Good evening. On behalf of AOFAS, I want to welcome you to tonight's program, Ankle Fractures, Getting Them Right When They Aren't So Simple. It will be moderated by Dr. John Kwon. Joining him is Dr. Max McCullochy, Dr. Joseph Park, Dr. R. James Toussaint, and Dr. Anish Kadakia. You can find their full biographies and disclosures in the program document posted in the chat box and on the PRC. The 2022 webinars are provided free to AOFAS members and orthopedic residence fellows with funding from the Orthopedic Foot and Ankle Foundation, supported by grants from Arthrex, Inc. and Stryker. I'd like to run through a few housekeeping items before we kick off the presentation. For technical difficulties, please try closing your browser and logging back in the same way you did the first time. Registered physician attendees may earn one hour of AMA PRA Category 1 CME credit by completing an evaluation and CME claim form at the end of the webinar. You can find the link to claim CME in the chat tab, and we will follow up with an email at the conclusion of this broadcast. The webinar is being recorded and will be available for on-demand viewing on the Physician's Resource Center in approximately one week. We encourage you to ask questions during the presentations. To send your question to the faculty, click on the Q&A tab on your navigation bar. If we cannot get to your question during the live broadcast, the faculty will reach out to you following to respond. I will now turn the program over to Dr. John Kwan. Thank you. Thank you. So I'd like to thank the AOFAS and all of you for tuning in tonight. We have a great faculty of rising all-stars leaders in this field. And if Dr. Kadakia had hair, I'd say a gray-haired early sage. But nevertheless, I'm really excited for this group. So James Toussaint is the Chief of Foot and Ankle University of Florida, and he'll be talking, giving us an overview of the syndesmosis. Max Mikalski, who was one of our fellows at Harvard some years ago, is at Cedars-Sinai, and he'll be talking about the deltoid ligament, when, why, and how to fix it. My good friend Joe Park, who's the Chief of Foot and Ankle at University of Virginia, he's going to hit on multiple concepts related to stability in high-level elite athletes. And Anish Kadakia, who's the Chief of Foot and Ankle at Northwestern, who I've learned so much about ankle fractures from over the years, he's going to focus on the posterior malleolus. So we'll start off with Dr. Toussaint, who's going to give us an overview of the syndesmosis. James, you're on mute right now. Thanks, Sean. I'm just going to share my screen. Give me one second. Okay, so the topic that I'll be talking about today is the interoperative assessment of the syndesmosis. It's a brief literature review. Again, I'm James Toussaint, the Division Chief of Foot and Ankle Service at the University of Florida. My disclosures are there. So the agenda is on the screen here. So the first thing we'll talk about is the incidence of syndesmosis injuries, followed by the interoperative assessment of syndesmotic instability, and finally, the interoperative assessment of syndesmotic reduction. So first, the incidence of syndesmosis injuries. So the syndesmosis injuries are perhaps more common than we originally thought. And depending on the author that you quote, the incidence of syndesmotic injuries for all ankle sprains without fracture is anywhere from 1% to 16%. Ankle sprains and syndesmotic injuries. As we continue here, the incidence rate that was quoted by Vosler et al. in 2014 is about two syndesmotic injuries per 100,000 person years, or 6,400 syndesmotic injuries per year in the U.S. Waterman et al. in 2011 did a prospective study looking at the incidence of syndesmotic injuries among U.S. military academy cadets. This is over a four-year time period. And they found that the incidence of syndesmotic injuries is around 6.7% of all ankle sprains, with most of them occurring during sporting activities. When you're considering ankle fractures and syndesmosis injuries, I think we know by now, that the level of the fibular fracture does not necessarily correlate reliably with the integrity of the syndesmosis. And that was supported by a paper by Nielsen et al. in 2004. And furthermore, Tornetta in 2007 found that when looking at Weber B SCR pattern ankle fractures, the syndesmotic instability remained common even after stable bony fixation of the fracture itself. This leads us to an ambitious study by Plessis et al. in 2008. And what they did was, they looked at the incidence of syndesmotic injuries among all types of ankle fractures. And they found that, again, syndesmotic injuries were higher than expected. So about 33% of all the ankle fractures that they saw had a syndesmotic injury. And as you can expect, Weber C's had a higher correlation, but they also found syndesmotic injuries in Weber A's, as well as Weber B type patterns. So moving on to the intraoperative assessment of syndesmotic instability. So correctly diagnosing a syndesmotic instability remains a hot topic. Of course, preoperative imaging, such as CT scans, MRIs, and stress X-rays can help you detect instability, but you're still going to need a dynamic test in order to decide whether or not operative fixation of the fracture is necessary. As far as these provocative tests go, we have a handful that are commonly used. The most commonly used ones are the external rotation stress test and the hook test, but there's also a torque test that's been described, a tap test, as well as arthroscopic visualization. Several studies have looked at different methods to assess the syndesmosis intraoperatively. Again, the ERST and the hook test are the most commonly used ones, but the interpretation of these tests can be somewhat subjective. Bumer in 2003 and Jenkinson in 2005 described some limitations when evaluating the syndesmosis instability with external rotation stress test. And namely, it's difficult to sort of standardize how much to sort of externally rotate the ankle or how hard or strongly you have to pull on the fibula during the hook test. And so they found that a standard force of 7.2 newton meters to 7.5 newton meters of torque may increase the sensitivity of the results and reduce interpretation variability, I'm sorry, variation when employing the external rotation stress test. On the left of the screen here is the setup that was used by Jenkinson in 2005. So they used an F tool that was secured against the leg and they used basically a strain gauge to pull at about 7.5 newton meters. In further sort of investigation, I found that 7.5 newton meters is about the amount of force it would take to start to crush an open soda can. So that just gives you a frame of reference. So Pakharan and colleagues in 2011 used the results from Jenkinson and employed approximately 7.5 newton meters of torque to compare the external rotation stress test and the hook tests and analyze their sensitivity, specificity, and inter-observer reliability. And what they found was that the sensitivity was relatively low between the two tests, but the specificity was pretty good at 0.98 and 0.96 for the hook test and external