B (4:18)

So Andy, is this amazing? Number one, the amount of work that it required in the thought process is more of a what's better for society, for the patient and what's better for the surgeon. Clearly that's what this falls down to. The question then, is that a Liverpool only at your hospital because you're a trauma center, is that a generalized NHS system change that you've created for your society.

C (4:45)

So when I first presented this at AFAS and then at bofas is I had some people congratulate me on, if you like, the bravery of the paper showing poor results from the hospital. You had other people saying, oh well, your hospital is just terrible at it. And so from BOFAs there were actually nine different studies which showed pretty similar results in every hospital. Four of those were published. So it wasn't just us. So when we devised the treatment algorithm, and I'm sure we'll go on to this about direct versus indirect reduction of the fractures, is that what actually I think tended to happen across the country was these post mal fractures gravitating towards the foot and ankle surgeons or people who had a specific trauma interest. So it wasn't just that the ankle fracture was put on the end of a generic trauma list or like one of the residents to do with some mild supervision, if you like, is that they tended to go to people who had a real interest. And that's the thing, it's not just that you're foot and ankle trained, it's that you've got a real interest in doing these and that's how we'll continue to obtain the best results for our patients.

B (5:58)

I think that's a big deal because obviously for the society, I think all of us struggle with who does ankle fractures better? Traumatologists putting ankles, trained surgeons, or is it just a random thing that the sports doc can just do at the end of their day, just like you're talking about. And I think when you look at all the data, like you've shown specifically that bad reductions occur all the time, and we know the data shows bad reductions give bad results, you can actually actively have a change. So I think when you look at our society here in America and across the world, these fractures, it's actually our duty, I think, like you've done, to fight the quote, unquote power or the regime that's in there that says, look, everybody can do these fractures in America. It's a money thing, right? They pay, they pay well. But it's important for us to improve outcomes for society, which is what you did. And I know it made your life harder, right? You had to work harder, do more work. I'm sure people are mad at you, but I think what you've shown is, and all of us need to do at one institution, is that a protocol? And having trained people that care about the ankle does make a difference for the patient. It's not just an easy thing to do.

C (7:08)

Yeah, I absolutely agree with you. And it's the same with many types of fractures, whether that be lumping all into trochanteric fractures as being the same thing. There are very different kettle of fish. Some of them, if they're highly common, neutered, you wouldn't want doing that hip fracture for you. You'd want one of the trauma surgeons or one of the hip surgeons. So it's doing things that you're comfortable with. I don't think we can be dictatorial and just say you need to have done this to be able to do it. But I think what is really, really important, and AFS has been a great driver in this, as has bofas with our national registry and things like this, is that collect data on what is done so anyone can fix these. But everyone's data needs to be looked at and we need to carry out an audit process of looking at that. Whether it's doing continuous on all patients is quite difficult. You can, with software platforms now, do patient reported outcome measures more easily. But even if you just do a snapshot each year or every two years of a few months worth of ankle fractures and see what the state of the department is. Because any surgeon should want to know what their results are. And you want to be doing a good job. And if you're not doing a good job, you either change what you're doing or you don't do that thing.

B (8:30)

You would think it'd be that simple. It's very prophetic. But I guarantee you not everybody thinks like that. So, I mean, that's why I love you. So, okay, I break my ankle, I had a simple lateral mal, 6 millimeters of medial pair space widening. What happens and what would you do now? Do I get surgery? Me, I'm 48 years old now, healthy, extremely physically fit and good looking individual, as you know. You're going to fix my ankle or are you going to say try cast? What do you do at this point?

C (9:01)

So I think with that, obviously for someone in their prime, a bit akin to an NFL player, that we'd want to be getting the absolute best results for you. So in general with the logistics of our department of insurance in yours is the trauma lifts are overstuffed for us. It takes some time to get to it. At the moment it's not as ideal as we would like, but it's going to be probably a couple of weeks till we get to it. So what we want is them to be put into a well fitted bulky cast or we call a back slap and then they get reviewed in fracture clinic afterwards and they'll tend to go to a foot and ankle specific fracture clinic and then it's about talking with the patients and it's looking about their comorbidities and things like that. But if someone is very four, is very active, then we want to try our very hardest to get an anatomical reduction. If it can be reduced in the plaster and you can, the most important thing is that you can get weight bearing X rays and it doesn't and that it stays reduced on that. Then you could try do a trial of conservative treatments.

