A recent systematic review and meta-analysis of 12 studies showed longer return with increased severity and the average for surgically repaired is about 14 weeks and that sounds about right. Less obviously for the non-operatively treated. But there's high variability. You see these huge ranges from six to 156 weeks. Some of that is the way the data's tracked but some of these get back quick and some longer depending on what other injuries exist. Now sesamoids, the majority of sesamoid injuries in athletes are non-operative. There are not a lot of cases of acute fixation of sesamoid fractures. This was one of our defensive backs. Another player landed on his foot. Classic mechanism, hyperdorsiflexion injury but he felt a pop. So we see this and there's always that debate. Is it a fracture or is it a bipartite sesamoid? When you see those kind of jagged edges and irregular surfaces, highly likely that's gonna be a fracture. So MRI confirmed it's a fracture with acute edema. So we treated him non-op. I put him into a toe spike, a cast, and a boot for six weeks and he was able to get back essentially at eight or nine weeks post-injury and x-rays showed that that fracture had healed back. Important to use a carbon fiber plate with a recess under the sesamoid to prevent pain but also provide stiffness so that they don't get the same injury under the same circumstance, especially when they're getting back the same season. Another case, a 23-year-old runner with a non-union after a fracture like that that just didn't quite heal together, persistent pain. So this one underwent a debridement of that fracture, bone grafting, and then we used just a small two millimeter screw just to get a little compression through there and add a little bit of strength to make sure that it did not recur. So outcomes of sesamoid non-unions are very good and this actually, I looked it up to see if there were more serious since 1997. Since you're serious, Bob, and there weren't. So this is the data. 21 athletes with bone grafting, no fixation. 19 of 21 healed and the two didn't, just it was probably just dead bone. There was still diastasis at the fracture so those two came out. So in summary, the big toe plays a really critical role in many sports, especially field and court sports. Turf toe injuries are important to recognize, particularly those that are of a higher severity and where you can change your ultimate outcome by repairing it early. It can result in significant dysfunction and long-term issues, so accurate diagnosis and appropriate treatment early on is really important. And thank you. Thank you. Thanks, Ken, great job. It is interesting that we're seeing more and more of the variant turf toe injuries. It's not typical to see the pure hyperextension injury any longer. Most common is a medial-based turf toe and that's one we're seeing quite commonly. And also when you get in there, a lot of times you'll find that the whole plantar plate structures have evolved off the sesamoid. And I don't hesitate to make a transverse drill hole through the sesamoid as my anchor point. So something to, you know, just a little tip you might wanna keep in mind. But it is interesting over the last two years, I've only been fixing the medial side. I have not gone laterally, even when they have a lateral-based injury. And we're finding that it seems to function just fine for these guys. I'm a good medial post, a good end point, so to say. Maybe we can talk about that during the discussion about just a sole medial approach. The other thing, Ken, just real quickly, is that I have a grade four, classification four, which is the dislocation, the true hallux MP dislocation, which I think is the epitome of the worst turf toe you can have. Interesting in those, the flexors don't rupture. They rupture through the inner sesamoidal ligament and it comes around. Do you take, are all those surgical in your experience or do you do anything different for a dislocation? I think, again, I really base it on whether the sesamoids are moving with the big toe. I think if they're not, it's surgical. The difference with those grade four dislocations is they really, really get stiff. So the rehab is a critical part of it. You cannot immobilize those for two weeks after surgery. They get too stiff. So I think repairing it if the mechanism's out is important, but I mobilize them really early. Excellent, yeah, great point. They do, they get really stiff. You gotta mobilize, but you don't oftentimes have to operate on them, which is interesting. All right, next, one of Dr. Hunt's fellow fellows, so to say, way back when, and now been at Washington University in St. Louis, doing extremely well there, is Dr. Jeremy McCormick, who has done articles on this particular subject and not an easy one to manage, the navicular stress fracture. Jeremy. Yeah, thanks, Bob, and I will echo, I appreciate being here and it's nice to be at a meeting with live people. I don't think I borrowed any of your slides, so hopefully we'll follow suit with some original work, but I did do a research project as a fellow, which sort of got me interested in this to begin with, so I do owe that to Bob. So navicular stress fracture is fixed now, fixed later, fused, inevitable. On my disclosure in the database, I am a consultant for Stryker. You will see some Stryker implants in this talk. Start with a case example. 12-year-old female soccer player. Had pain for about three months, was worse with activity, and presented with ankle pain. And so these were the X-rays that were obtained. No fracture identified. She was allowed to rehab. And unfortunately, three months after that, still had persisting pain, and an MRI was obtained, which showed this not-so-fun-looking navicular stress fracture. And so the question is, what do you do? Non-op in a boot, a cast, or IF? She's 12 years old. Maybe if we do just a boot, she'll be okay. Maybe a cast will be okay. What if it doesn't? I think we all wish we had a crystal ball on some of these. And so with this talk, we'll sort of look at what some of the data says to maybe give us some guidance on how we can manage these problems. So we'll look at some background on navicular stress fractures, clinical evaluation of patients, and then look at treatment options. Fix now, fix later, or is fusion inevitable? So as background, it was first described in Greyhounds in 1958, repeated injury to the outside hind leg of these dogs as they were racing around the track. In orthopedics in 1970, it was reported as two patients in a case report that had repeated stretch injury leading to navicular fracture. It's a relatively uncommon injury as far as fractures go. It can happen with acute trauma. Obviously, today in this talk, we're talking about chronic injury where there can be a delay in diagnosis of up to seven months. I just showed you that first patient there had about a six-month lag in diagnosis. And there's a wide spectrum of injury, avulsion fractures, comminuted fracture dislocations. Bruce Ann Georgian in the trauma world has done some work classifying those, again, looking at stress fractures, particularly for this talk. We recognize that it's a challenge. The navicular is covered mostly with cartilage. Almost any fracture of the navicular is an intra-articular fracture. And it's a high-stress area on the foot. There's compression between the cuneiform bones and between the talus behind it. There's some thought that a high-arched foot may be a bit more rigid, particularly with the lever, and push off of gait, and maybe that creates further stress at the bone that can compromise it. The blood supply has also been a topic of conversation, and does that jeopardize healing in stress fractures? And there's always been this thought of a watershed area. Well, at our institution, Sandy Klein spearheaded an anatomic cadaver project where we recognized that really only about 11%, 12% of the cadaver group we had really reflected that watershed zone. So is it really that the ones who have the problem are the ones who anatomically have that watershed blood supply distribution? So how do you evaluate these patients? Well, we'll use a case example here. 17-year-old football player, high school football player had three months of ankle pain, gradually worsening over three to four months, worse with increasing activity. Typically, these fractures will be better with rest. They'll have mild swelling. They will complain of ankle pain. This particular patient was wearing a boot at all times, except when he was at practice and at his games. He was a senior in high school, and there was nothing that was gonna stop him from playing his senior football season. On exam, they're typically nervously intact. These are healthy athletes most of the time. Minimal tenorist palpation at the actual ankle. Recognized, there's been a described end spot, just slightly distal to the ankle over the navicular itself, and sometimes it's slightly more midline on the foot than you might expect because most of these fractures are in the lateral third of the navicular. Alignment in this particular patient was normal. You can have a subtle cavus alignment to a foot many times. This particular patient had mild pain with a single limb heel rise. His ankle was stable. He was having pain over that end spot in the midfoot. So we got foot x-rays, as we often do. No real obvious finding on the foot x-ray here. Maybe you can see maybe a little something, but nothing really that jumps out, which is often the case. It is easy to mistake ankle pain for a navicular fracture, or vice versa, I guess, to mistake a navicular fracture for ankle pain. And so if there's any doubt at the ankle, get x-rays there as well, but don't forget to look at the foot carefully. An MRI, I think, is the best study to identify these early in my hands. It's easy to get, and you can identify other pathologies at the same time. It will also help you understand if there's edema within the bone or sort of a preceding finding to an all-out fracture. Here in this particular patient, you see the fracture very clearly through the mid portion of the navicular there. I will follow that with a CT scan. I think the CT gives me a better look at the fracture itself, assessing if it's a complete fracture and assessing if there's any displacement of the fracture. And I think that's very important as we think about decision-making. Bone scan can be used. It's not used very commonly. Certainly not something that's common in my practice. It can be very sensitive, but not particularly specific. So this patient had this navicular stress fracture. Well, now what do we do with it? What's the treatment algorithm? How do we treat these fractures in our athletic population? Is it a boot or a cast? Percutaneous fixation for this particular young man. ORIF, use bone graft. Should you not use bone graft? Well, Dr. Torg published in JBGS in 1982 a series of 21 stress fractures. It was really the first large series. 10 of 10 had union when treated in a non-weight-bearing cast for six to eight weeks. There were nine fractures that were treated with activity restrictions still allowed to weight-bear, and seven of nine had persisting pain and instability on return to play. Again, these were managed non-operatively. Dr. Khan had another series. This was a bit larger series, review of 86 cases. 22 were treated with six weeks in a non-weight-bearing cast, and 19 of those 22 returned to full activity by five to six months. If it was a partial weight-bearing cast, only about one quarter were able to return to full activity. So the message here is if you're gonna treat it non-operatively, it really should be strictly non-weight-bearing, ideally in a cast for six weeks. Well, when do we operate then? I mean, are we gonna ever fix these? Should we just treat them all non-operatively? Dr. Fitch in 1989 suggested failed conservative management should be treated operatively, displaced fractures. If it's a non-displaced, complete fracture with a sclerotic bone rim or edge, suggesting maybe more chronic injury, or if there's a cyst or some other suggestion that it may have trouble healing. 