rotation stress test respectively. Their takeaway was that the inter-observer agreement was excellent, but again, the sensitivity of these tests was insufficient to adequately detect instability of the syndesmosis intraoperatively. So that would lead us to what's been described as the torque test by Gosselin-Papadopoulos in a paper that was written for FAI in 2019. And the torque test is employed by putting a freer about two centimeters proximal to the articular surface of the distal tibia, and the freer is then externally rotated. And what's nice about this test is that it would give you a test that would look at coronal and sagittal instability of the syndesmosis, and the authors found that the torque test was more sensitive and specific than both the hook test and external rotation stress test when you're detecting syndesmotic instability. The next provocative test that I'll talk about here is called the tap test. That was originally described in 2010 by Richard Copeland, and that paper was a technique paper, and what they described was fixing the fracture and then drilling a hole where you would potentially put in a syndesmotic fixation device, but instead of putting in the screw, for example, you would put in a blunt tap, like a 3.5 tap, and as you advance the tap and it touches the cortex of the tibia, if the fibula basically gets distracted laterally, then it confirms some sort of coronal plane instability of the syndesmosis, and if that's found, then you can proceed with your syndesmotic fixation, but otherwise, you can then put in a standard, let's say, 3.5 screw. This test was evaluated by Cesar Netter et al. in 2018, and they found that the tap test sensitivity and specificity was 96.3 percent, and the inter-observer and intra-observer reliability was also high at 0.97 and 0.98 respectively. Picharenko in 2021 did a categoric study comparing the hook test versus the tap test for coronal instability and found that the tap test was more stable, more controlled, and reproducible than the hook test, and looking at the arthroscopic assessment, so the arthroscopic assessment involves utilizing the same provocative maneuvers while visualizing the joint under the scope. Ogilvie, Harris, and Reed in the Journal of Arthroscopy in 1994 used an arthroscopic diastasis of 2 millimeters as an indication of instability when testing for the syndesmosis. Ryan et al. in 2016 found that there were favorable results when fixing chronic syndesmotic injuries with an arthroscopic diastasis of 4 millimeters. The previous authors that I just talked about used 2 millimeters. Ryan et al. used 4 millimeters. However, a categoric study that was performed by Lovartz et al. out of Harvard in 2018 and Guyton and colleagues in 2017 found that a 3-millimeter diastasis reliably indicated a high likelihood of syndesmotic instability, so if you're using a 4-millimeter diastasis, you may be missing some, but if you're using 2 millimeters, you may be overly aggressive, so the Lovartz group out of Harvard as well as Guyton found that 3 millimeters is the sweet spot. Next, let's talk about the assessment of syndesmotic reduction intraoperatively. Most authors recommend open reduction, given that there's still a lack of reliable ways to confirm an anatomic reduction with closed techniques. Millan and colleagues in FAI in 2009 reported improved rates of syndesmosis reduction with direct visualization when compared to fluoroscopy alone, and then Pang and colleagues in 2019 reported equivalent outcomes with palpation versus direct visualization. In that paper, the takeaway is that in some cases, you may not be in a position to be able to directly visualize the syndesmosis, so let's just say you've got an incision, maybe you're going prone and the incision doesn't allow you to visualize the syndesmosis the way you'd like, but what they found was that palpation was just as good in their hands as direct visualization, and that was a cadaver study. Balso and colleagues in 2021 compared open reduction and fixation versus closed reduction and fixation and found better outcomes with open reduction. The study by Lilliquist and all in 2016 found that, thankfully, that there's a relationship that is pretty consistent between the margin of the distal articular surface of the tibia and the insertion points of the AITFL and the PITFL, so that's one thing you may potentially hang your hat on. However, Charney and colleagues in 2016 found that the syndesmosis morphology varies among the population, so that poses an additional risk to malreduction, which leads us to the paper by Cornetta in 2019, and they found that in their cadaveric study they compared the reduction of the syndesmosis when looking at the incisor versus reducing it while looking at the tib-fib articular surface as a visual reference, and all of their surgeons had a better result when looking at the articular surface, so their takeaway was that the articular surface is a significantly more accurate visual landmark for translational reduction of the syndesmosis than using the incisor as a landmark because of the morphology differences among the population, and that's all I've got for you. Thank you. Great, James, thank you. That's a great overview. You know, there's just an explosion of literature in regards to the syndesmosis that I appreciate you distilling that down for us. Okay, why don't we move ahead to Dr. Michalski, who's going to give us some insight on the deltoid and when we should be fixing it. All right, yeah, I'm Max Michalski from Cedars-Sinai. Today I'm going to be discussing the deltoid and its role in ankle fractures. I want to thank John for inviting me for this talk and for being a mentor of mine. Here are my disclosures. So when I found out about this talk, I decided to ask a lot of my trauma and foot and ankle partners about their indications for deltoid repair. The most uniform response was either a shrug or a sigh. Most ended up saying they'd fix it if they're already there in the case of an open fracture or debridement of the medial gutter. But what do we do when we're not already there? What do we do with the deltoid? Confusion regarding clinical decision-making usually stems from insufficient data. As most things in orthopedics, repair of deltoid injuries with ankle fractures has a positive literature, no randomized control trials. In 2021 alone, there were both a JAS review article and foot and ankle clinics chapter on whether or not to fix deltoid ankle fractures. So what's wrong with the literature? Almost all papers on the subject come with tables listing pros and cons. This JAS article from 2021 was probably the most comprehensive, which is why I'm showing it. But if I remove any paper over 25 years old, here's what we're left with. Now, if I remove NFL athletes, sorry, Bob, and an article from podiatry that had poorly explained methods and no comparison group, here's what we're left with. This table is also unfortunately missing two key articles, both from JOT, one from Jones and Nunley, another by my partner, Mitt Little. So I'll include those here. So with five studies, why don't we have better answers? And one issue is that we're looking for