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Lawrence A DiDomenico, DPM discusses the techniques of anchoring used for foot and ankle surgeries, the types of anchors available, the principles of insertion and applications of specific types. Dr DiDomenico also reviews relevant research and literature, and details cases that maintain his discussion.
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Male Speaker: Okay. Welcome back from lunch. Again, thanks for inviting me to participate in this meeting. Harold asked me to talk about anchoring techniques for the foot and ankle. As you can see here, there’s a interference screw on the X-ray. That’s an absorbable screw. And there’s other different types of anchoring devices out there. We’ll try to go through and review the literature and I’ll show you some cases for review. For foot and ankle surgery, tendon transfers are things that I use anchoring devices for or allogeneic bone block type of tendon transfers as well as ankle stabilizations. In fact, using tendon transfer is there as well as FHL transfer or actually any transfer or ligament transfer or anchoring that you use in the foot and ankle. Different types of devices available are sutures and different needles out there more traditionally over long periods of time. Interference screws are certainly been tremendously popular in the last 10 or 15 years. Particularly in foot and ankle surgery, I would say last 5 to 10 years. They proved to be very, very strong and predictable in their results. Bone anchorage has been around now for a number of years. There’s many different anchorage out there in the market. Then there’s your suture buttons or washers or spider washers that have been around for quite some time and even staples. A lot of the old and the new that is out there for you to choose from. Then you can look at different types you have. You have your metals and non-metals to choose from. You have the absorbable or non-absorbable type of implants. Then screws or press fit type of devices, barbed fits implants as well as suture anchors. And there’s even these newer knotless anchors coming up. So Rosalyn put this lecture together for me. Looked at the internet and just pulled up a conglomerate of what you can see is out there on the market in terms of anchoring devices. There’s many different types that are out there. The principles of the assertions are whether you’re doing a cortical bone or cortical cancellous bone, where’ you’re going into. You wanted to think about that when they’re deciding which kind of anchoring they’re going to use. Again, if you look at the periosteal attachments, are you using the absorbable sutures and non-absorbable sutures and the knots? Again, you want to keep those knots small and buried because most of the skin around the foot and the ankle is very thin. Therefore it’s necessary that we don’t have a suture reaction or spitting of the sutures when we bury those. If we’re using anchors or interference screws, the larger screw, the bigger screw you put in there the stronger it is going to be. If you’re using anchors, if you put them in directly in there, the pullouts is going to be more easily rather than if you have an angle as demonstrated here on this photo. The key thing to watch out for is not cutting the suture onto the bone. If you’re going too deep with the anchoring and it’s angled as you see at that 45 degree angle, the pullout is harder, however, though, your anchoring suture material can get cut from the bone itself. One has to be careful of that when employing these types of anchors. Where does anchors fail when they do fail? The suture is the weakest link part of a construct. It’s very necessary to be aware of that. Over-tightening can be a problem or putting too deep as I already spoke about. Cutting of the sutures at the islets can occur. You can obtain frame of the suture at the edges of insertional hole. Again, the pullout being one of the reasons that you need to be careful, but they’re certainly be failed from a pullout as well. The next generation of anchors coming out now are called soft anchors. Really what they are is a technology of just a suture-based anchoring system. It appears to be very, very friendly. Studies out there demonstrate that the load to failure in both cortical and cancellous bone is more or so than 3 millimeter anchors. I think you’re going to continue to see more development occurring with this soft issue or soft anchoring device. The questions surgeons often have, is what about absorbable implants? What about the foreign body reaction? Is that a big concern? Most of the industry claims excellent biocompatibility. Personally in my practice, I’ve not seen a problem with using those absorbable implants. Initially on, I was concerned about that but I’ve not seen anything to this point and I’ve used quite a bit of interference screws off for that matter, they’re absorbable. They’re probably easier to revise because there’s no hardware to remove. You can start to work around them, or if you need to core those out you can core them out. That depends how soon. The revision may need to be done. If it’s already pretty much dissolved, then it’s not an issue at all. Therefore, again, make the revision possible but easier. Then it won’t show up on an X-ray or a MRI if you’re a several months out. That could be a pro or con based on what time and length that you’re discussing about the absorbable implants. That can be a pro or con based on where you’re at.
