Welcome to the fourth webinar in the AOFAS 2020 Classic Webinar Series. Tonight's program, Syndesmosis, Current State of the Art, will be moderated by Dr. Cesar de Cesar Neto. Joining Dr. Neto is Dr. Alex Barg, Dr. Gregory Wariaz, and Dr. Kyle Dukeman. You can find their full biographies and disclosures in the program handouts, available for download by clicking on the handouts tab on the right side of your screen. The 2020 webinars are provided free to AOFAS members and orthopedic residents and fellows with funding from the Orthopedic Foot and Ankle Foundation, supported by grants from the following companies, Arthrex, Inc. and Wright Medical Group, NV. I'd like to run through a few housekeeping items before we kick off the presentations. Please make sure your speakers are turned on and that the volume is turned up. For technical assistance, you can reference the Help tab at any time. If you have any technical difficulties, your best bet is to close all your browsers and log back in the same way you did the first time. If you experience any buffering issues, please refresh your browser. 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. Questions for claiming CME are provided in the handouts tab, and you will also be reminded at the end of the program. This webinar is being recorded and will be available in approximately one week on the Physician Resource Center at www.aofas.org. You are encouraged to ask questions during the presentations. To send your question to the faculty, click on the question mark icon on the bottom right of your navigation column. I'll now turn the program over to the moderator, Dr. Cesar Hinojosa, to begin the program. Thank you. Hey, let me share my screen here. Good evening. First, I would like to thank AOFAS for inviting me to moderate this session. I would like to thank all of you that are online with us tonight. And I have to thank my colleagues that are participating with us. Gregory Juarez from MGH, he's going to be talking about clinical and imaging diagnosis of the syndesmotic injuries. Kyle Duckman from University of Iowa, we'll be talking about acute injuries of the syndesmosis. And Alex Fishbark, we'll be talking about chronic injuries. Alex is now in Hamburg University. These are my conflicts. So first, I just want a brief introduction. Like syndesmotic injuries is very frequent and extensive subject in the literature. The last time I did a search in PubMed more about 1,300 publications. And recently, I did a review for AOFAS. And I think it's very interesting when you look back to the literature in the past to see what they were doing, for example, about 60, sorry, 80 years ago. And we're going to see that the concepts that we're still checking for syndesmotic injuries were already there back in 1940. So if you see here, it is publication by Aldridge. He was mentioning that we have to usually people pay attention to the bony injuries. And there's a lot of very frequent to have unrecognized syndesmotic injury and diastasis. All right. Highlighted importance of stress views, especially in dorsiflexion and external rotation, very similar to what we do currently. And also highlighted the importance of the widening of the medial clear space and the correlated deltoid injury. At that point, they were still doing some conservative treatment. So that has changed. Most of those unstable injuries are fixed. But they already mentioned that you had to open redux and internal fixate the fracture or the injuries that you couldn't really reduce in a closed manner. They pointed out for when there's fractures associated of the importance of the fixation of the posterior malleolar fracture, the possibility or the need for hardware removal after the ligaments are healed. The same Bonnie in 1965, also in an editorial for the JBJS, also emphasizing the difficult radiographic assessment, the importance of the stress examination under anesthesia, importance of ruling out the deltoid injuries, and the frequent failure to recognize the instability of the syndesmosis and the development of abduction, deformity, and poor outcomes. So they highlighted the importance of the early recognition of the injury. So very similar concepts of what we still have today. I really like to reference this paper every single time I talk about syndesmosis because I think every single one of us should read it if you haven't had the chance to read it before. This is a publication by Close, 1956, JBJS. And they were, it's a cadaveric study where they looked into when you do from plantar flexion to dorsiflexion in the ankle joint, they noticed that the intermalleolar distance would not go more than one, increase more than 1.5 millimeters. So the relatively increase in the medial clear space and the tibiofibular clear space with either syndesmotic or deltoid instability or both, most of this magic number that I like to say comes from this paper. So it's referenced and referenced and referenced by different other papers, but that's the origin of that number. So if you have more than two millimeters, it would consist of instability of the syndesmosis and also in the medial side. So they did sequential cutting of the ligaments showing that only after you cut the deep deltoid you would have a marked increase in the widening of the intermalleolar distance. And this concept is still accepted. Some people believe that if you don't have the deltoid injury, you wouldn't have significant instability. And the two millimeter widening or the medial clear space also comes from this paper where they showed if you have more than two millimeter relative increase in the medial clear space, it would consist of injury to the deltoid. They also talk about stagital instability, also another concept that is discussed extensively in the literature recently, but this concept was there since 1956. So I just wanted to show that to, I think it's very interesting that the same struggles and same concepts that we were discussing 80 years ago are still very up to date. They're not outdated. We're still considering those stuff. But I do think that we still have problems in differentiating syndesmotic injury and syndesmotic instability. And for that, I think diagnosis is so important that that's why I invited Greg to give us an idea of clinical imaging diagnosis for syndesmotic injuries. And we're going to focus on the sub-syndesmotic instability and also the isolated syndesmotic instability. We won't be talking about fracture, ankle fracture, rotational ankle fractures tonight. So let's go, Greg, ready? Let's go. So we're going to be talking about anatomy and physical exam, x-ray, ultrasound, what's new in CT and specifically weight-bearing CT, what utility for MRI is, and then arthroscopy. So everyone on this webinar is familiar with the syndesmotic components. But just to kind of do a brief review, the AITFL, the origin is on the anterolateral tibia and inserts onto the Wagstaff tubicle on the fibula. We also have to worry about the interosseous ligament, the interosseous membrane, and the PITFL, which has superficial and deep components and also the inferior transverse ligament. So the most commonly mechanism for injury is external rotation and hyperdorsiflexion. We see this on game film all the time when we're evaluating patients and athletes. So initially, sort of on a historical perspective, this study showed that the AITFL contributed 35% to stability and the deep PITFL was 33%. This current study had limitations from Olga V. Harris, and the model was not stressed in the typical injury mechanism. So Dr. Clanton's group did a similar type of study that showed the AITFL injury resulted in 24% reduction of external rotation resistance, and also that it was important for the posterior translation of the fibula. And also was shown the superficial PITFL was an important stabilizer of internal rotation. So in terms of physical examination, you know, what tests should we be doing? So