one answer to what I think is two different questions. The first, can I fix the deltoid instead of the synosmosis? And the second, should I fix the deltoid in addition to the synosmosis? What it comes down to is the methods of these studies. And as always, you know, the devil's in the details. In order to get a clinical algorithm, we need to go through some of these key studies here. Since we're discussing devils, we might as well stay at Duke. 2015, they evaluated bimal equivalent ankle fractures that underwent fibular ORF, either synosmotic or deltoid repairs. With 15 patients undergoing synosmotic repair and 12 deltoid, they had comparable subjective functional and radiographic outcomes. This is the only study that really truly compared deltoid versus synosmotic fixation. Staying at Duke, they decided to look at biomechanical evaluation to determine if we should be doing deltoid repair in addition to synosmotic fixation. As a biomechanics guy, I'm kind of curious about the methods. They sectioned the synosmos and the deltoid ligaments to test the synosmotic fixation in isolation, then deltoid repair in isolation, followed by both. But I'm not sure, was the screw inserted for synosmotic fixation, then removed, deltoid tested, and then reinserted? I'm not sure how this affects the construct, but regardless, they found that a combined repair of both the synosmos and the deltoid significantly reduced translation with anterior, posterior, and lateral drawer tests relative to the injured state. Isolated repair of the deltoid only reduced anterior drawer translation, and isolated synosmotic fixation didn't reduce translation relative to the injured state in any direction. Interestingly, they also found that combined deltoid and synosmotic repair significantly reduced internal rotation relative to the cut state, but no difference in external rotation, which is typically how we test for stability. This paper by Sun from injury in 2018 is seen in almost every table on the subject. It's frequently used in the argument against deltoid repair. They reported no statistically significant intergroup differences in terms of neoclear space, clinical, and functional outcomes for no deltoid intervention, deltoid repair, and deltoid augmentation. Unfortunately, the methods mentions that the no intervention group had some with isolated fibular IF and others synosmotic fixation. Additionally, it says that patients in the deltoid repair and augmentation groups with synosmotic stability were treated with one or two screws. The results don't mention how many in each group got synismatic fixation or not, and there's no subgroup analysis. There is one take-home point from this study, and that was that deltoid augmentation with an anchor in the talus and sutures tied through medial malleolus drill tunnels decreased deltoid deflection almost 10 degrees. Overall, this paper gets my stamp of disapproval for comparing apples to oranges. Now, I have this one pretty large here because it's a study I want to highlight. It's from FAI in 2018. I think this is a paper that should be discussed and cited more often. They answered the question, should I fix the deltoid in addition to the synosmosis? The problem is they undersold their conclusions and watered down some of the important points with too much data. I've read this abstract conclusion several times after having read the entire manuscript to understand what it really meant. It said, although the clinical outcomes were not significantly different between two groups, we obtained more favorable final MCS in the deltoid repair group, particularly when accompanied by synosomatic injury, the final follow-up MCS and clinical outcomes were better in the deltoid repair group. So if this is clear to you, you're definitely smarter than me. The lack of statistical significance was comparing groups one, no deltoid repair, and group two, deltoid repair. They lumped all patients together regardless of synosomatic fixation. This study would also be getting my stamp of disapproval, but they redeemed themselves. In the subgroup analysis of all patients treated with synosomatic fixation, the addition of a deltoid repair has statistically significant improvements in AOFAS score, VAS, foot function index, medial slighted pain, and residual medial clear space over four millimeters. When they answered the question, they just didn't tell us about it that well. I promise this is the last study to review, but I don't think a single study should really completely shift clinical practice. So I want to briefly mention one more paper out of JOT that I had brought up earlier. They compared synosomatic fixation with screws to a quote, anatomic repair with synosomatic fixation of the PITFL using a soft tissue washer and deltoid repair. Patients got postoperative CT scans bilaterally to evaluate the reduction and were followed with x-rays up to one year. You can argue the clinical significance of medial clear space of 2.5 or 3.5 millimeters or a lack of three degrees of dorsiflexion, but a decrease in the synosomatic malreduction on CT was from 33% to 7% is meaningful. So here's my clinical algorithm that I can't take full credit for. I learned a lot of this from my time with John Kwon and also a lot of this is described in JAS paper out of Rush with a few modifications. So fix the fibula, stress the synosmosis. I do both external rotation and a cotton test. I like to pull the fibula both medial lateral and anterior posterior. And if positive, I fix the synosmosis. I typically use a flexible device, but later cases I show will contradict that. So following fixation and synosmosis, I like to perform a valgus stress test. And I think this is a point to stop and discuss because what is a positive test? And a lot of this is kind of a gestalt thing, but that doesn't really guide people. That JAS article out of Rush suggested seven degrees of valgus tilt based on a retrospective review of their cases, measuring who got deltoid repairs versus who didn't. I don't even think I can measure angles on the CRM during case, but without further research, seven degrees it is for now. Here's my tweak to the algorithm. So once you decide to fix the deltoid, I figured since these images get used in a lot of talks, I had to include them in mine since I got to assist on these dissections as a third year medical student out in Vail. But when you go to fix the deltoid, it doesn't look like this. Sometimes you get in there and you encounter the spaghetti deltoid. So my goal at this point is clear ligament out of the gutter and sew whatever I can. Sometimes I'll augment one or two anchors. Often if I don't get good bite with the first, I'll add a second. I don't like the idea of acute deltoid augmentation for fear of getting too stiff as they did in the sun paper. And I like to steal a term from one of my partners, Tim Charlton. Even if I don't have a great bite, I have some propaganda stitches telling the fibers where to go. I'll briefly do two cases here. First is a 50-year-old female had a fall. Here's her injury films with Weber B and the nuclear space widening. I fixed the fibula on the left and middle images and then stressed