And you can look at uniform properties. Pierce Scranton did a study here in 2005. He did five separate suture anchors with 12 tests for anchor. What he found is at least two anchors in each group of the 12 failed with minimal force. His conclusion was, really, you should put two anchors in per construct to give you a security with your anchoring devices. Brandon Donnelly also looked at using bioabsorbable interference screws and tested the drill size for a 5.5 interference screw. He used the 5.0, 5.5, and 6.0, and there is no really statistical difference in that in terms of pullout strengths. Really as long as you’re close to the size of your interference screw is really the bottom line what matters. Remember with interference screws, the bigger your screw is the more stability you’re going to have. From a tram application, the study demonstrate two lag screw fixations of a calcaneal avulsion fracture with a lag screw and bone anchoring augmented distally. What it showed is that the load at failure of lag screws with anchors was a higher or more stronger construct than just the lag screws itself. Here you can see a little bit more impact to your construct, really, will help you out from a testing standpoint. Then in this study, you look at tendon-to-bone and tendon-to-tendon comparison. The load at failure for interference group was 148 newtons and the load at failure for tendon-to-tendon group was 79. Those numbers are so strong. There is no clinical significance in terms of what you need to have from that standpoint. It really depends on what you’re putting in and how you’re putting it in. They look at in 2006 comparing into our tendon suturing versus a bone anchor fixation for FDL transfer. What they found is there’s no significant difference in strength between the two groups in this FDL transfer, but what they cited was the pros and cons were that there’s increased amount of tendon length needed to have this interosseous tendon and wrapped back on itself. So you need more length of the tendon. That’s the downside. It means more surgery more dissection and more time in OR. If you look at the interference screw, there’s increased cause for that. You have to sort of weigh out the options what you think your patient would best do. For this FDL, it probably makes sense, maybe used to a quicker type of procedure a shorter length of your dissection and giving to the implant itself. Really you start talking about interference screws, which I think is really probably the most popular type of anchoring device or the most predictable type of anchoring device out there now. It’s based on the success of the ACL ligaments from the knee world, and it’s really slowly transferred over into the foot and ankle world. It really helps us a lot with tendon transfers and ligament anchoring if you will. In 1983, Lambert presents a surgical technique for fixing the ACL ligament reconstruction grafts. The graft is secured with a screw by side-to-side compression against the wall of the cancellous bone tunnel. As you see in the calcaneus, there’s a lot of cancellous bone. So you want to put a large screw in here and you want to compress this tendon or ligament whatever it is that you’re trying to transfer, in our case it’s a tendon. You want to have a lot of bone surface area of cancellous screw with that. In Lambert’s initial paper, it shows you right here. There they have the graft. It’s being compressed, if you will, in the bone tunnels and sort of squeezed in there with a screw holding it in place. Now, initially on, I believe they used all metal screws to use this. We’ll come back and talk about that in a second. This technique allow for modulation and appropriate tension of the grafts. That’s a nice thing about these interference screws, which I’ll show you a demonstration. You can put the maximum tension that you feel like you need physiologically on that area. You lock it in place and not being able to get that same amount of tension with other products other than an interference screws. For me, I feel very comfortable doing that, particularly if I’m doing an FHL transfer, if I’m doing a lot of ankle stabilization using tendon graft. I could anchor and tension that exactly how I want and you can be pretty secure what you have on the table when you leave the patient. In this study, they talked about tested strength of a 9 millimeter interference screw, which is quite large. In the foot and ankle, the calcaneus in the area where you could use a 9 millimeter screw. They compare it to staples. You look at suture button techniques. You look at 6.5 millimeter cancellous screw techniques. It’s 9.0 millimeter and interference screw provides the greatest strength of fixation. Again, the larger the screw the more stability you’re going to have with it. In 1996, Pierce Scranton described a technique in which used a hamstring tendon graft without bone plugs. Because historically, they’re using the bone block plugs with the tendon graft from point to point.