B (10:08)

But that's a trial for me. Andy, I understand what you're saying and weight bear at a week. It looks good, the weight bearing X rays. We know there's a nice study that showed when you weight bear on a minimally spaced ankle fracture, it actually can relocate the mortise because it actually is more stable than a stress X ray. So I'm six. This is a struggle. I think all of us have. I'm 6 millimeters wide and I published an article years ago that showed up to 7. Doesn't seem to matter. That's not what I do now. But what now you have to tell me, hey, you're going to walk in this boot or you're going to, I'm going to cut you open.

C (10:50)

So I think that a boot is quite difficult to use anyway because people don't do them as tight, they can undo them. I think with that these days I would have a tendency to fix them because it's really predictable on the outcome that you get and provided you respect the soft tissues is the complication rate is really quite small. But it's about going through that with the patient saying, right, we can try conservative treatment but you're going to end up immobilized a lot longer or it can fix it. And at two weeks we can start range of motion exercises on you. We can start some isometric calf exercises so that you're not going to get as much limb wasting. Now some patients will say, well, if I can avoid an operation, doc, I'd like to avoid an operation. And we can treat that conservatively. But my leanings for that would be to fix it. And I think, and I think we showed in the presentation that was done at BOFAF this year, the critical thing with this is then once you fix the lateral malleolus to check the competence of the deltoid ligaments and it's the deltoid ligaments being involved in the ankle mortise, but also checking for subtalar instability on that and if there's any, I think query with that is that what you need to do is then go and repair the deltoid. As we showed a progression of flat foot in ankle fractures where the deltoid wasn't addressed. So I think that's a critical part. It's not just whacking a third tubular plate on the, on the outside of the ankle as used to be done back in our day, seeing as we are very old now.

B (12:21)

We are. So do you think then since we've trained 20 years ago now, because that's how ancient we are, when we first started, I think I was very aggressive with non operative intervention for these mild, mild displaced ankle fractures, you know, five and a half, six millimeter, you stress them. They don't go that far in a healthy patient. I'm not talking about your sick, super sick. Let's take that off the table for a minute. These are healthy, active, 30, 50 year old individual, 60, whatever you think the trend in the last 10, 15 years is more aggressive or even for these Mild displays for the reasons you talked about. Kind of more chronic pain in the future, medial sided pain, flat foot considerations. Is that the trend in the UK for sure? I know it's a personal trend, for sure. Yeah.

C (13:09)

I mean certainly for me it is. And I think for a lot of people, especially if you tend to deal with more sports people and things like that, as people will tend to have a leaning for that because it's about what the morbidity of it is afterwards. If you're immobilized for six weeks, you come out with a chicken leg and it takes a long time to get that better. Now we have possibly less of an availability of physical therapy than you do in the US as well. So it's what function people are going to get back to and how quickly they are going to get back to it. One thing that I think is important is not to just go for try and conservative treatment. Because of limitations of service. We don't have enough space on trauma lists and things. We need to offer the best thing for that patient. And I think that overall, from my experience over the years, is that patients tend to do with having these fixed early rather than being immobilized for six weeks and then getting them going.

