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So 151 slides to get through. So I'll get you a paper that would have actually been a good one to note, I do feel however, after the discussion this morning, I've let all my secrets out of the bag already, but I get through with some evidence behind it at least. So I do have disclosures, implant, designer for solutions and other companies. I have a youtube channel that I have a lot of these things on every time I've done a virtual talk since COVID, I guess. So I started putting on youtube to allow the juniors medical students to watch it and use it. And also so there's a lot of education stuff on the lost my own Twitter. It's pretty much the only reason I use Twitter for. Um So this is the plan of what going to get to is what's requested by our president. The first one being what is A two B fracture? OK. So I will regress back to 2017 the time of the third. So this was not really, it's not really discussed anymore. So I got little pockets around the country, but certainly elsewhere in America, for example, the time of the third is still happening, you don't fix fractures of the postural aspect of the distal tibia unless it's greater than a third. And this was back from the paper back in Nelson Jensen, back in 1940 on eight patients. And this is the orthopat dogma. It took five years to actually negate I do feel however been doing this now for the last 10 years that things have changed. And these two systematic reviews prior to 2017, start to understand it more was important. In 2017, we were looking at the difference, apple oranges and pears and the two B fractures, this fracture with the posture and me aspect. We go to that now. So if you talk about its stability, what on earth did the posture M give? So, so they just give X axis translation ie like sort of the posterior movement of the talus and hit in the back of the tibia. Now, it's also involved in your Z axis rotation. And pretty much this was what has been ignored prior to 2017. This was a classification that's from that paper and this is the two B so two B or not to be is the major rotational peel on. I said earlier, the rotational peel on the amount of times I've had papers bounce back to me with review of saying there's no such thing as a rotational peel on what it is. So an impaction of the talus and the distal tibia. There's other classifications, obviously, I'm going to use my own, but the rotational peel ons which are the ones have these factors. Now, if you imagine, I saw any force that's applied, the fracture line is going to occur 45 degrees that angle, of course, it's rotating. I'll give you a video on that now and this is the difference between the type two A and type two B. So if the force stops at that stage and doesn't progress to hitting the posture, medial aspect, you do not get the fracture of the posture, medial side. So uh for forgive me, this has got a company uh a logo, but I, so I couldn't get the one without the company logo to work this morning. So I had to put this in. Um And so I worked with an an animator and so all solutions paid for it. So to further describe this, rather me actually using flip a clip. So imagine like so your studs are in the ground, the tibia rotates on top of it impacted. So as the posture mal overhangs, it hits lateral side as it continues to rotate, it hits your posture medial and that's your two B, that's what A two B fracture is. Mechanically. The initial papers were all talking about your Z access rotation, sorry, your ex translation and completely ignored this. And this is what the biomechanics now doing a good paper by Tom Clamp this year saying that we really need to start looking at the rotational aspect of these fractures. This is one I do feel the foot was in the wrong position for it did give you this type of fractures. You can see the back here the rotational peel ons showing it is it to be or not to be this paper that we did then looked at it that we are all postural medial aspects A two B fracture. So one of my colleagues, Andy Goldberg text me about a case that he had with these saying, well, do I fix this? And I said, well, no, this is a intimal ligament avulsion fracture because that's where the intimal ligaments, secondary stabilizer of the ankle. So for that, you don't actually need to fix the small little fragment that sits on tip post and the tip post is incarcerated. But your type two BS are irritation pongs in comparison. Importance of CT most people actually ct in this. Now there's something that I was fought previously. There's many papers out there. There's also been so many papers saying that you need a CT for postural mal fractures saying that they won't even publish. So this study that we've done quite a large number of patients, they are refusing to let it publish every journal bounce back saying we know that they need CT to stop saying it. OK. But if you look at this two B fractures, sensitivity specificity, positive predictive value look how low it is on a radiograph. The reason for that I said earlier, the medial aspect of the tibia rotates around towards you. So true lateral, you don't see those fractures to give you some examples. So this is a lateral X ray perfect lateral. This showing a type two a fracture. This one is uh you may say OK, is that is that an incarcerated fragment? But actually this is a two B. So virtual A dental not a true lateral, I get it. This one. This is actually two B and you don't see the other aspect of that fracture. And the reason for that is because it's not in the line of the X ray. OK. So outcome specifically for your two BS. So this is our own paper initially showing how bad our treatment of posture MS