Pierce was one of the first ones to describe this, really using this fixation technique without having to have bone plugs associated with it. In the success of fixating soft tissue grafts without bone plugs directly to the wall of cancellous bone tunnel, has given rise to many variety of similar orthopedic techniques and then particularly in the foot and ankle. If you look at it here, lateral ankle stabilization, FHL transfers, FDL transfers, and again, like a split, tibial centric tendon transfer. These are type of procedures I think that are commonly used where you may consider using interference screw. Really what it has to be is the bone size has to be adequate to hold a inference screw. Different companies have different size screws out there. Some have very small ones and some have very large ones. Based on where your anatomy is and the size of the tendon that you’re passing through is the key. As you can see here, these come in different screw compositions. There’s different type of materials out there. There’s different shapes. There’s different diameters of the graft itself. There’s different diameters of the bone tunnels, diameters of the interference screws. They all need to jive together in terms of your diameter of your graft, your tunnel, and your screws. Then the length, the more the length you have the more stable you’re going to have, it’s going to be more predictably a stronger type of a construct that you have. You may say, “What do I use? Metal or absorbable implants?” You may think, “Well, I like seeing a metal and I feel more secure seeing a deeper hardware in there.” It’s really a dealer’s choice but we’ll talk about that in terms of the drawbacks of the using non-metal devices. Sometimes the metal is known to migrate outside the bone tunnel, because that means that implant has to go directly in there. One of the problems are the screw threads of the metal implants are so sharp. They sort of raid that area and losing your bone tunnel to some degree. One other problem you see with this, screw threads lacerate the graft, sometimes will cut the graft. As you’re putting it in there, they’re so sharp sometimes they’ll cut your graft even before it’s completely inserted. Therefore, your length may be altered and if it gets cut you may find yourself in a bad predicament there. Myself personally have gone away from metals and using more the absorbables because this has happened to me on several times. One other downside is once you have your implant in there, metal, it will interfere with your MRI where you get that scattered type of a look to it. Again, if you look at the metal and absorbable strengths, nearly equivalent in strength because the metal and the absorbable with the interference screws are about the same. There’s no great change there. If you look at the screw thread shape, the initial metal interference screws, was designed for compressing the bone plugs of the patellar bones. Again, that bone-to-bone contract, if you will, into different areas. That’s why they were so sharp. This is designed for the bone-to-bone fixation. This is where the downside is with the metals now. Sharp screw threads increase and weaken the tendon graft. I forgot to mention one of the companies talked about their wire or their suturing material being very strong and also had metal implants cut my suturing material as well. Be careful if you’re going to use the metal interference screws. They are potentially dangerous in some respects. Then if you look at metal and bioabsorbable interference screws with rounded threads, they reduce the risk of this problem that we’re talking about. There is some security if you have more of a rounded type of edge there. Now we’re going to look at the effect of the graft diameter, the bone tunnel diameter in the graft and the screw diameter. Because again, those are three things that really have to jive. And depending on what implant companies are using, some have a nice measuring device for you to measure the size of your tendon that you’re implanting is sort of correlates with your drills, for your tunnel, and also for your screw size. You wanted to be as close as possible and you want your drill hole to be a little bit smaller than your screw size forcing to get compression. But if you have it too small, it can also cause problems as well. You can’t just randomly do what you want to do or think you want to do with a good predictability. You need to really stay within the systems that the companies provide. The greater fixation strength is obtained when the drill hole diameter more closely matches the tendon and the bone plug diameter. Again, that goes along with the systems. If the drill hole is too small, the smaller diameter, the bioabsorbable interference screws may not withstand the insertion torque that’s needed and/or cause a fracturing of the screw itself or even a fragment into the bone tunnel. You have to be careful and you really want to stick with a system. And Louden looked at comparing the fixation strengths of tendons placed in drill holes of two different sizes.
