CME OnDemand: Putting It Into Practice: Ankle Instability (Part 2 - Syndesmosis)-Putting It Into Practice: Ankle Instability (Part 2

Putting It Into Practice: Ankle Instability (Part 2 - Syndesmosis)

Video Transcription

Good evening. On behalf of AOFAS, I want to welcome you to tonight's program, Putting It Into Practice on Syndesmosis.  Our moderators tonight are Dr. Tracy Herrig and Dr. Richard Zell. They are joined by our faculty, Drs. Carrie Bell, Kaitlin Neary, and Christopher Porter.  Disclosures for our faculty and program planners are listed here and posted on the AOFAS On-Demand Education Center.  This program is provided free of charge with funding from the Orthopedic Foot and Ankle Foundation.  To support education programs like this, please make a donation to the foundation on our website or by texting GIVEAOFAS to 41444.  Just like to run through a little bit of housekeeping items before we kick off the presentations.  For technical difficulties, please try closing your browser and logging back in the same way you did the first time.  Registered attendees may earn 1.5 hours of AMA PRA Category 1 CME credit by completing the 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 directly after the broadcast.  This webinar is being recorded and will be available to view in the On-Demand Education Center in approximately 24 hours. We encourage you to ask questions during the presentations.  To send your questions to the faculty, click on the Q&A tab in your navigation bar. If we cannot get to your questions during the live broadcast, the faculty will reach  out to you following the broadcast to respond. And please visit the AOFAS website to register for upcoming events, including the AOFAS Annual  Meeting taking place this September in Vancouver, Canada. And apply to be an AOFAS member. Members receive access to a wealth of resources, including high-quality research journals,  in-person and online education, and a global network of orthopedic foot and ankle specialists. I'll now turn the program over to Dr. Zell to begin. Thank you, Elena.  I'd like to thank everybody for tuning in tonight to our AOFAS Putting It into Practice webinars. These webinars are designed to introduce foot and ankle concepts.  And our target audience are PAs, MPs, medical students, our physical therapy colleagues. This is the second in their series of ankle instability, and today we're going to focus  on syndesmotic injuries. I'm very happy to introduce Dr. Carrie Bell. She went to medical school at Thomas Jefferson and is now a fifth-year resident at Henry  Ford Hospital in Detroit. And she will be going down North Carolina next year to do a foot and ankle fellowship.  She works with Dr. King at Henry Ford Hospital, and we're happy that she's going to present to us this evening. Thanks, Dr. Bell. Thank you, Dr. Zell. I'll share my screen now.  Thank you.  Can everyone see my screen double checking?  Hello, I'm Carrie bell and I will be discussing syndesmotic injuries, the diagnosis and the work above them tonight.  I have no disclosures. This is a brief outline of what we'll be covering tonight.  So starting with a brief overview of the osseous anatomy of the ankle, the distal tibia articulates with the talus and the distal fibula. The tibia has two tubercles, one anterior,  which is more prominent and overlaps with the anterior fibula, which is known as the Chabot tubercle.  There's also a posterior tibial tubercle known as the Volkman tubercle. Similarly, the fibula also has two prominences.  The anterior tubercle is known as the Wagstaff-Laforte and it,  the fibula also has a posterior tubercle, which does not have an eponym.  In regards to the ligamentous complex, the distal tibiofibular syndesmosis is comprised of four major parts, the anterior inferior tibiofibular ligament,  the posterior inferior tibiofibular ligament, the intraosseous ligament and the intraosseous membrane, which all of which we'll briefly go through.  The anterior tibiofibular ligament, also known as the AITFL is a trapezoidal shaped ligament. It originates on the anterior lateral tubercle of the tibia.  It contributes approximately 35% of the tensile strength of the syndesmosis. There can be an anomalous distal band called Bassett's ligament,  which can cause ankle impingement.  The posterior tibiofibular ligament also known as the PITFL is the strongest ligament in the syndesmotic complex.  It contributes approximately 42% of the tensile strength.  It's comprised of two parts, the superficial part and the deep component.  The deep portion is sometimes known as the inferior transverse tibiofibular ligament. And some anatomists consider this a separate ligament in and of itself.  It originates from the posterior tubercle of the tibia and inserts very broadly on the lateral malleolus.  Given its very broad origin injury to the PITFL  usually results in a bony evulsion, giving a posterior malleolar fracture.  The intraosseous ligament is a continuation of the intraosseous membrane.  Biomechanical studies have shown it contributes approximately 22% of the syndesmosis tensile strength. It functions as the main restraint to the proximal migration of the talus.  It also transfers about 10% of the axial load from the tibia to the fibula while walking.  The deltoid ligament, while not a component of the syndesmosis, is a very important stabilizer of the ankle mortis.  It is often injured concomitantly with the syndesmosis. Isolated injury to the deltoid ligament does not cause syndesmotic instability.  However, studies have shown that 50% of patients with a deltoid ligament do have a syndesmotic injury as well.  So if the AITFL, the deltoid ligament, and the intraosseous ligament all become injured at the same time, the mortis joint becomes unstable.  Moving on to biomechanics.  The function of the syndesmosis is that it resists axial, rotational, and translational forces.  During the gait cycle, there is an increase in the intramalleolar distance of approximately 1 to 1.5 millimeters.  There is a rotational movement in the horizontal plane of 12 to 17 degrees, and the fibula can translate distally between 2 and 2.5 millimeters.  If a force is applied through the syndesmosis that stresses the complex beyond these normal limits, it can result in either a ligamentous tear or a fracture.  Syndesmotic injury most commonly occurs due to supraphysiologic ankle external rotation. It can also occur due to eversion of the talus or forced dorsiflexion of the talus.  While some studies have hypothesized that syndesmotic injuries are more common in a pronated foot, these injuries can occur with the foot in any position.  While these injuries are most common in contact sports involving lateral movements such as running, running, running, running, running, running,  involving lateral movements such as football and soccer, they can also be seen in other activities that occur on turf fields, skiing while not a contact  sport is also implicated in high rates of syndesmotic injuries.  The syndesmosis has been found to be injured in between 1 to 18% of all ankle sprains, and it's important to correctly identify these injuries as ankle injuries  which involve the syndesmosis, uh, have prolonged treatment times and prolonged recovery compared to purely lateral ankle based, uh, ankle sprains.  It's important to note that while these syndesmosis can be injured in isolation, there are also other injuries that can be seen including OCD locations of the ankle.  There can be loose bodies within the ankle joint. Perineal tendon injuries are relatively common as well. As mentioned before, you can have deltoid ligament injuries.  You should also make sure to look for any ankle fractures, specifically Mason new fractures, which is a fracture of the proximal fibula.  In addition to an unstable ankle foot, Frank foot fractures are also not uncommon. Um, most commonly seen are those at the base of the fifth metatarsal, um, at the  anterior process of the calcaneus and at the lateral or posterior process of the talus, you can also have MCL injuries of the knee, uh, which is thought to be  derived from the external rotation of the ankle, putting a valgus force on to the knee.  In their history, patients may, uh, report a specific injury. However, reporting a specific injury is less common than in your typical inversion ankle injury.  Have a high index index of suspicion.  If a patient describes a external rotation of the ankle rather than the usual inversion supination, um, that happens with lateral, uh, ankle sprains, patients  will often report pain above the ankle joint, uh, functional instability, or a history of prolonged recovery with an old ankle sprain peanut rest can also help  differentiate high ankle sprains versus low ankle sprains. If a patient has a chronic injury, they may report a giving way sensation  difficulty on uneven ground stiffness, or even limited dorsiflexion of the ankle.  On physical exam, patients will classically have pain above the ankle joint at the level of the AITFL. Pain can also radiate proximally up the leg.  Acutely the ankle is usually less swollen compared to your classic low ankle sprains.  And patients may have possible tenderness of palpation at either the AITFL or the PITFL. Patients will also, or may also ambulate in a heel raised gate pattern where  they're basically just walking on their toes because this avoids ankle dorsiflexion and increased pain during pushoff.  Several provocative tests have been described in the literature. None of them are fully reliable.  These tests include the squeeze test, the external rotation stress test, the dorsiflexion test, the cross-leg test, the heel thump test, and several  different single leg tests, which we will briefly go through.  The squeeze test is the classic test for syndesmotic injury.  It functions to distract the distal tibiofibular syndesmosis, and it's performed by providing medial lateral compression at the leg.  You can do this several times as you move up from the ankle towards the knee.  Pain at the distal syndesmosis is considered a positive test.  It is considered one of the prognostic tests, and if it's positive, it is associated with longer return to sport.  The external rotation stress test is performed by having the patient sit with their knee flexed to 90 degrees, which is easiest done if they're sitting off the edge of a table.  The ankle is then placed into neutral dorsiflexion, and an external rotation force is applied.  The test is considered positive if there's pain at the syndesmosis.  Pain at the medial side of the ankle may also indicate that there is a deltoid ligament injury. This is also considered one of the prognostic tests, and that if it's  positive, patients, specifically athletes, will have prolonged recovery  compared to low ankle sprains.  The dorsiflexion test is exactly what it sounds like.  When you passively dorsiflex the ankle, you will have pain at the syndesmosis.  This is due to the wider aspect of the talus moving into the plafond, which  promotes the separation of the distal tibia and fibula.  Reproduction of pain at the syndesmosis is considered a positive test.  Patients may also have reduced motion in dorsiflexion compared to the contralateral side.  There is a modification of this test, which is called the dorsiflexion lunge test, and this is done where a patient performs a squatting or lunge motion,  thus driving the tibia as far forward as possible.  The cross-leg test is performed almost entirely by the patient. The patient sits and crosses their leg, placing their injured leg onto their opposite knee.  They then press downward on the medial aspect of the knee, and pain at the distal syndesmosis is again considered a positive test.  The fibular shuck test is also known as the fibular translation test.  This is done by stabilizing the ankle at mid-calf and then manually trying to translate the distal fibula from an anterior to posterior direction.  Pain at the syndesmosis is considered a test. You may also actually feel the fibula moving, either translating or subluxing, as you perform this test.  The heel thump test is performed while the patient has their ankle resting in plantar flexion. You stabilize the mid-calf and then using a fist, kind of thump the bottom of  their heel at the center of the heel. Pain at the distal syndesmosis is considered a positive test.  