the syndesmosis, as you can see on the right. There's a little Taylor shift with the external rotation, so I decided to fix it. After fixing the syndesmosis with a flexible device that I'm annoyed with myself for not seating better, I did a valgus stress, and there was only a small amount of Taylor tilt, so I chose to leave it. After measuring these postoperatively, it was about three degrees, so I followed the rush rules of less than seven. I also should mention I'm cheating because before opening, I fished out a bony fragment from the joint with a scope. On the left, you can see my shaver going up and driving through the syndesmosis easily. In the middle, you can see a bald spot on the anterior colliculus where part of the superficial deltoid originates. But then looking down the medial gutter, deep deltoid was intact. And moving on to my second case, 78-year-old female had a fall in the bathroom, suffers from pretty bad dementia. She had a medial clear space of about eight millimeters. If you look at the data from Tom Harris and FAI, showing unstressed medial clear space over 5.5 millimeters associated with complete rupture of the deep deltoid, I was prepared to fix this if needed, and drop and had anchors available. So I fixed the fibula, and that fracture ended up extending quite a bit more approximately than I anticipated, and knowing she won't follow any postoperative weight-bearing restrictions, I placed three transsyndesmotic screws, didn't stress the syndesmosis, I knew I was placing those, but afterwards I performed a valgus stress test. So as you can see here, this one opens up quite a bit, and while I wanted to limit incisions on this geriatric patient, I thought I could give her a much more stable ankle fixing the deltoid. Okay. So for her, on the left, you can see me inserting the anchor. I typically take an image while I'm drilling the anchor, and place a freer in the medial gutter, as Jeremy Smith taught me, keep the anchor out of the joint. And after the pair, you can see the restored stability. All right, thank you. Great, thanks, Max. A great talk. Quick question. So, you had presented some literature talking about how repairing the deltoid may obviate the need to stabilize the syndesmosis, and maybe outcomes are better if you do it that way. What's interesting, it seems that whichever one you fix first, whichever one you fix first, it oftentimes makes it so that you don't have to fix the other, right? Whether it's syndesmosis and deltoid, or vice versa. So why not repair the deltoid? I mean, I know I taught you the way I do it, but why not repair the deltoid first, and then go to the syndesmosis? That's a great question. And I think part of it is you see, well, there are kind of different tests based on, so the cotton or external rotation stress is not quite the same as the valgus. So it's a little bit different, and I don't know, it might be harder to interpret, but I tend to run into that kind of spaghetti deltoid, I think, more often than not. So I'd rather fix the syndesmosis, and then assess and see, go fix the deltoid, but you could go either way. Yeah, I agree with you. I think a lot of times when I'm looking at that deltoid, it's either evolved off the medial mal, which gives you more of a robust repair, but oftentimes it's mid-substance, and you are kind of just suturing it together. And it feels much better having some rigid syndesmotic stabilization than relying on the ligament to medialize your talus. But thanks, Max, awesome. So why don't we go next to Dr. Park, who's gonna talk about multiple concepts in high-level athletes. Great, all right. Well, John, thank you so much for inviting me to this talk. And I wanna speak to some of the things Max talked about. That was both James and Max gave excellent talks about how to assess this very complex problem. So I'm gonna try to go through some of the evolution of how I deal with the syndesmosis and the deltoid, just a lot of different topics. Here are my disclosures, none that are pertinent. I am at the University of Virginia. And so I'm gonna just start quickly with this case presentation. So this gentleman, 21-year-old fourth-year cornerback, he sustained a left ankle fracture dislocation during a game at Miami on national television. My partner was right at the field and he reduced his fracture immediately, put him in a splint. Of course, this gentleman was, a player was very highly touted. He was supposed to go pro the year before, but elected to come back for his senior year. And here's his X-ray, pretty, you know, very nicely reduced at this point. This is what they took at the stadium. But having seen what his ankle looked like when it dislocated, we know that, you know, there was definitely a Weber C ankle fracture with synesthematic disruption and deltoid ligament rupture. And so in trying to come up with my plan, obviously we're gonna fix the distal fibula. Question about the ankle scope. Questionable, do you fix the syndesmosis with screws or flexible fixation like a tight rope? And then do you fix the deltoid? And so I think the scope part in an elite athlete, especially with a fracture dislocation, I think that answer to me is pretty clear. Hinterman published this study in JBJS British in 2000, but he looked at almost 300 ankle fractures and he found that about 80% of them had articular lesions. And this is especially common in Weber C, pronation external rotation mechanism fractures that had synesthematic disruption. And, you know, for those of us who have to take care of these type of athletes, certainly a consideration for draft and combines and future team status is really critical to know what the joint look like. So, you know, Max and James both talked about how complicated this can be to know about the synesthesmosis. So I like Guyton's study in 2017 out of FAI. I think three millimeters is a good estimate or number to use to know if you have some damage. They make this probe with that specific three millimeter diameter ball at the tip. And I like scopes because you can assess for a chondral injury. You can look at the deltoid as was discussed previously. And obviously if you see the whole posterior tibial tendon, you know, the deltoid is completely torn. I also love biomechanics. And so this study by Wood et al. looked at the combined suture button, suture anchor augment. And there's a lot of information. I love how all of us interpret this data differently. But if you look carefully at the study by Wood et al, what you find is that the tight ropes, which I'm not against the tight rope, but I do think that it doesn't control external rotation of the fibula, even if you put two. And some of this, I have different reasons for why that might be. But if you look at this study two in 2018 by Shoji et al, they found that the suture button does not correct tib-fib diastasis or fibular rotation. If you do a screw, there's less motion than intact state. And if you do a suture button plus the AITFL, that is closest to the intact state for the syndesmosis. And they found that if you look carefully, they did not find a statistically significant difference if you compared the suture button and the AITFL