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CME Trauma & Sports Medicine

Common Ankle Fractures - Don't Forget the Syndesmosis

Louis Ciliberti, DPM, MS

Louis Joseph Ciliberti, DPM, MS discusses the diagnosis and treatment of ankle fractures. Dr Ciliberti reviews multiple cases while providing clinical pearls and treatment options for both simple and complex fractures.

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Goals and Objectives
  1. How do surgeons evaluate common ankle fractures?
  2. How do surgeons evaluate the syndesmosis and confirm disruption?
  3. How do surgeons treat and repair the syndesmosis?
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    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Louis Ciliberti, DPM, MS

    Foot and Ankle Surgeon
    Pennsylvania Orthopaedic Center/Premier Orthopaedics
    Malvern, PA

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  • Lecture Transcript
  • Male Speaker 1: Next talk is going to be given by a gentleman who we had the pleasure of listening to yesterday, Dr. Ciliberti which I also had the pleasure of going to dinner with and sharing a lot of our experiences in foot and ankle surgery. At this point, he’s going to give a talk on common ankle fractures. So please welcome Dr. Ciliberti once again.

    Louis Ciliberti: Okay. Hello, how are you all? Thanks again for the opportunity to speak. So, we’re going to talk about common ankle fractures and one of the big things that I’d like to emphasize is the syndesmosis. Dr. Schoenhaus beat me up a little bit last night, so bear with me with my voice. Something that is really kind of near and dear to my heart, ankle fractures, trauma, that’s predominantly what I do up in Pennsylvania and see a lot of ankle fractures and really try and emphasize with the folks that work with me and the residents and the students to not forget the syndesmosis because it can be devastating if it’s forgotten. It can be off by only one or two millimeters and have a devastating result so it’s important to really keep that in mind when you’re evaluating these fractures. So disclosures, no disclosures. I hear some examples of some ankle fractures that I’ve seen and one isolated syndesmotic rupture. So learning objectives. How do surgeons evaluate common ankle fractures? What are the things that we do when we’re considering treating an ankle fracture? How do we evaluate the syndesmosis? How do we confirm disruption and how do we treat and repair the syndesmosis. So here you can see some examples of some ankle fractures that I’ve done where we’ve obviously had a syndesmotic disruption and it’s needed to be addressed. I think it’s really important when you initially evaluate ankle fractures, assess the neurovascular status. I really feel that in recent years for whatever reason, this is something that a lot of physicians, a lot of residents, a lot of students can seem to forget. I can’t stress enough even with some of these minimally displaced ankle fractures that you can oftentimes have neurovascular compromise. I’m a big fan of mapping. I know we kind of talked about it yesterday. I’ll often use it to basically evaluate the vascularity of the limb. I’m always impressed with pre and then post reduction, the difference that you’ll see in audible signals. When it comes to biphasic, triphasic, I have difficulty evaluating that and maybe that’s just me. I’m looking more for audible signals, are they strong, are they weak and how do they change pre, post closed reduction. This is an example of someone that obviously had an ankle fracture that was closed reduced and we try to maintain the reduction with external splintage and a posterior splint and protecting the soft tissue below. There’s our definitive fixation following ORIF. This is an example of an ankle fracture dislocation, so this was actually one that did indeed had vascular compromise. We went ahead and closed reduced this and then fixed it. It’s important that you address this. I always try and emphasize this as well. I have a systematic way. The way I do everything, I do systematically. I do every case the same way every time. Absolutely, we have little bumps in the road that we need to overcome. But having a checklist and just going through that checklist with every single case, I think gives you have a better outcome. Noninvasive vascular testing, I’m using this more for an example. I have gotten this before with some ankle fractures that I was on the fence about whether or not I was going to fix them. They say well, getting an ABI at the ankle, that’s going to be really painful for the patient. It definitely can be but you need to evaluate the vascular system. If you have an ankle that you’re on the fence about, am I going to fix this, am I not going to fix it and you’re concerned about the vascularity of that limb, you need to decide first and foremost if it’s a limb that you can indeed operate on. Noninvasive vascular testing, I will sometimes use with some of these ankle fractures. Especially some of our diabetic patients and then you have to consider other comorbidity states and hemoglobin A1c and these other parameters that we look at. After all, this is exactly what we’re trying to avoid. This is an ankle fracture that another physician in the area that I work at did and it was well-documented in the notes that the patient had nonpalpable pedal pulses and they never addressed it from that point forward. They just went ahead and they did the ORIF. Couple of the residents came to me in the morning, I usually operate on Wednesday and Fridays, and it was a Friday morning showed me these pictures. There’s really nothing more you can do for this patient. This particular person went on to get a below knee amputation.