2000, there was a series of 26 stress fractures, and this particular publication suggested that maybe we should fix them in addition, not only those other indications, but maybe we should fix them to try to get them back on the field sooner. So this was 22 navricular stress fractures, nine treated with fixation, 13 in a non-weight-bearing cast. And this is where they first started looking at CT classification, Dr. Saxena published on that, as far as classifying the different types based on the CT findings that I showed you a bit ago. The premise of this study was to say, well, the ORIF returned activity about six weeks faster than the non-weight-bearing cast. So is the risk of surgery worth the benefit of earlier return to play? And there may be some credence to that. I think regardless of time to return, it's gotta heal. It really is a tough fracture to get to heal, and you have to really pay attention to it carefully. So which ones do we fix? Well, when I was a fellow, this was a project I alluded to, we did a database review of operatively treated fractures, and we wanted to get CT follow-up on all of them. And so we were able to get 10 navicular fractures to come back to get a CT scan for review. Looked at clinical outcome scores, union was defined as greater than 50% healing by CT scan, and eight of the 10 fractures we had come back, again, relatively small number, but we were still able to have the CT studies. Eight of 10 went on to union. Both of the non-unions started as complete displaced fractures. And so a little bit simpler look at the CT classification, looking at incomplete displaced on the left, complete non-displaced in the middle, and complete displaced on the right, the incomplete fractures typically should heal fairly well with or without surgery. We start to worry more about the complete displaced on the right. And so as we categorize these and look at those eight of 10, six of six non-displaced fractures went on to heal. Two of four complete displaced fractures healed with autograft, but two had non-unions. And those, coincidentally, were both allograft at the time of surgery. And so the conclusions really that we drew was that non-displaced fractures will heal with a very low risk of complications, but the displaced fractures are the troublesome ones. Those are the ones that are at risk of non-union. And so we should be aggressive in management to avoid that displaced fracture so we're not facing that problem to begin with. And so we need to avoid the complete displaced fractures. We can't put our head in the sand on these injuries because they have a higher risk of non-union and then concern for subsequent arthritis. So as we think about treatment and the thought of fix now, that's what we did in this high school football player that I talked to you about earlier. Here was his fracture. It was complete. I characterize it as displaced so that he could make an argument that it's not significantly displaced, but certainly a complete fracture, I think we would all agree. And so in him, we move forward with ORIF using autograft, brought him to the operating room. I use a slightly more longitudinal approach than this transverse approach that's been published in techniques. The screws, remember, have to come from lateral to medial and they're really fairly oblique. We'll show you the post-op x-ray, but on a lateral, it almost looks like the screws are coming in top to bottom. And remember that that's the geometry in order to get perpendicular to most of these stress fractures as they're oriented. So here are intra-op pictures. Be careful branches of the superficial perineal nerve. And then as we move down, sometimes use a needle to verify on portable fluoro that you do in fact have the fracture that you've identified because sometimes they can be hard to see. Open the fracture, drill each side, place the iliac crest graft, and then compress with a clamp. Use two partially threaded cannulated screws. And you see that central image is that lateral image that I was talking about where the screws are almost going dorsal to plantar, at least that's the impression, but it's because of the obliquity based on the fracture pattern that you'd like to traverse. And so that's fixed now. That patient went on to heal. And I would be a proponent of fixing them now when you identify them, particularly the complete fractures. Fixed later. Well, let's look at that first patient that I showed you, that 12-year-old soccer player. So she was in fact treated in a cast non-operatively for six weeks. She's 12. If it was my 12-year-old kid, I probably would have done the same thing. But here's what happened. She was compliant. She transitioned to a boot and progressed with activity. She returned to activity and did reasonably well, but there was no follow-up imaging. And then her rows wilted pretty quickly because she started having pain again. And so she had pain with athletic activity nine months later. Ankle X-rays were obtained. Again, no real identification of any navicular pathology. And the MRI was ordered and that's when I met her. So she came to my office with this MRI. Now in fairness, we don't actually know if she ever really healed it the first time around, but she was asymptomatic because there was no follow-up imaging. So I got a CT scan. You could argue that there's some partial healing, certainly on that left image, but when I can see the fracture line on X-ray, she was better and now not better with recurrent fracture. I think she needs to have surgery. So that's what we elected to do in this recurrent fracture situation, even though she was 13, skeletally mature. So here she is three months post-op. Fortunately, she's not having clinical pain. Got a CT to verify healing, looked good, and was a bit slower in her progression to activity. And hopefully, she will continue to do well. Healed by CT, but here's the thing, it took two years out of her life between beginning to end of this. And so I think that that's the important part about trying to help perhaps be more aggressive, particularly in these complete fractures, to think about surgery. So what did I learn? Well, non-operative intervention in a 12-year-old, probably not the wrong decision, but maybe should have had better follow-up, perhaps a CT to confirm healing. And I think with any of these patients, any of these fractures, no matter the age, you have to have a careful conversation about expectations and recurrent problems. So is fusion inevitable? Well, I think if the fracture's treated and it heals, it's not inevitable. I think we can get many of these athletes to do well. And in fact, there was a study of 30 fractures at about a 10-year follow-up in JBJS British that suggested both with operative and non-operative intervention, if they heal, at 10 years, they did not have significant radiographic changes and there weren't any fusions. But if the fracture is neglected, yes, I do think that fusion would be inevitable. This is a 25-year-old former collegiate baseball player. Had foot pain for several years that waxed and waned. He was better with rest. Didn't tell anyone. He was a walk-on. He wanted to play. He didn't want this to get in the way of his college dream. Eventually, after college, he underwent a quote-unquote debridement. That was about three years before I met him. I just met him recently. He now has persisting pain, and here's his X-ray. And so he's got an avicular that has had AVN at the lateral aspect of it. He's got collapse at the joint. And you could make an argument. Maybe this was a bipartite. Maybe this was Mueller-Weiss. Maybe this was a stress fracture gone bad. Whatever the pathology, it was ignored and it wasn't addressed early. And maybe there could have been something to help this patient through. So now he's looking at a tail-and-avicular arthrodesis at the age of 25, potentially with having to extend to the navicular cuneiform joint. So we need to avoid this because it's a deal-breaker. Again, the displaced fracture can be trouble, and we need to be aggressive in management. Dr. Torek still thinks we should treat these non-operatively. He did a meta-analysis publishing on that, and there was not a big significant difference in cast versus surgery in his group. But I would offer that the surgery is probably a biased group because they're a more difficult group to begin with. And so I think we just have to really, as with many things, think carefully about this. Torek suggests that conservative non-weight-bearing management is the standard of care for initial treatment in both partial and complete stress fractures. But I think, as with many things, we need a prospective randomized trial comparing non-weight-bearing cast treatment to surgical fixation. So fix now, fix later, fuse inevitable. And I'm just here to tell you that sometimes I just think it's maybe just not meant to be. And I'll share with you just a last case as we work through this. This is a 21-year-old D1 basketball player. I just don't think it was meant to be in this particular athlete. He had one year of pain before I met him. He did have a subtle cavus foot. Here were his x-rays when I met him. And you can see the fracture on x-ray, which usually isn't a good sign. And this was his fracture, clearly a non-united stress fracture. So we moved toward surgery. We did bone graft, two cannulated screws, felt good about the surgery. Here was his return to play. I had CT verifying that it was healed. There were his screws. And at one year after surgery, his pain was not limiting performance. He was ready to start the season. We went fairly slow. Completed his season, got a call. He's 18 months post-op. Doc, I've been having pain for two months. And I'm thinking, oh man, here we go. So here's his x-ray, not too bad. There's his CT scan. Refraction in nearly the same plane. And so now we're taking this athlete that wants to get back to play. He's a D1 basketball player. What do we do now? Well, I think he needs surgery again because we gotta fix it. If it didn't heal the first time, we gotta do better the second time. But the other part of this was trying to help the mechanic of his foot. Did a dorsiflexion osteotomy of the first metatarsal for his subtle cave of his foot. Did use some biologic augment, iliac crest bone graft. I also used off-label PDGF to try to help put some healing factors there locally. Did the additional debridement as extended up to the ankle to be sure there weren't any osteophytes at the tibia or the talus. And there's the picture of the osteotomy. Slower in rehab this time around. Of course, he developed CRPS. Everybody's got these stories if they take care of navicular stress fractures. At 11 months though, finally got a CT. He was ready to get back to play. At 14 months, it still looked okay. Here he is and he wants to get back for a season. And so then you get a call from the trainer and when you get a call from the trainer, it's never good, particularly if he sends a video. And so here's, hopefully the video will work. Well, it's not working anyway. It's the big kid in the middle here. He does a little slip screen, comes down and he jumps to catch a pass and he lands on his foot. And so he'd been practicing about a month, but he landed on his foot, had immediate pain and the story wasn't over there. Here's his CT scan. So now he's got a fracture in a completely different plane than what he had the first time through. And so this is what I mean by these are hard fractures. Sometimes they just don't wanna behave. This patient at this point, we decided to treat non-operatively and we put him in a cast. He started on senior night and then rode off into the sunset. He's now a rep for one of the orthopedic companies actually in Indianapolis, Dave. So if you see a tall guy rolling through and he's got a little limp, he's probably my guy. So at any rate, these are tough fractures, okay? And we need to really take them very carefully. Here he is riding off into the sunset. Literature suggests gold standard may still be non-weight bearing cast for six weeks. Get follow-up imaging and counsel appropriately. Navicular stress fractures can safely be treated with operative fixation. Avoid the complete displaced fracture. Why surgery? Because you can get him to heal. You can avoid non-union. Beware of the complete displaced fracture. With non-union comes reoperation, collapse, and arthritis. And consider surgery for earlier return to play. They're hard. Sometimes it's just not meant to be, but be sure that you and the patient understand what you're working through. Thanks. Thank you. Thank you, Jeremy. Yeah, if one of these comes in your office and you're not nervous, you should be. They are very unpredictable. And this is one area where I think classifications are very important. That CT classification of Saxena is extremely important because if you see something going from one to two, two to three, you need to jump on it real quick. So now we're gonna go into the perineal tendons. And our guy in the D.C., Northern Virginia area, who manages a lot of those high-level athletes and perineal tendon issues, is gonna talk to us about this. Steve Neufeld. Steve. Thank you. Thanks, Bob. Thanks, Ken, for inviting me to talk today. And it's great to be back in person with everybody. All right, so disclosure. I am a consultant investor with Ardalon. Nothing else is relevant for this talk. So unlike navicular stress fractures, perineal tendon injuries are common. They are missed frequently as a lateral ankle sprain. And as we heard, lateral ankle sprains occur all the time. And if the lateral ankle sprain is not getting better, like you would expect, then you should think about getting more imaging studies or really examine the perineal tendons. One, both could be damaged, but you need to think about it. So just a few slides on the anatomy because it is relevant on how we address these. Remember, the perineal longus runs under the foot and inserts on the base of the first metatarsal. So right where it inserts, I'm sorry, right where it goes under the foot, right by the cuboid tunnel, is an area of high stress. And we get damages and we get pain down there. Occasionally have a low-riding accessory of perineal brevis muscle, and that can cause pain as well, and not necessarily a tear. That needs to be addressed as well. On the undersurface of the fibula, there's a groove for the perineal tendons. In the past, we used to address groove deepening procedures in subluxating perineals. That's not gonna be the topic of this talk, but I've found over the years that groove deepening isn't as necessary as we may have thought it was at one point. It is held in place with an SPR ligament, and those injuries are seen where the SPR is pulled off, and they can be fixed without groove deepening many times. But just the anatomy of that small structure behind the fibula getting jammed back there with a low-riding brevis muscle can cause frequent problems and pain as well. Briefly, the perineal longus, again, it runs under the foot. It's innervated by the superficial perineal nerve. It supports the arch. It plantar flex the first metatarsal. These injuries, again, occur more distally than the perineal brevis muscle injuries. So an ankle sprain that came in as an ankle sprain, but they have more pain down by the cuboid or down the bottom of the foot, many are localized to that region or more of an os perineum or a POP syndrome or perineal longus injury, so you should think about that as a cause of their troubles and not the ligaments. Perineal brevis is SPN nerve. It everts and plantar flex the foot, and because it runs underneath and behind the fibula and it's held in place with a very fairly tight structure back there, and there's a high curve down here, that's where many of these injuries occur. Occasionally, you get an injury around the perineal tubercle as well or the base of the fifth metatarsal at the insertion. So when you really critically examine these, they are different than an ankle sprain, but you need to address them. In general, an acute