It's really important to note that this test is not very specific, as it is also used to assess for tibial stress fractures.  There are multiple single leg tests that are described in the literature. The most basic one is the single leg raise.  And if a patient is able to do this, they go from standing on a flat foot and then try to rise onto the ball of their foot.  If they have pain at the syndesmosis, this is considered a positive test.  The single leg stress test is where the patient, again, is standing flat on their foot, and then they rotate their pelvis across their body, thus providing an  external rotation stress at the ankle. Again, a positive test is considered positive when there's pain at the syndesmosis.  The syndesmosis tape test is when you have an improvement in pain doing these tests after you wrap medical tape around the syndesmosis, providing compression  and support to the syndesmosis.  And the one leg hop test has also been described in the literature. And this is when a patient is unable to hop more than 10 times on a single leg with pain at the syndesmosis.  However, this test is not recommended for acute injuries, chronic injuries only.  So this was a well-done systematic review done in 2021 by Drs.  Nederstrom, Wedin, and Bleakley, who looked at six published studies evaluating the diagnostic accuracy of these clinical tests.  They found that the highest sensitivity tests were palpation of the AITFL and the dorsiflexion lunge test.  The highest specificity tests were the squeeze test and the external rotation tests. However, they ultimately concluded that further imaging or arthroscopy were  best utilized to determine management of these injuries.  With imaging, we'll discuss both x-rays and advanced imaging.  We usually obtain three standard views of the ankle, including an AP, mortise and lateral view. Ideally, these are done weight bearing if the patient's able to  tolerate that. We also recommend getting an AP and lateral view of the leg to assess for any proximal fractures suggestive of a mason new fracture.  On radiographs, normal radiographic parameters when evaluating ankle films are usually measured 10 millimeters above the ankle joint.  This is where the most prominent aspect of the distal anterior tibial tubercle is located. These parameters include a tibiofibular clear space less than five  millimeters or less than 44% of the fibular width on an AP or mortise view.  You're looking for a medial clear space of no more than four millimeters or less  than two millimeters difference compared to the contralateral side.  The tibiofibular overlap should either be greater than or equal to six millimeters or more than 42% of the fibular width on an AP or greater than one millimeter on  the mortise view. Stress radiographs can also be obtained to do this.  You apply an external rotation and abduction force while obtaining the mortise view. With these views, you're assessing for an increased tibiofibular clear space  or decreased tibiofibular overlap.  A sagittal stress test, as shown in these images, is when you apply an anterior directed force over the fibula while obtaining a lateral X-ray.  It's shown in the literature that there's greater sensitivity in detecting a cynosmotic injury compared to pure AP or stress radiographs from a mortise view.  On CT, this gives an even clearer picture of cynosmotic injury.  The cynosmosis can be measured in a variety of methods. The most common method is the one you see here in picture one, where you measure the  distance between the anterior border of the fibula and the anterior border of the tibial tubercle, in addition to a measurement between the posterior border of the fibula  and the posterior border of the tibial tubercle. Cynosmotic injury is suspected when the gap is more than six millimeters or two millimeters wider compared to the other side.  You can also measure it on the coronal and a gap more than two to three millimeters is considered suspicious for cynosmotic injury.  If you're lucky enough to be at a institution that has a weight bearing CT, this can provide even more information.  With further weight bearing, you can further appreciate the stress applied to the cynosmosis itself.  So you can measure the tibiofibular diastasis, fibular rotation and translation of the fibula, which may be more apparent with weight bearing.  The literature currently suggests that doing volume measurements rather than area measurements of the cynosmotic space is more reliable and reproducible and more  sensitive in detecting cynosmotic injuries.  MRI is considered to be the non-invasive gold standard of imaging.  MRI has been shown to have a very high sensitivity, specificity and accuracy in diagnosing cynosmotic injuries.  It's been said in the literature to have 100% sensitivity and 93% specificity and a 96% accuracy for diagnosing cynosmotic injuries.  For these injuries, what you're looking for on findings are.  No visualization of the AITFL or PITFL ligaments, if you notice that there's an abnormal, coarse, wavy or irregular thickening of those ligaments, or if you're  seeing an increased signal, especially on T1 sometimes, sorry, on T2, sometimes on T1 weighted images.  Fluid within the distal tibiofibular joint is also suggestive of cynosmotic injury,  especially when it tracks more than 12 millimeters proximal to the plafond, which indicates that there's likely an injury to the intraosseous ligament itself.  Bony edema of the posterior malleolus is also associated with PITFL injury.  A lambda sign has been described as being highly sensitive and specific for cynosmotic injury, as you can see, there's a bright white signal at the level of the  tibial plafond, similar to the Greek letter lambda.  A ring of fire sign has recently been described by Dr. Calder et al, who found that sub-circumferential edema around the tibia,  approximately four to six centimeters above the ankle joint, was associated with a cynosmotic injury.  If you have a high clinical suspicion, but the X-ray and MRI are negative, you can consider doing an exam under under fluoroscopy.  During this exam, you do the normal standard ankle stability tests to assess for any injuries at the ankle joint itself.  Arthroscopy is considered the gold standard for diagnosis of cynosmotic injuries. However, it's an invasive test.  It allows for clear visualization of the injured site.  Measurements between the tibia and fibula can be measured using a probe, and usually between two to three millimeters is considered abnormal.  I'm not going to go into too much detail regarding the scoping, as I believe it's going to be covered in the treatment lecture.  Finally, there are several classification systems used for cynosmotic injuries.  The most commonly used one is the West Point grading system, which is based on radiographs and clinical evaluation. It's divided into grades one through three.  Grade one, a patient has mild symptoms and normal radiographs. Grade two, there's a partial cynosmotic complex disruption, so provocative testing  may be positive, but the radiographs are still normal. And grade three, the entire cynosmotic complex is disrupted, so the radiographs will show widening.  These are my references that I used, and I just want to thank you for your time and attention. I'm happy to answer any questions. Otherwise, I'll turn it over to Dr.  Neary, who will be discussing the treatment of these injuries. Thank you.  Carrie did an amazing job talking about really the history, physical exam workup, even classifications.  I love the ring of fire sign.  I'm going to start looking for that. That's my new favorite MRI finding.  But it really comes down, and maybe this would have been a better slide or topic to start with, but which do you fix and then how do you fix them?  And for me, I fix really any cynosmosis injuries that I think are unstable. And the classification system that I go by is grade one, two and three. Grade one is just AITFL.  Grade two is AITFL and interosseous ligament. And then grade three, you get AITFL, interosseous ligament and PITFL.  And what we know are grade twos and threes are pretty much always unstable. If you've got both AITFL and interosseous ligament out, it's going to be an  unstable injury, or if all three are out, it's unstable. I think the real question is the grade ones where just AITFL are torn. And that could be a whole talk in and of itself.  But I think we've definitely started to treat even the grade ones more and more aggressively because we are finding that it can still lead to chronic pain, chronic  synesthematic instability. And for patients who have concomitant lateral ankle instability, having that AITFL out and your fibula being able to externally rotate  can actually stress to your ATFL. So I don't wanna belabor that point on which ones we fixed, but I think it's something that was important to at least mention.  But really what I wanna talk about is synesthematic reduction. How do we fix it? Not only that, how do we get it right every time? Here are my disclosures.  Because what we know are synesthetic injuries are incredibly common, but we don't get them right all that often. Even though we think we get the reduction right,  over 50% of the time, we don't. And studies have shown that. And we care because of this concept of mortis stability. This landmark study by Ramsey and Hamilton  found that if that talus can shift even one millimeter, if the stenosmosis is out and the talus can shift even one millimeter, you lose 40 to 42% of your contact surface area  in your joint. That's a big deal. And we also know that those patients that don't have an accurately reduced stenosmosis have worse functional outcomes. The study out of JOT,  they had a 40% synesthematic malreduction rate. And those with synesthetic malreduction did worse. So we have to get the synesthesmosis right.  We know that the ankle doesn't tolerate even subtle mortis instability. And this stability of the mortis is driven at least in part by your synesthetic alignment.  So how do we avoid malreduction of the synesthesmosis? And here are my three steps to a successful reduction. And I follow these same three steps every time,  no matter how severe the injury. The first is visual inspection and reduction. You have to reduce the synesthesmosis under direct visualization one way or the other.  Step two is then double check your work with x-rays and make sure that you've got it right. And then step three, you still have to choose the right implant.  So step one, looking at the synesthesmosis and making sure you have it anatomically reduced. You can do this directly with your eyes through an open incision,  or you can also do it arthroscopically. When you're looking at it directly through an open incision, there's really one of two ways. The first is the incisura method  where you have a lateral incision. You're looking right over the anterior aspect of the fibula and you can see right into the incisura and the synesthesmosis.  And the second method is actually, it's called the articular surface reduction method, but you can make a separate interlateral incision  right where that interlateral portal for your scope is. And I usually just extend my interlateral scope portal and you can line up the synesthesmosis  at the interlateral corner of the joint. So when we look at that incisura reduction method, here you can see the lateral incision. I've got the fibula fixed with a plate  and you can really just get a good sense of right where that incisura is. And sure enough, that's an unstable synesthesmosis. And even with, you don't need a big clamp,  even with light thumb pressure, you can get the synesthesmosis reduced as you see there. The second method to look at it, once again, is through a separate interlateral incision.  And here you can see unstable synesthesmosis. And then just with thumb pressure, we can reduce the fibula, the tibia and the interlateral corner through that interlateral incision.  And what you're looking for when you do that is something we call a Mercedes-Benz sign. And it's made up of the incisura, the lateral gutter, as you can see there,  and then the articular surface. So that Mercedes-Benz sign is what we're aiming for. And you can do it open through an incision or if you're, you have to be a good arthroscopist  because this can be a difficult dissection to do. But if you really do an aggressive interlateral debridement through the scope, you can look for that same Mercedes-Benz line  and you can really see that your synesthesmosis is reduced. So here is a malreduced synesthesmosis. You can see the talus is way laterally translated in respects to the tibia.  