versus just doing the AITFL augment alone. But interestingly in this study, you know, if you read carefully, they did not repair the deltoid, even though they did section it to get the instability. So for many of our athletes, mostly our football players, I've been doing this sort of direct AITFL repair. I don't think I'm unique in doing this, but I have this slide here on the right, but the suture anchors are placed into the fibula and I'm docking them into the tibia and the foot tubercle. Obviously it's important that you reduce the syndesmosis first. I don't use the sutures to close it down, but I feel that it's very much, you know, an analog to the pelvis, where if it's stable in the back, the PITFL, that if you can stop or block that external rotation anteriorly and close down that AITFL, you could then restore that ring, the stability similar to a pelvis. And so I'm not gonna go through this because Max already did a great job reviewing this, but the study that they did at Duke, you know, if you look again carefully, 15 had transsyndesmotic fixation, 12, they repaired the deltoid, they did not find any difference between the two groups and they suggested that perhaps repairing the deltoid is the same as a syndesmotic screw. The question I came up with listening and reading the study was, you know, we always do these external rotation stress tests, but does that really tell you you have a syndesmotic injury or perhaps it means you have a deltoid injury? Max showed the great study or his intraoperative stress where the valgus test shows valgus instability or deltoid injury. But I feel very strongly, you know, medial clear space is very easy to see, it's easy to diagnose intraoperatively, but really I think that shows we're having some deltoid injury. This is a classic study, 1988, it kind of drives why many people do not fix the deltoid, especially many of our trauma colleagues, although I think that's starting to change. But if you look at this study, you know, they had their study, 28 had good outcomes, four had fair, four had poor, and they said, oh, there's no Taylor tilt on valgus stress test, and they had no medial instability or asymmetric valgus. But if you read the study carefully, 22% or eight of 36 had quote unquote loss of reduction. That image on the right is actually an image from their study where they fixed the Weber C ankle fracture with one syndesmotic screw. So I think I call into question a little bit about the techniques used in that paper. The deltoid ligament, here's a good study. Here's a good picture of what that looks like intraoperatively. I think this is very consistent, that avulsion that Dr. Kwan just talked about where it's avulsed off the medial malleolus. I love this study. Rosa et al. did this very nice study that was published in FAI 2019. And they found that if you have a partially torn deltoid, you can get about 5.2 millimeters of medial clear space and 5.8 if it's completely torn and normal uninjured is 2.7 millimeters. And so in my practice, if someone has more than six millimeters of medial clear space on any imaging, you know, x-ray that you see, I'm gonna go and explore the deltoid. I don't tie the sutures until I fix my fibula anatomically, but I do start on the medial side, which is a little different than some of the algorithms that we've already discussed. But here is what that looks like intraoperatively. You see that whole sleeve avulsion is now reattached to the medial malleolus using these suture anchors, especially the anterior colliculus, that superficial deltoid. The deep deltoid, I think, is very much more challenging. You know, Dr. Anderson, you know, he published this study in 2015, kind of the classic study, similar ankle fracture pattern. He treated all of them with fixing the fibula, scoping them, doing flexible synismata fixation, and then also fixing the deltoid. He had 14 players, 86% return to play, and all returned to running and cutting by six months post-op, and none had medial pain or instability. Average follow-up was almost two years. And again, a very similar picture as the one I just showed you in my football players, but this is what that often can look like. So the plan for this player, I plan to scope his ankle, fix his fibula, reconstruct his deltoid, repair his synismosis, in this order, actually. So again, I did explore medially first. Ankle scope looked very, very good. Had some synovitis, a little bit of chondral scuffing, but nothing full thickness. So it did not do anything other than just to breathe that tissue. Here is the medial approach to the deltoid. You can see it completely just evulsed off of that medial malleolus. I feel like every time I do this, it sort of reaffirms in my mind why I need to reattach it. But here's labeled, you see the talus, medial malleolus, and the deltoid. Marking the fibula fracture right here. Here's our fibular ORIF. I think we got it out to length and anatomically reduced. I then tie the medial suture anchors, having already passed them, and to get all the tissue out of that medial gutter. And then I go on to repair or close down the synismosis. So the first thing I do is I use an S mark, or now I've been using a Penrose drain around the malleoli. And I think it's nice because it's circumferential. It's very hard to malreduce the synismosis if you're just kind of compressing it circumferentially. And then I use a 3.5 millimeter swivel lock, and I pass the sutures from the distal two holes into that location. And then you can see here on the stress test, that's the stability that you see intraoperatively. That's an external rotation stress test. And here's the lateral view. You can see the swivel lock hole right there. And here's postoperatively. I think we got very good tib-fib overlap. Length is restored. And at six months postop, he was completely healed. Postoperatively, I treat them for two weeks in a splint. I do a cast for two weeks in this case. Sometimes I'll do it earlier, depending on how confident I am in my medial repair. And I let them return to running and cutting, usually by four and a half months, depending on their recovery. He was cleared for full football activity at six months postop. He was drafted in the fifth round of the NFL, and he returned to gameplay 10 months postop, completed his second season in the NFL. He's one of the top cornerbacks for his football team. So in conclusion, I think indications for synosmosis and deltoid are evolving. I think anatomic reduction of the synosmosis, however you do it, is probably way more important than what you do to fix it. The tight rope or flexible fixation may not adequately control external rotation by itself, but if you repair the deltoid, I think it makes the flexible fixation a much better option. Synosmosis may be analogous to an APC pelvic injury, and the ITFL reconstruction is likely sufficient if the PITFL is intact. Beware of the posterior malleolar fracture or that sleeve avulsion. If the ankle is unstable to valgus or external rotation stress, by definition, the anterior deltoid is disrupted. And again, in my hands and in the literature, six millimeters I think is a good cutoff. It's easy to