B (14:10)

I'm with you. I've changed a lot. My junior partner, Malat Patel really has changed my mind on how aggressive to be in the literature. I think supports that. And we looked at all of our cases too, which representing a natal fast tissue, I think for a healthy young patient, rotationalistic believe is a big deal, which we showed a long time ago, biomechanically as well. So now you brought up the Pandora's box of the deltoid ligament. Right. If somebody has a medial clear space or unstable ankle fracture, do you biomechanically, how is the deltoid not torn and why would you not fix it? I guess is a question. So somebody has an unstable ankle fracture, you know, you stress them at 7 millimeters. Original injury shows 6, 7 millimeters dislocation, things like that. There's no question, right? You fix the lateral. Now talus pops into place. But how is the deltoid not torn and why would you not fix it? Again, I'm going to talk about a healthy individual. You seem like you turn it towards fixing it for flat foot concerns, which is a whole other second level of thought process. Do you think you should fix them all? I do. I fix every deltoid. Or do you stress it in some rotational way or do you value it? Like what's your thought process and how you fix the fibula. What are you going to do next? Now for the deltoid?

C (15:26)

So I would have a really low threshold for doing it. It's nice if you can get some pictorial evidence on fluoroscopy by carrying out adduction to the ankle and trying rotation, but also having a look at the subtalar joint as well, because quite often you will see that the subtal joint actually opens up a lot on the medial side and tends to translate across. So it's not just looking at the ankle. But if there is a. If there, I. I would tend to do it. I would need to do some pretty definite proof that you didn't need to do it rather than prove it. To make sure to make me do it is I would go into the operation planning that this is going to happen unless it is just absolutely rigid as hell and there's no evidence. And I think it's really historical about why we don't do it. I think back when we were training and things is people didn't really address the deltoid ligament for anything and there was no confidence in doing it. I mean, God, we were. Even when we were doing brostrooms, we were doing interosseous tunnels rather than suture anchors or just starting to use suture anchors. So now, I mean, again, it's a really benign procedure to do. And it's amazing. I mean, you've seen this so many times. How many times do you go in and you find that the superficial deltoid, or in the deep deltoid is actually inside the medial. Inside the medial gutter?

B (16:55)

Oh, yeah. So the first time I realized this problem was maybe three years into practice. There's a Weber C. And I did what I was taught to do, fix the fibula. King tong clamps, crushed the syndesmosis 2 screws. Guy came back after three months. Maybe a little earlier, it was back, it was displaced again, screws broke, shot out. In my hyper intelligence, I just did it again. Shockingly, that failed. And then I went to the medial side and everything was stuck right inside. So, you know, I was dumb and I didn't understand. And then that's what keyed me into the delta. That I don't. I'm not sure that indirect reduction is the best. And yes, you always peel stuff out of a joint every time. And I agree with you. I think the trend is now what you said you should plan on fixing it. And I think if you're not on that bandwagon, you should ask yourself, why not? Because stability is the key. These patients do better. Less swelling. And although, yes, we don't have 15 year data supporting it, we will over time we're going to. So delta. It makes sense. You fix it. Rotational stability, angular stability. Then the next question again, same case.

C (18:03)

If I can just go, if I can, if I can just go back to one thing there. I think you may. You made two really good points. We also don't have data not to do it either. And the second thing is about that syndesmosis failure. We've all been there and we've all had it. And I think that this was responsible for a whole plethora of research that was done on what's the best screw to use for a syndesmosis, what size screw it should be, whether it should be three quarters, four quarter seas because of failure rates. I think the failure rates was purely because the deltoid hadn't been addressed. It's nothing to do with what size screw you put across there. It's just because the deltoid wasn't done.

B (18:47)

No, I think you're right. You're. You're smart. I mean that. I think. I didn't think about it that way, brother, but I, I think you're right. We were just, we were looking at it wrong. It makes tons.

C (18:56)

Yeah, I mean, seriously, 3.5 or 4.5 millimeter screw, that can't make that much difference, can it?

B (19:04)

Really?

C (19:05)

Yeah. So next.

B (19:10)

So now you have the. You went to the case, you're smart enough now, you figured out the fibula of the deltoid. Are you addressing the aitfl? Even when there's no, you know, you do a cotton, all that kind of stuff. We know by definition the AITFL is torn in almost every ankle fracture because that's the mechanism of injury. But the question is, does it need to be addressed? If you fix the deltoid and you fix the fiblet anatomically, do you think there's any value to it? I will give you my bias is yes, I fix it every time. I believe absolute stability is critical, but there's not a lot of data that says you have to do it. So I'm curious what your thought process is.