    [05:00]

    It’s one of the reasons why when I’m working with the residents and students, I always emphasize neurovascular status especially in these folks that you’re concerned about, okay? If you have any inclination, it’s usually your intuition telling you something. So investigate it further if there’s any doubt. This is another way that I look at ankle fractures. I always look at ankle fractures as if they’re a pediatric fracture. I don’t know about the people in this room but I treat a lot of pediatric patients, we see a lot of pediatric trauma. When I first started doing that, I wasn’t very comfortable with it and it took me a little while to get used to that. I try and look at all of these fractures as if they’re pediatric. I feel that we look at pediatric patients differently than we look at adult patients. We tend to scrutinize them a little bit more and be a little careful with how we’re going to go forward. I always try and look at these fractures as if they’re pediatric fractures. Am I missing anything? I look at every angle. I look at everything, every bone. What am I missing? How do things look? How do the joints look? How do the bones look? What’s the alignment? This is an example of pediatric patient, right? About to end their pediatric career and joints at the growth plates are starting to close. One of the views that we’re looking at, we’re going to look first and foremost at radiographs, AP view, lateral view, mortise view. And then those different views, we’re going to assess different angles, okay? Does anybody see anything in these radiographs that looks unusual? Do they see any fractures? Right there, you can see a posterior malleolus fracture, right? Anything else? Salter-Harris injury on the distal fibula? When it comes to pediatrics as a side note, I don’t use a lot of CT imaging. I do use a lot of MR imaging. A lot of the current literature suggest that people under age 40, we should really limit radiation exposure because it increases the risks of cancers down the road. Mild ankle fractures like this with the pediatric population, I’ll tend to use MR imaging. If it’s a really bad dislocated ankle or Lisfranc, something like that then I’ll look to use a CT. But for the most part, I’m using MR. The other thing about the MR is it allows you to evaluate the syndesmosis and some of the other ligaments in that area. Very uncommon that you see pediatric cases when they have syndesmotic disruption, however, I have seen it. It’s something that you need to address and consider. CT imaging, we kind of talked about this briefly. It’s definitely an option when you’re evaluating ankle fractures. This is an ankle fracture that I saw. Here’s the radiograph. You can see the CT imaging just prior to that. I wouldn’t say a common ankle fracture but certainly an ankle fracture that may walk into your office. This particular person did have syndesmotic disruption and you can be suspicious of that when you look at the talocrural angle, when you look at medial clear space and just the nature of the injury, a large to low fragment. You don’t usually see them that big. This particular person, when I brought them to the operating room and stress them under fluoroscopy, they did have diastasis. You could definitely see medial clear space widening and abnormal tibiofibular overlap. I went ahead and did the fixation on the tibia and then I did also fixation on the syndesmosis for the ORIF. For syndesmotic injuries, I like to use a small plate with two screws. Alternatively, I’ll use one or two, just isolated screws, 4.0 screws. MR imaging, we touched on briefly. This is another example of MR imaging and you can see here, fractures in this pediatric patient, right? Fibula, distal fibula, lateral malleolus, posterior malleolus. You can use the MR to evaluate the syndesmosis. I’ll do this on occasion. If I have a patient that I’m up in the air about as to what I think the issue is, I’ll often offer them either MR imaging to evaluate the syndesmosis. Or what I tend to do a little more commonly and some people may be resistant to it is bringing them to the operating room and doing manipulation under anesthesia to really stress that joint and see if there’s diastasis there. If so, I’ll fixate it and do the ORIF. Diagnostic ultrasound you can use as well. I use that quite a bit. I have used it with the syndesmosis. It’s not something that I use often with syndesmotic injuries but you could certainly use it because of the dynamic aspect of it. Literature, keep this in mind. Anytime we’re doing any of these procedures, we use the literature to guide us in what we’re going to do. It’s not necessarily gospel but it can help us in how we’re going to evaluate and treat these folks. There’s lots of great landmark studies that are out there. Lauge-Hansen classification system, what is that going to tell us? Well, that’s going to tell us basically the type of fracture pattern that you have. You may be suspicious of a syndesmotic injury, right? It’s also going to tell us how to treat those injuries. There are other literature in here. Some of them, sorry about some of the calcaneal stuff slid in there. Another one that I’m really big on, the SPN, superficial peroneal nerve and also the sural nerve.