The synesthesmosis has a positive drive-through sign. You can stick the scope or the shaver right up into it. And that's a pretty significantly unstable synesthesmotic injury.  But once you get it reduced, stick the scope back through your lateral portal and you can see there we've restored alignment and there's a Mercedes-Benz sign  at the interlateral quarter of the joint. So step two, once you've got the synesthesmosis reduced, you're pretty sure you've got it right. Now we move on to x-rays.  And this is where you double check your work. It can't just be a quick AP and go, yep, that's good. You really have to look at your alignment  in all three planes, the coronal, the satchel, and the axial plane. I've tried all different ways trying to figure out coronal alignment, but we know that distal tibiofibular,  clear space, overlap, et cetera, can all be really variable. And it's not all that reliable. And so I found just obtaining x-rays  at their contralateral ankle to be the most beneficial. And I'll either do it in clinic when they present with their injury or even do it in the operating room  right before the case starts. But that gives you a great gauge for coronal alignment and where that tibia or where that fibula is supposed to sit in the coronal plane.  And the bonus is it can also help you with your sagittal alignment on the lateral. When we look for the sagittal alignment, not only are you using their radiographs  of the uninjured side, but Croft et al also had a great study where they looked at this anterior tibiofibular ratio. You can see it with the red line from E to F here.  And what they found is that one centimeter above the joint line, about 40% of the tibia should be seen anterior to the fibula. And of course that's not the exact percentage  for every single patient, but that gives me a gauge. It gives me a starting point. And then I can look at their lateral from their uninjured ankle,  and then really dial in the sagittal alignment from there. The hardest thing for me to figure out was axial or rotational alignment. How do we know how much internal  or external rotation the fibula should have through the syndesmosis? And this one, I struggled with for a bit, but eventually I came across this study.  It was a great study published in Injury where they looked at the change of the lateral malleolus shape, as well as the change in the appearance of the syndesmosis with internal  and external rotation of the fibula. So you can see compared to a normal X-ray, so their other side, their uninjured side, if the fibula was internally rotated,  you'd have increased tibiofibular clear space widening and a spoon-shaped fibular profile. Whereas if the fibula was externally rotated, you'll have a more narrow syndesmosis,  more narrow tib-fib clear space, and your fibula is gonna have more of a pointed blade-shaped type profile. So I read this, I was like, that makes sense,  but I decided to try to figure it out for myself. So here you can see both saw bones and I put a cadaver, severed the syndesmosis in a cadaver and just did it under fluoroscopy.  And you can see, sure enough, as you internally rotate that fibula, it becomes wider, more spoon-shaped and the syndesmosis widens and then as you,  or narrows, and then as you externally rotate, the syndesmosis widens and you bring that flat posterior surface of the fibula into view,  which is what makes it look more pointed or blade-shaped. So really interesting way to look at it, but you just, I'll get my syndesmonic alignment done and get everything reduced.  And then I look at their uninjured X-rays and just look at the profile of their fibula. And if my fibula is more spoon-shaped or more pointed blade-shaped,  then I know exactly what my next move needs to be in terms of how to rotate it.  But step three, implant selection. You can do step one and step two to the best of our abilities, but you still have to choose the right implant.  And what we're really comparing are syndesmonic screws to suture button fixation. And truthfully, this could be an entire talk in and of itself, but I think for years,  the suture button was really fighting an uphill battle. Although I think you'll see once we go through the literature review that maybe that's not the case anymore.  But whenever you're looking at literature for any fixation or implant or device, I think there's five categories you really have to look at.  And they're reduction accuracy, strength of fixation, functional outcomes, cost-effectiveness, and how often are patients happy to go back for another surgery?  And so when we look at suture button fixation and all five of those categories, starting with reduction accuracy, there is no question that you have  significantly improved reduction accuracy with suture button than you do with a syndesmonic screw. Specifically with screws,  you'll have anywhere from 11 to a 50% rate of malreduction, whereas with a suture button, it's only zero to 20%. And the reason is screws are rigid.  So if your fibula is off even a little bit, or your syndesmosis is off even a little bit, which we know it is over 50% of the time, and then you put rigid fixation across it,  that fibula can't move at all. So it's going to stay malreduced. Whereas with the suture button, this is dynamic fixation, it's flexible. So even if you're a little bit off,  it allows the fibula to settle in, find its home, and really allows natural correction of any malreduction that you may have. And so that's why suture buttons are so much better  at achieving anatomic reduction of the syndesmosis than syndesmotic screws. When we look at strength of fixation and compare screws to the suture button,  there's no question a metal screw's going to be stronger  than a suture button. I mean, we're not arguing that, but the point I always make is that doesn't matter because we don't need the strength of a screw.  We just need something strong enough to support the physiologic loads that go across the syndesmosis throughout the gait cycle and on a daily basis.  And there have been multiple biomechanical studies showing that the tightrope is absolutely strong enough to withstand those loads. You don't need the strength of a screw.  The suture button is strong enough. And so that really brings home the point that stiffer is not always better. I grew up in Tacoma, Washington, actually looking at this.  This is the Narrows Bridge. And it used to be called Galloping Gertie because in 1940, it started oscillating in a windstorm and oscillated harder and harder  until the bridge ultimately collapsed. And that is what happens when you take something that's too stiff and expect it to move. It's the same thing that happens with these screws  across the syndesmosis. And when you have that level of stiffness, you're going to have a higher rate of implant failure. There's no question.  There's a higher rate of implant failure with screws  anywhere from 10 to 20 to 40%, depending on what study you read. Whereas with suture button fixation, it's hard to even find a study that has more than 0% failure rate.  If they are, nothing is perfect, but the failure rate is so low, it's hard to detect. And so I think that it's important to understand  that there's a significantly higher failure rate with syndesmotic screws. And when you have a higher failure rate, you're going to have a higher incidence of subsequent surgery.  And we know, and this is, there's a lot of instances where we have planned hardware removal of the syndesmotic screws. But if you even take that out,  which of course would increase the statistic, but just take that out, the overall incidence of unplanned subsequent surgery when we compare screws versus suture button  is 15 to 40% with screws versus three to 6% with suture buttons. So you can see it's a huge difference, significant difference between those patients  that go back to the operating room for unplanned surgery. But of course, none of that matters if we don't look at clinical outcomes. And if patients don't do better clinically,  then like I said, none of those other things matter. But the truth is when you look at how patients do clinically, they do significantly better with suture button fixation  than syndesmotic screws. And the reason is it's flexible fixation. So it allows you to leave the operating room with an anatomic reduction,  even if your reduction was a little bit off. And then finally, we're all being forced to practice in a more cost-effective environment at this time.  And this was a study that I actually published in 2017 in AJSM, where we looked at the cost-effectiveness of a tightrope suture button versus two, three, five screws.  I just wanted to see what was more expensive. And when we ran the model and looked at everything, there was no question that a single tightrope  or a single suture button was the dominant treatment strategy and was more cost-effective. In fact, patients with tightrope fixation on average  spent about $1,500 less and had a higher quality of life. And I didn't stop there. I then varied the cost. And even at $2,000, it was still more cost-effective.  And so at the time, I think the cost was $880. So even at 2000, it was still more cost-effective. And then in terms of the hardware removal rate  for screws to become more cost-effective, you'd have to have a less than 10% hardware removal rate. So pretty low. And just remember that unplanned screw removal  is anywhere from 15 to 40%. And this, you'd have to have less than 10% to have it be cost-effective. So there's no question suture button fixation is more cost-effective.  I didn't stop there either. Then I compared one tightrope to two tightropes to one screw to two screw. And even then, a single tightrope was still more cost-effective.  So those were my findings. And of course, from that, I was able to conclude that the suture button is going to be more cost-effective.  That study, to my knowledge, has been replicated in some shape or form at least two more times. And if we pool all of our results, we can assume that the suture button  remains more cost-effective when we pool all of our results when screw hardware removal rates anywhere from 10 to 18%, which once again is much lower  than the 15 to 40% risk or rate of unplanned surgery. So I think there's no question that it's the more cost-effective option,  even though technically it's more expensive than a screw. So really when you look at these five arms of the literature, there's no question that the suture button  is a better option for fixation for, I won't say all, but the majority of synosmotic injuries. And so for me, that's why I refer to the suture button as the closer.  You still have to go through the steps. You still have to actually get the synosmosis reduced, go through the steps of achieving anatomic reduction,  but on the off chance you're a little bit off and you have a little bit of residual malreduction, use a suture button. You're gonna make sure you leave the operating room  with anatomic reduction.  Thank you.  Thanks, Dr. Neri, that was a really great talk and really great intro techniques and tips.  So thank you for your presentation.  It's really been great getting to work with our physical therapy colleagues. And I've met a few of them over the last two or three years  and very happy to introduce Dr. Christopher Porter. He received his doctorate in physical therapy from University of Alabama Birmingham.  He is now works at Jackson Clinics in Falls Church, Virginia. And he's a director of residency and fellowship programs and has a foot and ankle fellowship.  He is a collegiate pitcher. And from what I read in his bio, he's had issues with ankle instability in the past.  And we're delighted that he's here today to speak with us about the difference between standard ankle sprains and syndesmotic sprains. So thank you, Dr. Porter.  Okay, so let's get to the rehab side of things. Let me make sure my slide deck here is gonna progress properly.  There we go. So that's me. So I'm involved in orthopedic sports residency and two fellowship programs and the nation's first foot and ankle fellowship program  for physical therapists.  