C (19:50)

So I think that is a really good avenue for future research. Because as I said before, if you look at, say, our original paper, even well reduced Weber B fractures had a OMASS score of 79. That's a long way from 100. So there's a lot of scope for improvement there because we were just, I say fixing the Fixing the fibula, I think one, I think we're gradually changing towards that is the thing that I would say is absolutely key is it when you're fixing your fibula, is that you need to see the anterior aspect and you need to feed that. That fibula is keyed into the incisura and then you can see the AITFL there. You'll, as you say, you'll almost certainly see that it is tall and you can stress it, and as James Calder published on, is that you're looking to see whether there's more than 3 or 4 millimeters of opening anteriorly. And if that's there, you can use your poison of choice. Whether it's something such as a infernal brace. I would tend to use a. Tend to use a suture, a tightrope or something along those lines rather than something that's absolutely rigid. But that's just, that's for my personal, personal choice.

B (21:11)

Really perfect. And I think that is the trend. You got to see the syndesmotic recess. Whether it's with the scope, which I'm not going to get into too much, or with your eyes, you have to see that recess and it's really the sagittal instability. These old sets of cotton external rotation stress X rays, in my opinion, and not only my opinion, but when you look at all the data limited to no value for subtle instability, such a high false negative rate, you're missing that instability that may improve or likely does improve the OMAS score and the functionality of patients. So I think that's key. I think you hit it on the head there, you look at the syndrosmosis unstable, stabilize it by whatever method you want. Tightrope, internal brace, it doesn't matter, they both work. You know, some mechanism works great and we all know, we look at all the data. Screw is probably not ideal for these factors. So now we kind of beat the Weber B down, but that's most of what we see. And I think, you know, in the UK and you believe Anatomic 3 is better, but now you get to a post map. So I'll give you a scenario. Weber B, 10% post male. You get a lateral X ray. It's a little off. Are you getting ct? You see a postmail. Is it standard for you to get a CT and are you not getting it? Because you can't. So you're not getting anything. There's no value.

C (22:33)

So every one of them gets a ct. And the reason for that is the diagnostic accuracy of a. Of a lateral X ray. So the. If you take a sort of average of. I think there are nine good level papers published on the diagnostic accuracy of a lateral radiograph and it's about 23%. There's no other test that you'd accept a 23% accuracy on. And you just can't tell how big this is. And we both got large collections of x rays and CTs that you can show where they all look exactly the same on the X ray but on the CT is that they're hugely varying amounts of posterior mal and whether it's an intraarticular piece or whether it's simply an avulsion. So I think you need that for diagnosis. And you've got to bear in mind.

B (23:27)

Would you say every post male. If you see a post male on a lateral X ray, you're not getting features in every ankle fraction, no matter what the hell the X ray looks like, Correct?

C (23:38)

No. So it's only if they've got a post male or if they are pulmonuted.

B (23:45)

Okay, so do you feel that should be the quote, unquote, standard? Now? This is a podcast. Nobody's saying anything standard of care in a podcast like this. But you think it's ideal, if possible. Like that's the best quote, unquote way to diagnose these postmaps. Every postmail, even if you. I know what that is. It's 20 to 10%. You believe that a CT is really the best thing to do. I know the data supports a lot of that. And you think that's what we should all be doing now.

C (24:13)

I think we should all be doing that because there's so much data to support it that you just can't tell from that X ray whether it is just a small flake. It's very easy in the trauma of eating in the morning, say, oh, that's just a small flake. Because the thing it comes down to is that there's a tendency when people say, oh, it's just a small amount, they're thereby implying that that doesn't matter. And this is the crux of the problem. And this has been one of the most difficult thing to change people's opinions on. So the original data for that, which said that, I mean, when we were training, is that if it's less than a third, you don't need to fix it. No, I think you know the answer to this. Do you know what journal that comes from?

B (24:56)

It's like an OB journal or some crap, if I remember.