You look at the FDL and FHL and their drill holes are closely approximate to the diameter of the tendon and the interference screw should closely be approximate the diameter of the drill holes. That’s a take-home message is that that tunnel that you create, the size of tendon in the screw can be very, very closely matched when you’re inserting these. Now getting back to length of screws, the longer the interference screw the greater fixation strength you have. That goes to say you’re getting more purchase and you’re going to obtain a more stronger construct with that then at a rather a shorter screw when you’re using this. If you look at screw lengths and then the type of bone you’re putting in, the cortical cancellous versus cancellous bone is different. Your strongest construct is the longer the screw again in cancellous construct or insertion versus the cancellous insertion. That’s going to be your strongest construct. You may ask where does it change clinically? I’m not sure anybody really knows but a lot of different tests have been done, and the laboratory has given us guidelines to keep these ideas back to your mind when you’re inserting these different screws. In terms of graft preparation, this is very important too. A lot of people use a whipstitch type of technique. It’s basically like a Chinese finger trap. Basically, you want to make sure you get a significant amount of your tendon and also be your graft site going into the bone tunnel. You want to make sure that’s nice and firm and you want to have enough length for that. The other thing you have to make sure is you don’t get accordion affect on it. So it’s still stable and still tubularized in some degree. Because if you get this accordion effect, it’s going to sort of get squashed inside the bone tunnel and therefore it may not go directly in there and then you’ll start fighting yourself and you couldn’t leave the problems. Very important to take your time in preparing that tendon with the proper amount of suture itself. The size in specific chemical composition of implant in terms of by absorption of the body’s immune response to such foreign material. Personally, I’ve thrown in a large number of these, I believe, and I have not seen it. The studies for the ACL really have some larger series there. That’s where most our work stems from. That’s really not been an issue, but obviously there’s always been issue at anytime with any patient. But in general, that’s a relatively safe or very predictable again with that in terms of how the body reacts to it. Now if you look at bone remodeling of the site of the biodegradable interference screws and you get a nice osseointegration occurs between 6 and 15 weeks after surgery. MRI and plain radiograph studies performed on average of 5.2 years after ACL, this again in the knee. After an ACL reconstruction demonstrate no evidence of cystic or osteolytic changes in the bone tunnels. The MRI studies show bone remodeling and new bone formation at the site of implant in both the femoral and tibial bone tunnels. This is done in the knee. I think you can summarize and take this material and look at in the ankle as well. If you look at the strengths of interference screws, again, overtime as you’ll see here there’s a gradient of different times at time zero, at six to nine weeks, and 24 to 52 weeks. The longer you’re out, the more secure it is, the more stronger your construct is. As far as the remodeling of it in terms of boney changes, as you can see it further out, the more osseointegration there is the more the changes occur making this all one solid unit. Therefore it makes a stronger pull because it integrates it very, very nicely relatively speaking. Again, in comparison to other tendon fixation strengths, here the study looked at comparing the strength of interference screw with that of a suture button fixation and the staple fixation. Here you can see the interference screws significantly more powerful than the others as you can see in terms of newtons, again, predictability for your construct is what you’re looking for with your patients. I think a lot of this has to do how soon can you get them to weight-bearing, how soon can you get them recovery, how soon can you give them a therapy. There are the advantages. Certainly if you put anybody into cast for two months, you can certainly probably end up with the same result, but can we give people moving quicker is our goals. These are type of things that you want to sort of shoot for when in fact you’re doing these type of surgeries. Interference screws are proven to be valuable, reliable means for securing soft tissue grafts and the cancellous bone tunnels is well documented in the ACL literature. Again, it’s transforming over to the front ankle. Again, several techniques that we have already mentioned, work very predictably very well. I know a number of different folks using around the country. I think it’s their first line of anchoring technique because of the predictability in the tensions rate that you can obtain when performing these transfers of these patients. If you look at anchors, just regular bone anchors versus interference screws, you conclude that the interference screws are stronger for tendon transfers, again, much more superior in strength for these.