were shown that even if you fix them properly, the mass scores, the functional score was very low. But then when you actually started using as an algorithm and fix them directly, your function scores go up same as by malleola. So not only our papers, many papers in the literature showing this 2 to 4 papers. This last review that came out in 2023 shows that in all the studies that have been published studies not even include in this shows a favor of open productive fixation compared to close reduction. This is the paper that I was involved with showing that again, not including our study because we used the all the studies that A A scores showing again that your two B fractures did worse, but we didn't see this in our study. So actually, if you fix them through an appropriate way, your functional scores are pretty similar across the different classifications, apart from three, a larger fracture pattern, which is showing a bit worse. And the reason why we think this the dye punchers, this is why I indicated earlier about the dye punch fragments, something that we now looking at two papers back in 2022 looking at this showing a worse outcome where we go back to our paper that we published in the JBs. If you look at the ones that did have a punch, one of our medical students look at this back in low functional scores again with these. And that's why we're looking at this in more detail, this paper by my colleagues and Stephan Rammel showing that the di punches are usually underneath the two a also promoting and why I'm using the media or po me a lot more now to get into these fracture patterns. So what approaches are needed to fix it? OK. So this was my own algorithm in the JBs paper and see posture laterals on most of them. So I'm not saying that I didn't use it. It was when I've been using. And as you can see why I said earlier, I don't use it anymore, are reasons behind this. So I got two cadaveric papers. The first one called the clockface looking at the different the alignment that you require to have the perfect screw and perfect metal work for it. And you got any post media aspect, then you need a medial approach. This is the clock face showing like your type two B and type three S. You need much more medial fixation. And this corner here not really giving you what you require. Not only that less of you can actually get across at all. So even your two way you can get a good reduction on. And what you're seeing with the MPM is this window here a little schematic, this little corner, the other thing. So we are ADL and put a similar incision. So seven cm incision on cadaveric limbs, put K wires in this little window and then try to measure it the surface area between those areas showing that through that seven cm incision, you only got three centimeters of posture tibia through that compared to your six centimeters of posture tibia that against the actual fracture pattern sizes. So you getting virtually only the two way that you manage to get a uh a good approach to a set up. This was discussed earlier. Most people are still doing prone. I used to do prone. I moved from prone when I didn't have a regular anesthetist to the recovery position, bad leg down. It's a lot easier the happy because the patients in this lateral position. Also as we discussed earlier, especially if you want to go, you really have to get to the lateral side and sys mosis or a peel on then doing a supine and changing the sandbags around can also be very helpful. So I don't say this lightly. The Bola approach has a low yield and high risk. I show you why. No, not good. OK. So vision or poster lateral fragment, OK. It's easy. So these two approaches media and through the media, poster media, the PM fragment. However, you can't see it. Why is this not going sorry access to the die punch again, you can't get to it. Nope, clearing out the front side, she can't get to it. I don't know why this is delayed. OK. Fixation like a high come to fracture. I know um uh Jane's a better surgeon than me because I saw the amount I used to struggle on the higher come defibrillator try and get length is very difficult. The the muscle is completely over the bone and you just can't get to it. It's not an easy way to do it all but through a direct lateral on you in simple realms of fracture, pattern fixation and then revision, you just cannot do it through the post lateral. I give you an anecdote on that. So one of my colleagues was doing a revision got this jig made to go through the pool lateral approach and you just could not do it. We actually do it through the media, post media and straight down without the jig in the. So all in all coming through your FD Ln A and to post, you can get through it all as um Alex was saying in his talk. So that's one of his work or supporters for, well, also mine the perineal artery. So this is the paper that we've done. So I'm quite lucky that I've got access to the CAD labs very easily and anatomists that do a lot of work. And they showed that got a huge amount of branches to your FHL. So I've seen ischemic contractures of your FHL as a consequence of tearing it. And the perineal artery is very variable in its nature. Also, there's a branch that goes from your perineal artery to your poster tibial artery. It's two of them, the one that's more dominant this branch about four cm from the factory line. So if you've never seen that, you've bled it because you will have to go through it. If you go through the posture, medial or posture, lateral approach, the MPM goes in front of it. So it's not a problem. Uh This is one of my colleagues put this on Twitter the other day. Look at this, it's perineal artery. And then this branch here is the dominant