C (24:59)

Yeah, yeah. The Journal of Gynecology Obstetrics. And surgery, I think it's 1959 and they looked at eight ankle fractures. And it's a typical thing where something is said, often enough it becomes truth. The, the size of it actually doesn't matter particularly. We want to, we want to determine what the size because that will tell us what type of posterior malleolus fracture it is. And that will then by determine how we're going to treat it.

B (25:26)

So the question for you is now that we know that the size is not relevant, right. Lots of data has shown it's the reduction that counts. Even a 2 millimeter step up is associated with the poor outcome. So when you get your ct, when do you get a ct? There's a post now. When do you say, hey, look, there's three things I want you to answer. I don't need to directly or indirectly fix this post. Mail this post. MALE I think I can indirectly reduce and stabilize with this syndesmonic stabilization. I don't have to fix it directly. And then which ones need direct fixation? Like that's kind of the crux you got to see. So I think we can. I agree with you obviously that CTs are important, but now you have this information. So now which of those what direction for one of those three scenarios? Because that's what you're doing with that information, I assume.

C (26:15)

Yeah. So I mean, Linda Mason and I developed our own classification, which is a variation on the theme of the other classification. And the reason that we developed that was because it showed ascending seriousness and intra articular parts of the fracture. But it also develops a treatment algorithm for it. So if it's a type one, that's a rotational posterior malleolar fracture. So it's a lateral small fragment that is caused from a rotation injury, usually with the foot implanter flexion. So that is an avulsion of part of a pitfl. Now it's only a very small amount of it compared to the footprint of PITFL. But what we found with those is 100% of them had syndesmosis instability. So for those type Bones.

B (27:04)

Yes.

C (27:05)

So that needs to be treated as a syndesmosis instability. So in general, I would use a tightrope for that. Some people would use screws, say there isn't conclusive evidence between them. But personally I'd use one or two tightropes, depending how, how much gapping you had in the thin dysmosis. For the others. For a type 2, which can be split into a minor, a major, which is again rotational. Is that basically the posterolateral fragment gets knocked off and then the posteromedial fragment gets either knocked off or avulsed afterwards. Then the type 3 is a true posterior pedal. All of those, in my opinion, need to be directly fixed. The last time I checked, there were three good studies that showed the accuracy of reduction of using direct reduction versus using a AP screw. And when we're teaching the residents the simple adage that I would say is if you were going to hang a picture on a wall, you'd hang it directly in the wall. You wouldn't go to the other side of the wall and then try and knock your nail through so that it went through the right hole in the picture.

B (28:26)

You know. So I think for again this is, I think the caveat is for a lot of people, these are for healthy individuals. If it's a. So I 100% agree with you. I'm not a big perk person. Now arthroscopically I say is a different, I still would say autoscope. My opinion is, and I think the data suggests the same if you're directly visualizing the reduction and the placement of your K wire and screw, it's better to go P to A than A to P. And if you ensure that you're actually in the fragment, you can percutaneously put it. But it's a skill set you have to have and you have to orthoscopically look at it. Otherwise if you're just fixing the pivot and firing the screw from A to P many times you're going to miss it. I mean that it's way lateral and you miss it a lot. I think that's a very, very good point and analogy. If you're going to fix it, you fix it correctly or don't fix it. But let's suppose it's like a 75 year old patient. So different scenario analogy. Because what I've noticed is sometimes we take these principles that are, okay, we fix every post now open, we make these big decisions. But you got a 75 year old diabetic, skin's not terrible. Are you still going to make that massive posture incision or do you change your plan and say, okay, this person? I can maybe use a fibular nail percutaneous fixation and that's okay for the 75 year old. When do you, when do you know? When is it okay to perk it and accept a little bit of mal reduction? And when is it not? We know, healthy, active, but when would you just say, okay, let me just perk this one because I Don't want to get a wound complication or is that never an option for you?