a squeeze test, you perform it with the knee flex at 90 degrees and apply medial and lateral compression to the calf, midway tibia, and it's positive. It's painful in the syndesmosis. The sensitivity has varied from 26% to 100%, and the specificity has varied from 63% to 8%, depending on what study you look at. External rotation test, typically performed with the patient seated and passive external rotation stress to the foot and ankle with the knee at 90 degrees. Sensitivity is not that great, either 50% to 71%, specificity 63%. Cotton test on the physical exam is looking for tailored translation from medial to lateral in the mortis and increased translation to the contralateral side or pain is a positive test. Sensitivity is only 29% and specificity is 71%. So the real theme is that none of our physical exam findings are that great. Fibular translation test, I like to call this one the fibular shuck test. You're sort of looking for translation of the fibula in the sagittal plane. Sensitivity is 64%, specificity is 57%. I find that it's important with this test to compare it to the contralateral side on patients because most people haven't felt this type of movement of their fibula before. So they'll oftentimes say, well, that feels funny. And then you check the other side and you just say to them, hey, does it feel the same? And they usually will say yes, if it's not involved. And otherwise, if it is involved, then you're talking about further workup. I like to do a single leg hop test in the office for patients with concern for chronic injuries. Oftentimes this is the one test that people are unable to do months after rehab. They'll say, I just don't have enough strength to push off and I can't hop on one leg. I also use a single leg hop test to help with return to play criteria for my office and with my therapist, which is not perfect, but I think it's a reasonable functional test. Cross leg test is another test that you can do. Gentle force on the medial knee causes discomfort. And then the stabilization test, I've never done this one in the office, but I'll ask athletes if taping their ankle helps them. And oftentimes with chronic syndesmosis injuries, people will be able to run around fine, but then when you kind of push them, they're using a brace or they'll admit to having to tape their ankle really tight, or they're doing different types of kinesio taping techniques that are helping them. And this oftentimes is the reason why they have pain, even though they're able to function at their sport. But you will normally see some type of side to side leg weakness. So I always start off with plain x-rays and weight bearing is preferred. I think it's important to get bilateral if I'm concerned for any type of syndesmotic injury. The normal parameters that we look at are a tibiofibular clear space less than six millimeters on the AP and mortis, medial clear space overlap equal to the superior clear space, but not greater than four millimeters. I think in particular with this, I look at the other side and make sure that they're symmetric because four millimeters can show an injury in some folks if the other side has maybe one millimeter or two millimeters, and you'll see that from time to time. Tibiofibular overlap greater than six millimeters on the AP and greater than one millimeter on the mortis view. This is sometimes very difficult to see. So stress radiography, a manual external rotation stress test versus a gravity stress. Lu in 2005 in Arthroscopy Journal found that stress radiographs only detected 45% of cases with latent syndesmotic instability and fracture patients. But it's a reasonable test to try to do. Another option is to have a patient's walk on it for a period of time and then repeat the x-rays. Ultrasound is a sort of a technology that a lot of groups are exploring currently, including my group. It offers a low cost noninvasive and can be dynamic as well. The dynamic external rotation stress evaluation of an injury if the tibfib widening is greater than six millimeters, Fisher found that last year. Our group has been looking at how reproducible dynamic ultrasound is for evaluating the tibfib translation in the sagittal plane. Basically what we found was that it's a reliable and accurate technique for sagittal plane translation of the tibfib joint. There is substantial variation between ankles is rare, and that underscores the need to use the contralateral side as a control as long as they haven't been injured on that side. And it's a cheap test that is a point of care. So you can have your portable ultrasound and get this study done during your office visit. CT offers both two-dimensional and three-dimensional evaluation. Diastasis greater than two millimeters can be seen on CT, and only 50% of three millimeter diastasis can be seen on plane radiographs. So plane radiographs tend to miss a lot, and so CT is a great use for syndesmosis. The image on the right is a baseball team I take care of, so if you guys ever get a chance to see that, it's pretty cool for blind athletes. Weight-bearing CT is a newer technology that allows for bilateral in comparison. The only issue that occasionally you have is that the slices don't match up on the image, but if you correct for that by using anatomic landmarks, it's pretty good at picking up subtle instability. 14% increase in syndesmotic area when comparing weight-bearing CT to non-weight-bearing CT for cases of arthroscopic proven unstable syndesmosis. And then our group looked at this as well and found a high intra-absorber reliability of syndesmotic area in unstable injuries for area as well as fibular rotation. MRI is often what you'll get sent to your office. I don't usually order MRIs acutely on patients unless I'm concerned about a different finding because ligament injury does not equal instability. You can see synovitis in the synovial recess, greater than 12 millimeters proximal to the tibial-tailor joint, and that can suggest an interosseous ligament injury. And with chronic cases, persistent edema and synovitis can be present, and also there can be changes to the ligament, which can be anywhere from thickened, wavy, or absent. And oftentimes you'll get a read that says that there's a syndesmotic injury, but the patient's not unstable, it's just an injury that healed back in a stable position. So the limitations on MRI is that it's an expensive study for a lot of patients. It's not a dynamic study. There's limited availability because it takes a while to actually do the test compared to something like a weight-bearing CT scan, which is much quicker to do or an ultrasound in the office. And it's not routine to have an MRI done weight-bearing. So arthroscopy, I think, is still the gold standard. That's what most of us would consider. In-office is a newer option versus operating room. It allows for dynamic assessment, and then you can also fix it at the same time. So our group sort of looked at different aspects of arthroscopy with our lab director, Dr. Lubberts, and he found in 2017 that stress maneuvers should be performed off traction. So that's something that I think you need to be reminded of, that you put your patient into traction for these surgeries. And if you're using a commercial device, you have to make sure that you take the patient off traction when you're assessing. Sagittal plane greater than two millimeters of AP transition is unstable. And syndesmic instability is a multi-planar issue that you need to be mindful of. We also looked at the coronal plane, and it was better to look at the posterior margin of the intraceura than the anterior margin. Anterior margin was only significant when there was combined syndesmosis and deltoid ligament transection. This was a cadaveric study out of our ferrol lab at MGH. So cutting-edge diagnosis, weight-bearing CT, diagnostic arthroscopy are the most accurate, sensitive, and specific. Who knows what the next advancement will