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Good evening everyone. I hope you can hear me. Um A warm welcome to the first Master Techniques webinar in 2024. The topic is very relevant to foot and ankle surgeons, especially who do trauma and those who don't do trauma also see effects of ankle malunion and have to deal with it. I have pleasure that we have two elite speakers today who are going to talk about the malunion after ankle fractures before I invite our first speaker, unlike our previous webinars where we did it on Zoom, the webinar on medal this time, uh the feedback and the certificate would be automatic. So you should receive a feedback form and hopefully you'll respond to it and you'll receive the certificate for attending the Master techniques go fast webinar. Um So our first speaker is uh NCOS Goglia, a very good friend, a member of the education committee in ea s great educator has done lots of publications. Uh and Nichols is going to talk to us about syndesmotic malreduction, how to avoid in the first place and if it happens, how to deal with it over to you Nichols. Thank you, Manish. I would like to thank you personally and both of us for giving me the opportunity to be here with you and for organizing this uh webinar again. So why is this a hot topic? Uh because unfortunately, we see pictures like this and these patients uh end up like that very often. So the messages I would like to give to our audience is that we should get it right first time. So how to avoid these problems. And if we did not get it right, we should revise it as soon as possible. And of of, of course, there will be people who say, well, this doesn't happen to me very often. But if you're honest with yourself and you audit your results, uh like our colleagues in the big from the north of England, did they found out that mao unions around ankle fractures are so common as well as complications. And once they started uh introduced in the dedicated forten uncle trauma list, which means these lists are uh uh being supervised by Forten uncle specialists, we could see that these complications are usually avoidable and mild reductions are not common uh anymore. So, and that reminds me of uh a case that presented uh back in 2008 when I was in a, during my fellowship as a simple uncle sprain. And uh six weeks later, uh uh this patient presented into the fracture bleeding scene by uh Matt sole, uh the foot and ankle surgeon in this condition. So what was not recognized initially is that there was a fracture, not in the ankle, but uh associated with an ankle injury and that caused damage, there was damage to the deltoid ligament as well as the syndesmosis and theos membrane. So sometimes uh what we see today are results of a bad surgical technique or of bad decision making because we did not assess the uh injury properly. And let's go back to some basics because some, some people in the audience might not be familiar with, with uh advanced knowledge in foot and ankle. So the distal fibula, syndesmosis is a very important joint. It's not immobile, it's a bit mobile. So it allows a little movement of the fibula so that the wider portion of the talus anteriorly uh can fit within the MSE when we dorsiflex the ankle. And uh so the that motion is a bit of rotation and posterior to anterior translation of the fibula. And that is associated with proper function of the ligaments around the ankle. And we know from all the studies and these findings have been confirmed with newer studies that even a slight displacement of the tails within the maltese is responsible for a uh a decrease in the contact area by about 40%. And that causes increased pressure in those areas. And that's the result of damage to the cartilage and uh development of arthritis in the longer term. So, and our uncle is subject to rotational injuries. And there are let's talk about these uh main mechanisms of injury uh described in the loud cancer classifications of the supination or pronation, external rotation injury. And that refers to the position of the foot while the rest of the body rotates externally. And there is a different sequence of events, the supination, external rotation injury, which the injury starts on the lateral side in the area of the syndesmos and the lateral male. Whilst with the it for the injury starts immediately, then goes to the lateral side, then it might break the fibula higher up. So the so called weber fracture and then it might go around the back because a a posterior malleolus fracture or an injury at the back and the ankle is a ring. So if a ring breaks in one place, it's still stable, it stays together. If it breaks in more than one place, it falls apart and where does it break? So it can break in the male, uh medial, lateral, posterior or anterior as I, I'm, I'm sure uh will, will present to you later. Uh or there can be a soft tissue equivalent to the bony injuries. And all these injuries affect what we call the distal tibiofibular uh syndesmosis. So let's look at this fracture. Uh Well, it it's, it's unstable. So uh there is uh evidence of injury to the deltoid ligament but when it's subjected to uh weight bearing or when we put the uh foot plan degrade, it reduces whereas this fracture does not. And in the past, with Anthony Sari, we published this paper and said, we thought that this is the result of the characteristics, the properties of the deep deltoid ligament because the deltoid ligament coming from the Greek were delta because of each tape, at least in the superficial portion is not one ligament. It consists of many uh ligaments. I would say there is a superficial portion that bridges the talus and there is a deep portion portion, which is the most important one, the posterior of the deep portion that stabilizes uh the tails within the maltese. And uh there are different characteristics of the different portions. So we when the foot is plan degrade, the deep posterior del uh uh deep uh portion of the of the deltoid holds the uh uh talus within the uh the, the maltese uh stable. But over the years, uh we have realized that there is something else going on. What is the difference between these two types of fractures? There is a difference lies within the syndesmosis injury. On the fracture you see on the top, the syndesmosis was intact whilst on the fracture at the bottom of your screen, the syndesmosis was injured. So that ring was now clearly broken into two places and the syndesmosis was not intact. That's why the second fracture is more unstable. Let's put it this way than the first one. And the, these are the synoptic ligaments, three portions, anterior posterior and the interosseous. And we see to what extent they provide stability. So the posterior P I TL, posterior inferior uh tibiofibular ligament uh appears to be the strongest. So, and these uh uh are some anatomical specimens. The A I TFL is what we see also on anterior ankle arthroscopy was the P I TFL is more difficult to assess only if you do posterior approaches to the ankle as also uh shown here by the images of pala. And what you can see on the CT image I've I've put up there is that the P I TFL is attached to what we call the posterior malleolus, which is a infection of bone. Really. Uh what is the mall really? And these uh uh uh avulsion affect the syndesmosis as you can see whilst on the anterior aspect of the uh of the tibia, a similar avulsion can occur. This is a quite large fragment here on, on this uh example, I give you usually they are smaller and that affects the sys as well. And why would we fix this injury anatomically? This actually would be for the ligaments to heal the right length and tension and for the syndesmosis and the call of the ankle joint to work properly in the future. Sometimes the syndesmosis disruption is obvious