perineal tendon tear is not always picked up, but it's a sudden onset of lateral hindfoot pain, trauma injury, it's an inversion injury, swelling tendinitis, so no question that it presents like an ankle sprain. There are some underlying factors which you need to think about. Recurrent ankle sprains, maybe the instability is causing recurrent inversion injuries and eventually the perineals get damaged. Hindfoot varus, as we talked about earlier, for ankle instability is an issue as well. A shallow groove I think is debatable, and D of dislocating perineal tendons as an etiology for the tears. So again, the perineal brevis injuries occur more or less behind the fibula, kind of around the lateral ankle ligaments where the perineal longus tend to be a little more distal. So the exam is really crucial, and it's amazing how many people will come in the office after going to the Urgy Care Center and saying they were diagnosed with ankle sprain, when in reality it's really a perineal tendon tear. It's a very common injury. Just one quick slide on dislocation and subluxation. I think it's beyond the scope of this talk. Shallow grooves theoretically can predispose to dislocating perineal tendons. An acute injury like an SPR injury can do it. A generalized ligamentous laxity. I've had patients that come in and they can actually dislocate their perineal tendons in front of you. Recurrent ankle instability and different events, skiing, soccer, dancing, cutting sports as well. If you don't treat perineal tendons, many of them will go on to chronic pain and tendinopathy. So I think it's an important thing to recognize, and I think it's an important thing to address. You can get snapping tendons across the fibula and that hurts, and eventually when you get in there it looks like this big bulbous, thickened perineal tendon. So I think it needs to be addressed. Let's see if we can advance this here. So the workup. Again, physical exam. Where is the pain? Is it on the underside of the ankle? Is it under the fibula? Is it by the base of the fifth metatarsal? Is there instability of the ankle? Is there weakness? Please look at hindfoot varus. That's very common. A subtle cavus foot. I know there's some lectures today on subtle cavus feet. They have frequent pathology with their perineal tendons as well. X-rays are sometimes useful. You can get a foot X-ray. You can see a little fractured os perineum. Occasionally you can get a little flex on in the outer portion of the fibula. But really it comes down to a physical exam finding most of the time. An MRI could fool you. How many times have you ordered an MRI in your office? It comes back and the radiologist reads possible perineal tendon tear or perineal tendinosis. I mean, we see that commonly diagnosed more times than not. This magic angle phenomenon has been reported. There's ways to decrease that magic angle phenomenon. Most radiologists really just take an MRI of the ankle and the foot and they diagnose a torn perineal tendon. And more times than not, it's not a torn perineal tendon. So just keep that in mind. We're lucky we have an ultrasound in our office. And I would urge everybody to get familiar with ultrasound. It's a very inexpensive modality. It's very easy to learn with some practice. And you can pick up subtle tears as well and subtle instability and dislocating perineals. It's a quick exam, do it in your office. It saves an expensive MRI and it saves a lot of time. So you find a perineal tendon tear. In general, what's our treatment thought process? Well, conservative management I would challenge at least for high-level athletes or even weekend warrior athletes that want to get back and play. Really does not work if that tendon is torn. Now you could try NSAIDs, you could try active modifications. If they have a flexible cavus foot or a slight subtle instability, you can immobilize them in a brace or a lateral post-orthotic. If the tendon's not ruptured and it's just some synovitis, but it's behaving like a tear, you can rest it in a cast or a boot and do some physical therapy. But I would argue that if it's torn, I think you need to think about fixing these. The extent of the surgery really depends on the extent of the tear. And a lot of it in my hands is made at game time, I think, or surgery time. I think the MRI typically can mislead you onto what you're going to do in surgery. And I think you should be prepared to do anything and be comfortable around the side of the ankle. If you get in there and it's a simple tear, you can usually just fix it, debride it a little bit, tubularize it. I think you need to be prepared to augment it or tinnitus if needed. I think you need to make sure that that ankle is unstable and do not hesitate to do a brass trim or a ligament reconstruction if necessary. And please don't forget about the heel varus. That will lead to recurrences. And that was the underlying problem many times to begin with. And if you're going to address that, you're not going to solve the patient's problem. So here's a split in the peroneal brevis tendon. I think in this type of case, if there's a low rotting peroneal brevis muscle, you can excise the muscle. You could suture the tendon. You want to maintain its structure as best as possible. And then you want to repair your SPR. Is there literature to support this? And there has been for many years. Good AOFAS scores, good return to sporting activities, good return to pre-injury activities in these type of injuries. But how about this too? This is when it gets more challenging. And like I said, be prepared for anything when you get into the operating room. This is a tough case. Here's a peroneal brevis that's shredded. Are you just going to throw lots of Ethabon suture in there and you're going to get lots of scar tissue? It's going to be bulky. You have very little space behind the retinaculum, behind the fibula. So what do you do with this? And just be prepared to do something. So if it's more than 50% of the tendon and you feel like you're not going to get a good primary repair, then in my eyes, there's really two options. One is you can excise the disease portion. You could tenodesis the peroneal longus. I would tell you that I think in a high-level athlete or in a young person, it's not the most ideal operation. It does work. There's some literature which I'll show you that suggests that it works well. I think in the last few years, I've been more apt to reconstruct with some sort of graft, either allograft or a synthetic graft. Here's option number one. And again, there are studies support that you can return back to activities. This is taking the peroneal longus, tenodesis into the torn brevis, inserting it to the base of the fifth metatarsal with an anchor and then closing it and rehabbing them. Option number two, which is my preferred way of doing things, is you can augment your torn tendon. You can either overlie the tendon with a graft and suture it in place, or you can create like a core. So you basically take the synthetic graft in the mid-portion of the tendon and kind of sew the biology around the tendon. So essentially, you're recreating or reestablishing the continuity of your previously torn tendon. And in my hands, I think this is a better option for the severe peroneal brevis tears. I think you can repair it easier, and I think you'd rehab them quicker. And this is a typical post-op protocol for a athletic person or somebody who wants to get back pretty quickly. They're splinted in the operating room, and it really comes down to the incision. I think if you're augmenting your repair and you get really good fixation, then you can feel very comfortable about being more aggressive on the rehab. I let them white pair as tolerated once the incision is healed. If it's a strong repair, I start early range of motion. If it's a questionable repair, then I don't. That's really what it comes down to. And it's really, you make the decision based on the patient's anatomy and based upon your repair. If it's questionable incision or if it's questionable repair, I will cast them for four to six weeks. I'll start therapy at around four weeks. And usually, typically in athletes, we'll get them back playing eight to 12 weeks after repair. So I tend to get even more aggressive if it's a young, healthy patient that I've augmented with some sort of augmentation and I get a nice, strong repair. Let's move on to peroneal longus tears. They are uncommon compared to peroneal brevis tears. We will see more often. There is some predisposing factors, diabetes, rheumatoid instability, again, hind foot varus, most commonly related to a direct injury or trauma. Again, you're seeing cuboid tunnel problems. So if you're seeing pain along the bottom of the foot, those tend to be peroneal longus more so than peroneal brevis. Treatment in general is you can tuberalize them, NTEN repair, or augment, and TINADIS if needed. I think there's a high incidence of failure with non-op treatments on these as well for young, healthy patients. So typical tear, this picture here, you debride, repair, plus minus augment, or you can do a tendon transfer and TINADIS. In my hands, I think augmenting really helps us and gets them back much quicker and allows you to rehab much faster. If there's an os peroneum, you can excise the os peroneum. I will challenge you to say it's a difficult repair if you have to take it out and there's very little tissue left to repair. So be prepared, again, to have some sort of graft, either an allograft or a synthetic graft, like this is an artelon graft that I use frequently for these cases. And the rehab is very similar. Again, it comes down to your repair and the soft tissue. So they're split in the operating room. Once the incision is healed, I put them in a boot and I let them walk. If my repair is strong, I let them do early range of motion. If it's questionable, I put them in a cast. I start physical therapy fairly quickly, around four weeks, and really, again, eight to 12 weeks, I get them back playing in sports as tolerated. How about if you have both tendons that are torn? Your options are you can tuberlize and do an end-to-end repair. I think it's challenging frequently. You can do a tendon transfer if needed. There's literature to support allografts. Nunley had some nice studies. Hunter rods, Keith Wapner presented that back in 2006. I will tell you that my experience with Hunter rods has not been favorable. I think they get very tight, and they get scarred down. I think nowadays we're trying to fix these and move them as fast as possible. Athletes do not want to be immobilized for a long time. They don't like it when their perineal tendons are tight. So I would say anything you can do to get them moving quicker is better. Here's an example of mine where we took the FDL, or you can use the FHL, from the medial part of the foot behind the ankle and transfer it down to the base of the fifth metatarsal. There is literature to support that as well, Brodsky in 2013. And there's some newer literature that supports that as well. Again, you get a good repair. You can splint them, let them walk, and start early motion when your soft tissues allow it. What if you have an unrepairable perineal tendon? Your bailout would be an allograft reconstruction. Nunley's published, and Parikh has published series on those. They had a 14-patient series, unrepairable, fixed with allografts, and their athletes were able to return to dancing, running, and cycling. So just be prepared when you get in there. If you can't fix it, then have an allograft in the back. How about perineal tendinoscopy? In the last few years, there's been more interest in minimally invasive techniques and quicker recovery. And just like in the knee, and in the ankle, and MIS surgery, I think there's a role for arthroscopy and tendinoscopy as well. The advantage is there's less morbidity. There's less pain. I think you're limited. I think it's very technically difficult. I think it's very good for certain things like synovectomies, adhesions. There are people who can, technically better than I am, I think, can repair a torn tendon through a scope. I find it difficult. The portals and the technique have been well described. Back in 2006, Van Dyck had a nice article in Foot and Ankle Clinics, where there's a distal portal, there's a proximal portal, and then one right off the edge of the fibula. And it's actually, technically, not a very difficult surgery to do. And I would challenge you, and I would say that you should try to do a perineal tendinoscopy. In my hands, if you have a clinical presentation that's convincing you there's some pathology, but you have some negative imaging, so the MRI is questionable, you have the magic angle, you're not sure. I think a perineal tendinoscopy is a very easy operation to do, and it really can reveal a lot of things. Serrato had a nice anatomic dissection, which showed that you can visualize most of the perineal tendons through a scope. So it's a little daunting at first, but try it, and you'll see that you can see a lot of pathology through the scope. So in summary, don't ignore the perineal tendons, an ankle sprain that doesn't heal, or if your exam suggests a tendon tear, it may be. Consider buying an ultrasound machine in your office and doing an ultrasound evaluation where you can see this pathology. Be prepared in surgery for anything, whether from a simple repair like a tubularization to using an artificial synthetic graft or even allograft. And again, tendinoscopy, practice it. Try it on a cadaver. It is useful. So thank you. Thank you, Steve. Totally agree. Try to avoid the tenodesis in the athletic population. It's just not as good as replacing the tendon itself and maintaining that independent power. Next, we're going to talk about the Jones fracture. Dr. Porter, who is well known for his management of elite athletes, particularly in the state of Indiana, actually wrote a paper on different screws to use for Jones fractures about, what, 25 years ago or so? So a lot's happened since then. So Dave, if you could tell us where we are with the Jones