And so we've been working with foot and ankle surgeons to have our residents collaborate. And I just wanna make a little plug for the American Orthopedic Physical Therapy Academy  and AOFAS in the last few years have been collaborating a lot. And it's really, I think, helped elevate our profession.  And I hope that we're able to do the same for you guys and produce better outcomes. Now, as far as how a physical therapist is gonna rehab these cases that come to us,  we have a lot of more soft things to kind of consider. Like the patient that comes to us, especially I'm thinking about higher level athletes,  high school, college, and professional athletes. What's their fitness base when they come to us even before their injury, their lifestyle,  especially their stress and sleep and nutrition management? What are the pressures coming from their coaches and their parents?  The point is the care is very unique for each patient when you're thinking about this from a rehab perspective. We gotta think about their fitness base. What's their lifestyle?  How often are they gonna be able to be seen? And sport demand and their positional demand, even more specifically, what surfaces they're gonna be on.  You actually see hardcore sports, for example, are gonna have more challenges typically. You would think maybe field sports, but you see a lot more high ankle sprains,  believe it or not, in hard surfaces.  What types of shoes they're gonna need? What type of fatigue, right? If they're a baseball player, which is me who had a high ankle sprain playing baseball,  but I only had to run a 10th of a mile during my sport. But Aussie rules football, you got eight miles. Soccer, five. Basketball, two and a half.  So you really gotta think a lot about fatigue because we know a lot of these injuries don't actually occur just because of trauma. They often occur because of fatigue.  And then the trauma comes secondary to that. We have to think about unique demands if they are a pitcher. Are they having contact? Are they in traffic?  Imagine football player and a basketball player, the amount of traffic they may have. It's a very different rehab consideration if they don't have traffic.  Individual deficiencies, right? Their mobility, endurance, proprioception, obviously. And then all the comorbidities that come with these joints, these joint injuries,  which we're gonna have to talk about. I didn't know if the previous instructors were gonna talk about the frequent comorbidities that come along with this.  So I'm gonna touch on those a bit because that has a lot of impact on our care. And then are they in the preseason, during season or postseason? So hopefully we'll get a chance  to talk a little bit more about that. Now, what are some things that are not different between lateral ankle sprains and high ankle sprains?  I was asked to compare and contrast the two. So I'm gonna talk a little bit about low ankle as well as I go through this. But we need aggressive management of inflammation,  swelling and pain.  And a very phased criteria driven return to normal weight bearing. And unfortunately I haven't seen very good protocols per se for high ankle sprains, especially non-op.  So I'm not really gonna present to you a protocol, a logical protocol.  It's really beyond the scope. But I do wanna hit a lot of the highlights and the principles of a criteria driven return to play in particular.  We either have to restore or protect lots of different joints. Do we protect the tip fib, right? We know that only a few millimeters of play  can make a big difference in our outcome.  Or do we try to mobilize it? Do we mobilize or protect the talocrural joint and the deltoid? Do we mobilize or protect the subtalar joint and the midfoot?  Because that also is often sprained as well.  I would also say immediate use of blood flow restriction therapy is probably the state of the art now. So if that individual cannot load at 50% of their previous injury one rep max,  I'd say blood flow restriction therapy is usually gonna be indicated, especially if they can't get to a fatigued muscular state  without discomfort in the ankle or some type of problem. I'd also say the plantar flexors are keen in general. If we think about the deep posterior compartment,  Tom, Dick and Harry tendons, obviously the superficial compartment, gastroc soleus and even the lateral compartment, peroneus, longus and brevis, they're all plantar flexors.  So we have to restore plantar flexion, strength, power, agility in lots of different contexts, which we'll talk about. And then there's a ratio that needs to occur  between the deep posterior compartment and the lateral compartment. It's not just how strong things are, it's how much balance is gonna occur between these two  and roughly in a one-to-one. And we'll talk more about how to do that. So other things is what's not different also between lateral and high ankle sprains.  These individuals, and these are all different contexts. Hopping in my world is different than jumping, cutting, pivoting and change of directions. So we need to make sure  that we test all these unique constructs. We're almost always gonna be bracing and taping for weeks and months. And there's some clinical practice guidelines out now  that actually say prophylactic bracing for even before injury and to prevent secondary injuries is actually potentially the state of the art.  We're gonna be doing ongoing special testing throughout care. Every week, I'm gonna be doing gentle stress tests to see if that ligament's healing, whether that's the, you know,  all the tests that were covered earlier in the lecture, whichever of those are just uncomfortable or present instability, we're gonna just gently be testing those  as indicators of healing, especially for the ones that are non-op, okay? And it's very important that early in the care, we tell the patient how to get out of rehab.  There's some strong evidence to say that if you tell the individual what they need, they're gonna have better outcomes. And speaking of outcomes,  we need to make sure we're testing using outcomes tools, especially in the rehab setting, at the initial care and at discharge, and ideally every month.  Especially the high ankle cases, you might be checking in with this individual for six to eight months, and you're gonna be testing using outcomes tools throughout the plan of care.  You may not see them for two months. You might see them, you know, a month after they return to sport,  or one to two weeks into the season is my strong preference. As soon as they go back to one to two weeks of activity, come back in, let's do all my tests, do another outcomes tool.  Look at visual analog scale as well, linked to specific activities. So don't ask them the generic pain, ask about after specific sports, specific activities, okay?  The FAAM or the LEFS are strongly recommended, but I wanna make a plug for two other outcomes tools, which is this, it's sane and simple. You ask a simple question,  what percentage of function are you now playing sports or whatever high level activity they have, compared to before. We know that captures  psychological constructs like kinesiophobia and fear, even strength and proprioceptive deficits.  All these things can be captured with that simple question, what percentage are you now compared to before? And then if there's any instability, ultimately both these injuries,  low ankle and high ankle, are instability environments. We know that chronic ankle instability is highly likely in these more significant injuries, and so I strongly recommend  the Cumberland Ankle Instability Tool. Obviously, we're not going to go through what the questions are, but they ask the patient questions about how unstable do they feel during  sport-specific activities, rolling their ankle, can they correct it, etc. Okay, so again, comparing, contrasting. We know that there's different ligaments involved, the low ankle,  ATFL always, but often the CFL and the PTFL. The high ankle, usually the AITFL, the PITFL, and IOL,  right? The mechanism of injury generally is inversion-based for low ankle sprain and plantar  flexion bias, usually not always, for low ankle. And with high ankle, we almost always are going  to have a dorsiflexion load or some type of vertical load, usually with an eversion bias. And thinking through that mechanism of injury is critical because there's so many other  concomitant soft tissue injuries and soft tissue and bony injuries that we have to manage in rehab.  Usually, we're just going to be just as limited by the sinus tarsi, the subtalar joint sprain,  or the cuboid midfoot sprain that also occurred at the lateral ligament, the perineal nerve  traction injury, the snapping perineal tendon. These are going to be all limiting factors for  our rehab. As in the high ankle sprain, they often have a low ankle sprain involved as well, the sinus tarsi as well, the midfoot, the deltoid and springling, the tarsal tunnel,  we have to think about the tibial nerve, and obviously the bony injuries.  Usually, low ankle sprains, you consider, you don't have to immobilize or less severe.  And then as far as the nerve injuries, we know about 40% of low ankle sprains, especially grade two or higher, are going to have a perineal nerve lesion and 40% of surgeries  for low ankle sprains. So the large majority of our folks are coming in with highly irritable  lateral structures. So we're going to have to use our knowledge of nerve anatomy that if you  have sensation loss, the dorsum lateral side of the foot or hyperesthesia, we're going to have  to really manage that well. We're going to have to try to prevent things like CRPS, complex regional  pain syndrome. So we've got to really treat the nerves with respect to prevent that from occurring.  We're going to test that with a straight leg raise or a slump test. So right when you take up that  limb into a straight leg raise, you add a little inversion and plantar flexion bias to make sure  to see if that nerve is irritable. And if you have a limb in a straight leg raise in that plantar  flexed inversion position relative to the other side. Okay. And that can be the way that you can  monitor nerve healing, nerve irritation. On the high ankle side, much more likely to have a tibial nerve injury, you know, tarsal tunnel involvement. So same, same thing. Sensation  is going to be generally on the heel or plantar side of the foot. Weakness is only going to occur  the intrinsic. So typically if it's the tarsal tunnel, if at all, and then our straight leg  raise test is going to be with the dorsiflexion and eversion bias and compare limb to limb.  Okay. Now, bracing is a really big deal. Lots of strong evidence that we need to be bracing these folks aggressively. I don't have any attachments to Donjoy, but when Josh Bailey,  who's one of my mentors, I asked him what braces would you recommend this population? He said  unequivocally go to the Donjoy medium support, which is up here at top or the extra support  right here. Now you also have a velocity plus brace, which is shown here where it's an addition  that you can use temporarily, which creates compression at the mid syndesmosis, because we  also have compression at the distal syndesmosis with this brace. So it's nice because you can  kind of scale it and progress it down. The alternative would be the ultra ankle CTS brace and your typical ASAP brace early in care for the grade two A's. The grade two A's are the  stable sprains are often not going to be enough. Now, as far as outcomes, you look at professional  athletes. You got post-op and I think they use suture buttons here. They're returning to sport  in three to four months. That's pretty quick. Now it's going to be delayed a week or two if you have  a cartilage injury. At least if it's a grade three injury, it's going to be an extra six weeks.  If it's when you think about when you're going to return to sport specific training, that's fairly  quick in these athletes. Obviously, these are younger athletes that are functioning at a high  level. If we're talking college, it's going to be a little slower. High school, a little slower.  That's the way I think about it. Okay, now if it's non-op, again in this pro soccer group in a two A,  so you have a stable mortise, in a couple months, that average return to sport for the high ankle.  