artery for this uh posterior tibial. So if you go through that, then obviously, there's, as I said, five per cent, 10 per cent of the population of infra popal vascular anomalies, which five per cent on either limb. So five per cent of the population now is the dominant artery. So if you've taken out that perineal artery, you're at risk. But if you go through the media, post medial, you go in front of the new bundle, you won't take it, you'll see it. This is one of our own papers looked at the different risks. The risks with the postlateral are quite low. Hardware removal were 13 per cent in the current literature, but you also have the nerve injury about four cent. So this is the approach we tend to use very easy one, you get the tibia very easily, invest in fashion you first pop and then you open up the sheath of tip post. So in between tip post and FDL and then you can peel back the tibia and you can move the tip post either way, the video. So that tip post being pulled out, you can actually put it the other way. This is already, this is your two A fragment, your two B fragment is here. This is the, that's, that's the indication of A two A fragment. So you can see it all and you can unzip it to the top. It's on your fascia occupy line. So, so you can do quite high fractures very easily through it. So my my algorithms change that me the post media now has taken over rather than the post lateral report of the consequence. Um OK, what surgical techniques is specific to this uh postural media or fracture? So we did uh talk about this a little bit earlier. So again, a colleague on Twitter, so er put this on saying what's wrong with this X ray. Anyone answer to guess. Yeah, it is. Yeah, well done. Yeah. So this is your this line here is your safe zone. So that's your lateral safe zone. Anything lateral to that is in the sys mosis. So this was a CT scan even showed a year down the line showing that it can be problematic with the arthritic changes as a consequence of the screw. So this is one that occurred in our POSTOP X ray morning. That's all they done a tibial fracture. They tried to put a front to back screw to stop it splitting. So had a unplaced post male and this wire was also broke. So the question was, was there a problem with this again? Similarly, we've passed that line and this is the paper from Boston showing that. So this is the line they they talk about and anything lateral to that line is in the sins moses. Yeah, you can, if you go in a direction from very lateral to very me, you miss it. But uh so otherwise I try to stay away from it, especially if you're doing the media posh Meal approach tip post entrapment. It's one of my hobby horses today. And so, you know, I've mentioned it quite a few times. So this is as you can see the tip post in the fracture plane there, ok. It's also in there to post. And so this is F DL behind it, so you can see it in the fracture pattern. And so we published on this so greater than 40 per cent, if the tenant enters the sheath are entrapped, we certainly missed it on some of ours actually more likely in these peel on subtypes that enter the fracture pattern. We did see something quite similar to this earlier. OK. The the next thing is like a placement of metal work. So, so this was the fracture. So this is the, it's one of my colleagues ones. Let me go back. Sorry. OK. Um So type two B fracture. So quite straightforward, you've got a tiny little inter calorie fragment needs to be removed. Um Anyone who has, guess what? Wrong with this one? That's what we've been talking about earlier. Yeah. Yeah. Yeah, perfect. Yeah. The post meal plate is exactly how it is described by the, by the tech the medial safe zone. So doing some work on this. Now, this was the CT scan of that one. Absolutely perfectly reduced postural mal fracture and the tip post actually then enters the sheath and the screws throughout untra it. So this is the, this is the concern then the the media safe. So, so this is another case of in our unit, a tibial fracture. This is the way that it was fixed from front to back. I remember I said earlier, the screws go in that direction and go all the way through. You got to worry about whether or not they're in the fracture. So here we are in the tip pore sheath all the way through the tip post going through there, see the screws going through it. So this is the cadaveric pictures on that showing anything media to that and anything that is beyond that line, then you've got to be concerned that you might be in the tip region. So these your safe zones really. So we got the media and lateral safe zones. So we have to keep in. So this is where your plate, that's that knuckle. I said when you come in here, that's that knuckle that we're looking for to get that perfectly reduced. So fixing rotational peel ons. The other thing to note is to fix the posture medial side first. So this was back in the day, this screw is worrisome. It's outside the safe zone, but only that project very well. We've also got a medial shadow here and a displacement on this position here. And the reason for that the left side is fixed and it spat out the medial side. So this is back from our paper in Js on our algorithm where the first bit that's put in is your posture medial before fixing your posture lateral. So just some cases to finish off. So it's the case from a few years ago for me. So trying to get this concept of this buttress plate trying to fix this back. Nowadays, I probably would have put a screw further down as well. This screw, a postlateral approach. As you can see the screws in this position, going outside the safe zone go immediately. And then we've got a plate at the back. It's allowing