fracture, please. Thanks. Thanks, Bob. I think it's really quite an honor to be here with such a distinguished faculty. When you're the second oldest guy up here, you have to wear glasses. So when I got this title, What's the Latest, Sir Robert, I thought they chose the wrong person to do the talk. So I think Sir Robert Anderson's supposed to do this talk, but I'll do the best I can, and we'll get somewhere. There's a disclosure. So currently, the standard of care in the athlete for a fifth metatarsal Jones fracture of any type is intermedular screw fixation. So why is intermedular screw fixation the current standard of care? One, because it works. Clinically, it works. But also, let's delve a little bit deeper. This fracture does not heal well without surgery. So the question is, why doesn't it heal well without surgery? There's three or four different types of fractures of the fifth metatarsal. There's just very little single location where we seem to have trouble. So one is biomechanics. So there's motion that occurs at the fracture. And two is physiology, which the blood supply at the fracture site can be a little bit tenuous. So if you can see on this video, the fifth metatarsal has to have a lot of motion to accommodate uneven surfaces, whereas the medial column is really very stiff for push off. When you get a fracture in this area of the fifth metatarsal, we know that the base of the fifth metatarsal has peroneus brevis, ADQM, lateral plantar fascia, tarsal metatarsal ligaments, and even the peroneus tertius tendon attaching to the base. So the head wants to move, but the base actually doesn't want to move. So when you get a fracture in that location between the two, it just wants to create a new joint. The second is the vascularity, as you can see from these Indian ink studies, that the vascularity of the metathesis is excellent. There's also the nutrient already comes into the shaft of the fifth metatarsal. So in this area of the base of the fifth, you have this watershed area. So when you fracture through it, you develop, at least in theory, we think, some avascularity or at least decreased vascularity, which also can contribute to the fracture. So intermedial sclerofixation addresses both the biomechanics, it reduces the motion at the fracture, but allows motion, the physiolyzing motion at the TMT joint, but also addresses the physiology, at least in theory, by improving the blood supply to the fracture site by drilling and creating, improving intermedial vascularity. So the first thing, so what do you need to know? What is this talk all about? What's the point? First off, make sure when you're dealing with a fifth metatarsal fracture that it's a Jones fracture. That's what we're going to talk about, but other fractures are treated differently. And that may sound simple, but sometimes it's not quite as simple as it sounds. So here's the things you need to know. If you can bone graft it, bone graft it. Use the largest diameter screw you can do that fits well lengthwise and size-wise. Fills the canal, but doesn't go out of the canal. Watch out for screw head impingement. We'll talk about that. You can get a great healing, and then all of a sudden the screw head impinges on the cuboid, and they still have pain. Correct malalignment. In the virgin case, in the original first case with the surgery, I'll use just typically orthotic management, but in the revision cases, I'll do some type of osteotomy if needed. Use a bone stimulator if you can. I say can because it's $3,000 to $5,000, and some insurances won't cover it in a high school athlete. Plan three to four month return. In most situations, we'll talk about when that's not the case, but if you can get three to four months, the fracture heals much more readily and you have a little bit decreased risk of refractures. If you can get the athlete through one year without any re-injury and refracture, you're good. Most of the time, re-fractures occur within the first year. Not exclusively, but most of the time. And don't be afraid of revisions. They actually can do very well. So 4.4% of elite football players have a Jones fracture. Not just one sport, I'm saying that's a measurable amount. So it's a significant amount. The fifth metatarsal is the most common metatarsal fracture in trauma and athletics, and usually occurs with a slight supination landing on the foot. 50% of all metatarsal fractures are fifth metatarsal fractures. It's common to get these fifth metatarsal Jones fractures in all fifth metatarsal fractures, but particularly Jones fractures in athlete. It causes missed time, but generally speaking, it's a temporary disability, and it's not career-ending. All sports involve Jones fractures, but running and jumping sports in particular are involved. And don't be confusing it with other fractures. I know all of us get fractures that are sent to us. It says, this is a Jones fracture that needs fixation, and it's not. It's an avulsion. And here's a fracture. We can treat it. It's been treated for four months. It's obviously a Jones fracture. It's a non-union. So making and identifying the fracture is really critical. This is a classification I think that's helpful for me personally. We publish it in the foot and ankle clinics of North America. So a Jones fracture is a transverse fracture at the metadiaphyseal or proximal diaphyseal area. It's transverse. It's sclerotic-looking, obviously, in some in the very plantar lateral aspect of the cortex. Here's a non-union of a fifth metatarsal base. But you see the fracture orientation is more vertical, and that's more than the apophyseal non-union. And then the true avulsion fractures are transverse, just like the Jones fracture, but they're in the metaphyses. And those should heal really well nonoperatively and only rarely require surgical intervention. Then obviously, your Dancer's fracture is a diaphyseal fracture, but it's much more distal, it's an oblique fracture, and heals very well nonoperatively. So all transverse extra-articular fifth metatarsal fractures and then metadiaphyseal to proximal diaphyseal fractures are Jones fractures and should be treated as Jones fractures, even when they start at this metatarsal junction and go proximal. But if you have just this real transverse fracture, and it's all metaphyseal, in the recreational athlete, and maybe the lower level athlete, these probably still can be treated nonoperatively because they're really metaphyseal. There's a lot of different types of classifications out there. I really think the classification on the anatomy is the most helpful. So the Stewart fracture becomes a type 1, it's a Jones. Zone 2 and 3 are the Jones fracture, but I'm not sure the Jones fracture is helpful because this is almost a type 2 zone, a zone 2 fracture also. And then all the Torque fractures are Jones fractures. So an acute fracture, what do you do with it? It comes into your office, acute fracture, you can see here there's very little medullary sclerosis, there's probably a little bit of early stress fracture, so it's a stress fracture, broke through it. It's a complete fracture line, varying degrees of prior changes. This is a particular division to a basketball player. What do we do treatment? In that situation, it's intermediate screw fixation. I like bone grafting all of these, particularly these acute ones too, because on the acute ones, you can make a small incision right at the fracture, you can actually displace the fracture, open it up, put bone graft in. I actually, in these acute settings, we'll use calcaneal bone graft. It's very easy to get to a small, you know, 1.2 centimeter incision, take a seven millimeter plug of bone out of the calcaneus, morselize it, put it in, you can actually drill across it a little bit, and here at 2.5 months, you can see really good incorporation, even though it looked like he had kind of excessive bone, it creates an increased diameter and actually becomes pretty much like a normal looking bone at that point. I use the largest screw that fits the canal, and you want to assess the vitamin D level, menstrual irregularities, and look at their diet. What about the occult fracture? We see this, we see it oftentimes, we see it at the NFL combines, we see it in other locations, you'll get an x-ray for another reason, you see this fracture, and oftentimes they're not coming in because they hurt, you're seeing it incidentally. So it's not a full fracture line, but you can see it's clearly becoming early osteolytic area, and so it's early stress fracture line. So this is one of the few times I think MRI is really helpful in the setting of a fifth metatarsal. It tells you if it's really physiologically stressed or not. So in this situation where you can see the stress fracture line, you can see this uptake throughout the whole fifth metatarsal, to me that's a developing complete fracture, and in that situation I do my intermediate screw fixation, address it, plus minus whether you tried any onlay bone graft, you can't open up the fracture. If the MRI is cold in that same setting, you have the same little early osteolysis, I treat it non-operatively, I do address the biomechanics, I kind of repeat x-rays closely. If it goes on to develop a fracture, you treat it appropriately, but I've had several of those, even they've gone back and played at high level and gone on to heal. So what about the end season Jones fracture? Immediate onset in a plane, the first thing you've gotta decide is it a complete fracture, incomplete fracture? If it's a complete fracture, I think it needs operative fixation, you may have to decide on return to play. Gets more complicated at the higher level, the NBA and NFL level, you got an agent involved, you got coaches and trainers, and this end up being about six or eight phone calls every time you see the patient. If there's no bruising, there's not an acute injury, there's not an acute fracture, in some situation, in season, I use a wrap around with those as a carbon fiber plate, modify their practice, and get them through the season. If they continue to hurt some after the season, then fix it definitive for that time. But I think if it's a complete fracture and there's displacement or a complete fracture all the way across the medial side, I just think it's hard to treat those in season without operative intervention. Bent screw, what do we do? Okay, if there's no pain, you just watch it. If it's healed, you can just watch it. If it's in season, it's mild pain, I use an orthosis just like we did kind of on that occult fracture. Look and try to correct the biomechanics, vitamin D I think is helpful, about somewhere between 50 and 80% of division one athletes are deficient in vitamin D, so it's really something we have to look at in these stress fractures. If it's off season, there's pain with nonunion, you're basically gonna treat it like a refracture. You're gonna bone graft, you gotta take the screw out, look at the vitamin D, sometimes you foretell, particularly at the professional level or division one level, return to play, it's gonna be four to five months, and I bone graft all of these. If it's a refracture, it's essentially gonna be the same as just what we talked about. But I think in the refracture, look and say why did that refracture? That's important to assess what it is so that second surgery is more successful. So number one, the biomechanics. And there's subtle cabovarious foots and more severe cabovarious foot. So this is kind of a moderately to subtle cabovarious foot here. If the first metatarsal ray is plantar flex, then I like doing a first metatarsal osteotomy, I think it's really well tolerated, it heals well, and it can take some of that load off the lateral side. Again, look at the vitamin D level, we wanna keep them above 40. Some literature says 32 is normal, we try to keep all athletes above 40, preferably even above 50. Look at the screw size, is it too small, is it too long, is it too short, is the position wrong? So in revision surgery, we take down the fracture. And this is not obviously a revision, but it helps show the point. Oftentimes on the revision, there's this intact or very corticated medial cortex with a lot of osteolysis around the more plantar and lateral aspect. So I think in that situation, going in with an osteotomy, completely taking down the non-union so you can actually take down this medial cortex, it maybe shortens the metatarsal a millimeter or two, and that may be helpful, maybe that takes a little more stress off of it. I do an exchange screw if I can, I'd use a larger screw. I do an osteotomy if needed, I prefer not to do a baris, I'm sorry, I prefer not to do a Dwyer osteotomy, particularly if the Coleman test is positive. I just think with the calcaneal osteotomy, it's just a little harder, the mechanics change a great deal at the elite level. I always bone graft. In that situation, I like the Iliac crest bone graft, I think it just gives you the highest cell count. Sometimes use the bone marrow aspect concentrate or some other biologics, their extracorporeal shockwave is something you can be used in the post-operative period. I have not used it a lot, but some do. I make those non-weight bearing for four weeks, whereas in acute setting, I only have them toe-touch weight bearing for a week or two. They're in the booth for a full eight weeks and return to play, it's four to six months, and I've had, fortunately, really good success with the revisions. What about screw head impingement? It does happen, it's not rare, unfortunately. Prevention is the key, you have to really look closely at your x-rays. You're looking so much at the screw and the length and the size and the feel, and sometimes you just don't look closely enough at the head itself, and you can see on the CT scan, there's an erosion there already in the cuboid. This is the division one women's basketball player, the fracture completely healed, but she had just persistent pain. So doing revision screw is very good on that. It can be a quick return, sometimes even four to six weeks, but you still have to repeat x-rays and make