Now keep in mind, what's the season length? High school and college football and basketball is three to four months, right? So these are often going to be season-ending injuries.  If they don't occur right at the beginning. Okay, so now that we're past kind of the basics of  healing, how do we talk about actually getting into some higher level rehab? So with the low  ankle sprain, we're obviously going to protect different structures. We're going to protect the ankle into more inversion and plantarflex positions. We're going to really focus on  restoring dorsiflexion and pronation to that foot. And the opposite for a high ankle. We're going to really work on initially restoring plantarflexion and supination of the foot,  protecting, it says midfoot instability, but I meant to put protect dorsiflexion and pronation.  That's probably the most important theme here, right? Is during rehab, the one most important  thing we need to protect dorsiflexion and eversion and grade that mobility. It's really helpful for  rehab specialists to really think about when are these events going to occur in the gait cycle,  especially right when we're teaching people to walk with crutches and we're trying to wean off  crutches, when you really need to protect them at initial contact for low ankles and an inversion  and a terminal stance, they plantarflex and invert. So we're going to really be careful that initial  contact heel walking and toe walking is going to be something to use early in care, but with a lot  of caution. And the opposite is true for a high ankle. I'm much more worried about mid stance  when we're under max load. Okay. We're certainly going to be using the braces throughout these  phase two stages. You're going to want to think about if you're using a lace-up brace, if you're  weaning out of those bigger braces, you can certainly think about the direction of pull with the strap. You're going to pull a lot harder medial lateral. If it's a lace-up  brace high ankle, you're going to do the opposite. You're going to pull that strap harder lateral  medial. I said that backwards. Medial, did I say that correctly? Yeah. High ankle, you're going to  stabilize lateral medial to put it in a little bit of inversion. Okay. And that's the same for  taping, right? Okay. All right. So now we're going to get into some mobility considerations.  So there is strong evidence for manual therapy in this population, lymphatic drainage, soft  tissue mobilization, protecting all the irritated structures, the concomitant injuries. That's where  a lot of our failure is going to occur in PT is not really managing the concomitant injuries.  Joint mobilization, not as much high-grade manipulation, but very carefully dosed  is indicated. But I want to highlight the importance of weight-bearing mobilizations, mobilizations with movement. Okay. There's really weak evidence for the following. You know,  unfortunately, cryotherapy and ice in our clinical practice guidelines isn't shaken out to be that  useful, perhaps only for a narrow window of time, inflammatory stages. But I would use it if it's  something the patient needs, but we know it delays nerve conduction, and we know if we have a  proprioceptive deficit, that actually could complicate someone's rehab. So be really careful icing and doing a lot of high-intensity proprioception post. Acupuncture, diathermy,  electrotherapy, laser, even dry needling is showing some pretty weak evidence, and ultrasound is basically definitely a no. The big thing here is dorsiflexion, right? Dorsiflexion  is king. Eccentric control with the plantar flexors is king. And so we really do need to specifically measure this. We want to isolate gastroc length, minus 10 from zero, going to  that R1, that five pounds of force, soleus. You get a 20 extra degrees, you go 10 degrees past that  90. But the key really is collis chain dorsiflexion. We should get 45 degrees or 11 centimeters at the  needle wall test. And the problem is, this population is often going to present as a deficit in dorsiflexion mobility. But what we're going to encourage you, is there really a  restriction? We're going to talk about that in a moment. But what we do know, if there's a 2.5  centimeter, even a 10 degree difference side to side, that correlates directly with low ankle  sprain risk. And obviously for high ankles, that data is not there, but differences matter and  function. So we need to be really precise with our mobilizations, and often we need to stabilize the  fibula and retest dorsiflexion with tape, or even with manual mobilization. I might anterior glide  the fibula, see do they restore dorsiflexion? Can they move 10 more degrees of dorsiflexion, 15 more  degrees of dorsiflexion with less pain, especially after some gentle mobilizations in the  stiff direction? That's not a stiff mortis. That's something that you need to protect. Okay, so we need  to make sure your rehab specialists are doing specific high and low fibular mobilizations.  And again, dorsiflexion is king. We're going to run into a lot of problems with dorsiflexion, so let's  talk to the most common problems that we're going to have. Some of the most common problems, I want  to make sure I'm looking at time here. I know we got started a little late. Richard, I'd love to  know kind of what our target time is, probably about five more minutes. Is that okay?  Okay, I'll keep going and you can answer me. You're doing fine, Dr. Porter. You're doing fine, go ahead. Okay, a lot of our patients are going to describe anterior ankle discomfort.  So obviously, do they have synovial impingement? And one of the ways to test that, you press the  soft tissue into the mortis and dorsiflex and see, does that reproduce your pain? Or you can  pull the skin out and see, does that take away their pain? If so, we may have a synovial impingement,  so you need to be thoughtful about pushing through that. If there's no tailor cartilage or bone  involvement, make sure, if you don't know rehab specialists, make sure the imaging and the doctors  communicated with you how much bony involvement we have. We can stabilize the ankle, like I said,  manually and like in this inferior image, and if they can restore motion, then we know that  we have an unstable mortis here, and so we don't want to really stretch hard in dorsiflexion.  A lot of people are going to have anterior shin discomfort. Is that because the anterior  compartment's pulling? It could be that simple, or is it really that interosseous membrane? So you  got to really think about relaxing this anterior compartment to make sure it's not actually a false  positive, but if it is the mortis, and again we have to protect that, put them back in the brace.  Certainly, we have to check our palpations, especially that strong PITFL. If they have  posterior ankle pain, see if that is problematic. Make sure to protect the deltoid spring ligaments,  so don't let them overpronate, and see if dorsiflexion improves their comfort, if you protect that, etc. Okay, now I think I'm going to skip several slides here,  and this was kind of planned. Give me just a moment. Didn't mean to kick that out.  And I want to skip down to the most important things here, which is discharge criteria.  Okay, all right, so when I want to get someone out my door, what do I need to think about?  Okay, there's four key things to think about. What's going on limb-to-limb, so limb symmetry index, what are their age, gender, and sports match norms,  what's their prior functional level, so asking them what was your previous 40-yard dash and  shuttle run time and endurance times, your max lifts, and then we got to really think about what  the athlete themselves, the coaches, trainers, and parents think. As much as we don't want to include all those subjective elements, that is going to be something to consider. Now,  these are the basic categories. There's a lot to cover here when we talk about discharge,  okay, and I'm going to cover this in a little bit more detail here. So what do I mean by patient  perceptions? We talked about those outcomes tools. We want minimal pain during and after  participation. Figure 8 malleolar measurements, as much as that's in the guidelines, I will tell  you you cannot pick up more than at 1.5, 2 centimeters difference, so visual estimation is probably even more important than actual measuring the tape. I'd also say the mobility  demands for the sport. If they're a ballet dancer, it's very different than a football player,  so we got to make sure they have the mobility demands for that particular sport. Again, ongoing stress tests, as we mentioned, should be negative, and we need symmetrical strength  side to side, but the problem with using a limb symmetry index is that we have detraining, so we know that limb symmetry index scores are not always adequate because oftentimes that  healthy limb might be detrained by 20%, and so if we assume that someone is 90% compared to the  other limb that's 20% detrained, we might be sending someone back to play with a 30% strength  deficit, so we need to try to use other things if we possibly can, like their prior numbers on back  squats, deadlifts, if ever possible. We're going to talk a lot about different hop testing here,  and I think we're going to have to close it out there, and dynamic balance. I think it might be  better to kick over to that quickly, but we really also want to think about endurance. I mentioned  earlier that fatigue is one of the primary drivers of failure, so we need to make sure that they can  repeatedly sprint and run at their prior distance without this difficulty, that they can handle  traffic and cognitive challenges, they have adequate agility speed, and I really strongly  recommend video analysis. So the Y balance test is our probably go-to dynamic balance test. We  try to normalize that to limb length, so even a 5% difference or a 2 centimeter difference can  be clinically meaningful in the ankle sprain population, okay, and for high ankle sprains in  particular, I'm most interested in this anterior direction. That should be 66% of limb length,  and we know that if we don't have that in a military population, ankle sprain risk goes up substantially, and I would say from a hop testing perspective, the side hop test is money.  This is the guy that I would use more than any other test, and for physicians in the audience,  if you can kind of simulate this in clinic, I would recommend that. So 30 second hop side to  side, because that integrates plyometric power, endurance, speed, it kind of captures a lot of  elements, and don't count the errors, and compare side to side. So how many can they do side to side,  and the other reason this is such an important test is that there's been a study in ankle pain population that if you fatigue someone, so if you actually have them go run to fatigue  or strength train to fatigue and do this test, we got dramatically different results. So we need to  make sure that we're testing these individuals in a fatigued state before clearing them to go back  to sport and handling fatigue. Vertical jump may capture a different construct, so strongly recommend looking at single leg dead jumps, penultimate jumps, where you actually have to  take three steps, just one big hop, and then land on one leg and jump, and then compare side to side.  Those are the two most common things that happen, or excuse me, the two most common sports that's  critical is volleyball and basketball, okay, and then adding mid-air traffic to these lands. So  when someone's jumping the air, add light perturbations, and can they land an unplanned environment? That is critical, and whenever possible, try to do a 2D pivot plant analysis  where you're looking at side to side hopping, their ability to stop on a dime and compare limb  to limb, again, ideally 240 frames per second with this 2D analysis, and ideally cutting at  different angles that are critical for their sport, that's 45, 90, 135, okay, and this is one of the  simplest tests for physicians or anyone to use in clinical practice is a demi point or stork test.  Inability to hold this position for five seconds increases likelihood of re-spraining 2.5 times,  so this is one of the simplest return to play tests you can do, especially for low ankle sprain.  