remember. And I think it does signify a complete rupture. If the fibula is broken, obviously it must be fixed anatomically. And again, for elite athletes, I think ankle arthroscopy makes a lot of sense. Return to play can take anywhere from six to 12 months. I think it depends when they break their ankle, but I wouldn't rush these patients back. Most importantly, protect our patients, allow time for biologic healing, and remember that initial mechanical stability may not equal long-term stability and healing. Trust your trainers and physical therapists, and most importantly, football is a very violent sport, and thank you very much for your time. This is our UVA team. Thank you very much. Hey, Joe, thank you. Great talk. I just had a quick question about that one patient. So, you know, obviously a little bit of a higher fracture in a high-level athlete. It looked like an LCDCP plate or something that maybe is a little bit less typically used. Do you tend, in your high-level athletes, you tend to use thicker plates? Or what's your thought on, you know, plate fixation? Yeah, that's a great question. Many of these players are quite tall and quite large, right? So some of them are, this gentleman is, this player is probably 6'2", 6'3". And that plate is, it's a metadiaphysial plate. So as you said, more proximally, it's an LCDCP style plate, and then distally, it kind of narrows down to like one-third tubular thickness. And I like it because it gives me a more rigid fixation where the fracture is, and then it's more low-profile, closer to the malleolus distally, so it doesn't irritate them as much with return to play. But I've had good success with that plate. I think there is room for improvement, but I'm always nervous using a one-third tubular for some of these athletes. You know that they're going to be back on the field. Sometimes, you know, they may want to go back before everything is completely healed, which I try to hold them back. But, you know, I do think that plate gives you a little bit of extra protection. Great, great. Thank you, Jim. All right, so our last speaker will be Dr. Kadakia, and he's going to talk about the posterior malleolus. Okay, sorry, I had to unmute myself real quick. Thank you again very much for allowing me to present. So my job is the posterior malleolus, which has been a big thing for me my whole career. And hopefully, I think we're all fixing these much more than we used to back in the day. There's no question about it that it's much more than it was, but I still think there's a lot of controversy. And even I still struggle when I'm supposed to do this, when I'm not supposed to do it. These are my disclosures. They are relevant for this particular talk, specifically the AcuMed plates and the Arthrex products you're going to see. But it's not the point of the talk. So ankle fracture, I think everyone's done a phenomenal job already today. It's not a fibular fracture. That's the key, right? These are 360 stability. You have the fibula, the sypnosmosis. We've talked about the deltoid, the anterior tibia. You can get those split fragments. And then my job is the posterior malleolus. So that's how you think about a fibula. Anatomic stability in both coronal, sagittal, and rotational stability is what we're supposed to achieve to give the patient the best outcome. So articular congruity. And I think one of the big mistakes with ankle fractures are it's not an articular fracture, right? We think of PLAN fractures, that's your articular fracture, and you got to get the joint reduced. Then you come with that rotational ankle fracture, and we just suddenly, we don't care about the joint. The back of the joint suddenly no longer matters. And that's what it was when I trained. And I think that's changing now, but it does matter. So this is a nice study in 2013. I think I've referenced this a bunch of times. It's such a good study. Long story short, incongruous articular step-off is a problem. You can't have more than two minute step-off. It shows you the worst outcome. Loose bodies are not good for the patient. It doesn't mean that they're going to be disabled if you leave a little gap, that's not the point, but they are going to have a problem. Not as good as they would be otherwise. And so you're trying to get this joint as perfect as possible. So yes, it does matter. Their symptoms of pain are better if you get an anatomic joint. So why do we need to be as accurate as possible? Well, you can argue there's a waste of time, too much, but here's a 59-year-old physician, trimalleolar ankle fracture. This was the operative treatment. You can argue the post-mail is not more than 25%. The reduction wasn't that bad. Looks good on the AP lateral, but why is this a big deal, man? This looks fine. It was easy, two approaches. I didn't waste my time with the post-mail. She's five months out. Again, it doesn't look that bad. Mountain out of a molehill, right? This is what people say. However, if you follow your patients and not everybody follows up, but if you get that follow-up, this is a problem. This to me is an unacceptable complication from an ankle fracture. I don't think this is a bad fracture. I don't think it's AVN of the tibia. I've been told that before. To me, this is malreduction, post-autosubluxation, persistent instability to get this rapid within a year arthritis. And I've made this mistake too, and I'm trying not to. That's what I think our job is. So here's a case example. You can see here, bad fracture. Weber C was fixed. And really, there's really not much of a post-mail. To be honest, it's not a big deal. So do you really have to deal with the post-mail in this case? Why does something fail? We always ask ourselves that. Was it fibular length? Deltoid should have been repaired, as has been nicely discussed. Does the stenosmosis need more fixation? We saw some really novel ways to fix the stenosmosis. Or is it the post-mail? And it's really kind of small. Well, my answer is it's the post-mail. You fix the post-mail, you reduce the fibula back within the incisora, you restore sagittal stability, you make that joint anatomic. And so this patient is now two years out. I did a colectomy because he had some problems. But in the end, I was able to get this person to be able to stand, walk, bike, and restore some function, likely get arthritis, but it's not as devastating as it once was. I've talked about this a lot. There's limited research, but there's an overwhelming amount of literature. If you go to PubMed and look this up, you get hundreds of articles now. The first question is diagnosing the problems. You have to identify it. So I think there's an old article that looked at rotation ankle fractures. If you had a dislocation or a bimal, or a trimal on x-ray, that if you got a CT, it would change your operative plan. But what about actually identifying the post-mail? This is a really nice study done that looked at all their ankle fractures. They got a CT just out of routine. If you look for a post-mail on x-ray, you'd identify it only 58% of the time. But if you got a CT, you would see a post-mail 88.3% of the time. And although you may not fix that post-mail, it really