sure they don't kind of develop a refracture. What about screw penetration? It's not rare, but it is avoidable, as prevention, again, is the key. Always get three views intraoperatively to look at this very, very tip. Here's one on my patients, and you can see just a little bit of cortical breakthrough immediately, and if you see this post-op, they usually will go on to heal and get some callus around it and just create a canal, the cortex around it, and it works well. If there's severe penetration, it's just the screw is in bad position, you just have to redo it. So hopefully, if it's not bad, you can observe it. It gives good stabilization at the fracture site, it's just you're concerned about a secondary fracture distally. So know the anatomy. I think it's better than the zones. I think know the principles. Metaphyseals heal well. The metadiaphysal fractures don't, and they need to be treated as a Jones fracture, and screw fixation is the current treatment of choice. Plantar plate is something we can talk about maybe in the discussion. It has its place maybe particularly in the revision. Always look at the biomechanics. Always look at the metabolic area also. Try to keep them above 40. Menstrual cycle irregularity has to be addressed. And always get help if you need help, and I do that a lot. Bob knows that because I call him a lot. So thank you very much. Thank you, Dave. Thank you, Dave. And we'll have some cases to illustrate more about Jones here in a few minutes, but our last talk here, Greg Wuerzest is gonna talk to us. He's at Harvard with Dr. DiGiovanni, and has done training in both sports and foot and ankle, and he's gonna enlighten us more about stress fractures in general and what we need to do with them, how to prevent them. Greg. All right, we're gonna talk about stress fractures in the athlete and kind of go around the world real fast and so we have good time for cases. So I have no disclosures related to this talk. So stress fractures are definitely in your clinic, probably every day. They're about 10% of injuries that we see in rec and competitive athletes. And it's thought to be due to repetitive submaximal mechanical loading that leads to bone adaptation, but microscopic bone injury occurs if the threshold exceeds, leading to reactive bone edema, incomplete fracture, or complete fracture. It's really all about a good history in my clinic. I see a patient come in, they have a complaint, figure out what sport they're doing, how they're training. I have a background in strength and conditioning, so we talk a lot about sort of how they're cross-training, what they're doing for cycles, how many miles a week are they running, did they get new shoes, all those kinds of things are really important. You should ask about when they started having pain. Was it acute onset, gradual onset, did it involve some type of rolling mechanism or not? And then as orthopedic surgeon, I think it's kind of awkward sometimes to talk about this, but we really need to do a better job of talking about the female and male athlete triad. And energy deficiency, is someone trying to cut weight? Are they trying to gain weight rapidly? Are they taking some type of supplement? Reproductive suppression in menstrual disturbances in females, or even male hypogonadism. And then any type of impaired bone health. Do you think they have some type of collagen disorder or bone disorder? So plain radiographs are oftentimes negative when you first see these athletes. And repeat radiographs in a few weeks can confirm diagnosis. So the cheap way on a lot of the stress fractures is have them come back in two weeks after you immobilize them. MRI has largely replaced bone scans, I think in most people's practices. Not all edema leads to stress fractures. And there was a study in 2002 that showed that tibial stress reactions were found in 43% of asymptomatic college distance runners. So something to be mindful of. And you oftentimes have to explain the MRI back to the athlete saying that you don't hurt in that area, but there's edema there. And that can be very difficult to do. Low risk stress fractures, these are the ones we don't have to worry about as much, but they can still be annoying. Posterior medial tibial shafts, fibula, calcaneus, cuneiforms, cuboid, metatarsal neck, and shafts. So the posterior medial tibial shaft fracture is thought to be due to compressive load and tensile muscular forces of the gastroc soleus and the deep plantar flexors. The posterior medial pain is worse with activity and oftentimes tender to palpation. This is the one that I oftentimes will see, some people will have done exertional compartment testing on or sometimes people can have a combination of both. So we oftentimes, even if they have this and we see it improve on the MRIs, I'll oftentimes do an exertional compartment test, not even necessarily for the actual pressure numbers, but so I can evaluate them after they're running. Because that's one of the things you don't see in the office when they're just there, is when they're actually having a lot of this discomfort. And then the grades that we talk about. So the treatment time average four to eight weeks in a boot until the pain tenderness has resolved. Grade one can return as early as 16 days, grade two, three, and four A, 39 to 44 days, and grade four B, 71 days. Fibulous stress fractures usually occur the distal third proximal to interstitial. Make sure that you get a good hind foot alignment in the office. I routinely will take photos of the patient's hind foot alignment. So I'll always have a memory of what it actually looks like. That way I can get them the right orthotic prescription afterwards. Because oftentimes your high school kids haven't, they have flat feet, but they don't necessarily have an orthotic. And so wait there early, return to sport two to three months. And sometimes they do need to be fixed. I think the more flat footed the athlete is, the more chance there is of new need to fix them. Calcaneus is due to a combination of repetitive heel strike and non-cushion surfaces. The Achilles likely contributes, and 65% may have an additional tarsal stress injury or fracture. I usually get an MRI if I get a positive calc squeeze test when I'm evaluating an Achilles problem. I limit weight bearing and immobilize, and I advance the pain as allows. This is often one where I'll use a lot of shockwave for. So cuneiforms and cuboids, they're really uncommon. I think it's important to, if you get one thing out of this talk, consider neoplasms on this one. So this was a case that I had of a 35 year old woman who had an MRI that was read as a stress fracture. It hadn't gotten better. She came in and saw me. We repeated the MRI and it ended up being a atypical osteoblastoma, and she has a bologna amputation now. Metatarsal shafts are a common distal second metatarsal. Radiographs can take a few weeks to show callus, so be patient with these. Oftentimes in a high level athlete, we get an MRI soon, but seldom are operative. I think the one thing is looking at the metatarsal head alignment as they heal. That can be a challenge. High risk stress fractures are anterior tibial shaft, medial mal, talus, navicular bases of the metatarsals and the sesamoids. So anterior tibial shaft, often in repetitive jumping athletes, it's a hypovascular tension side of the tibia. We're always looking for that dreaded black line. And it's really a debate between op and non-op, and then how long you can non-op someone before they should have surgery. And we really get this debate as to nail versus open compression plating. And then even with a nail, do you go super patellar through the patellar tendon or lateral parapatellar? Talar stress fractures can have more vague symptoms like anterior impingement. And so these oftentimes don't, they take a while for them to get diagnosed. Consider non-weight bearing until symptoms resolve. And an orthotic with a medial post for a hind foot valgus patient can be helpful. Talar head involvement really depends on talar navicular joint involvement. And beware of a case that also has a OCD in the talar head. Medial malleolus stress fractures, repetitive torsion and shear across the medial ankle. And they're often seen with capoveris alignment, but typically a more vertical and unstable pattern. Usually we'll non-op the ones that don't have a fracture line, and I'm really aggressive operating on them when there's a fracture line visible. And really you have to decide between plating versus screws. And oftentimes it depends on sport. So if they play hockey, the plate might really bother them. So you might wanna try screws, but it's a good thing to discuss with your athlete because you wanna make sure that, you know, you wanna make sure it heals first, and then you have to deal with the hardware issues sort of after. And navicular stress fracture, we already had a great talk about. So I'm not gonna go into that too much, but just be mindful of the possible navicular OCD that can be present. I did an arthroscopy on one of mine. She had an OCD, so we grafted it, and then she did fine. Non-fifth metatarsal base fractures. We see local swelling and tenderness. On-point athletes, repetitive impact. Cavus are more impacted. Usually okay with a boot. Non-union can require ORIF or fusion depending on location. I think oftentimes we do resort to fusion. Before doing this, I'll oftentimes do a joint injection with lidocaine under image and track their symptoms to see whether or not I think a fusion is actually the better of the options. We already had a great talk about proximal fifth fracture, so I'll just skip past that. And then sesamoids, repetitive compressive loads, offloading dancers pad to Morton extension, sesamoid offload orthotic. I've had some success with more of a flexible carbon fiber orthotic that I also use a sesamoid pad with. And then making sure that when I put patients in a boot for these, I actually make sure they have a sesamoid cutoff in the boot. So if you actually take the insole out of a boot, if say you're seeing someone that's been in a boot for three months and you're seeing them as a second opinion, you'll actually see where they're driving their first metatarsal head into the boot. And so that means that we're probably not offloading it well in the boot. So I put the sesamoid pad in, a couple layers of felt, make sure that that's offloaded. Sometimes even tape the toe down a little bit to rest the tissues there. Consider open bone grafting, ORIF excision. And then in recalcitrant cases, you might wanna consider gastroc recession or a first rate dorsiflexion osteotomy to offload the pressure that patients get. So treatment strategies, medical management, getting vitamin D levels, parathyroid levels, DEXA scan to evaluate bone marrow density, treat with calcium and vitamin D, bisphosphonates, and PTH analogs. Teraparitide has some role. I don't know many orthopedic surgeons themselves that are prescribing this, so you wanna make sure you have good friends in the endocrine department, which we do through our women's health initiative at Mass General. And then we get to this bone stimulator versus shockwave. And I think someone already mentioned the pricing on bone stimulator. So if you can get it covered, great. If not, sometimes the shockwave, when it's not covered by insurance, is actually cheaper. And so make friends with someone that does some high level shockwave and that has maybe a radial on a focus machine. We talk about cast versus boot, surgical treatments. So really shockwave is something that I tend to use a lot of for non-operative management. For these, I have a great colleague at Spalding in physiatry that does a combination of focused and radial shockwave on my athletes. And so this is something definitely to consider. There was a study in 2010 on medial stress syndrome that actually showed that there was better return to play with shockwave treatments. But it's usually a non-covered entity, but it can be reasonably painful for people to have during the treatment, but it can work very well at speeding up their recoveries. And I really think the best offense is a good defense. So I'll oftentimes take the athletes to the treadmill and see them run and we'll do a running assessment with our therapy colleagues to see if there's things that we can work on biomechanically to prevent these from occurring again, especially after we get them treated. Good dietary habits are something worth talking to people about. A running assessment with a running professional can be really helpful. So we're blessed at MGH, we have great therapists there and over at Spaulding that do these routinely and gait analysis. Jump landing training can also be helpful. And you talk about what kind of shoes that they're using during these activities. So are they using Olympic weightlifting shoes for their Olympic activities, or are they using very minimalist shoes and what's bothering them and what's not. Orthotics for people that should have them. There's debate about when people should get new running shoes. Sort of what's in the literature is 200 to 300 miles, which may not be that many weeks for some people. And then avoid year round sports participation in the same sport for the pediatric population. And that goes the same for the adult population too. And really I'm a big proponent of cross training for these athletes. So it's really hard to get a stress fracture person to stop their activities. So if they're big time runners, you gotta try to find something that they can still do. So maybe that's running in a pool or using one of those zero gravity treadmills. And that oftentimes helps them realize that they're still doing their activities and they're happy, but you're offloading them still. And then with a zero gravity treadmill, you can sort of increase the amount of weight bearing as they go. That can be really helpful for these athletes. So takeaways, make sure you ask about the male female athlete triad. Don't miss a tumor. Consider early advanced imaging on athletes. Early surgery on higher risk fractures may