and sometimes not so obvious. And therefore, you need more advanced imaging to assess all aspects of the injury to your ankle. And that's the CT scan. And as you can see here, we have to think of the ligament or structures as well as you can see, this fibula is not well aligned within the incisura. The ligaments might be intact or uh sometimes they're injured as well as uh at the same time with the bone. But it's the bony injury, the avulsion of the bony fragments that causes, that causes the displacement of the fibula within the uh tipi fibular syndesmosis. And that appeared to be a simple stable fracture. A bit later. There is some evidence there are already on six weeks. So there's something not right, it's opening immediately, there is something at the back of the ankle. So that so our the initial diagnosis was not right and uh uh within uh a year and a little bit more, it uh ended up in this uh bad situation that was avoidable. So this is a little bit more obvious that this is a serious injury. And I will say if you have a fracture dislocation uh for me always rings a bell. There is something strange and wrong here and you have to be very careful uh because what happens is we use these ankles and you and if you just rely on this X ray, you would say yes, this is not very bad and that's what the colleagues. So they fixed it, they did a hook test and they interpreted this picture on your right as well, not opening up on the media side. I one can disagree with this and this uh fracture ended up like this already in three months time. Now we asked for a CT scan a bit late I would say, and now we realize what was missed. So there was avulsion anteriorly and posteriorly. And this was the reason why the syndesmoses was not a uh was not in the right place even postoperatively. And this is not so rare. This is common, more common than you think like in this case. So there is a little fragment there accompanying the fibula and that's part of the posterior malleolus and this is really small. So, so the surgeon said, well, I don't have to fix this little fragment. I just put in the Moses screws to stabilize. Well, the fixation of the fibrilla is not strong enough. Uh The reduction, I don't know if it's good enough and the fixation of the symptom is most probably not good enough. And the posterior malleolus was ignored and that's uh some uh that's how it ended up within eight weeks from the injury. And the CT scan shows exactly the same from the last one I showed you. So this is not so uncommon. So get a CT scan in the first place and that will reveal all the injuries and then you decide what you do with those little fragments or how you will stabilize, reduce and stabilize this in the small. And we have these two classifications uh well uh produced around at the same time saying exactly the same. So I II don't think there will be, that will be the start of the German British debate. And I would say probably it would be the uh ancient Greeks who would have discovered this if they had ac scan uh a few 1000 years ago, but they didn't. So ct scan is important because it changes your management plan. And what we know is that the small posterior malleolar fractures affect the syndesmosis and that's why they should be fixed. And also if you fix the posterior malleolus directly that produces very good syndesmosis stability. Whilst if you rely on syndesmosis schools, that's not so good. And yes, a big fracture, you fix it to restore the tibial platform, but even the small ones need fixing are repeated to reduce the syndesmosis. A posterior malleolus fracture or an anterior malleola structure is equivalent to a syndesmosis injury. And as you can see, even a small displacement of this tiny fragment of the posterior malleolus affects the uh the the the size of the syndesmosis and how the fibula sit with it as this uh study uh shows. And of course, we should abandon this dogma from uh uh several decades ago that has no scientific validity. So, what kind of fracture is this? What are we gonna do with that? We don't know until we get a CT scan and this is a fracture with a Malign Syndesmosis. And if you fix the bony fragments, this is what you have to do in order to, to get the fracture reduced. And that will reduce the syndesmosis. And do I need syndesmosis cruz now? No, because I have free attached all the uh ligamentous avulsions back to the uh main bone and they will heal at the right length and tension. And I can assess my syndesmosis through the posterior approach. Again, another unstable fracture, you fix the bony fragments anatomically, so do a total, not a partial open reduction, internal fixation and you don't need syndesmosis screws. Now, this is a high energy injury here, we haven't got a broken medial malleolus. We have a fibular fracture, a posterior mallear frac fracture, that's equivalent to syndesmosis injury and the deltoid is gone. Uh for sure. Now, we fixed the fractures. Do I need syndesmosis cruised? Now? Well, previously, we had the anchor ring broken in several places, three places. Now, it's only the deltoid I haven't repaired. So by fixing the posterior malleola, it is as if I have repaired the syndesmosis. So I don't need to uh uh repair the, the, the deltoid and I don't need to put a syndesmosis screw uh if I fixed everything else. And uh these uh of course, I tested intraoperatively and I have tested uh checked the syndesmosis reduction under direct vision through my posterolateral approach. In this case, again, another uh injury, close injury, but a fracture dislocation that rings a bell. It is nicely reduced. If you just look at the uh X ray on your right, you will say yes, that's uh not so bad. Uh But remember it's a high fibular fracture we by sea pro external rotation injury that has disrupted the inos membrane as well. Uh Well, you get your CT scan with the ankle reduce, what do you do? Now? Just rely on your syndesmosis screws only fix the fibula, fix the fibula and the posterior malleolus. Do you still need the small screws? All these are things you have to consider uh fixing the fractures, you do your uh checks. And as I said, we have turned a posterior uh a non ST ankle injury to the stable one. Uh Well, the Interros membrane must have been damaged here. So this is debatable whether you should use a synthes Moser screws or not. So I wouldn't blame anyone for using the synthes Moser screws screw here. I haven't done so, but and the the patient had no problem. So uh by testing it intraoperatively with the hook test, but also with rotation test, make sure uh the syndesmosis is right. And it's not just uh me. So in this uh show in a couple of cases, uh there is a study showing that fixing the posterior structure reduces the need for syndesmosis screws. And for me that's very important because uh uh synthes mosis screws are a source of many problems if you just rely on that. So, when do I need? Since the motor screws, despite that, you fix the fracture, you have to consider whether you have fixed everything else and uh your uh ankle is stable and you check it on the table. But the likelihood is that if you fix all the bony components, the need for synthes mosis screws uh might not be there, fracture dislocation. So, so that ankle was reduced in the emergency department uh because it was uh the patient was in a lot of pain and then an x-ray was taken, you have to consider the history of fracture dislocation because that rings a bell. That's a serious injury, be careful. So no CT scan was done. Uh The patient was uh taken into the operating theater uh relatively soon after the uh injury, uh fibula is fixed, uh medial side is still open. Now, this call it though. Well, if you, if I reduce the syndesmosis with a clump and uh and position it there. So the media side closes, we put the