Then another one looking at interference screw versus anchor. And that conclude interference screw stronger at the ATFL ligament reconstruction in their studies here. Multiple studies, multiple area showing you that the interference screws are pretty significantly a much more stable construct. If you start looking at transosseous suture versus anchor, and here this is done in a rotator cuff. It’s a shoulder study that was done. They compared pressure distribution of a bone anchor with transosseous suture in rotator cuff surgery. They found that transosseous suture creates greater contact area and a larger pressure distribution as compared to a bone anchor. That makes sense because now you’re bringing the tissues through a tunnel and back up around itself, and you have much more bone contact there versus one point of fixation. Again, getting back to Scranton’s one article we talked about leaving, at least you need two points of fixation if you’re using bone anchors. It makes more sense to have that. Then this study done in foot and ankle in 2012, compared the bone anchor versus transosseous suture for modified Brostrom procedure. Now, the problem as I have a hard time understanding how they did a transosseous suture technique for Brostrom. I’m not really sure how successful, if I understood that very well. But really in this paper that you came out to conclusion, there’s no significant difference between the two groups. I’m not really sure if they can really get a true transosseous type of suturing up. I’ll take you through a couple of cases to show you here’s a relatively young guy who’s just walking down the street in the middle of the night and minding his own business. And somebody robbed him and then shot his foot. His entrance wound is proximal, his exit wound is plantarly. His X-rays, he had shuttered his base of 5th metatarsal and his peroneal brevis tendon was completely gone by the time you debride out all the boney fragments. Again, this is an open fracture, high velocity type of injury. But after cleaning him out, debride him and getting the patient on appropriate antibiotics, basically what we end up doing is an old-fashioned spider washer because the tendon was split quite a bit, it was frayed and try to advance it down. And this is just an old-fashioned technique using a spider washer catching a large amount of surface area. There wasn’t enough tendon here to grab a whipstitch because you need a significant amount of length in order to create a bone tunnel. In cases like this there isn’t any, so we just put a spider washer on here, put a whipstitch on his open wounds to make sure he won’t be infected. Then eventually the guy went on and did very well with no infection, not a problem. We reattached his tendon near the base of the 4th metatarsal instead. Here’s a patient who had a significant calcification. As you can see on the AP view, that large mass that you’re seeing over here is a calcification of Achilles, which you see here. It’s quite large. Basically when they took it out, it’s really stiff as this wood on this podium. This whole thing needs to be cleaned out. When performing an FHL transfer, I was taught, from a guy [Indiscernible] [23:04]. He told me to be very, very aggressive when you take out your deceased tendon because that deceased tendon is an inflammatory marker and that’s what causes patient’s pain. Inherently he goes against what we want to do is to keep the Achilles tendon intact. And it sort of makes sense because it’s almost like debriding a wound. You want to get all clean margins and you want to get rid of all necrotic tissue. You want to get rid of any of the dead tissue. It’s hard to do it but you’ve really need to take out a wide, wide aggressive resection of this tissue. And you have to rely on your flexor hallucis longus tendon, which works very, very well. As we know it’s the second strongest tendon in the lower extremity. It makes sense and move forward with this. Basically what we do with this patient is took out this big old chunk of Achilles tendon. I can promise you, there’s no flex in there as you see my finger grabbing this. This is stiff as a board and it’s useless to leave any part of that in there. Take out as much as you need plus more and have your nice defector. That’s what the FHL tendon transfer is for. Here we did this patient a number of years ago. Here you can see when one performs an FHL transfer, once you get past the Achilles tendon you have that deep fascia layer that you have to cut through. Once you get to the deep fascia layer, you’ll see this very rich blood supply of low-lying muscle belly. The idea is this is the second strongest tendon as we said in the lower extremity. You have strength here but the vascular-rich area and particularly if you want to do tenodesis of any kind to relatively a vascular area, this really makes it very nice. As you can see, the calcaneus is quite low but you can see the amount of muscle that is there in this region that really helps revascularize that area, if you will, when performing this tendon transfer. Here is a short harvest. You can see there’s plenty of length by doing the short harvest. What do I mean by short harvest? I described two different types of techniques when harvesting the flexor hallucis longus. You can do a long harvest so you go into the mid-arch and cutting the FHL right proximal to the master knot of Henry.
Second is the right as it goes into the tarsal tunnel, cut it just short of the tarsal tunnel, that area, the adductor canal and along the medial malleolus area. You can pull that plantar flex of foot and pull up on FHL, contract FHL and cut it and you can get this kind of length. So you have plenty of tendon graft to go ahead and insert into the interosseous tunnels. Basically here you can see in our movie video just outlining Achilles tendon. If I’m doing FHL transfer I’m going to stay a little bit medial to stay away from a sterile nerve and more on the medial border of my Achilles tendon. And here’s when FHL is intact. The foot’s plantar-flexed. You can see by pulling up on that, plantar-flexing the foot, and pulling up on FHL. Muscle belly will contract that toe and allows you to get as much length as you can without going into a long harvest, which takes longer in surgery and there’s more dissection. There’s of course more potential problems and more morbidity for the patient. Clearly, this makes more sense and using interference technique allows you to use a short harvest which is a quicker surgery and again less morbidity for the patient and less risk for you as a surgeon. Basically here it is. This is formed in a whipstitch or if you want to call the Chinese finger trap, however you want to look at. There’s a Krackow’s stitches, several different types of stitch but the whipstitch seems to be the most