lead to increased return to play. And you should consider adjuncts like bone simulators, shockwave orthotics, PT, and biologics when you think it's indicated. Thank you guys. That was a wonderful overview, Greg. Thank you very much. I didn't hear, I didn't know there was a male triad. You know, we talked about the female triad, the male triad, I wasn't familiar with that. I mean, have you seen a lot of that? It's on a low testosterone level, so yeah, that's a big thing in male health that's sort of forgotten about. It's sort of forgotten about, I think, so I'm gonna look into, and might consider people that are coming off of cycles and medications and things like that. So we talked about the female triad, particularly in those sports where the woman is sort of featured, you know, an individual, track, you know, gymnastics, things like that. Are there sports that the male triad comes into play? Is it the same thing? Is it track, gymnastics? Same sports, and then you consider energy deficits. So if the average NFL lineman consumes 7,000 and 9,000 calories a day, then they're probably fine, but oftentimes it's hard to get that much into them, so they really have a caloric deficit, so something to consider. Yeah, fascinating, good. You know, a couple of points just to reiterate. You know, Torgh studies, we rely a lot on Torgh in his studies and meta-analysis and such. You gotta remember, he never used CT scan to follow the patients, so that was a major deficit when you start talking about some of Torgh's results. Never CT scan proven healing. The other thing that I think Greg brought up that's very, very interesting, because I see a number of these, is osteochondral lesions of the navicular. It's the tail navicular joint, navicular side, that get these osteochondral lesions, and I've seen several people come in that have been treated as a stress reaction when it's actually been an osteochondral lesion. I'm not sure, Greg, how you treat those. They're very, very difficult to manage when you have that osteochondral lesion with very localized edema just under the lesion itself. I mean, do you have any suggestions on what we do? So what I'll do is I'll use a Hennerman retractor, and because it's really difficult to get into the tail navicular joint to begin with, I'll just put in a scope dry to evaluate it and use a curette, and then sometimes if they're rather sizable defects, you can use an allograft morselized cartilage matrix with PRP or BMAC to kind of pack it in there and glue it in place, and I've had pretty good success with that so far, but numbers are low, and so just something to consider. The tail navicular joint scope is really technically challenging to do, so it's something that you're gonna do a couple of them and just look at it, and then eventually you might get lucky enough to get a curette in there to scrape, but use it for visualization. I've used the Hennerman retractor, too, but you gotta be careful. You only got a few minutes to use it because it'll get some skin necrosis and soft tissue issues if you use it too much, but no, that's fascinating, and you also can get a stress fracture with an OCD, so the OCD can create enough weakness in the bone underneath it where eventually it will get a stress fracture. You can see that combination. Now, I know you might all have some questions. We certainly wanna get to the audience questions, but I thought rather than this barrage of different questions on different topics, what I thought we could do is maybe just, let's tackle Jones first, show a couple cases, and you guys, if there's questions on Jones fractures, we'll do that, and we'll just go down the line if that's okay with everybody. So the first, and what I wanna do, misclosures don't have anything to do with these particular things, so I wanna do with more of a situational thing with these cases. These are questions I get every day. I get people calling and saying, what do I do? So here's the first one, so Ken, I'm just gonna go with you. Since Dave gave the talk, I'm gonna go with you. Here's a junior college wide receiver, top 10 high school prospect. He was one of the best guys coming out of high school, but he had some academic challenges, unfortunately. Went to JCO, but now he's got the ability to return to D1, so wants to come to Colorado, but he's gotta prove his stuff, right? So he had sudden lateral foot pain during practice end of August. No prior issues at all. So I'm just gonna show you, this is what he's got. He's got an incomplete type two Jones fracture. Normal foot posture, just he's got this thing there. I know it's hard to see, but it's an incomplete little defect right there, as Dave said, at the metaphyseal to aphyseal junction. All right, what other imaging? Anything, do you get? Yeah, I would routine, I mean, if you see a fracture line, I'd get a CT scan. I think if the fracture line's subtle, I think I see a fracture line there. There's a small little defect. You can't, it's definitely incomplete. I'd get a CT to better understand that, to see how far the fracture extends. I don't think an MRI's necessary, because if he's tender there and he's painful there and there's a fracture line, we know what's going on. And see, that's interesting, because like when we go to the combine, if we see this, we'll get an MRI, because we wanna see if it's an active or not active lesion. And then maybe get a CT scan after. And so in this case, he got his MRI. So the MRI shows edema, you can see that small little area right there, but edema and really the whole fifth metatarsal. But so it is edematous, so we assume it's an active lesion. Now, question for you, he wants to get back to D1, he's got to play, are you gonna let him play with this? So I think that's the discussion. I think yes, you can let him play with it. The risk is number one, it can hurt and limit performance. Number two, it can complete and buy a surgery anyway. So the value early in the season of fixing it is you can get them to return relatively aggressively without that risk. So, but yeah, if he said, look, it's a little sore, but I can play through it, it's an option. You know, there's, as we talked about, this is never a career ender, but it could change kind of the way the season goes and timing of return if you don't. So you would let him play? Well, I would let him play if he was able to perform and he understood the risk. And he's sore, but he's able to play through it. Yeah. All right, anybody shutting this kid down? So how important is this? This is really important for him. This could change his whole family forever to get in that D1 scholarship. So if he blows this comment, he doesn't get paid? If he doesn't play this fall, he's not probably gonna go on. So then I'd probably let him play. All right. All righty. I put a screw in it and let him play. If he's screwed, he's not playing. Yeah, why not? Wow. Never know. He's getting recruited now. Just a question. All right, so at any rate, you guys pretty, okay, let him play. All right, just situation number two. Let's just move on, all right? This is a D1 college defensive back. He's an NFL prospect. He's definitely coming out first, second round projection. He's got lateral foot pain with push-off maneuver on September 20th. So again, early part of the season. But now, this is a little bit different. So Dave, this is more of a type three. This is a little bit different. And again, you'll even see it. To me, it looks a little bit maybe acute on chronic, a little sclerotic there along that lateral cortical border where the fracture's taking place. I know it's hard for you guys to see, but again, this is a, basically now you got a complete fracture at a little bit more distal level. So Greg, there it is right there. All right, he was fixed. All right, just listen to Dr. Porter's talk. He had a intramedullary axial screw fixation. This is done percutaneous. They also use a little BMAC injection. Question here is when can he go back? When are you gonna let this kid go back? So there's two different ways you can do this. I think it'd be reasonable to consider six to eight weeks to usually get a CT scan before to make sure we have a reasonable amount of heal. All right, let me hit you right there. Okay, so are you one of these guys that says he's gotta be radiographically healed before he goes back? No, but I think he needs to know the risks of what that involves. So if he says that, hey, I feel great at two and a half weeks, you're gonna let him go back? I think that's too early. Why? If you're not based on CT or X-ray, and I'm just playing devil's advocate, so I'm not picking on you. So if he feels like, hey, clinically, I can go back there and play, and you're not following the X-ray, you're not gonna use X-ray criteria to get him back, is there a reason he can't go back when he's able to function? I guess it would depend on what game he's trying to get back for. So we'd have to have a discussion about that, but I still think that's a little too early, because you're not gonna see any healing at that point. Anybody on the panel saying that he's gotta be radiographically united before he goes back? I think the timeline matters for this kid, because if you say he's a defensive back who's an NFL prospect, and he's coming out for sure, and his status is established, then I would argue that you need the fracture to be healed, because it's probably a bigger problem for him to have this linger into the off-season and need another surgery. But he also needs to show you what he can do. Well, so that's different. I mean, I think that's the conversation. And I think, Dave, you brought a great point about it. Also, this is sports-specific. So in basketball, you might go a lot slower than you would in football. You could get a short season and different pressures on you. But I think your point, too, was good, is that these are rarely ever career-ending. So what's the worst-case scenario? The guy plays through, still has soreness, has a persistent non-union re-fracture. You can do something formally later on with open bone graft. I think I'd want to know what year he is. Is he a junior? No, he's coming out. Yeah, he's coming out this year. So the reality, and you know this as well as I do, there's already an agent involved, okay? So you're gonna- Family advisor. Right. Not an agent, family advisor. Yeah, he doesn't talk to- Well, no, now it doesn't matter. Now it can be an agent, right? We know he doesn't talk to the athlete, but he talks to the athlete's family. So yes, and so I think there's an issue there where I think some of the agers are gonna say, look, he's established, he's a first-round, second-round draft pick. What Jeremy is saying, some agers are gonna get and say, I don't want him to go back until you're 100% sure he's never gonna re-fracture. I think the numbers, I mean, you did the study looking at, it was about 20% chance that they'll re-fracture during the season if they go back. So I think everything everybody said is accurate. You have a discussion and you make a group decision. You don't let the coach make the decision, by the way. So you let the family and whoever's counseling the family and the trainers to some degree also, I think, and the athlete, and you say, what risk do you wanna take? Is it more risk to go back, try to play, have a re-fracture, don't look as good as you think, or is it more risk to not get out and play if people think you're not tough? There's a discussion you have to have. We don't have the crystal ball on that, and I think that's a discussion you have to have. And it's interesting, Craig Leroux, when he looked up all our NFL guys, we did have a 12% chance of re-fracture non-union, but also, as you may know, I'm very aggressive with my post-op course. I don't look at x-rays, don't look at CT, I just go by functionality. And again, I mean, it's something you just have to have that discussion. But interesting, we did not see in our study that there was any difference whether you send somebody back at four weeks or four months. They still had a risk of non-union re-fracture. So just give that some thought. Well, here's situation number three, then we'll open up for questions on Jones. So you fixed it, all right? You fixed this person. He has minimal pain, but this is his x-rays and CT scan at six months post-op. He's got an obvious non-union, all right? The resorption, non-union, plantar lateral, like Dave said, they usually heal along the medial side, but not plantar lateral. Maybe a little stress reaction, stress riser, so to say. The season's underway. You guys, Jeremy, any hesitation in letting this guy play with what he's got? Well, I think, again, he's gotta know what he's getting into. If he's got minimal pain, I think it's arguably a ticking time bomb if the x-ray looks like this. But if he's in season and you're gonna fix this surgically as a non-union, you're probably gonna want it to be healed because it's a rotation coming back. So why is he a time bomb? What's he a time bomb for? For the potential of having this get worse, clinically become more symptomatic. Well, it's already pretty bad. It's already a non-union. But clinically, he's doing okay. Clinically, he's okay sore, but he's okay. He could have an acute injury. So you're worried about screw breakage? Screw could break, fracture could. I mean, it's probably a fibrous union of some sort that could displace or could become unstable. Something could happen to this kid, and I think he just needs to be aware of that. And when you revise these, what do you tell them? How long are they gonna be? If it's a revision in my hands, it's gotta be healed before he comes back. A revision is where I would get him a CT. Four to six months? Yeah. Okay. Ken, any issues with letting this kid play with this? No, I totally agree. I mean, the only risk. I'm sorry, Ken, I meant Kent. He said, the T, Kent. I missed the T. I'm sorry, I meant to put a T on the end, Kent. This would be. I don't wanna hear what Kent has to say. No, no, too bad. So this would be something to talk about, work him up, vitamin D, that kind of stuff. See if