C (29:59)

So yeah, I mean there are some things that won't fit into classifications and they're sort of in between different types. And then when you have people who are dramatically unfit for doing a direct fixation, obviously you need to put them pro. So are they fit enough to go pro? What's the skin like and such like? So for One of these 75 year old diabetic, if they've got poor skin, is that in general with some of them I would cheat and just fix the syndesmosis together with the fibula and say to them like, listen, you are going to get some arthritis in this ankle but hopefully it won't be too limiting during your lifetime. So with those I would always, always tend to, to openly reduce and fix the fibula. Our experience and Lyndon wrote a paper on this with three other hospitals I think in the country or they certainly presented it where they showed pretty disastrous results with fibular nail with regards to accuracy of reduction, what I found is that if you leave them a good length of time, so the soft tissues have settled and you really respect soft tissue, so you've really got to make some periosteal flaps. You're basically going pretty much straight down to bone and then you fix it and you take real care with your soft tissue handling is I think that the complication rate from doing that is pretty, is pretty low.

B (31:35)

Really. No, I think it's a good point. I think when you look at these fibular nails now, a lot of people advocate a small incision, get the reduction and the nail. So I think the mistake initially or the topic is I'm just going to fire in a nail. I'm going to call it a day like you do for hip practice, different animals. The idea now is small incision, get an anatomic reduction and fix it by whatever means you desire, whether it's a plate, whether it's a nail. I think that's the, that's what you're saying. You still got to reduce these things perfectly.

C (32:06)

I mean, I've got some bias with regards to that because I did a couple of fibular nails in training and I haven't done one. When I've been an attending I say I've just always gone and fixed them. So I'm sure in, in other people's hands they may get great results with fibular nails. But it's just not my experience and the experience from what I've seen things that have been Referred to me.

B (32:25)

I think when you and I train, you know, you and I train in some of the stuff that she's. That's just. You're firing the nail in. And I think any of these new technologies and new ideas, we don't. The terms that we use when we're young are like, I'm gonna throw a nail in. I'm gonna. We don't. We don't do that. Right. That. It's fun to say it that way. And sometimes we act like that's all we're doing. But I think it's really important that that's not what we do. And that's. So I think the key thing I want to make is dogma. Dogmatic thought process never works. And I'll give a shout out to my buddy, Dr. Clicking Armin Kalikin, who I think a lot of people know. He has a great line, and you are echoing that. It's rigid fixation, but flexible thinking. Like, not everything fits into a bucket, like you said. And you've got to. You can't just say, everyone gets a large poster lateral incision, and then you get a wound complication. You lose a leg on a, you know, diabetic kidney failure patient. Not everybody needs perfection. They need stability. But I know we got time issues. So posterome, medial posteromedial fracture. How do you approach it? Separate post, remedial incision, posterolateral incision. How you get into it?

C (33:31)

So we published a paper on that, doing a clock face, where basically we did a cadaveric study and we made. Made the different incisions, we put K wires at their extremities, and then we took X rays and you could map out what the area you could see through each incision. And so we were quite dogmatic, and what we said is that these are the approaches that you should use for each different type of fracture. But over the past few years, I think it has really evolved. And I would say for all posterior posteromedial fractures, you can reach really easily through a medial posteromedial approach. So that's an approach which is really nice and extensile down the posteromedial border of the tibia. You go down through the investing fascia through the retinaculum around tid post. You can take that in front, and then you can go down and you can see the whole of the posterior posteromedial fragments. The other benefit with that is there's quite a high incidence of the tid post being trapped in these fractures. So you can clear that out, but otherwise you can't see that. If you did a posture, if you did a posterolateral fracture approach, you will never see that the tip post is trapped in there. But that medial posture, medial approach is really nice and extensile for going down. And you can get a great view over all bar the very lateral part.

B (34:54)

Of.

C (34:57)

The back of the tibia.