    [10:01]

    The SPN, there’s lots of anatomic variants. When you’re doing your lateral incisions on the fibula, lots of anatomic variants is that nerve pierces the crural fascia. This is a good example of it. You can see a branch of the SPN and it’s kind of difficult to see. Let’s see if we can. The SPN is right in this area and then it courses over the distal end of the lateral malleolus. Seen this quite a bit. I bet you probably with all the ankle fracture that I’ve seen, I wouldn’t be surprised if I’ve seen this about a dozen times where you see the SPN coming into an unusual area and coursing the distal lateral plate. So keep that in mind. Lots of anatomic variants with the SPN. On the other side, when you’re doing your medial malleolus, you’re going to look for your saphenous, right? That’s oftentimes right in the area where you need to place your incision. Also back on the lateral side, the sural nerve, something else that you want to keep in mind. There’s far less variants according to the anatomic studies that were done on cadavers with sural nerve. It’s usually about six or seven millimeters distal to the tip. I just thought I would include this and this was a pediatric ankle fracture that I saw and her mother was kind enough to go ahead and send me these photographs. We have lots of horse farms near us and we commonly see these horse injuries especially in the pediatric population. Here you can see her going down. When I initially saw this, really busy day in the office, when I initially saw this, I missed distal low fracture and you could see it clearly on the MRI. The radiologist that initially evaluated her in the ER missed it as well. Shame on me. What I did, I ordered an MRI because she had point tenderness when I did the squeeze test over the syndesmosis. It wasn’t the syndesmosis that was bothering her. It was that juvenile Tillaux fracture. Luckily, when I ordered the MRI, she came back into the office. I saw it and you can clearly see it here as it lights up. So again, this is just to really emphasize when you’re seeing these patients, when you’re seeing these fractures, don’t just look at the lateral malleolus. Don’t just look at the distal fibula. Look at the tibia. Look at the lateral tibia. Look at the medial tibia. Look at everything. This one is a little bit clearer. This is a young man, football injury. Most of my pediatric population, I’m a big fan of using cast. The other thing that I’d like to focus on and I often will tell the residents, you need to order some tibiofibular films and I’ll always look at the high fibula. Is there a high fracture? Is there a high fracture on the fibula? Anytime you’re suspicious of an injury, if you see medial clear space widening, an abnormal talocrural angle, see an abnormal tibiofibular overlap, order high films and see. Is there a fracture in the high fibula? Because they may indeed have one. This is an example. I always include this and I like to poke fun of myself for this. This is the first ankle fracture that I ever did on my own. The story behind this, I’m hoping I get some laughs out of you all. When I first did this, I was a resident in Texas and I had worked with another physician and we’re in the operating room. First time I had ever worked with him and this ankle fracture came in. I was one of the only guys there. I said, “Well, I’ll stay and help him out.” They didn’t have enough staff to help and this is at one of our VA hospitals. I’m going through the case, I’m reviewing the case and he comes up to me and put his hand on my shoulder. He was an older orthopedic surgeon. Really salty guy from Southern Texas. I started telling him about the fracture and I started using Lauge-Hansen classification. He kind of put his arm on my shoulder and he said, “Ciliberti, I have no idea you knew Lauge-Hansen is.” [Laughs] So we went ahead in and we did the case and he left me in the room. I did this case on my own. I was certainly nervous when I was doing it. You can see that there are lot of mistakes that I made, and what can we learn. I think there’s a lot we can learn from this x-ray. You can see that my plates way to anterior. You can see that I put screws into the joint. Is there anything else that you can see here? This needed a syndesmotic screw. I stressed him when we were in there and it definitely needed a syndesmotic screw. The surgeon didn’t think that it was necessary when he came back into the room. He’s like, “Just close it up, we got to go.” And so, something to keep in mind. Is there anything else that you see there? You can see, when I put my first screw in on the plate, does anybody know what I did? I went right across the fibula into the tibia, so lots of mistakes. What was missed? Here’s a good example of what was missed. This was an injury that came into the office that I saw an ankle fracture that was done a number of years ago. Patient came in with ankle pain. You can obviously see that there’s destructive changes to the ankle.