that fixation of the posture, medial side. First, this was done through A MPM, small MPM and a posture lateral at this stage. This is the second case. It's quite a straightforward simple fracture. We see again, type two type of fracture. This one. Now we got a direct lateral, medial posture, medial, staying outside the safe zone at this area here. And we done two screws. That was quite a small fragment for that. This was at six weeks doing well. I've just given a lateral to give an example of that reconstruction another case. So again, we got this unknown whether or not this is a two A or two B, it's A two B type of fracture pattern, much combination underneath that fracture. So not much weigh into calorie. Again, similarly, we've fixed the back first, fixed the posture medial side first before fixing this posture, lateral to get that done. And then the AFIB which was quite segmental would actually then fix this screw, see the additional screw because of the syndic fixation. In most instability, another fracture, you can see a little bit more that this is a two B because we've got a little medial, clear, sorry, medial side, sort of double shadow. And this is the fracture pattern we have. So these are a lot easier because you can stay well out of the way of the tip post by fixing it more proximately. And then we have this fracture here and then the fi can be fixed through a direct lateral rather than coming through this position here. So this becomes a little bit more difficult. So again, similarly to be played from first two A plate on and then we got the fibular fixation on the lateral side, the sys was stable. Now, again, similarly, this one here, we've got a anti collicular fracture that means that we're going to bring the incision down and bring it round anterior. This is a small fracture. They often get malreduced if they are really small. I don't tend to use the tension man wiring but actually used little headless screws like a, a track three mile or something like that. Um But again, similar, we can stay the metal work a little bit further up because it's quite a high fracture. And then we've got a high com fi which is much easier than done laterally to get your length. And this is the the fracture pattern here. As you can see, I am fully reduced this and the back looks uh uh OK. Oh I did have a uh six month course of uh that's gone. OK. Um Just to give it, that's the only reason I added this one in just to give you an example. So this was the incision that I did all this through. So you can see even with that small incision, you can put the plate on the back and the plate on the side without a problem and then do a direct lateral. So the incision is not big, you can get to it very easily. That's another case. What was the reasoning for that? Oh Yeah, this is one of my colleagues cases. So again, a two B type of fracture, he used a larger plate on this on the back of this one. But what he's done, why is that not give me a laser? Yeah, sorry. But what he's done can see this headless screw and also where the headless screw starts. So exactly as we showed earlier on that medial safe zone area. So he's done a headless screw further down, but look where it starts and that's where our medial side is. So if you got any metalwork going from front to back, just be a bit cautious when you get the medial side there, this case, it's getting a little bit more comminuted now. So, not too dissimilar to one of the ones that the president showed earlier. OK. We've got a lot of combination, a lot of uh dien fragments uh on this and a medial wall blowout. So I'm starting to do a lot more work on these now, these medial wall blowouts. And so, um so it's, it's not as simple as just a big spike. We've got two fragments on this one. So the back is fixed first and then got a medial plate to try and get that in the right position. So we've just finished a study on this looking at the medial fractures. And if you had a medial wall blowout, you're much more likely to have a malreduction if a plate wasn't used because they tend to fix them and they will push out the medial wall blowout blows out. This is uh we're almost getting there. Now, how many more slides. So just to finish off these ones. So this is a two A two B type of fracture. But then you've got a small combination more proximately. I've got a few of these and segmental fibula. So my little nice plate around this side here, sorry, show it. I apologize. The laser conked out the but the other, no pain on the top here. Not really gonna work very well. He also had a uh medial uh fracture was split into two different fragments. So for this one, so I've got a medial plate rather than a posture, medial plate. And because you're through the MPM, you can fix it all through the same incision and then a much longer plate to incorporate that top segmental fi then is fixed distal la as you can see on the left hand screen, I pull the length and many different techniques to try and pull the length. You can do a lambda spread at the top. And such like that, I tend to just pull and see and then K at the bottom and then you've got that length. So this was him then six months, six months down the line. So it's been more oblique, know most looks open a little bit on this one, but he actually was pain free doing normal function. And then this one is very similar. Apart from this dye punch, we got very small medial fracture. And that one, you can see the addition of the little screw medially to allow that reduction. So sometimes you need the bigger plates if the fracture extends up. And that's the importance of the CT scan. OK. So that's what we've been through. I'm happy to take questions. It's done. Silent.