B (35:00)

I think that's a brilliant point. You know, when we first started, I did a posteromedial approach in the Achilles to see both sides and that didn't work out so well. Hit the soil over 100 times. Posterolateral is great, but you really can't see that postrometal piece. So that postromidal posture we think is dangerous. It's not. The nerve and artery are a million miles away from you. Yes, you do have to cut the push into tendon sheath, but you repair it if you need to. It doesn't subluxate and you really have to go. You look at that fracture and it makes it a million times easy to get a reduction. Are you using screws in the back or a plate or does it depend? Like, when do you choose? What do you use to fix the posterior medial side?

C (35:40)

So, I mean, I'll use a plate and obviously I've got some bias because I helped design a plating system for it and that was designed to try and aid with the reduction. If you don't have the ones that.

B (35:54)

I've designed, I believe that's the ongoing top box.

C (36:00)

Yeah, yeah, yeah. But I think, yeah, I think plates make it easier. They get the aid of the reduction. You get good fixation if you don't have them available, I've done plenty of these just using screws before plates were developed. So you can do that. The one thing that I think is really key with this is the positioning of the patient. So if you're going to do a medial posture, medial approach, you want the patient prone, but you don't want them just in standard prone, which the anaesthetists don't like that much anyway. Because when someone lies prone, the legs are externally rotated and it's actually really difficult to get to the medial side. So what you want to do is put them prone in, well, a semi prone position as if they're in the recovery position. And that way the posteromedial aspect is pointing directly up and you can easily rotate the leg to get to the lateral malleolus as well. And that will make your life a lot easier because otherwise you're chasing down a deep, dark hole round the corner. So don't Put them straight prone, put them in a semi prone recovery position.

B (37:05)

That's actually a cool idea because I do struggle. I just have a lot of help. So I can easily make people move the leg for me. So I cheat, but that the media mal runs away from it. It's painful. So here last couple questions before we end the lateral malleolus and a posterolateral approach. Are you making a separate incision? Are using the same incision, moving the cranials anteriorly and putting a port solidal plate.

C (37:29)

So it depends on the size of the patient. I will. If it's a big patient, I will do two incisions. If they're a smaller patient, then I will do a long incision based on the posterior part of the fibula. And then I'll just reflect up so that I can do a lateral plating. And then I can do my approach the other side of the peroneals. Obviously being very careful looking for. For the superficial perineal artery perforating there. I don't particularly like posterior plating on the fibula. I think it's very difficult to get a plate down low enough so that it will fix a lot of these fractures. And it really does concern me about the peroneus brevis rubbing against it because if you look at what you're putting that posterior plate on, it looks like articular cartilage. So I will always place it laterally.

B (38:23)

I think it's a. It's a great point. I disagree with you wholeheartedly though. I poster replace all of you, but especially for the Weber beast. But you know, I think it's a. These are two different thought processes. You know, I don't have that bumpiness of the screws in the back. But you know, I. No one really knows the answer. But I.

C (38:47)

Think that's. I think that's a really, really good point. For these things, you can't be really dogmatic. So okay, that's what I do and you do something different. It's what works well in your hands is just because you do that really well and you get really good results doesn't mean say that I will necessarily do so. I think that's one of the things when you become an attending or when you're going through your senior residency is just trying to find out what works well in your hands, what is the most predictable thing. And to do that you'll always want to try and learn new things. But learn what is works really well in your hands rather than someone wrote a good paper on it.

B (39:24)

Perfect I agree. The principle is you fix these anatomically by whatever means necessary. I think that's what this. If you summarize our podcast, that's what it boils down to. So last question before I have to let you go. The Weber seed. How high is too high before you stop fixing it? Because we're going to fix up like a low Weber C, right? We all fix that. No big deal. But now you're in the mid shaft of the fibula. Is that too high? Where you just fix the syndrosmosis. When do you stop? No one knows the answer, but when do you stop?