screw and everything is held together. Now, I can see that there is a little flake at the back which might have been an avulsion of the posterior malleolus. And this is why, because I haven't fixed the posterior male. This is why I needed the syndesmosis screw and this patient did well, with the syndesmosis screw in situ. So, but we have to be careful if we miss the posterior malleolus. If we haven't done a CT scan, at least we have to uh bear in mind that the ankle might still be unstable. Similar case fracture dislocation, uh ruptured deltoid, we did the hook test, but it's the external rotation uh test that shows the the instability on the medial side and the syndesmosis screw uh is essential in a case like this. And once the uh unstable injury is turned to a stable 11 can leave the deltoid ligament alone. I uh not repairing in such case. And this is a nice example in a publication uh uh by Matt Sole and colleagues. So you see fracture dislocation, you see the tiny fragments of the front of the back of the ankle, avulsion of the, of the um bi TFL and A I DFL. So the fibula is brought out to length, fix the Weber C fracture. And now what has been done is that the uh anterior, the A I TFL has been reattached, the P I TFL has not been. And the, the authors ask themselves, should you want to fix the P I TFL? Then we might not have needed the synthes monster screw at all. However, I would say because the, the membrane is torn as well. It's not a bad thing to stabilize the synthes mons with the screw as well. In this case, So take a message from this. Fix the fractures, total fixation, not partial fixation of the fractures around the ankle that reattaches the ligaments. And that turns the unstable injury to a stable one. Even if you don't repair that the altoid, the ring is still stable and that should be ok. Now, if you fix the syndesmosis, should you use screws or, or shoot your button? Well, looking at the literature, that's not the point. Uh uh the, the, the point is, have you reduced the angle? Have you done anything else? Right. How many screws or who knows? How big? Yes. How big should the screws be? Three or four? Cortices? I would, I'm sorry. Yes. Three or four cortices. Does it matter if, if they break? Probably not, you take them out. I now do not plan to take the screws out unless they cause symptoms. So stiffness in young patients. And I have seen that I rarely have to go back. It's usually young athletic people. I would have to go back and remove the, the screws. I warn them that they might break. And that's not a problem as long as the ankle remains uh reduced. So, and you see all these publications, Ty versus screws, I think this is not the point. So you see all sorts of, um, I would say also nonsense in the literature. That's not the point. And again, hybrid fixation that about confuses me. Why should I use? And why should they use a partially threaded screw to compress the syndesmosis? Is it a positioning or a compression screw? So let's uh II would say, would not focus on this object because that's not the point. My point is try to avoid using syndesmosis screws, fixing the fractures uh properly. Like in this case, we haven't fixed the posterior malleola. So you're cynthy mosis fixation, which is a little bit high as well, is weak and that might cause problems. So you're not sure whether this synthesis is reduced. My uh advice is reduce, make sure we have reduced the synthesis before putting the screws in and you put the screws in. I would say neutral position. How do you as reduction, arthroscopic or open through your surgical approaches? That's the best way to confirm if you have a inter C scan, that's fine. That will give you uh the answer. But most uh people here uh have not an interop ct scan and do not miss the tibia or the fibula because in this case, even the fibula uh was missed. It started like this. Uh the uh in the or the images were not uh really good, uh not assessed very well. And then you revise it. Even here, I would say the fibula is slightly short and probably Marot because of the high fibular fracture. And there is a question, should we anatomically fix the fibula? It doesn't matter how high the fracture is. I haven't got the answer, but probably uh that's something to think about young patient. 17. Uh he was supposed to have a stable uh weber b supination type two injury at four weeks, uh comes back for follow up something doesn't look right. One does an X ray of the other side. And there is a in the appearance of the syndesmosis, whether these two X rays are uh taken the same way, we don't know what will give you the answer is the CT scan. And it clearly shows here here that the fibula is too anteriorly in the incisura. So, uh an arthroscopic assessment of the joint found that there was a, an uh an anterior syndesmosis, uh a syndesmosis injury, I would say we clear the scar tissue and you can see here the position of the fibula. I have rotated the CT scan image anteriorly to the tibia. And once you put the clump on the outside, you see the fibular sliding back in the correct place and you can assess it like this and you put the screws in the reduced position where you have checked in this occasion. Uh arthroscopically that the fibula is reduced in the instance, you are using your cr at the same time. Now, if you have a mild reduction of the ankle of the syndesmosis, and you have used syndesmosis screws admit the problem and revise early. This is a high demand. Um uh young patient who is in the special forces in the army had an injury at work and uh he was fixed like this and he was still in a lot of, of pain. He was fixed in different hospital. Came to Friley Park was when I was working in UK. And even he was seen by a non for the surgeon. He said the patient is a lot in a lot of pain. Could you please see him? And we did the CT scan that shows yes, these little fragments within the joint, the posterior malleolus uh fracture is is is not reduced. The fibula is not really anatomically reduced in the syndesmosis in the incisura. And there is slight displacement of the posterior ma fracture, but also the fibula is short and probably malrotated. So, should we leave it as it is remove the loose fragments only or wait until 10 weeks to remove the screws as well or proceed to the vision fixation? I think here you should uh do something for the non anatomically reduced fibula which is short and malrotated. Uh that is essential and this is not, is a surgery, you reduce the, you fix the posterior malleolus. And once you bring the fibula out to length, the correct rotation, the uh fibula has reduced within the inci and this patient had a very good outcome. So this is the from the the geometry of a normal ankle joint. Uh these little uh uh like a chant line in the distal fibula. So you can uh look this up and check all your X rays and see if you have reduced the fibula anatomically. When you do your fracture reductions. This uh case was uh uh given to me by a colleague in Athens. Uh He came across this patient who was originally fixed in a in another hospital had an open fracture dislocation, playing football, that was the reduction of the fibula. And a few days later, he sought a second opinion and my colleague did that. Well, not even in eu he took the patient out of cars and did an X ray with the image intensifier really. And that's what's happening there. So we have a short fibula, rotated, torn the membrane and syndesmotic ligaments and torn deltoid ligament that was an open injury on the medial side. So the they in the, during the first surgery, they had, they had removed that butterfly fragment from the fibula. Uh he brought it out to length and checked the position of the fibula within the intra the way you can see with open reduction, took a picture because of