be? And oftentimes for chronic cases, I will do a diagnostic lidocaine injection under image to see if that helps the patient. That's something that should also be in your arsenal to use. So what other factors are there in play? Is there a fracture? Are you already planning on treating the fracture? And then is there any other obvious reason the patient needs an operating room evaluation? So this is a case of a PITFL avulsion fracture, removing loose fragments and debriding some of the frayed ligament as well. So to harp on Cesar's point before, you can have injury but not instability. And that's where we are still failing at finding all the cases of instability in our practices. Pre-op workup for cases that are suspicious. For me, that's syndesmotic tenderness anteriorly 5 centimeters proximal to the joint. For patients that I'm more concerned about, anything over 3 centimeters, I'll often see them back in a week or two. And then if they're still very sensitive along their syndesmosis, I'll have a low threshold to get an axial view study or do dynamic testing. My new preference is weight-bearing CT over MRI. If I had to choose just one exam due to the dynamic nature of it and the ability to get bilateral for comparison. And our athlete population will oftentimes get weight-bearing CT and MRI because it can help with prognosis as well on the MRI. And if you're not sure, it's acceptable to do an exam under anesthesia with an arthroscopy or an in-office arthroscopy. Other factors in play are whether or not the patient's an athlete versus a non-athlete. If you're going to be fixing an athlete early on in the season, is it going to get them back on the field quicker than waiting? We always hear about the pro athlete who had an ankle injury and rehabbed it. And then at the end of the season, even though they didn't get back on the field, then they are getting fixed. And people always wonder, well, why didn't they just have it fixed to begin with? Well, a lot of patients don't need to be fixed. And so that's where it's challenging. I think some of our diagnostic techniques that we can do is more than one to try to get a clearer picture early on. And then is fixing your non-athlete going to get them back to work or normal life quicker? This is important for your workers' compensation patient. And then is something like arthroscopy worth the risk of the surgery to get the diagnosis right for some of the more subtle cases in people that are more sedentary? So just a couple quick cases. A 19-year-old female, her basic history was that she had Ehlers-Danlos and had a modified brochure with an ankle scope, but she always had some degree of instability afterwards. She rolled her ankle again and came in to see me. So we did an intra-op stress test, her varus stress was positive. We did an allograft reconstruction of her lateral ligaments. During her arthroscopic portion of the procedure, this was unexpected. As I'm pushing on the fibula, she had gross instability. So she ended up getting that fixed as well. So I always tell patients that I'm going to stress their syndesmosis in the operating room and fix it if needed. This is another case of a more subtle injury, 39-year-old female with a softball injury residing into second base. She didn't get better with conservative measures, presented to the office. We did a weight-bearing CT scan as well, took her to surgery where she had a grossly unstable syndesmosis, and you can see in the posterior aspect of the intertia that it's significantly wider than anteriorly. I'm actually getting a good view looking up into the syndesmosis, into the intertia. She got treated with a construct. This is a fracture case that I just wanted to show quickly, 53-year-old female, underwent ORF at an outside hospital. The physician there wasn't happy with her x-rays, just had her non-weight-bearing, but she had this medial clear space widening and shortened fibula on exam. This is where weight-bearing CT scan is helpful, although not fully necessary. But I got the weight-bearing CT scan for preoperative planning so I could measure how short her fibula was compared to the contralateral side. And here you can see her diastasis of the syndesmosis compared to the contralateral side, which is actually, she has a pretty tight syndesmosis on the contralateral side. And she got a fibular Z lengthening with syndesmotic repair revision and did very well afterwards. I'm going to be turning it over to Dr. Dukeman. Great, thank you, Greg, that was a great talk. I'll get my presentation enlarged here. I want to thank CSER as well as the AOFAS for putting this together. I think this is a very helpful and applicable topic to be discussing. I think all of us are seeing these injuries fairly frequently. Can everyone see that around the, this icon here that I'm dragging out of the way? There's no icon. We're not seeing any icon, Kai, I think you can continue. Great, so my disclosures are listed here. So what we'll try to answer today during this portion of the talk on acute syndesmosis injuries, again, isolated, no fracture cases, who needs surgery, what are the goals of surgery, what surgery do they need, and how do we effectively perform surgery? Lastly, I'm actually sports medicine trained and cover University of Iowa athletics. How do we safely and efficiently get athletes back to sport? So who needs surgery? I think Greg did a great job of outlining some of the challenges we have with this as our studies advance as well as our in-office exam. So we have all these fancy tests, fancy studies, and still ligament injury does not equal instability. So CSER brought that up, Greg brought that up, I'll bring it up again. This is not made off of a single imaging study or a clinical exam. One point for me, Greg brought up the single leg hop test. I do like to do a single leg heel rise test, I think for differentiating acutely syndesmosis and low ankle sprains, if you will. People with even very significant low ankle sprains can do a single leg heel rise almost immediately, whereas with a significant acute syndesmosis injury, they really struggle with that. So that's another test that I've added to my arm inventary. So using diagnostic tools, this is the West Point syndesmosis injury classification. Again, these grade three injuries with frank diastasis, they're easy to diagnose. They need surgery in the vast majority of our athletes. So really distinguishing these grade one and grade two injuries is where the question comes up. Even if we look at grade two injuries and these so-called dynamically unstable injuries, you can break those down even further as Calder did here. Some of those athletes will do well with non-operative treatment. Some will fail and require operative treatment. And still a question remains, which category do they fall into? So for me, MRI is still an important component. I think weight-bearing CT is quickly catching up and certainly in some ways is an easier and more effective study. In addition to my in-office clinical exam or on-field exam, I often look at the MRI and look for what I call ATIFL plus injuries. So you have the anterior inferior tib-fib ligament plus a significant interosseous ligament or membrane injury, a PITFL avulsion or even a posterior malfracture, and then a significant injury to the deltoid. If you have one or two of those, in addition to the AITFL injury, that's very clear on the MRI acutely, those are individuals, if they're highly competitive athletes that I worry about having long-term issues with, maybe not just getting back on the field, but really competing at a level that they want to compete at, especially skilled position players in football. They're tough guys, they can get back out there, but at the end of the season, they'll tell you, I just wasn't the same player out there and that's very frustrating for them. Secondly, you need to consider your patient. While these two individuals both meet the