allows you to understand what you need to do to achieve stability both the coronal and sagittal plane. So CTs for rotation ankle fractures are important. Not for that subtle, simple, whatever it be probably, but for the bimals, dislocations, you really need to understand what's going on. Why should we identify it? Why waste your time and get that CT? Why give yourself headache? Well, a millimeter step off actually is independent risk factor for arthritis. Not two, even one. You've got to get this joint as anatomic as possible. And when I did this talk, I tried to pull up all the articles from 2018 to 2022, not picking on some 2015, 2014 article. These are over and over. Outcomes of the post-malarial fixation and ankle fractures at trauma center. It's basically long story short, they randomized them. And if you fixed it, they did better than if you didn't fix it. Although there were complications from the extra hardware. No one should think that a post-ralateral approach is benign. And I've struggled with that because you cause FHL scarring, you get stiffness in the back, you hit the sore nerve. There are downsides to it. But despite that, as a group, they do better if you get that post-mal reduced. Some will do worse. That's always an outlier. How big is too big? Well, this article looked at patients and their outcomes. If more than 10% of the post-mal was involved, they did better if it was an RIF versus doing it indirectly. So my philosophy is if you can fix it, you think you can get a screw or a plate on it, you should do so. If you can't, we'll get into that as an option. And why does the small fractures matter? Because that's subtle post-ralateral subluxation, and that's what they showed, results in an unstable ankle and arthritis. It's not the coronal plane in isolation. That's bad. But sagittal instability is also very bad. Joints do not tolerate instability. There's another good article looking at whether you should RIF or not, or PERC it. So a lot of us talk about, I'm just gonna clamp it and PERC it. The problem is when we PERC it, we do not get that joint reduced that well. So they noticed in their small numbers, they had a step-off in 34% of patients that had a PERC. No fixation step-off was slightly worse. But if you look at it, no fixation versus PERC, you really don't change much. RIF is where they did the best, even then they couldn't get it perfect. But that PERC fixation, if you look at x-rays and a lot of times you miss it. So arthroscopy is a good way to evaluate it. You can look sagittally through the fracture, but you need to see that reduction and not rely on x-ray. But you can't fix them all. We know that. Either they're too old, bad soft tissue, they're obese. You just don't wanna do it that day. So what else can you do to not let this x-ray occur? And I give these authors a lot of credit for publishing this. I've had this happen to me. We all have, but we wanna avoid it. So you can go through the lateral approach and just loosen the posterior malleolus if it's been a week or two to get it loose and watch it reduce. You reduce the fibula with the K-wire and then you get that internal oblique so that you get a perfect lateral or perfect parallelism to the fractional line. You can see here on a lateral x-ray, the fibulas posterior relative to the tibia and the obliquity of the fractional line is not in line or the line of the fracture is not parallel to a lateral of the talus. So you have to internally rotate and then get a perfect shot down that fracture line. And then you can see if you've got this reduced or not. If it's small and reduced less than 10%, fix the fibula and open reduce the syndesmosis and K-wire the syndesmosis in place so it doesn't fall off the back. I use a suture button for coronal stability and the EITFL reconstruction as Dr. Park talked about the sagittal stability because that's the most anatomic. We want to restore anatomic stability. I'm not a screw person for all the literature that's out there that shows a screw is just not as good as a suture button, but I do agree the sagittal instability, a suture button in and of itself is not sufficient. You additionally need to place a EITFL reconstruction. If you'd never want to do the EITFL, then at least put a second screw in there. And again, plenty of data shows screws are bad in isolation. So as a simple bi-male and a 73 year old, is there a post-male? Why didn't get the CT? There's nothing wrong with this person, right? Fix the fibula, fix the deltoid, fix the medial male, go home. Well, you got to look at the literature and believe it. There is a post-male. This patient has sagittal instability. You cannot just fix the lateral male and the medial male because even though the fracture is slightly distal to the syndesmosis on the AP, the syndesmosis is involved because the post-male is busted. So in this case, I did an RAF for the syndesmosis, the post-lateral plate, her bone was not great quality, pin the syndesmosis like I'm talking about with an open reduction. I know it's in place. Then I fixed the medial male. Then I did a suture button and an internal, a suture tape, internal base construct to ensure that I have that ankle stable in both coronal, rotational and sagittal stability. Or you can fix it directly. This is a Bosworth fracture, bad fracture. Get that CT. When they tell you it can't be reduced indirectly, believe these people. Small fractures, but anatomic fixation. These are post-medial, post-lateral plate and a post-lateral fibular plate. This is two years out now, can give you a good reduction, good function, good outcome. Bad fractures do not mean bad outcome. You can try. They don't all work great. And it's a pain. I agree. Everybody knows this is a painful procedure. You got to put them prone. Huge incision because you can't get access to anything. You got to move the FHL away, but it is worth it. One thing I've learned is for the post-remedial side, just make a small post-remedial incision and move the posterior tip out of the way. You have easy access to the post-remedial fragment, chip shot to put the plate on. These new anatomic plates, multiple companies have them now, are very low profile. Do not irritate the post-tip tendon. You should be fine. So in conclusion, large fragments, you should probably fix arthroscopically assisted, open approach. You can reduce it through the post-lateral approach directly if you want and fix P to A. A to P is just not ideal unless you are arthroscopically watching it reduced. If you refuse to fix the post-male or it's a very small fragment, remember the tail is unstable and post-lateral stress. So the methodology I think to stabilize is important. Coronal stability with the suture button and then an AITFL reconstruction or a syndesmotic screw and never take it out. And you know the post-male is seeing you. You just got to see it. So get that CT. Thank you very much. And Anish, thank you. A great talk. I learn so much every time I hear your talks. I have to digest them. And I've heard certain of your talks more than once and I learn a little bit more each time. So question for you. You know, there's, as you know, a lot been written about, you