that to show that exactly he had checked it. And you don't, you don't rely just on the AP view. We know uh X rays or imaging density. Five years are unreliable in order to detect any uh displacement of the fibrillar in the incisura and this patient went away. And uh well, that was the final fixation. The patient went away and a few years later, he called him to see what's going on and he said, well, I'm playing football again. Never bothered about. We never know when the screws broke. He had the excellent outcome because the fibula was broke because the fracture was fixed properly. And the syndesmosis was stabilized. You see the new bone formation in the fibula. This was a young patient, good biology and that was probably the reason why his syndesmotic ligaments healed with some scar tissue uh in the distal tibia fibular. So is more area and that's why his ankle remained stable. The same applies to the deltoid ligament. Uh My colleague did not repair the deltoid ligament. That's a slightly different case with a high BM I young patient who was uh uh of Chinese origin in the UK for an Erasmus program. He had uh an injury of his ankle. This one, my little structure, uh our colleagues fixed the posterior malleolus but did not fix the high fibular fracture. They just relied on syndesmosis uh fixation with these screws, but the fibula is short and probably malrotated. So it wasn't uh really anatomically reduced. Uh The patient was scheduled for removal of screws. Uh He ended up on somebody else's operating list and uh uh uh a less experienced uh surgeon uh uh not a consultant was in the operating room. You see the night that he wanted to take uh the screws out uh with small incisions and that's what was discovered in with a patient of a general anesthetic. Now it doesn't reduce, we re removed. OV uh I was called in, I asked for an uh another code to have a look to confirm because we didn't uh uh uh have consent from the, the patient was consented for screws removal, not for any reconstructive surgery. Um still not reduced properly. We put an arthroscopy and cleared the medial side. Yes. Then we could reduce it and did that fixation and he was due to leave the UK, go to Spain to carry on with his Erasmus program. Know what happened to the patient. But I would say ideally one should have done what was a uh sort of elective case done. A fibular lengthening osteotomy to get the fibula out to length and make sure the patient will not run into problems in the future. Osteotomies can be a solution. In this case, it was a 44 year old, uh 44 years old, uh female teacher who said, I don't want nephrosis. I wanna be able to wear high heeled shoes and she had a weak, unstable and painful until eight months after fixation of this fracture. So, arthrodesis was an option. The patient didn't want it. She's too young, I would say for, for a knee replacement. So we tried joint preserving surgery, doing an arthroscopic debridement and a distal tibial osteotomy was prepared to do a fibular osteo artery but once the tibia was reduced and the alignment of the ankle was reduced, then there was no instability around the ankle. So the mal union was the problem, not any torn ligaments at the time. And this was the only X ray taken to this patient a month after the surgery. I know this patient and she doesn't want another X ray taken for nine years. She did not need any other intervention and she is able to wear shoes and well, osteotomies do not always work like in this 49 years old uh nurse who had uh uh uh an ankle fracture with it was treated as well with a syndesmosis screw that was removed, but she was unstable. I tried to salvage the ankle but it did not work in this uh case. Or if you have a 79 year old uh patient. According to her medical records, she had the deltoid repaired and syndesmosis fixation then complicated by infection screws were removed, ended up with arthritis. The only option is to salvage it with an arthroscopic arthrodesis in this case, which is a very good salvage procedure. And then you have a young patient with a plain of valgus foot. Uh I'm uh I'm going towards the end of the, of the presentation we does who is on Cortisone? He has a significant comorbidities ends up like this. I don't think a deltoid ligament reconstruction and any fancy surgery is a good option for such a patient and an arthroscopic arthrodesis would be in a hi foot nail was the salvaging procedures. So to conclude, do a CT scan, fix what is fixable and avoid synthesis screws. Uh If possible, checking the reduction of the syndesmosis open or arthroscopically or with a drop CD. And if you have a problem, admitted and revised early to avoid an arthrodesis osteotomy might be an option. Uh but usually you end up with f in the joint. Thank you for your uh uh attention. Thank you, Nicholas for presentation. You've shown us a lot and lots of examples uh and very clear messages and I'm sure that will be uh interesting discussion which we'll do in the end once uh our second speaker of tonight has given his talk. So let me welcome uh Professor Stefan um Rat. He is uh head of the Foot and Ankle Service in Dresden and is also the Vice President of the German Foot and Ankle Society is going to talk about his vast experience uh with uh the classification of the mallear muns and how to manage these over to you, Stefan. Thank you. Thank you very much for the invitation. It's an honor to speak here. And um I wanna show the presentation. Can you all see it weekend? Yeah. Yeah. OK. So this is the little town I come from. It's a little smaller than London, but also lies on a nice river. These are my disclosures, not uh related to the next talk. The talk is uh stated to be about classification. So there is no real classification for ankle mail unions. And it was only uh during the time of the pandemic that we had time to think about it. And um I like to keep it simple for the surgeon and for myself. And uh so I classified them for my practical work just like the acute mallear fractures according to which Melius is fractured. We already heard about the ring concept. And so the anterior and posterior syndesmotic avulsions working like Malili, although they don't look like them. And uh so one of the basic laws in surgery is Murphy's law. Anything that can go wrong will at some point go wrong. And as you can see fractures of all the four corners of the ankle or all the four Malaya, you can also see mal unions. Then of course, there are pong mal unions, there are s Malar MS I will not speak about them that would lead us too far. So let's start with a simple case and you have in similar ones in uh the previous talk. This is a classic case, 45 year old patient or if you can see maybe the media side is a bit wide, um maybe the fibula is not in exactly out uh to length, she's still painful after one year. Then what is done? The German uh solution is hardware removal. It didn't help. And then the patient was told nothing else can be done. But is that really through here, you see the radiological landmarks, you see Weber's circle that is not hit by the tip of the fibula, which means the fibula is too short. You cannot always see the line of the ankle uh after a fracture, but uh the length can be easily seen and you can see how the talus is slightly shifting laterally and uh it's tilting. And you can also see that the syndesmotic clear space is a bit wide. So there is like a secondary syndesmotic insufficiency in those cases. And these are the principles of correction. I do not need to repeat this. We have to bring the fibula out to length and uh if it is in a valgus position, we have to correct that. And uh so we did this in that case and we shifted it down. You can really titrate this under fluoroscopy. So that in the end, um the Weber circle fits again. And