I'll do this test for high ankle sprains with the heel closer to the ground and the ankle massively dorsiflexed in range without the heel touching, same kind of modification,  and neurocognitive training essentially is basically we need to add lots of stimulus to athletes. Can they tap only the blue, not the green, not the red device on an unstable  environment that's being mainly perturbed while dribbling? You know, if they can't handle lots  of cognitive stimulus and they fall to pieces, then we know they're not ready for return to play.  All right, so those are my references, and thank you for the opportunity to be here.  Dr. Zell, I can't understand you. You're a little broken up.  No.  Dr. Porter, thank you for that. I have a question for you. What is your recommendation for getting  back to play with the brace? So, for my little guys that are going to go back to play sports,  I recommend wearing a brace, I don't ever know for how long, the remainder of the season, but now these kids play sort of year-round sports. So, what do you recommend for both low  and higher ankle strength? Well, there's two different categories. That's a great question.  There's two different categories of instability. We have structural instability and functional  instability. So, if someone's structurally unstable, they need to be continuously be using  the brace for that ongoing special testing, and then there's a case for even functional instability  as well, but if that individual can compensate for that through all these tests, you could argue  there might be a time to wean off. However, we know that these ligaments are only about 70%  healed in six months. So, my general rule of thumb is I try to keep on a brace six months if I can,  just to make sure the ligaments are fully healed, and in the new clinical practice guidelines that  came out, I did mention this, that prophylactically using it forever, there is a case for that.  Even for people who haven't sprained, my argument against that is you brace, you lose dorsiflexion,  okay, and that could be good, but we do know that loss of dorsiflexion leads to more genivalgus and knee rotation, which is an ACL risk. So, I haven't really seen data on  bracing and ACL risk yet, but I really think that's where we need to go to figure out the safety of long-term brace usage.  So, with the female athletes that are already at increased risk for the ACL instability,  you would be a little bit nervous about having those girls? I'd be sweating bullets keeping them in a brace that's going to limit dorsiflexion for sure.  However, you know, it's one of those things where I think it's really working with that individual and having them do all these tests in the brace and see how do they feel,  like their kinesiophobia, their fear, their comfort, I think plays in, because I think there's a sixth sense. I think the patient knows and something doesn't feel right.  Not really.  Yeah, it's kind of very far away, it sounds like.  Gosh, we typically get a ton of questions in our little chat box here. We only had two. They were both addressed to Dr. Neary and she was able to answer both of them. So,  I'll just, for the recording, kind of go through them here.  And they were both related to the, let's see, number one was related to the diabetic patient,  what's the best sinus monofixation? Would she still recommend the button at that point?  And she writes, it's a different story, I prefer two to three sinus monofixation for those patients with a combing method. And that's what we've seen in our practice as well.  And then the second question.  Oh, you're still here? Okay. I can zoom in on him. Yeah, totally. Right, we're just gonna, it's gonna be the first baby on AOFAS.  So, I think, yep, he's losing it. So, here we are. So, I think that, to me, there's, like,  the well-controlled diabetic, minimal neuropathy and still pretty active patient. And then there's,  like, the blazing neuropath, you know, like, insensate, out of shape, twisted their ankle,  like, falling over their coffee table. Like, those are two very different patients. So, for me,  if they're a well-controlled diabetic, they have minimal neuropathy, they're active, I'll still use the tightrope. I don't think they need to be combed or have, you know,  multiple sinus monofixation screws. But if they have significant neuropathy, unhealthy, poor functional status, etc., etc., and are going to be really non-compliant  because of their neuropathy, those are the ones that I think the tightrope probably can't hold up. And those are the ones that I'll do  two, three, four synismotic screws. I mean, we call it the combing method because it looks like a comb. So that's, I didn't want to type all of that out,  but that's how I think about it. And it's, and these, they can't help it. You know, these patients, it's actually not non-compliance.  I call it A-compliance because when you have neuropathy, they put their foot down, they don't even know and, or don't even think about it.  So it's just, you have to be aware of that, but I don't think all diabetics fall into that category.  And so just something to, something to think about.  And with your syndesmotic group, let's say for non-diabetic post-op protocol for, let's just say, I don't know, let's just say a, you know,  fibular fixation with a syndesmotic button.  Do you non-weight-bear, do you weight-bear, do you use a boot? Do you have, what does that look like for you? If it's a, if it's a significantly unstable injury,  like we're talking like a Mesa nuve where the tibia and the fibula are in different galaxies, those all keep non-weight-bearing for probably about four to six weeks  and really give that ligament a chance to scar down. But if it's just a fibula fracture with a mildly unstable syndesmosis, I'm weight-bearing those patients at two weeks.  No problem.  And I think that, so once again, there's a difference, but the really significant injuries, I do think you have to give it time to heal. I also would say,  if you have a really significant syndesmotic injury, there's almost always a deltoid ligament injury, so don't forget to fix that.  But if I fix the syndesmosis and the deltoid after about three to four weeks, I start to feel pretty good, but I do a progression.  I have them start with 50% weight-bearing for a week, then 75, then a hundred.  So by six weeks, they're a hundred percent weight-bearing feeling really good, but at least that keeps them from fully loading their leg until about the six-week mark.  But at three weeks, you can at least trick them into thinking they're starting to bear weight. That's how I do it, but I know there are,  we have colleagues that are more aggressive than that and you probably can be, but I just feel like for those more severe injuries, you have to be careful,  but the less significant injuries, you can weight-bear these patients early.  And do you start physical therapy after two weeks or do you wait a little bit?  I started usually around six.  Okay. Yeah, but you can start at- You can do it on your own. Yeah, I'll have them do motion. I mean, I get them at least getting their motion.  If they feel like they need PT to help them with that, then I'll do that, but otherwise, I feel like until they can really bear weight and walk,  there's not a ton you can maybe can get out of PT, although Dr. Porter may disagree with that. Look, Dr. Porter may disagree with me, but there's probably a ton you can do.  Well, the blood flow restriction would be one thing I would really drive home is, you can really do the low loading to really prevent atrophy. Yeah. Yeah, 100%.  Dr. Porter, can you explain to us a little bit how the blood flow restriction works and what patients would be a good candidate for it?  Well, there's a long list of vascular injuries  or vascular health we need to consider with that, but it's been used for 50 years. The incidence of injuries is very low and basically creating an environment  where the limb has a blood occlusion of about 50% to 80% of its normal blood flow. And we know that if you essentially create an oxygen debt in the limb,  you can selectively fatigue fast twitch muscle fibers fairly easily. And so that is fantastic because a lot of these injuries, you lose a lot of fast twitch very early  because you're not doing any athletic type movements. And then once you fatigue the fast twitch muscle fibers, then the slow twitch starts to kick in.  So if you push the individual hard enough, you can get a nice slow and fast twitch muscle failure with sometimes only a third of the load  you would normally be able to fatigue a limb at. So if you're doing heel raises, normally it would fatigue at a hundred pounds, let's say on someone's back,  they can fatigue at 30 pounds. And a posterior tib in this high ankle population is really important to get back. You might normally fatigue it with 30 pounds load,  you can fatigue it with 10 pounds load. And that might be within the amount of tolerance that Dr. Neary would be okay with. If they're weight bearing that individual,  they should be able to tolerate 10, 15 pounds of load to the peroneals and the posterior tib and maybe 30 pounds load to the calf.  You know, we can really unwind a lot of atrophy that way.  Are there, I know this is a synopsis webinar, but while we have you, are there any injuries that in your opinion, it would be maybe harmful to start blood flow restriction early?  I don't know. I've thought about this like with patients who are high risk for wound complications. Do you feel like you could potentially disrupt the blood flow to the incision?  Achilles, I worry a little bit about that, although I know it's been incredibly helpful with Achilles ruptures. But that's been a question I've had  and I just wondered what your thoughts would be.  You know, I don't think it's been, you know, I'm not aware of it being studied in wound healing, you know, per se, but I know it's been, you know, studied in the Achilles.  It's becoming part of the protocol that I'm starting to see. But again, we did a case report on it, you know, recently and, you know, person had great results.  So as far as, you know, obviously if we're gonna have actual vein compromise,  you know, I'm not gonna be doing in that population, congestive heart failure, you know, kidney failure, you know, any type of vascular disease  is usually the things that I'm concerned about. As far as like how early after an injury to do that, you know, we really been doing it on surgeon preference.  And so most surgeons I think lately have been a lot more aggressive with letting us use it. In fact, there's even protocols where we might be using a week post-op ACL,  used one yesterday, or we don't actually even do anything besides a quad set. You know, we're just actually doing a cellular swelling protocol.  So we're actually just trying to create muscle swelling. We're not actually trying to create muscle load. And we know that if the cells can swell,  that they're actually gonna be able to produce more energy and they're gonna atrophy less. So there are some protocols coming out now. They're using it very early on.  I haven't seen any negative data to that effect, but I'm definitely not an expert. So I do have to say I rely on physician preference a lot.  We do have a question from the audience,  possibly for Dr. Neary. What is the approach to fail syndesmotic reduction six months post-op or if the patient had an injury and wasn't managed?  So if you see those patients in the office. Yeah, that's, it's a loaded question, although I'm sure they didn't mean it that way, but it all depends on the injury pattern.  It depends on the injury pattern. If it's, whether it's a purely a missed syndesmotic injury, was there a fibula fracture? Is the fibula now malreduced?  I mean, there's a lot of things that go into this, but I guess generally speaking, number one, especially if there's a fibula fracture, you have to make sure your fibula fracture  is anatomically aligned. Because if your fibula is off, you'll never be able to get the syndesmosis right. So you have to get, if there's a fibula fracture,  fix that first and get that aligned. If it's, then you go to the syndesmosis, whether it's associated with a fracture or if it's just a pure syndesmotic injury.  