    [15:03]

    It was a syndesmotic injury that was missed in number of years ago. There’s really not a lot that we can do with this at this point. Okay, so this is exactly what we want to avoid. You can see the ostosis that is formed, where the syndesmosis is. You can obviously see this widening of the medial clear space. How do we check the syndesmosis? Commonly, what I’ll do is in the operating room, I’ll stress these folks under manipulation, under anesthesia and I’ll use live fluoroscopy and I’ll really stress the ankle in multiple planes to see if there’s widening. If I have any doubt, I’ll also sometimes use the contralateral limb and see if there’s any similarity to the contralateral side. But I will tell you, when we go through school and the things that we learn, we kind of overemphasize tibiofibular overlap. When I was a fellow, one of the big things that the orthopedic surgeons taught me was to not focus on tibiofibular overlap. You need to look at the whole picture. That is a really good point. You need to look at the talocrural angle, lateral talar shift. You need to look at the medial clear space. Many of people, if you see a lot of ankles and if you’ve repaired a lot of ankle fractures, a lot of people have what we would consider an abnormal tibiofibular overlap that is in fact anatomic. I caution you to just keep that in mind. It’s a really important point. I see it all the time. It’s something that you want to consider. A lot of our orthopedic colleagues take these in and they do manipulation under anesthesia. I’ve adopted that. I do it all the time. You manipulate the ankle joint. Stress it under live anesthesia, under live fluoroscopy with anesthesia and test that ankle joint. It’s a great way to do it and it’s a great way to document the fact that there is or is not a syndesmotic disruption. You can’t always rely on MR imaging or just the clinical exam. The other thing that we may do is use a hook test or you can see me using a bone hook to pull on the fibula after I’ve done my definitive fixation on the distal fibula. Sometimes it can be very obvious, as an example of one where the medial clear space is very wide. This person had disruption. Again, manipulation under anesthesia, manually stressing and manipulating the ankle via live fluoroscopy. Squeeze test. You know, we’ll often talk about this and we’ll kind of squeeze the syndesmosis in the office. It’s a good clinical exam and it’s a good way to have some suspicion of syndesmotic injury. This is an example of a college football player that came to me. It’s one of the first cases I did on my own. A guy comes into the office, I just got on my own and I’m like, “This is a great day.” Collegiate football athlete comes into my office with an ankle fracture. It’s just one of those things that you’d love to see on your first couple weeks out in private practice and this was the case with me. This guy came in and obviously had this high fibula fracture. What are we going to think about? Syndesmotic injury, right? High fibula fracture. What are we taught in school? Think about the syndesmosis. He also had a medial malleolus fracture. What did I do? I brought him to the operating room and I fixed the fracture, right? I fixed both two, both fractures. The medial malleolus and I fixed the fibula. What did I not do? I did not use a syndesmotic screw. What I will tell you is that I was absolutely stressing this ankle, believe you may. I did it more than once and this guy did not have a syndesmotic injury. The reason why, what I’ve seen and I’ve seen this following this case. When folks have a lateral blow to the fibula, they don’t necessarily have a syndesmotic disruption. You’ll see this in this type of an injury with football injuries, sometimes with hockey injuries. Direct lateral blow to the fibula does not necessarily mean that there’s going to be a syndesmotic disruption even with a high fibula fracture. This is a good example of that. Okay, so something to just keep in mind. But absolutely, when you’re going to fix these or bring them to the operating room, you need to document that you stress the syndesmosis and that there is no disruption. So this is just an example. I got away from the way that I was originally trained with medial malleolus fractures. We did those percutaneously. When I did my fellowship, we did them percutaneously as well. But also a lot of the orthopedic surgeons that trained me with open knees, and I’ve really kind of adopted that. I pretty much open all of my medial malleolus fractures now. I tell you why, the ones that were done percutaneously, I saw some take a while to heal. When you open these and when you see enough of them, there’s always that invagination of the periosteum and some of the deep tissues. Even some of the deep deltoid can get invaginated into that area clearing that out. I think it’s paramount. The other thing and something that you should all keep in mind is oftentimes, the deltoid ligament is injured and it’s very laxed. That can be deceiving radiographically because a laxed deltoid ligament can actually look like a syndesmotic injury. If you open these, you can evaluate the deltoid and at the same time, repair the deltoid with whatever technique you find appropriate.