he's got some issues. You could try some shockwave. You know, bone stem. Just if, since he has minimal pain, you could try those modalities, but I'd let him play. And the comments that have been made a few times about, you know, he's gotta know what's going on. I get that. We're all about informed consent. But we just spent an hour talking about Jones fracture. A bunch of people are smart and know what's going on, and we still don't know what's going on. So eventually, you gotta have to be the doctor and give the patient your best recommendation and kinda man up and do something, right? So, and I would decide, in this situation, work him up, make sure nothing's crazy, let him play, and see how he goes. Yeah, and my feeling is always, if it's a good screw, that's why, if it's a good, solid screw, appropriate size, no evidence of bending, I'd let him play. I'd let him go through. As long as it's a good screw. This is very complicated, because his lateral x-ray looks like he's in pretty significant cavalvaris. Right, that's a weight-bearing view, I'm assuming? There? Well, very good. That's non-weight-bearing? So, no, that was weight-bearing. So here, this is the other thing to bring up, is does this change your perspective, Danny, if he's got a cavalvaris? So, Greg, you got, now you got those x-rays, but he also has this posture. How much of a cavalvaris reconstruction do you do on them for a revision setting? You can just keep putting a screw in over and over again. So the question is, does this bother you letting him play? We already said you'd let him play with those x-rays if it's a good screw. If he's got some cavalvaris, does that change anything? I think it just changes the discussion about a revision. So, he's really teetering on ending his career over this one. So I know we said that they're not career-ending, but you have to have a cavalvaris reconstruction. You might not be as explosive as you were before. So maybe your people are walking around fine, but they aren't, you know, they're no longer at, you know, their 40-yard dash goes up and then that's it. That's what they had. Just something to think about. Good point. So, Dave, go back now. It's your turn again. Do you do BMAC injections on all your athletes' Jones fractures? On the initial case or revision? Initial. BMAC, no. I try to bone graft all of them now on my initial cases, but I don't necessarily take aspirations from the Iliac crest. On primaries. You just put the screw in and don't. It's if a professional athlete where nothing else matters and there's no cost issues. Anybody using BMAC routinely on primary fracture fixations? All right, I do, so I don't know. So I do it acutely and obviously we do it late, if not bone grafting. Then the question comes up, too, is I've been toying with this a little bit with the Jones 3, the type 3. Why not primary bone graft those? Make an incision, bone graft it right away. How much more time does it add to your recovery? I mean, they're so hard to get to heal and stay healed. I would bone graft all of those, yes. So you bone graft type 3s? Even primary bone graft? You do primary bone graft on type 3s? Yes. Okay. All right, any other food for thought? You mean like autograft or you mean DVN? I do autograft. Autograft, okay. Yeah, I do autograft in the hip. Small, percutaneous, trefine. Just get a little bone graft and put it right in there. I just seem to help my type 3s, which are hard to get to heal and stay healed anyhow. So it seems to help. And then just lastly under this, Greg brought this up, I thought a great point, shockwave. And I think shockwave's incredibly helpful for stress fractures. I just wish it was more available. I don't know if you guys down here, Kent, do you still have access to high-energy shockwave? Basically, no. Yeah, I can't get it in Wisconsin. I just can't get that truck to come up there and do high-energy. And I think it's extremely valuable. It is pricey, it's expensive, it's not always covered by insurance. And now we do have these handheld, lower-energy ones, Greg, that can be used in the outpatient setting. And is that what you're alluding to, is not the high-energy where you put him to sleep, but the low-energy? Yeah, in the outpatient setting. Yeah, not asleep. Yeah, so-called radio devices and such. I think it is something we forget about. There's been some good articles, John Furrier's article out of Penn State talking about it was as good as revision surgery for Jones non-unions. So I think it is something to at least think about. It's just not very available and it's not well-covered by insurance, which is unfortunate. Talk about whether, in that setting, I don't know, you and I and Marty have had some conversations about this, and Marty is very pro-Ashakwe. And it sounds like his approach is like multiple repeated low-energy ones. And I don't think that's covered by insurance either. All right, so I don't know how that works in a clinical setting, but it is something where you don't have to do anesthesia. And so the question is, does repeated low-energy in-clinic shockwave therapy over time give you the same as the high-energy, one-time, under anesthesia? And I don't think we know that. I know the article you referred to, Romp, he had articles about more is better and things like that, but I don't know. I don't think those studies are out. Any questions from the audience on Jones fractures specifically? If there are, please use the mic. Troy, Dr. Watson. Quick question for you guys. No mention of plate fixation in revisions. What do you guys think about some of these newer plates that are specifically available for the treatment of Jones fractures? Yeah, great point. And use them for revision. Plate fixation for Jones fractures, Kevin Varner has been advocating that now down in Houston for a while. Anybody using plate fixation for Jones, either primary or revision? I did mention that, and you only have so much time, and I think it is something that I kind of wanted us to talk a little bit about. I have not used it in the revision setting yet. Now, I do think it has a place also with some of these Jones variants, where sometimes you get a component of it that's a Jones fracture, but they also get some kind of comminution proximally, and that's hard to treat with a screw. Or some of the Jones fractures that are really, really proximal, it's almost like, is this a Jones or is it not? And there's such little proximal bone that sometimes a screw may be just not a very logical choice. So I think there's probably gonna be a place for it. I just haven't used it personally. But David, if you use a plate in an in-season situation, do you expect it's gonna be longer to get that guy back than if you just put a percutator in it? If you plate it? If you plate it. I'm gonna bone graft it too, so I'm hopeful not, but you would think the mechanics are not quite as solid as an intramuscular screw. Am I concerned about plating and acute Jones in-seasons just takes longer to heal? I don't know, but I think the revision is a good point. But I have seen some problems. I've seen stress fracture at the end of the plate, and I've seen screws break off in the canal. And then you got a real disaster. Dr. Cohen. Hey, so let's go back to the case you showed. So now, season's over, symptomatic non-union, capoveris foot, NFL prospect. Who's going to his heel to do an osteotomy? So who's gonna do an osteotomy on that kid I showed? You have to revise it because he's symptomatic. Okay, let's assume you're gonna do the revision, bone graft, whatever fixation you want. To Bruce's point, who's gonna lift that first metatarsal up? I think if it's a positive Coleman's test, I would do the first. I think a first metatarsal osteotomy is tolerated pretty well. I would not do a Dwyer. And see, I don't do a first metatarsal osteotomy in the first revision situation, because I don't want to create an asymmetric foot. But you know he's gonna be asymmetric once you do it. So I think it depends on the amount of overload you have laterally. Good. How about the rest of you guys? Anybody do an osteotomy? I mean, with a positive, if it's a forefoot driven, I would have a low threshold. And it's symmetric to the other side. This is not an asymmetric capoveris, he's symmetric, but you'd still elevate. It's rigid, can you correct it with an orthotic? Yeah, I mean, with Coleman block, you can post the first metatarsal, the hind foot corrected. But that's a situation where I'm also more likely to use a plate, this is a tension sided problem. And with even a subtle cavus, you're putting a lot of tension there. And that's why the screw has trouble doing it. So in a revision setting, I'm more likely to plate that. You have to formally bone graft it, because the edges are sclerotic. So you have to get better biology. So am I getting the flavor you guys would add a first metatarsal osteotomy in that revision case? All right, Bruce. All right, I want to hit this case, because we didn't get it in our talks. I think this is sort of important. 22 year old football player, left foot injury. Recall somebody landed on his foot while the plate was engaged in the turf. He's unable to full weight thereafter. So he pops off, he can't put full weight on. He's got mid foot pain, minimal swelling, minimal tenderness, x-rays are done. These are sort of partial weight bearing x-rays. So here's his MRI. And I'm not going to ask you guys to evaluate this on these, you know, MRI studies, but at any rate, it got read out and I thought it was to a, it looked like a partial Lisfranc ligament rupture. So you could, the Lisfranc ligament's still somewhat intact, but it is edematous and so it was read out as a partial tear of the plantar portion of the Lisfranc ligament, all right? So that's what this kid's got. He's got a Lisfranc injury, minimal diastasis, minimal tenor, minimal swelling. We do sero-weight-bearing x-rays. We did weight-bearing CT scan, which just basically shows no significant or obvious diastasis. This is not a full-blown guy. He's got no instability in his exam. He's pretty comfortable walking around in a boot, you know, after a couple of weeks. He can do a double limb heel rise after a couple of weeks, but still can't do a single limb heel rise after two weeks. Again, no instability. What do you do? So Kent, let me start this way. So I want to get to Steve too. I haven't gotten to Steve in a little bit, but Kent, so you got this guy. He's two weeks out. You got these kind of studies, and again, you can see on this weight-bearing CT scan, I guess it's hard for you guys on the left. On that left side, it may be a half a millimeter, a millimeter different from the other side. Yeah, common finding, I would treat him non-op and transition from the boot and with a carbon fiber insole and let him get back whenever he could. So you treat him non-op? Yeah. Okay. Jeremy, we're going to go right down that way. So you treat him non-op? Yeah, I would do the same, and I would want to see clinical improvement progressively over the subsequent weeks. Okay, so there again. So what's your threshold? What week do you finally say, okay, we need to go, we just got to open this up and find out what's going on? I think in my mind, it depends on timing and it depends on, like if it's May or June for an August season, I think you probably, I would consider moving towards surgery sooner than if it's January. All right, Steve, this is one of your Washington football guys. He comes in. He's now two weeks, two weeks, and he still can't do a sling and heel rise. And he's got this, it's definitely asymmetric, but it's not a horrible diastasis. Yeah, that team's not doing well anyway. Why wouldn't you look at it like any other ligament? I mean, we know that an ACFL ligament heals, CFL ligament heals if it's not stressed. So I would give it a trial of conservative care, not in weight bearing. And if he's progressing, like Jeremy says, and feeling better, and he could eventually by six weeks do a single toe rise, I think you're out of dodge. I think you're fine. Okay. But I think if it widens, and we have a weight bearing CAT scan in the office, which helps us, and we would just, I would take serial CAT scans. And if it's widening, then it's unstable, I would fix it. So what I'm hearing is you guys don't think two weeks is a good threshold to say this guy needs something done. I mean, what ligament is healed in two weeks? All right, so Greg, let me ask you this. What is your threshold for diastasis? So two millimeters, five millimeters? When do you say you have to have surgery? You've got this much diastasis. So somebody wrote an OKU chapter in 1992 saying it was five millimeters, and there was absolutely no support for that. I'll be the first to admit, I don't know where that came from, but that's what I wrote. And it has no basis. It has no basis for anything, that five millimeter diastasis. But what is your diastasis? Hoping that the patient has the internal control on the other side, I get the weight bearing CT on both, and then we do a comparison area and volume analysis to look for that, and then we see what we've got. Well, you don't have a specific, if it's two millimeters different than the other side, you don't say this needs surgery? So I mean, one thing is second TMT step off, automatic surgery for me. First TMT step off, if you'll see some dorsal gapping sometimes on these subtle ones, that is an automatic surgery. I'll use a mini C-arm oftentimes to do stress radiographs in the office to see if I notice any difference, but I'm always comparing to a control side. Let's say they think what sport they're playing, that's really important, so are they a hockey player? Because that's a little different than if they're playing football, and you have to talk to them about what their goals are, because I always am wondering at, if you non-op them and they're three months out and they're not better, can you just fix the diastasis? So let me, not to cut you off, does anybody have a diastasis amount? Ken, Dave, do you guys have a, just a real quick, I don't want a dissertation, just do you have a