definition of athlete, they're certainly very different individuals. So what are the goals of surgery? First and foremost, I think it's to prevent long-term negative sequelae of syndesmosis malreduction or missed syndesmosis injury. We know from Dr. Hunt that significant changes to the tibiotalar articulation occur if the syndesmosis is malreduced. This is a case that I had yesterday, this is actually a 19-year-old who over 18 months had very, very rapid progression of tibiotalar arthritis due to a syndesmosis malreduction. Secondly, when dealing with athletes, we want to provide consistent, but more importantly, safe return to sport at a pre-injury level of performance. And again, consistent does not always mean faster. If we look back to even 2007 and one of my mentors, Dean Taylor, published this article, they were doing single screw stabilization for grade three or frank diastasis injuries and getting athletes back as quickly as four to six weeks, which even today it would be deemed very quick. So where have we really come since 2007? When discussing surgery in the elite athlete, what surgery do they need? Well, we have a lot of biomechanical studies to help us. These are time zero studies. There's definitely a trend towards flexible fixation, then a tendency for malreduction, and it does have improved clinical outcomes in my studies in the fracture patient populations. However, no matter which way we take these implants and which way implants advance, we really cannot recreate the non-injury at time zero. Maybe addition of an ATFL augment or even a deltoid augment can get us closer, but it's still not quite the same. So what do we know from these biomechanical and limited clinical studies? Really what we can take away is that flexible or dynamic fixation is preferred in the majority of scenarios. There are some exceptions and we'll get to those. However, there are a lot of limitations of these time zero biomechanical studies in the current clinical literature. A lot of these studies don't really look at the deltoid. We've talked about the deltoid already a lot. It's getting more and more play in this area and needs to continue to do so. We know that it's almost always injured in the classic dorsiflexion external rotation mechanism, but it's variably included in the biomechanical models that many of us make our decisions based on. Additionally, these are also time zero studies, so there's no capacity for healing over time. And typically they assess load to failure as opposed to fatigue failure, which may be more clinically applicable. So what surgery do they need? For me, agreed, diagnostic arthroscopy is a huge component of the procedure. You want to make sure that you're doing the right thing for the right reason. We have a normal and an abnormal image here. That's actually a 4-0 shaver up in the tip-tip space. You want to stabilize and repair the injured structures. So for me, and again, this is a simplified algorithm, a lot of things come into play. Size of the athlete, position played, time of year, in-season versus off-season. Flexible suspensory fixation for these grade two injuries, and then flexible suspensory fixation with some sort of AITFL augment and deltoid repair in grade three injuries or in larger athletes. So exceptions to the rule for flexible fixation, excuse me, at least in my practice, if there's a proximal fibula fracture associated, I typically use a screw or hybrid fixation. In very large athletes, so for me in the state of Iowa and with football players, that's athletes over 280 pounds, and athletes with significant planovalgous deformity. If you walk through a locker room, you'll see that many of our elite athletes have very, very flat feet. So diagnostic arthroscopy, again, images here from left to right, an AITFL rupture very clearly by the shaver there. You have tip-tip widening and then a deltoid injury on the far right. So after you diagnose these things, what do you do? Here's the diagnosis again. Shaver carefully going up into the tip-tip space, that's a four millimeter shaver. Also by criteria, very clearly an unstable syndesmosis. External rotation stress exam here. You can see the sagittal plane instability during an ER stress maneuver as the fibula translates posteriorly. And then after you do that exam, you can need to clean up the AITFL. That's just a setup for further soft tissue impingement. If there's any cartilage injury here in the middle, you can see a chondral shear. And then also debride some of the tissue from the syndesmosis that may cause a malreduction or prevent reduction in that area, which you can see here on the far right. Probably most importantly, but most often overlooked, is having a systematic approach to reduction. This was really drilled into me by one of my mentors in residency, Dr. John Famino. So you need to look at the syndesmosis. You need to get it cleared out either arthroscopically or open. In the acute setting, I think it's relatively easy arthroscopically. If the deltoid ligament is interposed or torn, you need to get that out of there to allow reduction. For me, I like having the ankle in neutral dorsiflexion, even though there is some literature to suggest that position doesn't matter. I think some of that literature is flawed when we consider contact pressure as opposed to how far you can force the foot. And for acute injuries, I use the thumb reduction maneuver, kind of push the fibula into the incisura after taking the ankle through a range of motion. The precision article by Dr. Famino, again, takes a very systematic approach and I think is something that would be beneficial for everyone to look at. It's the most overlooked portion of the procedure, and particularly if you're using screws and you don't have any slop in the system, you need to be precise with this. On the lateral side, I like to use flexible implants. So this is a buttress plate. It helps prevent stress reactions on the fibula. It doesn't necessarily help prevent fractures in a contact athlete. So if you do have a contact athlete, you can put a short bridge plate there with screws to protect the drill holes that you have for the flexible fixation. On the lateral side, in more chronic injuries or in very unstable acute injuries, I will add an AITFL augment. It does add some sagittal plane, as well as rotational stability. And then on the medial side with the deltoid, if I'm dealing with a very large athlete or an athlete in Plano-Velgos, I'm almost going to repair it every single time, regardless of my scope images. But I think these scope images show good distinction here of a very clear deltoid injury versus a less severe or even partially healed deltoid injury in the chronic setting. So how do I work to get my athletes back to sport? Just as a disclaimer, there's almost no evidence for this. Phase one for me, so week one, I like to put athletes that have access to a training room essentially 24-7 in a cam boot because I like to get them moving early. I also think that being able to take a boot on and off allows you to work with swelling and edema control a bit better. So that's week one, non-weight bearing. Week two, they progress to weight bearing in the boot. They start some strengthening and proprioceptive exercises. Week three is gravity-assisted linear motion progression. They continue strengthening and proprioception. Week four, they're getting into a lateral movement progression. These are simple things, controlled environment in the training room or on flat surfaces, starting some sport-specific drills. And then beyond 28 days, getting to a return to sport progression where the athlete, as they're comfortable, begins increasing their training volume to replicate sport. I do like to use a functional movement screening. There's not a great test out there for the ankle. I use aspects of the ACL and limb symmetry indices to help with this. And typically, getting these people back to high-level