    [20:03]

    Whether it be a cruciate technique or just a direct repair. For the most part, I tend to open all of these. This is an example. This is another one. This was probably about my first month out in private practice that I got called on which is a guy that I think still hasn’t paid me who, three years later or whatever it is, who was riding his bicycle and got hit by an automobile. This came into the ER. So we closed reduced it, put him into a splint and took him to the operating room. Here, you can see the distal fibula fracture. Here you can see the interfrag screws. There you can see application of the distal fibula plate. I used to use this large pelvic reduction clamp. The way that I was trained in Texas, we always use these big pelvic reduction clamps to reduce the syndesmosis. I was trained you can’t over tighten the syndesmosis. I disagree with that. I’ll tell you why, because I believe I’ve over tightened the syndesmosis before. Okay. This is an example of where I may have done that, right? Using a large pelvic reduction clamp, this is also an example. You see the tibiofibular overlap, medial clear space. This guy even after reducing it, you can see that the tibiofibular overlap is normalized, the medial clear space is normalized. That was syndesmotic screw that I used. I will tell you that I believe I over tightened this. You need to be cautious with that. I don’t use that large reduction clamp anymore and I don’t tighten them as much as I used to. Every time I do a syndesmotic disruption, I put the foot on my chest, I dorsiflex the foot. Anytime, I’ll throw my syndesmotic screw as I put the clamp on. I clamp down the tibia and the fibula and then I’ll place my syndesmotic screw under fluoroscopy. Try and go about a centimeter and a half of the tibial plafond and trying for a parallel with the tibial plafond and the ankle joint. This is a good example of syndesmotic stabilization. Again, what I want to emphasize is the over tightening aspect. Don’t crank down on this. Don’t over tighten them too much. I’ve done it two or three times. I really feel that you can over tighten the syndesmosis. I know some of the literature supports the fact that that’s not possible. I really disagree with that. One of the things that you’ll find is the late sequelae where we’re tightening that syndesmotic injury, these people will have extreme equinus. It’s very difficult to get them out of that equinus postoperatively. Okay, so syndesmotic screw placed about 1.5 to 2 centimeters above the plafond and you’re going to throw your syndesmotic screw at about a 30-degree angle. That’s what we’re taught, right? Well, we’re human and anatomically, we’re all a little bit different. Not necessarily the case, 30 degrees, it also depends on where your plate is placed and if you’re going to use the hole in the plate for your syndesmotic disruption. Okay. Or if you’re just using isolated syndesmotic screws, if you just have a short plate, whatever it may be, 30 degrees is not necessarily the case. Make sure that you get lateral radiographs or you go live with your radiographs and really look at the tibia and where your syndesmotic screw is going. What I always do, after I drill these, I disconnect the drill. I leave the drill bit in and I check under flouro and I look to see where my drill bit is. From that point forward, if I’m good, I try and get about that center in the tibia, I go ahead and put my syndesmotic screw. Posterior malleolus fracture is the south principle. We’re all well aware of that after reducing the lateral malleolus. Typically, you get good reduction. Absolutely paramount, getting good reduction on your distal fibula for your posterior malleolus. I rarely fix these. I think if you get really good reduction, it’s not necessary. Okay. Fracture involves about 25 to 30% of articular surface or greater 2 millimeters and you need to consider fixation. I like an anterior to posterior approach. Some folks use a posterior to anterior approach. These are examples of isolated syndesmotic injuries and here you can see the radiograph on the left, suspicion of a syndesmotic injury. Need bringing this patient into the operating room stressing them under live fluoroscopy. They do indeed have a syndesmotic injury and then using a three whole plate with two screws. Another example here. Below that one. I think I just jinxed myself. Sorry. There we go. Sorry about that. Okay. This is something that I wanted to talk about too. I prefer to be in the operating room than to be in the office. I think a lot of us are like that. However, there are those cases where you really need to be cautious in what you’re going to proceed with and if you’re going to indeed operate on those people.

    [25:03]