this is the same patient. Eight years later, she came from another part of Germany, but sent me the X ray and said that she is uh so far pain free. And you can see the syndesmotic uh somehow stretches a bit when you do this lengthening of the fibula. If the lengthening of the osteotomy is above the syndesmosis. And uh Rne Marty who worked with uh Hardy Weber quite some time, even sometimes had the feeding, he had to loosen up the syndesmosis for this type of osteotomy. I try to avoid this because I want the fibers to be stretched out and uh to be really under a good tension again. And um you can see this can work for quite some time. There are some series out of more than 1015 years uh without uh significant progression of arthritis and with very, very few secondary fusions. So this is the media Medius, which can be uh united. Here. We see another female patient 42 years old, two years after the injury, she already underwent two revisions for media medulla, non union. She was first fixed with screws, then with a plate, then finally, it healed. But as you can see it healed in V and um that you can also see when looking at the patient from behind, you can see that the talus then shifts a bit forward. And here you can see the shortening of the medial malleolus. This was obviously a supination injury which produces that uh vertical fracture of the media malleolus. And uh now finally, it healed but not in the correct uh position. So when to correct it, we have to bring it down and we have to bring it, get it out of uh virus, which means here we have to cut out that triangle that belonged to the former non union. We didn't go to the lateral side because the fibula was not shifted. There was some kind of a plastic deformity, maybe slight malrotation. We started with the medium lis and saw that the tas centered nicely below uh the tibia and this is the patient one year after correction, the CT scan, you see how the talar shifts back, how the calcaneus uh shifts back and the heel gets the natural physiological valgus uh position. And you can also see the correction of rotation of the medial meis. Uh most of these patients uh if they have a plate on the medial side, they feel it. So we took it out and she got quite some nice motion back. This is the function two years after the surgery and the scar formation. Now, of course, uh both the media and the large leaders can be made united like in this patient uh who had a easy weber a fracture, but it was a stage two. So again, the media me went up and went out and in this case, also the leader uh was healed in a man united uh medial shift. And um so that, that was what we saw on the media side that was already somewhere of the cartilage at the medial talar dome. On the later side, we saw that large step off in the distal fibula. And so the correction osteotomy was exactly at the site of the Mal Union. And uh so the media me had to be lengthened had to be shifted lateral as had the lateral Melius, which also needed a slight closing wedge osteotomy. This was the result uh after surgery, the patient uh who was not very compliant, started walking on it uh and presented four weeks ago with pain. Uh luckily everything was still in place and this is him two years later, with everything has healed and uh still at that point, uh no progression of arthritis. Of course, all the the post malaria matters, not only for syma congruity, but also for stability of the ankle and of the joint surface. And this is even more important. The larger the fragments are. So this is a 38 year old female patient persisting pain. After trime fracture fixation, you can see the posts was fixed in a classical way, indirectly from A to P the screws that were meant to be compression screws with uh partially threaded ones and cannulated ones, then the German solution taking the hardware out and the patient still has pain. But uh there was no improvement. And uh when you look at the Weber criteria, the fibula, it's definitely not too short. But if you look from the side, you can already see there's a large meal postular fracture. And uh you can see the step off in the uh radiograph and you can even uh see it more so in the CT scan, everybody in Germany that has has ankle pain also gets an MRI for some reason. And uh here, you can see how the loading of the anterior part and particularly at of the edge of that form of fracture affects uh the tibia. You see the bone marrow edema, you see the cartilage is still there, but it starts wearing out. So it's really time for action if you want to save that patient from a later uh arthritis and fusion. So this is the form of fracture line and we put the patient prone at this time, the hardware was luckily out already. So it was good for one reason. And this is a poor man's navigation. You just uh put the K wire in front of the side where you want the osteotomy and then you work your way through with a chisel. Of course, you have to recreate that slightly curved form of fracture and then you bring it back. And of course, you have to turn the tube, the X ray tube to really make sure that there's no tilting of that fragment. And then in the end it's fixed. And of course, I it is stable because uh it's a large fragment that carries the posture in this moses and to interosseous ligament. This patient too came from further away, but she kept sending me x-rays and was at that time, absolutely pain free. Now, of course, uh we have that anti fragments and uh snickers already showed uh they can be smaller or larger syndesmotic avulsions, but they can be some kind nasty fractures uh if they result from abduction injuries. So you see a valgus deformity and pain. After bima fracture, fixation, nothing was done uh to the anterior uh lateral part of the tibia. You see a slight valgus of the fibula, maybe some uh shortening if you consider the, the tibia. Uh but not if you look at the Weber ball and uh probably this is a result of uh pronation abduction type fracture where the talus um impinges uh on the distal tibia and produces some impaction there. And um we looked at the path anatomy of these anterior fragments. And of course, the majority of them are avulsions, syndesmotic avulsions which regularly um result from rotational type of injuries. Then you can have the larger fragments that NCOS also already showed that are intraarticular and they always also contribute to the in. So if those are united, then the fibula doesn't know where to go. And uh it takes that a while fragment with it and it, it results in the malposition of the distal fibula and it results in an insufficiency of the syndesmosis. And then we have that nasty type three, which is a lateral, an interlateral infection of the tibial platform, which is like a transitional type to a pong fracture. And interestingly, when we analyzed them, we saw that the majority of those cases were initially pronation and abduction uh fractures. So here we probably have an overlooked uh infection of the lateral tibial platform of the anterolateral or, and this patient uh didn't want a fusion. Although you can easily see that this joint is far from being innocent, but uh we promised to try our best. So we did an osteotomy of the lateral tibial platform through the fibula and we shifted the fibula and that an lateral fragment down, put some bone graft in both of these um osteotomies. And we buttress the anterior platform with uh buttress plate. An anterolateral plate is the patient born you later. She's not absolutely pain free, but she can walk on even grounds without uh pain has some limited dorsiflexion, doesn't do sports. So we took the fibular plate out. I didn't dare to take the tibial plate out and left it in because uh it is far away from the skin and uh she comes uh from the, from the on Flatlands of Germany and keep sending me uh images every year. So she lets the horse do most of the work and her husband. But uh she has a beautiful function. 