diastasis amount? Yeah, I think if it's beyond two millimeters, I'm probably going to fix it, if there's dynamic instability. Dave? You know, unfortunately, I don't get a measuring device out, so if it's wide compared to the other side, I'm going to assume that that ligament's completely torn. So somewhere between one and two millimeters is going to be my threshold. In that situation, I would numb them and make them stand, and I'd do it more, the rest of the stress is right. I think we all agree with Nunley that, you know, he has that type three, that if you start seeing postural changes in the foot, you need to do it, that's inclines instability. But seriously, there's nothing out there on what your threshold for diastasis should be. So anyhow, this kid, I took the operative, so I'm getting this, the kid's just not clinically getting better. And look at what you find. We're seeing more and more of these subtle, you know, this is, that's a second metatarsal, I've not dissected that, that's just, and it's a rupture, but what he's got instability, he's got instability in a sagittal plane, and we're seeing that more and more commonly. It's not this, it's not the open book, it's the sagittal plane instability that we're seeing more and more commonly. And my threshold for opening these things has actually gone down, because I think now I've got, I've got a baseline, you know, I've got day one, I know he's fixed, I've got my home run screw in there, he's now stable, I can start the clock, I know how to rehab him. Whereas, again, if I just keep waiting and waiting and waiting, you get to six weeks, you get to eight weeks, when do you finally pull that trigger? I'm not saying I'm right here, I'm just saying these are the questions that we all face. So just to push you, Bob, though, I mean, what's the natural history of that? Do you think he got better faster because you did that? I think he will. Because I know how to rehab him now, I know what to do. So, and this is the kind of guy, we've had actually some of these get back at 11, 12 weeks post-op, you know, where we protect him and we leave the screw in and let him play through it if they can. You know, so I think you can, I mean, I usually tell these guys it'll be four months or whatever, but we have people back quicker. The real question then for you all, anybody want to tackle this, is do you take your hardware out routinely? Do you guys leave your hardware in, do you give them the option? This is a, basically it's a non-articular screw, right? This is an extra-articular home run screw, it's not filing any joints, do you have to take it out? For me, I would let him play one season and then I'd probably take it out after the season. So if it became a timing issue, then I would certainly let him play one season. It's going to get loose and it's going to be non-effective after the first season anyway. So I think, for me, usually they feel a little better if you take the screw out later, but I have no problem with them playing one season with it. All right, just food for the, Dr. Clark. I just got to quick, because we had a case that I sent to you with a University of Arkansas player, similar thing. If that guy gets treated in non-weight bearing with that MRI early, don't you think he heals in six weeks and he can start playing? Maybe we're trying to be too, we put him in a boot and we think that's a solution, that probably doesn't do squat. If we make him non-weight bearing with a partial ligamentless injury to his Liz Frank ligament, then why wouldn't he get better? If you can, or let's say he's not going to play the rest of that season, you say this, we've got plenty of time. I mean, he's not going to play for two months if you fix him, right? You can maintain foot posture, you can keep him from having any increased diastasis, I think you're absolutely right. I think we try to get too aggressive early with partial injuries. That's a good point. How do you treat him post-op? Pardon? How do you treat that, Liz Frank post-op? So I take him out of their splint at a week and have him go and start range of motion, all these other things, BFR, and then they usually weight bear in a boot at five weeks, weight bear in a shoe at 10 weeks with a orthotic device in place. They go back with midfoot strapping, taping, if they're alignment, you can spat them. That's really pretty easy. It is interesting though, we're finding, Rankin had, Steve Rankin had a nice study years ago about if you have an intact Liz Frank ligament MRI, that should be a stable foot and not need surgery. But beware, because we're seeing more medial column Liz Frank variants, and that Liz Frank ligament can look like it's intact on MRI, and yet they have that split off of the whole first race. It's something to think about. Real quick, because I think this is an important case just again to talk about, the navicular. And you can't underestimate these things as we talk about. So Jeremy did a great talk, and Greg too talked about this. 20-year-old college basketball player, two-month history of ankle pain, as typical, they come in with ankle pain. They don't come in and say, oh, my navicular's hurting. Their worsened by activity, denies any injury, exam, he's got pain over, tenors over the end spot, otherwise normal, no postural abnormalities, x-rays are unremarkable. So he's got this MRI, he's got some edema in the navicular. Interesting too, he's got some dense cortical bone over the dorsum. Sometimes you'll have that little lip up there, that little ossicle up there too. And he's got this weird-looking little cortical defect, like an osteochondral lesion, Greg, in that navicular, on that tail navicular side. So what do you do with this? Do you guys pretty much all take these so-called early type 0s, maybe OCD type, early type 1s, do you guys treat them just non-op, weight-bearing, non-weight-bearing, cast, or boot? So real quick, if you can just sort of limit it, you do, with this case, do you let them weight-bearing or boot? I would treat it non-op, I would use a boot, but I wouldn't make them non-weight-bearing. Okay, Ken, perfect, that's perfect. Sam? I would treat it non-op, boot, so that they can do range of motion, but non-weight-bearing. Everybody the same? I'd put them in a cast. You'd put them in a cast? I don't trust them. Okay. Well, you let them weight-bearing or not? No weight-bearing. Non-weight-bearing. So what's your cast doing? It's making sure that he's not being an upple-head. Okay, all right, so you did that. So we got a CT scan, so any positive MRI, I always go right to a CT scan. Here's the CT scan, this is sort of, I thought this was a very fascinating CT. So the first CT scan's up on the top, right, and you see that, and I guess that'd be a type 1, but it looks like a type 1 that extends into that little defect, that joint defect. All right? So Steve, the one below that is four weeks later, and you can see it's propagating. It's going from a type 1 to a type 2, which Dr. McCormick said we better look out for. So what are your thoughts now? What do you do now? I think it works. Yeah, well, it's healing. It just does. It's just a curiosity of class or eating away. It's not healing, basically. Well, it's actually, it looks like it's propagating. I'm sorry, it's trying to heal, but it's just not progressing fast. Is he painful, or he's been non-weight-bearing? Well, he says he's non-weight-bearing, but to Jeremy's point, I mean, these guys are non-compliant. You put them in a booth, they go home, they walk around. So what do you want to do at this point? I think you paint the picture that this is going on to a non-union. You've tried conservative care, and you can offer bone grafting and screw fixation. I think it'll get him back quicker. So you would still go even non-op, even on this one? No, I think I would talk about fixing it. Oh, you're going to fix him at this point. Anybody not fixing this? Kent? You fix it? Everybody fixing this when it goes from one to two? I assume he hurts. Yeah, I mean, he's got, he's been non-weight-bearing, so he doesn't have that much pain. All right, this was not my case, so, but he did go on and have percative screw fixation elsewhere. So he had a screw placed over the top where the main fracture line was, so they decided to do a screw more dorsal. And you'll see that those are CT scans at two-month intervals. So you start there on the left, go to the right, and you'll see, basically, it does heal. All right? Appear to heal. He's happy. He's now, he's running, he's doing things. He's back in his shoe at six months, running, doing full drills, so on and so forth. Everybody's happy. All right? No symptoms, but when he came back to school for his preseason evaluation, they did a CT. And this is a D1 basketball player. He denies any pain whatsoever. His exam's normal, but that has happened. So guys can't, let's go this way, what are you going to do? So he's now got new changes dorsally, basically he's got a loose fragment up there, but the plantar two-field's just healed. But he wants to play. What do you say? Is he symptomatic? No. I'm leaving him alone. You're leaving him alone. All right? Jeremy? Yeah, if he's asymptomatic, I think I would leave him alone, but I would watch it carefully. I'd probably follow up with another study to see if that fracture line propagates. All right. Steve, same? Yeah, I would do the same thing. All right. Anybody, as we go down, anybody not letting this kid play? Just long discussion? Okay. So let's say that in a month after starting basketball season, he has pain. I mean, I'd get new imaging. It's possible that that dorsal fragment is impinging on the talus and creating pain, and so maybe you get lucky and it stays healed, and you don't have to worry about getting a fracture to heal you. So let's say he has the exact same CT scan, but now he hurts over that dorsal area. Ken, what are you going to do? So I think you've got to get a three-phase bone scan to make sure that bone's alive. If it's viable bone, I think you have to bone graft and really drill out the sclerotic edges, because there's just no blood supply in that area. And if it's not alive, then you have to do sort of a vascularized bone transfer from the cuboid, like Jim Nunley has described and done, in order to salvage that. The problem is that the joint's going to degenerate, because there's this big defect dorsally, and that area sees a lot of load. So that joint's going to wear out eventually if you leave it alone. So Dave, can you just take the P cell? Well, that's a good question. And when you look at his lateral of his ankle, he does have some kind of prominence to that navicular. You know, I think the screw may be a little bit more dorsal than I would have preferred it to be, and I think it's not quite as oblique as I would have liked it to have been. I have a lot of questions whether you're going to get that dorsal fragment to ever heal anyway. So I think if you think it's a small enough piece you can take it off, that's probably his better chance long term. But I think you're going to have a hard time getting that piece to heal. Yeah, my recommendation, I thought the piece was dead, and I would take the screw out, put a second screw, more planter to protect the rest of the bone, and I do basically a cholectomy. I take the piece out. And so that's what we ended up with. And just to the point of the screw, Bob, putting those screws in is not easy. It's a really weird trajectory. I'm sure everybody in the room's had experience, and you just have to be real careful. I know Marty in his recent Yellow Journal article talked about having an intra-op CT. But you know, what I find, too, is I have a very low threshold to open them now, because not only can you scratch up with a little bone grab, but then you know, you see the fracture, you know where the fracture is, and it's much easier to get your screw in because you see where your pin's coming in. You can actually do it openly like that, and it just saves you a lot of stress when you're trying to do it percutaneously, not knowing where your screw is entering. Are you close to the fracture, not close to the fracture? So I don't hesitate to make a small incision and actually look at the fracture line. Would you agree, Bob, that in that fracture, with the amount of sclerosis they had originally, you have to open, debride, and bone grab that. Like, that bone's never going to heal normal. And I do, do, usually do exostectomy, a little chiolectomy over the dorsum when I do these. Any questions on Lisfranc or on navicular or anything else? I'm sorry, we ran, we just buzzed through and we're right at our time limit, but if there's any other questions on anything. Dr. Watson. Yeah, one question. Recently in the AOFAS little discussion thing that comes in an email, there was a question, somebody submitted a navicular fracture case, and there was an interesting discussion about Aquinas being a root cause of this and potentially being able to alleviate your stress fracture or non-unions with aggressive stretching and then an orthotic to offload the midfoot. Is there anything to that? What are your guys' thoughts on that? Anybody would just try to work on your Achilles contracture? Certainly, an Aquinas can create stress there. I think the difficulty to get that to heal only with stretching, we don't have any literature that would say that would be true. Troy, I thought you were going to ask, would anybody do a gastroc recession? Yeah. Anybody doing gastroc recessions on an athlete? Not an athlete, no. Everybody knows I'm a staple junkie. I've fixed several of these and Jones non-unions with a staple and so far have done quite well, so just another strategy. Great. Thank you all. Thanks to the panel. Great talks. Appreciate you all being here. Thank you.

navicular stress fractures

early diagnosis

appropriate treatment

healing

long-term complications

non-operative management

surgical intervention

timing of surgery

avascular necrosis

stress fractures in athletes

thorough evaluation

immobilization

orthotics

Teriparatide treatment

bone stimulator