    This is an example of a patient that I could not operate on. She was a cancer patient. She was not at the level of being able to take her into the operating room and operate on her. There was far too much risk and she was very sick. Okay. What I did with this particular patient, I closed reduced her in the office and I used the total contact cast. We used total contact cast for lots of different things. Charcot neuroarthropathy. Why not use it in trauma? I’ve done it before, it works. This is a good example of it. I put a total contact cast on and then I cut a window in that cast for an external bone stimulator that I used. You can see the transition from the initial injury to a number of months later. There’s probably about five, six months later on the final radiograph on the right where everything had healed and I had treated this conservatively. Keep that in mind. Anytime you’re operating, you need to keep the patient in mind. We all like to cut. We all like to operate. Again, I’d prefer to be in the operating room than to be in the office. However, there are certain situations where you need to consider the patient and whether or not they are candidate for surgery. This is a good example of that. This is another example that I’d like to touch on. This is a patient that came in with a high fibular fracture. Okay. What’s everybody in the room thinking, high fibular fracture, syndesmotic disruption. Something else that my ortho colleagues had taught me when I did my fellowship, don’t just focus on that high fibular and don’t just focus on the distal fibula. Look higher than that. Okay? This is a good example of that. Here, you can see a fracture in the proximal portion of the fibular head. Okay? This person in this particular motor vehicle accident, the vector of the force broke the fibula and then it traveled high and exited through the top of the fibula. Alright, this is a good example of that. There is no syndesmotic disruption there. This is another example of what the orthopedic community commonly refers to as a night stick injury in the arm. I’ve only seen one of these. This is a young man who was playing basketball and fell. He walked into the office with this kind of segmental injury of his fibula. Immediately, what was I thinking? This guy’s got to have a syndesmotic disruption, got to have a syndesmotic disruption. Seventeen-year-old kid, basketball injury. I need to make sure he doesn’t have a syndesmotic rupture. I brought him to the operating room and I stressed him in the operating room. I did it like four times, five times just to make sure, right? His syndesmosis was perfect. That ankle joint was perfect. This is another example of what looks like it may be a syndesmotic disruption but actually it’s not. However, I took the right steps, evaluated it. And then went ahead and put him into a cast. Kind of a weird fracture. First time I have ever seen that, I don’t know if anybody in the audience has seen a fracture like that on the fibula. I left it the way it is. You can see on the lateral plane. There’s no angulation on the oblique images. You can kind of see it on the AP image that there’s a little bit of angulation. Talked to a bunch of my colleagues about this and they all said the same thing. “Louis, leave that, put him in a cast. There’s no syndesmotic injury, leave it.” That’s exactly what I did. What I’d like to leave everyone with is respect the syndesmosis even in basic lateral malleolus fractures, done my share of fractures, this past winter, god, it was nonstop. We had over about a five, six-week period. I did 15, 16, ankle fractures with the winter that we had up in the northeast. I’m always impressed with some of your very simple lateral malleolus fractures that had syndesmotic disruption tested. Make sure that there isn’t a syndesmotic disruption. If there is, address it. Really important. Here are some cases of syndesmotic disruption that I’ve done in the past where I’ve used syndesmotic hardware. These are my references. Thank you all. Much appreciated. Any questions? Please e-mail, see if it comes up. Any questions? I think we have a couple. I have two minutes. Anybody have any questions? Yes.

    Male Speaker 2: Why do you use syndesmotic screws instead of a tightrope?

    Louis Ciliberti: Okay. Good question. So I get asked this quite a bit.

    Male Speaker 2: How long do you leave them in as well? That’s the other question.

    Louis Ciliberti: Okay. So syndesmotic screws, I get asked this all the time, how long do I leave them in? I leave them in three, four months and then I take them out. The reason why I do that, couple of reasons. One, I feel like I can control the rehab course. I put the syndesmotic screws in, I send them to rehab. I use locking plates for pretty much on my ankle fractures. I usually walk those about three or four weeks based on the type of ankle fracture in a fracture boot. Send them to rehab, three, four months, I take the syndesmotic screws out and then I reinitiate the rehab process. I put them into an ASO or a fracture boot for about two weeks. As soon as the skin heals, they’re back into PT and I feel like I can control the rehab. That I think is the critical point.

    [30:01]

    Yes. You can bill another procedure so you’re over that 90-day global. In the world we live in with how much we get paid, especially up in Pennsylvania for the procedures that we do, that’s certainly something that I think about, absolutely. However, my big concern there is that you can really control that rehab course and how you’re going to proceed forward to get them back onto their feet. With regard to some of the other fixation techniques, I’m kind of a keep it simple guy. I use screws. I use plates. I get good deformity reduction. As far as using tightrope type procedures, it never really made sense to me. And the reason why is because that procedure is still allowing torsion where the syndesmosis is and of the tibia and fibula. We all know that as you walk and ambulate, the tibia and the fibula rotate, right? It’s in multiple planes and they rotate on the talus. If you have a tight rope in there and it’s allowing some of that motion, I never understood that. You want with ligaments and tendons, you want to shut them down and let them heal. You don’t want any motion. It’s like lateral ankle stabilization procedures. I do a lot of those. When I do a lateral ankle, I put them in a cast for six to eight weeks after I do the procedure. You want everything to heal and heal in a tightened fashion. That’s why I don’t use a tightrope. I don’t know if that answers your question but I don’t believe in the philosophy. I like screws. I put screws in. I lock it down. I can control the rehab course, I take the screws out and I feel more comfortable doing that. Any other questions? Thanks for bearing with me with my voice. Thank you.