sport in my hands is somewhere between four to six weeks. So if we look at Dean Taylor's article from 2007, how have we really changed that? I'm not sure that we have, and there certainly are things we need to improve on. So how do we do that? We need to study the fatigue and creep properties of these implants. We need to understand the relationships of implants, time and biology that we don't appreciate in biomechanical studies currently. This will really help us define how fast and safely we can progress through this process. We need to better define a functional movement screening task for the ankle, and we need to see how do athletes that return to the field after ankle injuries respond. Are they at risk for other injuries outside of the ankle, other ankle injuries? That needs to be studied more carefully, and hopefully it's something we can do with the NCAA injury database information. So in conclusion, acute surgical stabilization can provide safe and consistent return to sport at a pre-injury level in high-level athletes. Diagnosis remains a challenge, as Greg reiterated, and I continue to reiterate during this talk. I think arthroscopy is an extremely effective tool. Use it and be good at it. And rehabilitation is guided by level five evidence. I think a functional movement screening for the ankle would be very, very helpful. So thanks again to everyone for listening. I hope everyone's staying safe and healthy during these times. I'm going to pass it off to Alexi, who's joining us from Europe at about 3.30 or 4 a.m. So thanks to him and appreciate everyone being here. Ladies and gentlemen, dear colleagues, also I would like, first of all, to thank AOPS for a really great and perfect organization of this webinar. And of course, my special thank goes to Cesar for the kind invitation of my person to this webinar. This is my topic of interest. None of them are related to this talk. And before we speak about possible treatment options for secondary syndesmosis reconstructions, we need to understand a little while it happens at all. And Greg and Kyle did a really outstanding job demonstrating the complexity of the ankle syndesmosis. We all know it consists of four major parts, and you should keep in mind, the acute syndesmosis injury can involve actually all four parts of it. Then it has been mentioned several times, and I think that's a quite important point. Many doctors do an outstanding job to address the ankle syndesmosis injury accurately. However, they forget about the deltoid ligament, and the deltoid ligament is commonly seen in patients with acute syndesmosis injury. And I'm actually a little bit on the side with Kyle. That means when the patient has an acute syndesmosis injury with significant involvement of the deltoid, in my opinion, this needs to be fixed at the same time. The problem is the syndesmotic injuries are common, but unfortunately, they're not always appears as on this x-ray, so they're not always that obvious. Very often, syndesmotic injuries present with non-specific findings. Another big problem is that syndesmotic injury occurs often as a concomitant injury. For example, together with ankle sprain and ankle fractures, that means that some doctors just concentrate on kind of more important part of the injury, for example, bony injury, and completely neglect the ligamental injury. Imaging, that's by far not perfect. Of course, all of us have access to the x-rays, but the x-rays cannot predict syndesmotic injury reliably. CT is much better, especially wave-bearing CT. A big problem is actually MRI has been demonstrated to have 100%, up to 100% sensitivity and specificity, but how about correlation with patient's complaints? And another big problem are the patients with the suckles syndesmotic instability where MRI can be completely normal. That means because of the high incidence of acute injuries, also the chronic syndesmotic injuries are common. We don't know exactly how many are initially missed, but because of the shortcomings of imaging, because of the complexity of these injuries, I think the number can be quite high. But what we definitely know, it has been demonstrated several times that the patients with the chronic syndesmotic injury are not doing well. They have a painful chronic instability, which almost always results in a significant physical impairment, so that means the patients cannot get back to normal job, they cannot do normal sports. And maybe one of the most tragic point of it that the patient over the time do develop the generative changes of the ankle joint, as we have seen in one of the previous presentation. So let's now look through the literature what is available, so what we can do, what we can offer to our patients. This is possibly one of the first publications in the recent time by Dr. Kottmusser from Israel. Those patients assess first instability clinically, then they proceeded with open procedure, syndesmotic debridement, and then they decided to proceed with the salvage procedure, which means fusion of the distal tibiofibular joint. They used a local bone block, they just turned it in 90 degree, proceeded with one screw fixation. They did a cast for six to 10 weeks, they removed the screw of the solid fusion, which actually has been seen in all five patients, so it's a quite low number. And all patients were pain free, however, one patient had some reduced range of motion, possibly due to over tightening of the distal tibiofibular position. Dr. Gilbert Harris, we heard already some of his publication in the previous presentation. So they described the arthroscopic technique. They mentioned that you can actually, if you're just patient enough, you can direct visualize PITFL, ITFL, and IOL. Then they stressed, or they mentioned a lot about the arthroscopic assessment of instability, and then finally what they performed, they did inter-articular debridement, the ruptured portions of the syndesmotic ligaments were resected, so no fixation. Surprisingly quite good results. Pretty much all patients reported pain relief and improvement regarding stiffness and instability. Only one patient had a prolonged recovery. In my personal opinion, I think the patients were doing that well because possibly they did not have a huge instability, otherwise it may be not that great. Then the study from Netherlands, on Dr. Boerma, part of PhD thesis, they had an observation during the open surgeries that quite often they saw elongation of ATFL. So what they suggest is to carefully dissect ATFL, to perform the bone block osteotomy on the tibial insertion, following vasodismal inductions with one-screen fixation. And then actually finally the bone block was medialized to get the tension of ATFL, and also the block has been fixed with one screen. Nine patients, functional improvement and no instability in all nine. And regarding the complications, two patients reported transient sympathetic reflex dystrophy, however it has been resolved within the six months. The paper from a group from Dresden, including Dr. Rommel, this is possibly one of the first study where they used a graft to try to reconstruct it anatomically. So they performed a tibial fibula joint space debridement, that's quite important. They used actually the Pyreneus longus tendon graft. They mentioned explicitly that the Pyreneus longus brevis may not be long enough for this purpose. Cannabis preparation, one-screen fixation, a partial weight bearing for eight weeks, so it's a quite long recovery. The follow-up in this study is quite short, it's a little bit more than one year, and pain relief has been achieved in all but one patient, and this patient had actually complications, screw breakage due to the non-compliance. Then this is an interesting study by Dr. Ham, because this study is suggesting that patients with symptomatic pain are not always equal. So this is the study where they definitely, they definitely recommended to assess