7.5 years later, you see, of course, some Antero so the arthritis doesn't go away. But so far the ankle joint has been saved for quite some years, which can be good in these patients. And finally, according to Murphy's law, all of the four malili can be in a malposition. Of course. Also, according to Murphy's law, this must be an orthopedic surgeon that was treated by his colleagues of his own clinic, he was unable to go back to work. And four months later, after that, uh quadri malleolar fracture, he presented with those images. And if you look at the CT scan, uh you can really see that all Foreli American United there is uh uh of the distal fibula which is short and shifted anteriorly. The media meus is malrotated, the poster meus is too far down, creating a step off in the joint and the anus is broken off. And so the fibula doesn't know where to go and the whole ring is uh broken in and m in all four corners. You can see the uh CT scan that shows that, that uh relatively shallow uh posterior fragment. But that shows how uh this old dogma of one third or 1/4 is not valid. Also a small fragment can lead to instability because the er is gone. It is taken away by the fibula, which is in addition here, also a wh uh with an anti tibial fragment. And uh we went there and we corrected uh three of the former Leli because we didn't go, uh we didn't dare going through that full thickness, skin necrosis over the medial malleolus. So we, we went there, we um put the posterior uh fragment back and uh supported it with a plate. We uh brought the antio fragment back with a screw and a washer. And we added that Syndesmotic screw, not because we felt it was really needed. But uh this is a, this is a mal union. This is not an acute fracture. So the, the bone is brittle, it's a bit osteoporotic. So we added it like a, a tibia pro fibular screw. And of course, uh uh later mole was uh corrected and for these chronic cases, uh um maybe a hybrid fixation is not too bad. In this case, we just left that um suture button implant that was already in uh on the top and probably not very effective there. We just put um um smooth elevator between the mediums and the talus and try to push it back because we didn't want to go through that skin necrosis. Uh Maybe it helped a little, you can see how the posterior and anterior fragments are brought back. This is a CT scan six weeks uh which he sent us. And uh so hopefully, uh he's doing better now. So in summary, all four of the malili can break and all four of them can munite. And if so, this can rapidly lead to incongruity and uh arthritis of the ankle joint. And of course, osteotomies can help in those cases. And uh even if you buy your patients some time, particularly if they are young patients, uh then you have already won the game because neither a fusion nor a total angle would be a permanent solution in a young patient address all for malili correct as early as possible because then it is number one easier at number two. Hopefully, the arthritis hasn't gone too far and you can get really good long term results if the patients are reliable, if there's still some reasonable bone stock and some cartilage, of course, if the cartilage is gone over most of the joint, uh, then, uh, you can, uh, go straight on to a fusion and you need at least this time exact realignment and then you might see progression of arthritis, but it does not necessarily lead to symptoms. The ankle can take a lot even if uh it doesn't look uh in emergent like an aerin state and not all of the arthritis that you see on the X ray really lead to symptoms and need uh later on effusion. So, thank you very much for your kind attention and of course, I'm open to discussion, great talk. Thank you so much. So, we will open up discussion. Thank you Nicholas for bringing your screen on. So I've got a few questions from um our audience. Uh So first question is to you Stefan. Um How do you decide when it is too late to do salvage surgery of this sort rather than doing fusion surgery? How do you decide? And is there any anything, any factor? Yeah. So my rule of thumb is if the cartilage is gone or severely damaged over half of the joint or more, then it doesn't make sense, uh reconstructing it anymore, the patients will still have pain, the talus will still be tilting because of the different he if it's up to one third. So it's medial, the uh it's basically the medial or the lateral talar dome that is affected, then it's astonishing. Uh how long those patients prevail without a secondary fusion? That is my personal experience, my my rule of thumb. So you may say a Takakura stage one and two, you can uh easily correct uh if it's, if it's getting out, then it's probably too late. But of course, you have also have to look at the patient and uh the residual function. If the the ankle doesn't move, it's probably not worth trying to get it moving again, except if they are really large osteophytes that you, that you can take off. And of course, the patient has to be reasonable uh and has to follow your instructions, your nonweightbearing uh instructions, but also then physical therapy to really benefit from the uh salvage of the of the joint. Otherwise uh smart solutions for smart patients. Yeah. No, sounds very reasonable. And that just uh brings me on to the next question automatically. Do you have um uh POSTOP regime for when you're correcting the ma do you keep your patients non weight bearing when you're fixed these sides? I typically try to reasonable patients that can, that can do a partial weight bearing because the bone needs a signal to grow together. So uh you should at least put the, the leg to the ground with its own weight, uh 1520 kg. And the patients should also do early range of motion as soon as the wound has healed to, to really benefit from, from the joint preservation. And then it's typically, if it's a simple osteotomy, it's uh six weeks. Uh if the bone stock is already bad, it's a bit longer. And if you need uh, bone grafts, uh for correction, then it's 10 to 12 weeks, partial weight bearing, then then, uh typically, at that point, I see them back in the office and if the bone has healed on X ray, then we rapidly uh go on to full weight bearing. Thank you very much. I just need to go through the quite a few questions. So I want to cover them all as much as possible. Uh So the next question is in contrary to what we previously are. So how do you decide it to it, whether to revise the fixation if x-rays don't look great, but the patient doesn't complain of any pain. I'll ask you both, what, what are your views on bad looking x-rays, but no issues from the patients, then probably, uh it is still early. So if I see a bad looking x-ray, uh the day after surgery in the morning conference, uh I'll do something about it right away and then hopefully the patient doesn't have symptoms from that. And, uh, so I would, uh, I would really go for it because we all know that, uh, if it's two millimeters of shift two millimeters of step off, then there will be problems down the line in a weight bearing joint. Uh, of course, if the patient doesn't have pain because he's neuropathic, that's a different story. Thank you, Nicholas. Yes, you might agree. There, there are some MD reductions which are unacceptable. So if it's the day of the surgery, you do not expect the patient to be in pain. So the patient cannot, if it's four or five months after surgery and the patient has started weight bearing and comes back and it's or he, he comes for a second opinion or a routine follow up appointment. There is no pain. I would hesitate to operate on an asymptomatic patient several months down the line. But