know, these small posterior males. And, you know, I think the traditional thought was the posterior syndesmosis was attached to these little avulsion fragments and Mason and Malloy and other people have said, well, you know, there's a broad attachment or whatnot. So, you know, if we're talking about potentially stabilizing small posterior male fractures to stabilize the syndesmosis, is an OIF okay? So if you got a small fragment, is just stabilizing it okay without going through that big approach to get that small fragment anatomic? You know, it's a great question and I struggle a lot with it. So that small fragment, like 5%, 10%, even 15, it's not a huge deal. And you know, this is gonna be a pain to get to. I wanna tell you an OIF is okay, but honestly, I think when you look at all of the data, it's not. And I have a patient that I did during COVID that I OIFed. She likes me a lot. I did a bad job. She has post-traumatic arthritis. Within a year, she's gonna get a total ankle and it's about a 10% piece I missed. I literally missed from the back. I don't know what I did that day. And I OIFed her. Corona looks perfect. Sagittal is fine, but that talus just went out the back a little bit. And so I will tell you from my heart, no, it's not okay. Unless it's a very small fragment, like two, three millimeters, a little fleck, then it doesn't matter as much. Still gotta stabilize it. But if it's a real piece, yeah, I think we're obligated to make it right. Yeah, yeah. Well, and Anish, thank you. I should have made it clear to the audience, some of the people, the audience, what I'm referring to is not anatomically reducing the fragment, but fixating it. So some people may not be familiar with that OIF term. Okay, well, we got just a couple of minutes here. So I'm gonna go ahead and share my screen. And I was hoping at least just to get through one case and certainly wanna just see what the panel thinks here. Can you guys see my screen here? Yeah, okay. All right, so this is a 42-year-old healthy female. She twisted her ankle. She's swollen. She's tender over the fibula. For what it's worth, she has a little bit of tenderness on the medial side of the ankle. And so there's no tricks here. I think in these webinars and at the AOFAS meeting, we talk about a lot of complex stuff, right? But this is the fracture that we see in everyone in the audience sees every day and every week. And so I'd like to go to the panel. Why don't we start with James and we'll go through the same order as the speakers. What do you do at this point? In your practice, what's your next management step here? So, John, do you have additional images or is it just the AP or in lateral? That's what you got. AP, lateral, no advanced imaging. Okay, that's fine. So, just based on Anisha's talk, it sounds like a CT is the right way to go after this. But commonly, this is something where it looks like a Weber B with some combination. And so I would expect to do, obviously you fix the fibula, intraoperatively assess the syndesmosis, plus or minus syndesmosis fixation. I will commonly scope these just like Dr. Park mentioned. And if the deltoid is unstable, I would fix the deltoid as well. I think that's what you're getting at, John. Yeah, so James, take a step back. So this X-ray, when I look at it, I'm not sure if this is displaced or unstable. So I might've been leading you to thinking about surgery, but how do you assess instability in your practice? Do you do a gravity stress to you? Do you trial a weight-bearing X-rays, weight-bearing CT? What are your thoughts? Yeah, I don't have access to a weight-bearing CT, but commonly, this is one of those where I would see what kind of patient it is, because if I can get a stress view in clinic, I will, but I can't always do that because of patient factors. And so I may take them and do a intraoperative stress view. And if it is unstable, then I would proceed with surgery. And if it's not unstable, then I would splinter cast and then send them out. All right, Max, what do you do? I get weight-bearing films. I'm very, it's taken me a lot of time because I will stand there with a patient like, look, it's fine, you can stand up. And I tell them, I basically tell them like, look, I need to know if it's stable or not. If we can't stand, I can't assess it, you're probably getting surgery. And it's amazing when people think they might not have to get surgery because they can stand on it, the way they'll do it. They're almost uniform when patients will stand on that ankle. Okay, Joe? Yeah, I agree with that. I really like the, there's some good studies recently showing that gravity stress, I think is a good stress test. I would say like, for example, even in the sector on the left, there's a lot of plantar flexion in the ankle position, which I think can really mislead you with the medial clear space. And you see that often in gravity stress. So I like a weight-bearing stress, even partial weight-bearing. And I would probably treat her in a cast for two weeks. And then sometimes I'll do a weight-bearing test X-ray at two weeks. And if it displaces, I tell them I'm gonna have to fix it. And if not, they're more than happy to treat this non-operatively. Okay, Nish? So for me, this is a gravity stress. I don't do manual stress because I'm lazy and busy in the clinic. So I think gravity stress works really well. One of the weird things about weight-bearing is that there's a study that showed weight-bearing actually improves the stability on ankle, on an ankle fracture with a deltoid disruption. So I'm not sure what to do with that information. I used to think you could weight-bear them all and they'd be fine, but a standing weight-bearing and actually, you know, not inadvertently, but it actually stabilizes the ankle. So maybe giving you a, so it's interesting how you wanna think about it, either a false negative or a functional positive, like it doesn't even matter if it's positive stress. So I gravity stress, and I think over the last five, 10 years, I've become much more aggressive about fixing ankle fractures than not fixing them. Even though when I was in Michigan with Jim, we wrote an article that you can not fix up to six millimeters and they do fine, but I've gradually changed over time. If they're unstable, and I do believe rotation is important, I fix them. So I gravity stress this and have a low threshold to fix it. Great. All right, guys. Well, yeah, I have a couple more cases, but we're really pushing a couple minutes past the hour here. So Anisha, I gravity stress you as well, but oftentimes get x-rays that are suboptimal, then sometimes you gotta do something else. So nevertheless, I want to thank all the faculty for joining and for your input. Certainly thank all the audience for tuning in tonight. Hope to, let me just get through this. This was my case I couldn't show, but thank you all. And hopefully we'll see you in Quebec City this summer. Thank you, everyone. Thank you, John. Thanks everybody. Thank you guys.

ankle fractures

treatment

anatomic reduction

articular congruity

syndesmosis

deltoid ligament

posterior malleolus

diagnostic imaging

surgical intervention

arthroscopy