stability, and they realized that pain patients were quite stable. So then they said that pain is possibly due to soft tissue hypertrophy, so they proceeded just with the debridement. However, in pain patients, they observed instability. Please remember the major number from Dr. DeCesare Netto, so two millimeters in this patient, one-screen fixation has been performed. Good results, substantial functional improvement, pain relief, however, you can imagine that the second group where only debridement has been performed had of course much more aggressive rehabilitation. This is, in my opinion, also quite good study by Christina Olson, and this study is a bit different than the first study I showed. Also, this study described the salvage procedure, that means fusion of the distal tib-tib joint. However, in this study, pain patients have been included, and all patients, unfortunately, had already some degeneration of the tibiotelar joint, and actually all patients had some concomitant problem, including malunion of the fibula. So here, what has been performed, the concomitant problems have been addressed, and at the mean follow-up, which is quite long, so the minimum follow-up was 24 months, the very good news are that no progression of ankle OA has been seen. Then another study by Dr. Ryan, so also here, they performed first the arthroscopic assessment of instability, and they actually said that it's very important that when you have a widening and sagittal translation of more than four millimeters, then they proceeded with debridement and suture button fixation. 19 patients have been follow-up for two years, pain relief, functional improvement. However, range removal of hardware was needed due to the local symptoms in two patients, and I think all of our patients, where we used any type of implants, we should consent them for these possible complications. This is the paper from Germany from the group from Dr. Hoffman, and here, they also suggested stage-graded treatment. They always started with arthroscopic assessment, as it has been beautifully demonstrated by Kyle before then. They said in some patients, it's just enough to suture ATFL, and some patients, they proceeded with periosteal flap, and in some patients with a significant instability, autologous plantarus tendon graft has been used. So in total, 32 patients with quite equal distributions between the groups, functional improvement in all three groups, no differences between the groups. Suture granuloma has been seen in two patients. Again, this comes more often than many doctors think or many patients think. However, this study has some limitations. First of all, short follow-up, they used AOPS score, which is not a validated score, and I could not get information from the paper regarding the pain relief, which is maybe one of the most important thing when we proceed with the surgery, and return to sports activities. Just recently, it has been also demonstrated what we do in an open way, which actually, I like to do in my practice. You can do it all inside arthroscopically, so here, the authors describe the surgical technique, how to use gracilis or EHL allograft for reconstructions of AITFL. So the authors describe in greater detail how they proceed with the surgery, including one similar fibula bone test, possibly to reduce iatrogenic risk of fibula fracture. However, it's just a simple surgical technique. Descriptions would definitely need further clinical studies to verify expected results, and actually, we don't know about complication rates. So, Nikola Kramgul reviewed all papers regarding the surgical Altman and Karnic and vasomotic injury. In total, 17 studies have been included, published between 83 and 2016. All but one patients were retrospective, all single center, all level four, and there were definitely surgical techniques, but right now, it is extremely important that there is a consensus that every surgery should be started with arthroscopic assessment, even if you proceed later with open procedure, and then, depending on stability, you can just proceed with local debridement if it's stable. If it's not stable, you should definitely proceed with anatomic repair reconstructions with or without graft, with rigid or dynamic fixation. Keep in mind, arthrodesis as a salvage procedure. However, we need further clinical studies because, as you have been seeing, pretty much all of the studies have a low number of the patients. Most of them are retrospective, and actually, follow-up is quite short. The question is always, does it really matter when we do late reconstruction? Is it okay maybe just to try conservative treatment, and if the patient is not doing well, then we can just do it later? And actually, I was very glad to find this paper by Stephen Kansas, published 2020. This is a multi-center study with three centers, all patients included between 2010, 2016. All patients have been divided in three groups, active versus sub-active versus chronic injury, and two time points have been chosen for definition, six weeks and six months, and as you can expect, the patients with chronic injury who had the reconstructions had a much worse outcome, including lower FAOS subscales, especially with the greatest difference in quality of life. So, I would say the questions whether it doesn't matter or not can be definitely answered with yes, it does matter, and we know that undiagnosed or not appropriately treated patients are not doing well because they have lower outcomes, and they may have a degenerative changes over the time. This is patients, one from my, we performed, he had surgery performed outside, and because of significant tibiotelar arthritis, I proceeded with diffusion. Thank you very much for your attention, and we look forward to have possibly a short discussion regarding our talks. Thank you. Thank you. Okay. Thank you all for the presentation, very, very outstanding, great presentations. We're gonna start with some questions from the attendees. So, I'm gonna open some questions. I have the questions here, give me one second. So, the first question for all three of you is, how are you stressing the syndesmosis in the OR? Question mark. Viewing with the scope. Radiographs, question mark again. Is external stress appropriate? That question came from Clarence Key. Dr. Clarence Key, wanna start with, let's start with Greg. So, I take my patients off of traction, and I push on the fibula for sagittal plane, and then for coronal plane, I use either a probe or the shaver to assess the amount of diastasis. And I'll also do a fibular shuck test under direct guidance. I don't typically do, I typically scope a lot of my fractures anyways, so I'm able, I don't do a lot of X-ray stress. Any external rotation stress applied, Greg? That's part of it, that was part of the question. Yeah, I don't really do that one, but it's every once in a while. Not routinely. Kyle? Yeah, so I usually have fluoroscopy in the OR, whether it's a fracture or isolated syndesmosis case. And honestly, mainly for resident education, I usually do an ER stress exam. All those videos that I showed, none of those would have opened up on ER stress. So then it's pretty impressive for the residents when you get the scope in there and you're able to stick a 4-0 shaver up the tib-tib space. And I think I make more of them believers that, hey, this is a real issue. I then do a dynamic ER stress arthroscopic exam that shows that AP translation. That's really hard to quantify, but I just take a collective look at that. I almost do all my arthroscopy other than when I'm doing cartilage work off of traction. So again, keeping it off traction during that assessment, I think is important. Interesting. Alexej? Yeah, similar to Kyle, whether I do bonding procedure or not, I'll always have a C-arm. And before I prep sterilely the patients, I do a rotation test on the fluoroscopy. I do actually both sides, injured and non-injured, for