if I see something that doesn't look right, like a fibula that's MBI used not brought out to length, syndesmosis, not uh reduced, then you should intervene early. So sometimes we have, we have to treat the X ray and not the, the patient's symptoms as early as possible in this case. But to be honest, uh most of the patients come to me because they have pain in the ankle and a ton of MRI S and nobody knows what's going on and the x-ray looks bad. So I rarely see patients with bad x-rays uh and uh with metal x-rays, let's say that with metal x-rays, I see patients that have arthritis on x-ray, but with a metal ankle, they still cope for quite some time. And I think that is the, that is the, the message. So for them you can still go uh preserve the joint um instead of doing uh sacrifice. So II would say yes, Stefan S one case where he has done osteotomy. I have a very good example of an osteotomy that I did. There is arthritis, but it was asymmetric arthritis and the patients do well for many years. So you can preserve the native joint once it's as long as. Thank you. Um The other question is regarding incision choice from previous surgery. So somebody has fixed the use the lateral approach and and obviously not addressed the posterior malleolus. Would, would you be happy to go through the new incision or you tried to use the same old lateral incision? Probably it's hard, isn't that you need to go posterior? But I just wanted to hear from you. Would you go do a poster lateral approach in a previous lateral approach being done? Absolutely. And you can even do a poster lateral and the lateral approach at the same time as long as you stay parallel and have a reasonable distance between the two approaches. And also I see that question. So some people try to not fix the post because they want to avoid a poster lateral approach. Uh We looked up our cases and we did not see more uh infections or wound issues with the poster approach as opposed to a lateral approach. In contrast, you have less reasons to take the implants out because patients don't feel them, they don't bother them. You have a nice cover through the uh uh FHL muscle which is there. And uh you have uh a stronger buttress when fixing them directly from the e better reduction, stronger buttress. And even for the fibula, if you fix the fibula with the same approach, you have uh an anti glide plate from behind, which is stronger than the lateral neutralization plate. So uh for me, there's no reason to avoid the postlateral approach. Of course, you have to take care of the wound and you have to avoid that the patient when he's lying on his back is also lying on his wound. So put some cushion beneath the the the calf that that the ankle, that the foot is really free and avoid direct pressure on the wound, which could lead to problems. But it's not the the approach itself that is to blame. I agree 100%. And all the problems of the audience, all the problems we have seen with wounds around ankle fractures is where you see the fibular plate sticking out the wound. When it's a direct lateral. With the posterolateral approach, the skin is much better. They are usually not as badly affected by the injury as well. And it's a lot. Thank you. Uh tips regarding the use of syndesmosis clamp. Could it cause malposition when reducing syndesmosis? Of course, it can. So, um I tried to put it exactly along the axis of the ankle joint which is from the tip of the media meus to the tip of the later medianus if possible if the, the fracture or fixation allows it. But typically, it is after fixation of all mali. And then this clamp also gives you the direction uh for the syma screw or dynamic implant or whatever you want to have. And uh if that clamp is a bit off, uh then of course, you can reduce the, the, the fibula uh with the clamp. And also you have to have a look at the bony anatomy of the, of the incisura. It can be retroverted, can be introverted, it can be shallow, it can be deep. So all this has to be taken into account before reducing it. And then you can quite reliably avoid m reduction. Apart from what NCOS already said, go open. Uh see the, see the alignment with your, with your eyes. Use a scope if you want if you sure. Well, it we have lost for a while. Yeah. Yeah. So II would say yes, since this Moses mal reduction can be associated with wrong position of the clumps. So you have to be careful and that's uh there are also some studies that have shown that you can have up to 30 to 50% mild reduction of the syndesmosis if you do a CT scan or stop. However, that's why I say try to avoid using syndesmosis screws. And especially you will see the problem with mild, reduced uh fibula fractures. When you try to hold the whole construct with the syndesmosis screws, then I'm sure you can't reduce that. Uh the syndesmosis. If the fibrilla is short mull line, there are all sorts of problems there. So sometimes the reason you put the screws in the wrong place is because the fibula is in the wrong. Thank you. Um Seven audience uh for a quadri fracture. What's your fixation order? I uh almost always start with the posterior ius patient in a prone position that already helps with uh reduction. And uh as long as there are no other implants, this also gives you a nice read of the lateral view and the fluoroscopy to really see that you did a good job reducing the posted. And then the posterior incisura is already corrected. Typically, the posterior fragment is larger than the anterior one and this helps with fibular reduction. So then you have recreated the incisura from the back, you reduce the fibula mostly through the same poster lateral approach with the posterior plate. Then the media meus and then um I slightly bend the knee or an assistant, does it or just put a put a bolster underneath the, the leg and with a small interlateral incision, I fix the anti syndesmotic ul of the Antalus. So that's my typical uh fixation. It is a bit different if you have what we call a quadri equivalent, which is a fracture of the wax stuff fragment. Then I do this at the same time, I fix the fibula because when I fix the fibula from the back, you can have very long nice screws, but they can push the wax fragment even further out or hamper reduction. So I do a small incision contralaterally and put a put a reduction clamp from the posture to the anterior margin of the fibula to make sure the wax fragment is in place and then I can fix it from behind, can fix it from the front or both to make sure that everything is in a nice place. But uh most of the time I really start with the posts because what, what you see more often than not uh uh people do the media medial later, then they try to fix the posts from the front. You do not even see a step off because there's already a plate on the fibula and screws in the tibia. So you, you stop guessing. Uh When you start with the post Nicholas, do you have anything to add? The, the only indication for an ap screw I find is when you put a nail for a tibial fracture and your posterior myo opens up. Then it has happened to me twice in 14 years. So then yes, I haven't. I II hate to put it, but that's a low energy injury. Let's put it this way. That's the only indication II agree. Once you reduce the posterior malleola, suddenly your ankle stops dislocated, you can see it, you can, then it's stable, then you can, everything becomes easy for me. That's the key. Thank you. There's another interesting question. Uh How about adding infra cellular correction on the medial side? So, medial slide osteotomy for deltoid and syndesmosis disruption, malunion or malrotation question to both of you. So uh in familiar would, would mean Taylor or Calcaneus. I do this uh in cases where uh it's typically not a mait ankle fracture. It's that chronic instability