popular. Basically what you want to do is tubulize that and make it nice and stiff. If you want to get about an inch to 2 inches of that so that whole braided area is nice and firm when you put it in your interosseous tunnel. Here is using an arthrex system. It just happens to be an arthrex system, so you can measure right of the top, it gives you an idea which are millimeters of diameters is for your tendon size. Again, we can correlate our bone tunnels and our screw size, to match up with our sizes are going to be. Then right here is our guide wire down the middle of calcaneus. You want to be medial or do you want to be lateral. You don’t want to fracture calcaneus. You might want to do some serum check a calcaneal axial too, to make sure you have this place is perfectly where you want. And you want to try to mimic where the insertion of Achilles is posteriorly as possible they’re being too anterior so you realign your insertion more naturally. Then you drill over top and you correlate this is going to create the bone tunnel, and you correlate your drill size over top of it in accordance with the size that you measured. Again, most of these drills, no matter what company has used, has more markers on there so you can drill to your length that you will achieve whether it’s 20 millimeters or 25. You can see where you’re going or you can do it under flouro which is really dealer’s choice on how you handle that. Then here’s a guide wire as to where you’re going to put your interference screw over. And somebody’s going to pull the FHL tendons through the plantar aspect to the foot under appropriate tension. And you’re going to set the foot at 90 degrees or 5 degrees plantar-flexed or wherever it is that you think it needs to be. And I want somebody back here just lying on that tendon. I want really good strength on that, a physiological tension on there and I will put my screw in there to button up. This is what it looks like, so you could see how the foot at 90 degrees. And you have tension on that tendon as you’re going on. Here’s somebody who has not respond to a retrocalcaneal exostosis with calcifications in their tendon itself and you get MRIs, to show these little micro tears. So somebody like this are going to take off of that bump, debride that tendon, again, perform a wide aggressive resection. And here is my drill guide and drill as you see going down, you’re measuring to where you think how long you need to put the screw in here. Here’s a bioabsorbable screw. You can see its length, it’s pretty darn good. And the longer and the bigger, the stronger it is for this. Again, check reactions to make sure you’re not in trouble in terms of your location. Here’s somebody with clearly a disrupted anterior talofibular ligament as well as calcaneofibular ligament on stress. Here you can see the interior drawer in the inversion stress test showing you this patient is completely unstable. Here we did a two ligament technique. Here all I’m showing is how to do the whipstitch. This is a striker product using the system. And basically you need three hands, somebody to hold the Allis clamp. And you just continue to use the whipstitch and create this Chinese finger traps if you will. It’s a slow process but I think it’s probably one of the more important processes when performing this to make sure you get enough lengths and you’re getting that stability and that tubularization done so you don’t get that accordion effect when we move in there. Then as you can see, the new graft just come around to replace the ATF and replace the CF ligament, and then put it into body of the calcaneus coming down that way. Over top of the remaining peroneal tendons there, so this also acts as a retinaculum.
It’s a two ligament replacement technique. Here is a guide wire. Here’s guide sleeve. Put it in the middle of calcaneus. You can do this under flouro or you can check under flouro once you’re done with it. But basically, this is your guide wire and you’re aiming for the central body of the calcaneus and you want to try it for posterior or relatively close to posterior aspect. And be careful not to drill your partner’s chest there. As you see, it pops right through. This guide wire has nylon on it. Basically, here’s the cannulated drill. Again, it has markers on it to drill over top of it so you can measure the length of your screw. Again, kind of what you feel deemed is necessary in terms of how deep you want to drill this, so you can see the length of this screw insertion, what’s going to be. Here are wire pores. Basically what’s you’re going to do, the suture is in the islet and this now pulls the tendon graft through the bone tunnel. Typically what I have is a hemostat wrapped up. Like I said, I want somebody to sort of water ski and lean back on it. I want really nice physiological tension. I want somebody else holding the foot exactly where we want it whether it’s 90 degrees or minus 5 or plus 5 whatever it is, then as simple as this. Here is the guide wire. That’s a cannulated absorbable screw. You can see my ligament construct there. Then basically, here it is, just putting this over to this cannulated area. Somebody’s holding a foot as you notice that. Somebody’s pulling the fiber wire tension, very, very nice and tight. What you’ll typically hear with this bioabsorbable material, hear squeaking, and you’ll know that purchase is very, very good. It makes a nice squeaky sound and it gets tighter and tighter as you go in there. Again, you want to make sure it’s recessed all the way. And again, I advice you to use intraoperative fluoro but check your alignment each time with one of these screws to make sure you know where you are, make sure it’s seated deep enough in the main body of the calcaneus. Then simply you just cut the fiber wire on the plantar-flexed foot and put some tension on it. That’s what you get by doing that. And here we’re pulling the guide wire through and then you cut the suture. Thank you Harold and Guido and Bob for inviting me. I appreciate you all coming to this conference. Thank you.