And for me, it all comes down to how well I can get that reduction. So I try to at least start with tight ropes because I do think ultimately that's probably better,  but the more chronic the injury becomes, I think that fibula has a lot of memory. And even if you get it reduced, its tendency is to go back where it was.  And I have rarely had to bail to screws in that case,  but you can get a pretty good sense, especially with those more chronic injuries. I don't ever use the clamp for acute injuries. I just use thumb and finger pressure,  thumb over the lateral malleolus, the other part of my hand over the medial malleolus and just reduce that way. That's all you need. For those more chronic injuries,  sometimes you do need something more powerful to get that reduced. So I would say at six months, I'd have the clamp in the room, just don't over compress.  We all want to squeeze too hard with the clamp. There was actually a great study done that showed the amount of force required to use the clamp as the amount of force required  to smash an empty beer can. So it's really not that much,  however many Newtons per whatever that is, but that's what it is. And so I'll use the clamp, but cautiously, because you don't want to over reduce.  But after that, then I just decide, like if I had to really work to get that reduction, you probably need screws to hold it. But if I didn't, and it reduces pretty easily  and it seems stable, then I'll use tight ropes and type of suture button.  And I think the success, as long as you get it reduced is fine, but you just don't know what type of hit the joint took during those six months.  That was an unstable joint for six months. And so I think the success rate, assuming you get the syndesmosis reduced, the success rate's not going to be reliant  on your syndesmotic work. It's not going to be the syndesmotic injury, it's what type of hit did the joint take those six months.  But I think the success rate can still be reasonably high.  So a question for Dr. Bell. So sometimes when we're in the OR, we'll reduce the syndesmosis with tight ropes or a suture button and things are very stable in the sagittal plane.  And other times that's not the case. And when you were reading for this talk, did you read anything about the depth of the syndesmosis or its anatomic variance in patients  with a flatter syndesmosis or one that's more conforming?  Or Dr. Neary could take the question as well.  Yeah, no, that's a great question. And it's something that I've been asked over and over. The hard part is you don't really, at least I don't really know that  as I'm staring at the syndesmosis. You get a sense of which incisors are more concave and which are flatter, but you don't know exactly how much concaveness you have  or concavity or how flat it is. And there's no question, the flatter ones are a bit harder to reduce, but then again, you're not really relying on the incisor to hold it.  You're relying on your alignment in the coronal and sagittal and the axial planes. So I do think there's probably some benefit to having some concavity to the joint,  but at the end of the day, I don't think that's what's holding your fibula where it should be. Does that answer the question?  Yes. And then there's certain patients that require a reconstruction of the AITFL,  possibly with suture tape.  Dr. Neary, any thoughts on  if that is necessary and when it would be necessary and what outcomes those patients have had? No, it's a great question and something that we're all paying  more and more attention to.  I still always start with a tight rope and then I just check. And if there's still a lot of external rotation, then I'll add in an AITFL type of fiber tape.  I think that that is great for resisting that external rotation,  you have to be really careful with the tensioning. And that's where I think some of these can make it too tight. If you tension it too tight,  I mean, the fibula does need some external rotation. So you just have to be really careful with how you tension it. And you also have to be careful if it's a grade three injury  and AITFL interosseous ligament and PITFL are out, then if you put that AITFL fiber tape too tight, it's gonna actually book open the fibula posteriorly. And I've seen that happen.  I have a really interesting axial CT cut where you can literally see the back just booked open. So I like to use a tight rope first  just to help the fibula sort of settle in and find its home. And then I'll just use a freer or I'll grab it with a clamp and just do a quick little external rotation.  I also do that when I'm doing a brostrom. I think that we miss a lot of syndesmonic injuries, high ankle sprains with patients with low ankle sprains and especially sprain of AITFL.  And so when I do a brostrom, I'll cinch everything up nice and tight, but I'll still check at least and see how much external rotation I have of that fibula.  And I use fiber tape and internal brace for my brostroms for my AITFL reconstructions. I won't cut the ends of the fiber tape and I'll check the fibula.  And if it externally rotates, you can then dock that into the chiput tubercle. And it ends up looking like a V. So you go from talus to fibula, fibula to tibia,  and you can do reconstruct AITFL that same way.  So it's something. Next time y'all are doing a brostrom, check the fibula. There's some patients that have quite a bit of external rotation and between scoping  and looking at it and then stressing it, I end up fixing quite a few of them.  So a question for Dr. Porter or Dr. Neary. A lot of these patients, when they come in to see me, I put a lot of people in cam boots. Is that a mistake?  Should they be going in a brace instead?  And how, from a physical therapy standpoint, what are your thoughts of the patients being in a cam boot and how quickly do you try to get them out of it?  Yeah, I'd say is it a stage, are we talking 2B, like an unstable? Yes, yes. Oh, yeah, I would definitely think a cam boot makes sense for a 2B.  Yeah, yeah, definitely needs some healing time from my perspective. I'm not sure what the other doc says. And what about ones that are less severe?  Yeah, I mean, if it's stable, I don't really see the value in doing that outside the inflammatory stage, maybe the first few days, maybe five days, seven days, maybe.  But as far as early in care, what I see is a cam walker boot, especially if it's prolonged use, not only is it severe atrophy, but the midfoot joints, the toes, subtalar joint,  all the soft tissues, the tib-fibs approximately are all really locked up. And so that is a case for coming to PT earlier is I don't have to touch the area that got treated.  You know, I touch all the structures around it and I do a lot, I make sure that the individual can really strengthen their knee and their hip and their trunk and core  and, you know, that kind of stuff. So that'd be one case for a few visits with PT early in care and that would also help me determine  whether or not they're ready to come out of the cam boot. Like, can they restore a normal gait cycle or not?  All right, thank you.  I have a question for my frontline urgent care workers. Someone comes in and they do the standard, you know, weight bearing ankle x-rays.  They don't see a fracture, you know, patient's tender, you know, from the knee down to the toes kind of thing. Do you, and they think, well, this seems like  a bigger injury than an ankle sprain.  Do you guys do gravity stress x-rays? Do you recommend that sort of everyone gets an MRI? Like, how do you tease that out for your APTs that are working at the urgent care?  Or just the sooner follow-up or what do you guys do for your protocols? What does it look like?  Tracy, I can answer that from my perspective. The, for our acute ankle sprains that come in, I give them all three weeks.  There's no literature behind that. I just feel like most ankle sprains seem to turn a corner within the first few weeks.  A lot of them will still come back to clinic and say, I still hurt, but there's a difference between I still hurt or like this hasn't gone anywhere.  And that's when, so I pull the trigger for an MRI at like three or four weeks. I start them in PT right away, but I don't, I've gotten more and more aggressive  with getting an MRI because, you know, I care about these people and I don't want them to be in PT for six, eight plus weeks and then come back and it turns out  we've missed synesthematic injury, perineal issues, you know, whatever. I think, and most patients would rather know. So I pull the trigger after three weeks  if they're still really not doing well and haven't seen much improvement, but that's just, you know, my own protocol, but not based on any literature that I've ever read.  Dr. Zell, is that what you guys do as well or? Yeah, we're a little bit more conservative, I think. I think we usually give patients usually four to six weeks of physical therapy.  I mean, we're not ordering an MRI immediately when they present to clinic at our institution. We usually give them four to six weeks in physical therapy  and see if they have improvement as well.  Yeah, I think that's the, I think it's, I don't know if any of us would ever agree on that. It's an interesting conversation to have.  I just, all it takes for me was missing one syndesmotic injury, and then someone's coming back two months later where I'm like, ah, I should have done that sooner.  And it's, if at three weeks patients are like, you know, I don't really want to do that yet, then we don't do it. I don't force them into it.  But, and I'm with you, I don't offer it right up front unless there's something I'm worried about, perineal tendon dislocation, something like that.  But, but yeah, I think three, four, five, six weeks if they're not getting better, somewhere in that timeframe is really reasonable.  Yeah, we do similar here. You know, say we have a kind of a two to three week follow-up from the urging care to a specialist. And, you know, either they just don't show up  because they're doing well and they've moved on in life. But, you know, two to three weeks or we get to make that call. So it turns out to be about the same.  It's hard when they order the MRIs right up front because if it's like a grade one or two, you're like, well, is this going to get better on its own?  Or that's where I struggled is if we got the MRI too soon and there's just kind of fluid everywhere and all your radiographs look stable. And I think these are tricky.  I think these are tricky to sort of predict, especially in your athletes who just want to get right back to it. And you don't want to make them languish for too long  because they are never going to get better and they just need to be surgically reduced, but you also don't want to push a kid into surgery that ultimately they didn't need.  Tracy, over time, the way I approach it has changed, but where I'm at now is I think of ankle instability as tearing of one of three ligaments,  synesmosis, lateral ligaments, or your deltoid. I mean, those are the three main ligament complexes that stabilize your mortis.  And it seems like if you just tear your lateral ligaments, it's a real simple ankle sprain. We know that there's about an 80% chance you're going to do well and about a 20% risk  that you're going to have continued instability. But my experience has been once you tear two or three, that statistic goes way down.  So those are the few, like with the MRIs that I get up front where they come with an MRI and there's fluid everywhere, you can still tell which,  like if synesmosis, lateral ligaments, deltoid ligament is out. If it's just their lateral ligaments, we'll go to PT. I don't jump on that. But if they've got a synesthematic injury  plus lateral ligament injury, or if it's lateral ligaments and deltoid, or if it's all three, we're going to have a serious conversation about just fixing now, as opposed to,  I've just, a lot of those don't recover the way you'd want them to. I know that's asking a lot of the ankle, but once again, that's based off experience,  not necessarily the literature. But I think that it's more important, maybe take home messages, the more ligaments involved, the higher chance they may not recover  with non-operative management.  I think we've come to the end of our webinar. Wanted to thank all the speakers and thank you for all the great conversation  and look forward to seeing everybody at the annual meeting.  Thank you.