comparison. I do it, of course, on the AP view. Then I like actually also to check radiographically the sagittal fibula translation on the lateral view. Then during the arthroscopy, I like to use the dive test with, dive in test with a shaver. My personal opinion is, especially if I teach it to the residents, to use the probe instrument, it's sometimes a little bit difficult. It also depends on the power of the resident. So I think the dive in test with four millimeter shaver is a good test. That's what I suggest. Excellent. Just adding to the comments, I go in the same, pretty similar way Kyle comment, did the comment. The only difference is I have been using spheres rather than the shaver, just because depending on the angulation that you're introducing the shaver into the syndesmosis, the width of the shaver would be different. If you use a sphere, you're controlled because then you have the radius of the sphere. So it's a little bit more precise. I follow Dr. Greger's guide and one of my mentors for that. So I think it's pretty precise for corona instability. And similar to Kyle, I also push the fibula anterior to posterior through the scope. And finally, I look to the medial clear space. Once I'm done with the fixation of the syndesmosis, I check the delta again with external rotation stress that's looking directly to the medial clear space through the scope. And if needed, at the end, if I need more, then I use the fluoroscopy. Let's go to another question here. We have, does presence of proximal fibular fracture suggest instability even with no medial clear space widening or widening of the syndesmosis on weight-bearing x-rays and or weight-bearing CT? That comes from Steve Cosigliola, VA from Special Surgery that I had the pleasure to work with. Thanks for the question, Steve. Let's do the, let's change the order now. Kyle, can you start? Yeah, so I'm in a sports medicine practice. So I see a lot of proximal fibula fractures related to multiligamous knee injuries. So for me, I think the biggest thing is, is this proximal fibula fracture occurring with ankle pain? So do they have a swollen ankle? Is it a rotational ankle injury? Because I have seen, you know, fairly low revulsions in a multi-leg injury. I've seen direct contact fibula fractures with a perineal nerve injury that do not result in ankle widening or mortis widening. So for me, it's fairly simple. Is it a rotational mechanism and do they have ankle pain? And if they do, they probably have a syndesmosis injury. Great, I think you went right to the point. Let's get one more comment. Alex, can you comment on this? Yeah, I'm actually quite aggressive regarding the syndesmosis fixation and even the x-ray looks completely normal. If the clinic, to me, the clinical science speak to me for syndesmotic injury, I like to discuss with the patient, I like to explain to the patient what this may mean to him, especially with regard that he may have a later problem. He may need later the chronic syndesmosis, secondary syndesmotic instructions, which has actually a lower outcome. So then I think the most reliable test to check the syndesmosis, to look at syndesmosis at the troscopy, to check it atroscopically. The patient has pain in the ankle. There's always a reason for the pain. Quite often, it can be just impingement, some scar tissue, which can actually also be treated atroscopically. But very often, you still find some instability and then you just proceed with fixation. That's my purpose. Great, we have some more questions here. That's why I'm gonna move to the next question. Do you routinely remove flexible suture button fixations or just syndesmotic screws? Or more specifically, in a hybrid construct, just remove the screw and leave the suture button in a belt and suspenders kind of situation? Dr. Oscar Castro. Let's start with Greg. I don't do a lot of hybrid constructs, but sometimes when you're taking out the screws, if you're scoping at the same time as you're doing hardware removal, you can assess the syndesmosis or do an external rotation stress radiograph. And oftentimes, for patients that I knew were very unstable to start with, talk to them about the potential of doing a ITFL internal brace or tight ropes at the time. But I don't usually do hybrid constructs. Alex, I think you're a good one to comment on this. Would you remove a flexible suture button? Yeah. You do remove that? Yeah, I would only remove them if the patients would have some local symptoms and they may have actual local symptoms due to irritation on the lateral but also on the medial side. Other than that, I would definitely not recommend to remove it. However, when I proceed with the screw fixation, I like to remove the screws because quite often they may break, as we all know, and I just don't feel great about this. And here is also very important, as it has been mentioned by Greg, I think if you remove the hardware, it is quite important still to repeat the arthroscopy just to assess whether the previous surgery was successful or not. Of course, it gives a bit more time to you, but it costs you about five, 10 minutes to do it very quickly, but then you know how the patient is doing. That's my answer. Yeah, just one comment on that. I did a hybrid fixation today. I usually do for, I think about in the chronic cases, especially with high BMI, and like I think what Greg mentioned, in the super unstable cases, I like the concept of removing the screw later and keeping the switch button to provide residual stability. Let's move to the next one because we have a bunch of questions here. So that's gonna go straight to Alexej. Sorry about that, Kyle, but I'm gonna go back to Alexej because it's his topic. What is your preferred way to address the chronic syndesmotic instability? Dr. Baquero. Yeah, great questions, and these questions cannot be clearly answered with just one answer, and here is it important that you really understand what are why the patient has the symptoms, and if the patient has a chronic syndesmotic instability symptoms and you check them atroscopically and the patient is completely stable then you really, really need to be careful. As I mentioned before, or as my colleagues mentioned today before, I think you should do it in the oral-aromatic combination of both. Before you prep the patient, just check the stability clinically on the fluoroscopy. Also use both feet, both ankles to have a comparison. Then do a very careful assessment during the atroscopy, including the syndesmosis testing, including the testing of fibulotranslation. If everything is stable, you just proceed with the treatment. Quite often the patients still have a lateral instability, and when the patients have a lateral instability with symptoms kind of radiating approximately, it can kind of mimic chronic syndesmotic instability. Of course, the ligaments needs to be addressed. Then, for me, it's been a magic number, two millimeters, not four millimeters, as it has been shown in some studies. If the patients have some instability that needs to be fixed, is it a rigid fixation or dynamic fixation or hybrid fixation? It's really up to you. Then, if the patient already had some surgery that's not working, then you need to proceed with anatomic reconstructions using autograft or allograft. Unfortunately, in my clinic, I quite often see the patients where they have already degeneration. If the tibial joint is still okay, but then I just proceed with the fusion of the distal tibial joint, and if the patients already have a significant bone-on-bone contact in the tibial-talar joint, then I like to proceed with tibial-talar fusion. Now you can see, that's why I mentioned at the beginning of my answer, this question is a great question, but you should not just learn one surgical technique, which you think is the best for your chronic syndesmotic injury patient, because chronic syndesmotic injury is not equal to chronic syndesmotic