C (39:55)

I think that's a really good and difficult question. So thank you for finishing with such a difficult question that we don't really know the answer to. You could have made me look good at the end. I think I take quite a pragmatic approach to it is look at your expertise X ray. How thin is that fibula on the where the fracture is? Because if you're looking at something which is very thin is that you are unlikely to get a plate on. But you also need to bear in mind there's that rotation of the fibula and you get that lateral prominence. So unless you've got a plate which you're going to try and curve around. So I think once you get above, probably above 10, 12 cm above the ankle joint, it starts getting very difficult to fix that. So I would have a. If it was a big fibula, I might have a look and tell them that I'll make an incision, have a look at the fracture. But if it's not platable, I won't. But I will also when I'm fixing it. The one like that is that I think that you can't use flexible fixation. I think you and Norman Espinosa showed that the most rigid construct for that was two screws through a plate. Because the important thing with that is that you need to prevent axial translation of the fibula. And I'm not too sure whether flexible fixation will control that. Axial translation, the superior translation of the fibula.

B (41:19)

I think that's again, good point. It's amazing new injury where you're not going to fix the fibula, where you have to use screws and for sure fix the deltoid. I don't think that's in any doubt to stop that thing from translating. My partner, who does a lot more trauma than I do now, funny, I never fixed a lot of proximal fibula. When you look at some of the data and better rotation and Obviously, extra bill. And he fixes all of them now. So his threshold is mid shaft. He'll fix every single one. And he says the outcomes are way better. I think the traumatologist will tell you the same thing. And I honestly don't fix autonomy. I don't see this as much as I'm old, but the proximal third of the neck, that's kind of where we stop. That's where I advocate. And he advocates not to fix. With mid shaft, we've become more aggressive. A buddy of mine, Anand Bora, kind of taught me this too. He was much more aggressive about it back then, and I disagreed with him, but I think he's right. Anand taught me a lot that. I think if you can fix it safely, you know the anatomy. There's a lot of muscle there. That's the problem. You're gonna crash a lot of perineal muscle getting there. But if you're not gonna openly reduce the syndesmosis and make it perfect, fixing that fibula is probably in your best interest, as long as you don't hurt the patient on the way in, which is.

C (42:33)

So what's that. What's. What size plate would you use on that?

B (42:37)

These small ones, actually. So you're really just getting it so that you have the length correct. So quarter tubulars work pretty well. They have these rigid 27 plates that you can use because the fibula is really small. So I don't use, like, LCDCT plates. We're not using these. Anatomic plates don't reach up that far. There's a separate small plate, six holes, four holes for the fibula, then a separate incision distally to reduce the syndesmosis with flexible fixation. Typically, at that point, kind of two separate workhorses that you're doing that you're doing it for.

C (43:11)

I think that's a really interesting concept. It will be. It'd be really interesting to see what the results are of those, because I've tended just to. To reduce the syndesmosis and fix the syndesmosis with rigid fixation rather than going more proximally. But I say just because I've done something for a few years doesn't mean it's always the right thing to do. So it'll be interesting to see. To see what the outcomes are of that.

B (43:36)

Well, Andy, I think we've run the gamut of ankle fractures. I know there's more we can talk about, but I'm sure people don't want to listen to us for much longer. This is awesome. Thank you so much for your time. We had a lot of fun points. Hopefully generates a lot of discussion and interest. I can't thank you enough for being a great friend, a phenomenal surgeon, and your contribution ankle fracture literature. If everybody on the podcast hasn't read Andy's contributions, my advice is look him up on PubMed. He's got a ton of literature. So I mean, it's basically based off all of my ideas and my thoughts and my teachings from him in the last 20 years. But, you know, he's been a major leader and so thank you. You're an amazing guy.

C (44:21)

I'd really like to thank you for the invitation. As you say, you're a great friend. I'm very lucky to have met you, to work with you and to have learned a lot from you. The stuff that you're doing on this is incredible as well. So thanks very much for the invitation. It's been been a pile of fun and I will see you soon.

B (44:38)

Thank you. Thank you all for listening to the AOFS welcome podcast, the Natural Factory, Dr. Malloy, and Hope to hear from you. Listen to you. Soon we'll be talking to Dr. Neri about the American perspective. Thank you all.

A (44:53)

Thank you for listening to the AOFAS Ortho Podcast, a Convey Med production. To learn more about joining our dynamic community of highly skilled orthopedic specialists, visit aofas.org.