where the talus works its way towards the media melleus and uh towards the media uh tibial platform. And uh sometimes it even creates deformity and the lateral side goes unstable. And when you do weight bearing films, you see that it the tibial platform is not varied, it's straight, maybe there's just a dimple on the medial side, but the talus tilts and the Calcaneus of course goes with it. In those cases, cases, I do the correction but the deformity is below the malleoli at the Calcaneous level. And then I do that uh Korean style osteotomies or oblique osteotomy, um sly to close the ankle, more ties and to gain some stability. Still, the x-ray will look weird after that because the, the cartilage has worn on the medial side and it will not be restored by that procedure. But uh if the, if the deformity is really in the submalleolar level, then of course, you have to correct there. I have no personal experience of a, of an infra osteo on the medial side. But II agree the concept and the rationale is is correct uh of what Stefan just I think what they are asking is, you know, sometimes you get deltoid um deltoid injury and you get valgus deformity. So they are saying that can you do a calculon? No, to me, that's what I get um uh to do a medi medial side calos toy. If they've got a valgus deformity due to deltoid injury, II showed I watch out for them, I watch out for them, but I rarely see that uh after malleolar fractures, it can happen uh in, in flat feet uh in a severe stage four flat foot. But uh I have yet to really see that in um in a malleolar fracture. So the, the valgus deformity typically uh is the, is the uh the, the culprit is the fibula if the, if the anchor goes into valgus and then the talus shifts over and then typically, the correction is uh at the level of the lateral malleolus and then the medial side closes. And of course, if it's a long standing deformity, you have to clear it out on the medial side, arthroscopically or open and then the talus will come back. Thank you. II agree. Another one. Yeah, good. N because this is question directed to you. So there is no fracture and patient had an MRI scan and it shows that the anti inferior tibiofibular ligament is disrupted, intra membrane is damaged as well and there's possibly a sprain of the posterior tibiofibular ligament. You do weight bearing x rays, the ankle motor is intact but there is a little bit less overlap between tibia and fibula or, you know, hardly an overlap. What would you do in these situations? So, well, that was not the topic of this talk because that was in this mosis disruption associated with ankle fracture. Here we uh talk about uh these questions about a severe high ankle sprain. So uh I would I have not seen one where II should uh let's say uh fix it acutely. Uh If I have a patient who is in a lot of pain after an ankle sprain, I uh I'm suspicious of a high ankle sprain and I treat patients non weight bearing in a boot uh for, for a bit longer and to watch them carefully do an MRI scan at around six weeks. And then I decide usually by that time, the symptoms have uh reduced a lot. So I uh it's a different topic. Yes, there are some rules. You do arthroscopy to assess them. And if the uh symptoms is really unstable, you can stick the scope in which is about 44 millimeters wide. Then, uh, that's an indication for uh fixation of the syndesmosis with screws or tiro. But that's a, a different topic. I would say it's not, it's not, we have to start from the beginning not to confuse us with what we said today. Now, that topic was syndesmosis injury associated with an fractures. So that's fine. Um Last question, I'll try to summarize two questions. So two people have a similar things. So one of the question is that should we be fixing postular fractures in older or frail patients? And the second person who asked that if patient has got lots of comorbidities such as poor vascularity, neuropath, poorly controlled diabetes, does your um treatment plan changes? So you both of you can start n because you can start first for both of these questions, old patients, postular fracture and neuropath or vasculopath. So if it's a geriatric patient with a fracture dislocation, I would consider primary hindfoot, nail fixation for the fracture. So the same way with hip fractures just to get the patient up and moving. So put the nail for the patient to start weight bearing if it's an 85 or 90 or so, this is a consideration for, for these patients. If the patient is treatable or if the skin is very bad, et cetera. So if the patient is suitable for open reduction, internal fixation, I could do the same. If the bone is osteoporotic, I would consider. And if you put a AAA fibular plate, put in lots of screws from the fibula to the tibia for better uh fixation for purchase. So use more metal, stronger construct in in diabetics. Uh So it's two different things. Is the patient suitable for open reduction, internal fixation. Can they cope with postoperative? Is it worth coping with postoperative nonweight bearing status, et cetera? Yes, you open reduction sternal fixation in the, in the same way. If not do I, I would say the same. It's not about age, it's about uh the health of the patient. So the comorbidities uh are those who define the prognosis and also define your approach. So if it's an 80 year old who wants to uh hike with the grandchildren, I would do the same as uh for a 20 year old. If it's a 70 year old diabetic with neuropathy, I would go for a hindfoot nail and hope he gets at least a fibrous nonunion that he can walk on with a, with a, with a orthopedic boot. So it is really the comorbidities that dictate what you are doing. And of course, if they are bedridden, uh and uh if they're not able to comply with anything, then you should consider those uh measures doing nothing. I don't think it's a good option. Tho those people don't do well in the cast, they will get ulcers, they will get, uh, thrombosis. So you have to do something. Uh, and it's, uh, I think it's dictated by the functional amount of the patient and its comorbidities. Yeah. No, thank you. No, I get the message. I think the person who has asked this question has, uh, taken into consideration a trial. We had, uh, in UK, uh, ankle injury management trial, um 60 years uh or uh uh above and uh open internal fixation versus um total. Um The cost, the molded cost for, for, you know, uh for a three point fixation and the results of that trial, they came and the results were not dissimilar. Clinical results were not dissimilar having said that radiological results were different. But I think it's very crystal clear from your talks that if you can, then you should go for anatomic reduction and that sorts out or, or, or takes away the issues which we later see with malunion. So do it right in the first place is the message both of you have given particularly in osteoporotic uh fractures. Uh If otherwise patients are healthy, then with posterior plating, you can get a lot more stability and get the patients back. So according to this trial in five years from now, nobody would fix my ankle. Um I would not like that. I get it. I was thinking whether to ask the question or what anyway, questions are there to be answered. And I think it's important that you've given the message to our audience. We have really enjoyed. There are lots of messages saying that the talks were great. Thank you very much. It was a great session and I'm sure we'll receive formal written feedback as well. Um So thanks everyone for joining us. We are going to put this uh session to an end. Uh I would like uh Stephan and ncos and the bofa's uh it team to stay back, so we'll just have a catch up but um goodnight everyone else and uh we'll see you for the next mas technique se session very soon. Thank you.