injury. I hope it makes sense. So you need to understand what is the problem and to address this problem, which I tried just to summarize in the last two minutes. Sorry for this long answer. No, no, it's a complicated, we were discussing before we started the webinar. I would like, before I give that back to Kyle, I would like to add something else to that same question. Do you guys think that we're in the ankle joint, even though we don't think about this all the time for chronic syndesmotic injuries? I've been, my experience here in my practice now is that most of those injuries are kind of multi-ligamentous injuries. Every single time I did a chronic syndesmosis here, I also did lateral ligament reconstructions and I tested the deltoid. I probably repaired the deltoid in 50% of them. Kyle, are we treating multi-ligamentous instability patients that maybe before we were not really paying attention to the other ligaments and just focusing on the syndesmosis and sometimes in the deltoid? I would like to know your opinion about that. Yeah, I think we're definitely treating them differently or approaching them differently than we had in the past, whether that's driven by the literature or what, I'm not exactly sure. But certainly in my hands, in the chronic setting, there's not a scenario where I'm not at least doing something on the lateral side with the syndesmosis and also the deltoid. The lateral ligament complex is a little bit plus minus on the symptoms. You know, a lot of these patients in the chronic setting are extremely stiff. They may be developing some early tibiotelar arthritis. And in that case, I'm not too concerned about their lateral ligaments as complex as much as I am getting their rotational stability with the syndesmosis and deltoid. Great. Greg, do you wanna quickly comment on that, on the mood ligament is being? Yes, it's very common. The thing you also should look for is subtle perineal subluxation at the same time. I've seen some cases where it's been sort of around the world, I like to call it. But I get routine stress radiographs, anterior drvaris and valgus on my patients that I'm concerned about. I do bilateral for comparison. So often I agree, you'll do another ligament with it. I only do the deltoid if it actually stresses positive. Preoperatively. We do have two, we had some questions here by Dr. Ramirez and Anthony Yee about weight-bearing CT. So I'm gonna kind of combine. One of them is asking, is there a pathognomonic sign in the weight-bearing CT for septal instability? And Anthony was asking, what specifically are you looking for in the weight-bearing CT? I will kind of jump into this first. There's a lot of recent publications on the subject. Some kind of various studies by the MGH group and Alex Barr, both groups are here with us today, showing that corticodivers initially, if you just apply the weight and you don't do any stress, you might not see it. Clinical study on the MGH group showed a very interesting, and it's probably my favorite measurement, that is the area measurement between the tibia and the fibula. And they showed that it's probably the most reliable and might be the most accurate. And we have been working here in Iowa and also I know the MGH group, so we're doing some stuff together about the volume. And we're very confident that the volume, measuring the weight-bearing CT, the volume of the proximal part of the syndesmosis might be the most accurate way to find and diagnose these injuries. Since I know that Greg will say something pretty similar, I'd like to know from Alex Sessions first and then Kyle, if they have anything else to comment on that. So, thank you. Thank you, Cesar. Good questions. And the problem is with the supposed syndesmotic injury, as you mentioned, if you just applied the weight, then you may not see the difference. Here's what I think is extremely important that what you can do is that you have to do the weight-bearing CT of both ankles, always of both ankles, because the differences may be very small. So when you just see something on the injured side, you may just not recognize it. What we started since we did this, because we're very excited, we just asked the patients to apply their rotations. They have to do it for about 20 seconds, because that's about the time to take the weight-bearing CT. And I think the combination of both weight-bearing CT and the torque helps to see the injury. However, also here is it not perfect. Quite often, like the normal proteo, like medial clear space, et cetera, et cetera, are completely normal. What we try to do, we actually use the software to mirror the two images. That means that we do it without, we do it like we take the image of the contralateral healthy side and we mirror it with the injured side after application of weight-bearing, after application of torque, and then we may see some difference. But it's definitely still a problem. This problem definitely hasn't been solved yet, but I think we are on the way to solve it. Kyle, quick comment. We have to be done in three minutes. Yep, so I take a bilateral weight-bearing CT one centimeter above the plafond and measure the area between the tibia and fibula there. Anything greater than 20 millimeters squared, I consider a syndesmosis injury based on some of the literature out there. I agree with Cesar, as we get more imaging and better volume calculations that are automated, volume is probably the way to go. But for right now, for me, that area measurement one centimeter above the plafond is a good surrogate. Yeah, I totally agree. Last one, it has to be quick. How well, in your opinion, does the suture button fixation stabilize the fibula in the AP direction versus a screw fixation that comes from Dr. Ashraf Panza? Kyle, oh no, sorry, Greg. Kyle, you just did it. Greg's time. I think a screw is better. Do you all agree? Cesar, I'm old school guy. I think the screw is better too. Kyle? Yeah, I think the screw is better. My one point that I will say is you have to be more accurate with a screw than you do a suspensory device. So all this systematic approach to your reduction, putting a screw across the tibia and the fibula is not open reduction internal fixation. It's internal fixation. You need to do the open reduction part. Excellent, guys. Just a final remark. I mean, I really love the skull part. I think it's very fun. I love the spheres to check for the instability, but I can't really accept the fact that we still cannot really tell if a patient has instability of the syndesmosis or not only with imaging and clinical and physical exam assessment. We can't rely on a surgical procedure to tell the patient if they have it or not. So we have to continue to do research and we have to get to a 100% accuracy in diagnosis for septal syndesmotic instability. We should pursue that all of us together. Guys, thank you so much for being here. It was great. The lectures were outstanding. I think it's gonna be a great addition to our PRC AOFAS. Thank you for taking the time. Thank you AOFAS for organizing this excellent webinar. I hope you guys enjoyed and we're gonna see each other hopefully in San Antonio. Thank you all very much. Thank you. Thank you everyone. We have come to the end of tonight's webinar. I want to thank the faculty for their excellent presentations and discussions. To claim CME or CEE credit, please click the link located in the chat box on the right side of your screen. To receive credit, you must complete the evaluation first and then you may claim credits. On behalf of AOFAS, thank you for spending time with us tonight. Please visit the AOFAS websites and PRC to learn more about other upcoming programs and activities. Thank you and have a great night.

syndesmosis injuries

ankle

diagnosis

treatment options

MRI

weight-bearing CT scans

surgical goals

rehabilitation timeline

returning to sport

functional movement screening tasks

individualized treatment