Video Summary

The video discussed syndesmotic injuries in foot and ankle health, featuring experts who emphasized accurate diagnosis and management through various treatment options such as suture button fixation. The program, supported by the Orthopedic Foot and Ankle Foundation, aimed to educate healthcare professionals and encouraged donations for future programs. Dr. Bell covered anatomy and imaging, stressing accurate reduction and implant choice. Dr. Neary focused on suture buttons' benefits over screws, while Dr. Porter highlighted tailored rehabilitation protocols based on various factors for optimal outcomes. The content also addressed ankle injuries, emphasizing thorough assessment, testing outcomes, imaging decisions, early intervention, and individualized care for return to sport. Braces, blood flow restriction therapy, and progressive rehabilitation were recommended for treatment. Overall, the program provided diverse insights into diagnosing, treating, and rehabilitating syndesmotic and ligament injuries, aiming for personalized care and optimal outcomes.

Asset Subtitle

Putting It Into Practice is a series of virtual courses providing the basics of foot and ankle care. In this installment, multidisciplinary faculty will discuss injuries of the syndesmosis. Topics include Diagnosis and Work Up, Management and Outcomes, and Physical Therapy. This course is ideal for physical therapists, physician assistants, nurses, nurse practitioners, athletic trainers, orthopaedic residents, and primary care physicians. This webinar is free for AOFAS members and non-members.

Moderators: Tracy K. Harig, DNP, APRN, FNP-C and Richard A. Zell, MD
Faculty: Kerri Bell, MD; Kaitlin Neary, MD; Kris Porter PT, DPT, OCS

At the conclusion of this webinar, you will be able to:

Describe the evaluation, treatment, and outcomes of a syndesmosis injury
Describe when to refer a syndesmosis injury for surgical management
Describe the pre-, intra-, and post-surgical plan for a syndesmosis injury
Understand the physical therapy goals for a syndesmosis injury, including return to sports protocols

Keywords

syndesmotic injuries

foot and ankle health

accurate diagnosis

management

suture button fixation

Orthopedic Foot and Ankle Foundation

healthcare professionals

donations

anatomy

imaging

reduction

implant choice