Sa m A. L a b ib , MD F AOA E mo ry Unive rsity. Atla nta , GA. - PowerPoint PPT Presentation

ART HROSCOPIC ANKL E ST ABIL IZAT ION. IT ’S T IME HAS COME ? Sa m A. L a b ib , MD F AOA E mo ry Unive rsity. Atla nta , GA. e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

DISCLOSURES • Re se a rc h/ F e llo wshi p F unding : Arthre x, Ossur, L inva te c • Co nsulta nt: Arthre x, Me dsha pe , Stryke r

NAT URAL HIST ORY OF CHRONIC ANKL E INST ABIL IT Y L o fve nb e rg R e t a l: F &A I nt. 1994 37 pa tie nts tre a te d c o nse rva tive ly • 18 - 23 ye ar s follow- up e valuation • 60 % or 22/ 37 still unstable • 10 unila te ra l a nd 12 b ila te ra l invo lve me nt • 6/ 37 ha d De g e ne ra tive c ha ng e s b ut no • c o rre la tio n to a g e o r insta b ility.

ANKL E SPRAIN: INJURY PRE VE NT ION T APE + HI GH-T OP SHOE S • I N BASK E T BAL L GARRI CK E T AL 1973 L ACE D-UP BRACE + • L OW- T OP SHOE S ROVE RE E T AL 1988 AT HL E T I C • PE RF ORMANCE BRACE S > T APPI NG RE NSROM&L YNCH 1999 SE MI - RI GI D BRACE S • BE T T E R UBE L L E T AL 2003

SURGICAL T RE AT ME NT (L IGAME NT OUS RE CONST RUCT ION) Ana tomic : • Bro stro m L ,1966: L a te re pa ir o f AT F L +/ - CF L . 2.9 ye a rs F / U in 60 pa tie nts 46/ 60 “ Ba c k to No rma l” 1 F a ile d with CMT dise a se • Go uld N,1980: E xte nso r re tina c ulum+ L T CL suture d to F ib ula .

SURGICAL T RE AT ME NT (L IGAME NT OUS RE CONST RUCT ION) Non- Anatomic (T e node sis) : Pre mise : c hro nic a lly to rn • lig a me nts a re de fic ie nt Mo st use s Pe ro ne us • Bre vis te ndo n E va ns, Wa tso n- Jo ne s, • Chrisma n-Sno o k. Pro b le ms: Diffic ult, • Supina tio n de fic it.

ANAT OMIC RE PAIR IS BE T T E R • Shor t te r m: Pro spe c tive , ra ndo mize d c o mpa riso n: 29 mo s.- Bro stro m > Chrisma n- Sno o k in e xc e lle nt re sults/ le ss c o mplic a tio ns He nnrikus e t a l: AJSM 1996 5 ye a rs F o llo w up: F ull a c tivity a nd no insta b ility in 91% a na to mic re c o nstruc tio n ve rsus 54% T e no de sis pa tie nts Ma b it e t a l: F o o t a nd Ankle Surg e ry 1998 • L ong te r m: 12.3 ye a rs Re tro spe c tive re vie w: Bro stro m > PB te no de sis in Sta b ility te sting , a rthritis a nd pa tie nt sa tisfa c tio n K rips R e t a l: F o o t a nd Ankle I nt. 2001

BIOME CHANICAL T E ST ING • T e node sis: Alte r Ankle K ine ma tic s Ba hr e t a l, AJSM 1997 • Ana tomic Re pa ir : Re sto re Ankle K ine ma tic s Sc hmidt e t a l, F &A 2004

+ ANKL E ART HROSCOPY IN UNST ABL E ANKL E S • 13 - 35% Re sidua l pa in po st sta b iliza tio n. • 95% Co nc o mita nt intra -a rtic ula r Pa tho lo g y • Up to 55%: Me dia l Cho ndro ma la c ia / OCD 40% De lto id lig a me nt injury • • Syno vitis, Bo ne spurs, L o o se Bo die s Ankle a rthro sc o py b e fo re sta b iliza tio n impro ve d • re sults re : pa in a nd disa b ility= 100% G/ E xc e lle nt Va n Dijk CN, JBJS- B 1996 K o me nda G & F e rke l R, F &A I nt.1999 Hinte rma nn e t a l. AJSM 2002 F e rke l R & Cha ms R, F &A I nt. 2007

MORE RE ASONS T O SCOPE ? Hinte rma nn e t a l re po rte d o n • 148 pa tie nts with intra -a rtic ula r pa tho lo g ic fe a ture s a sso c ia te d with la te ra l a nkle insta b ility 66% o f pa tie nts ha d c a rtila g e – da ma g e F e rke l a nd Cha ms re po rte d o n • 21 a nkle s tha t unde rwe nt a nkle a rthro sc o pic e va lua tio n b e fo re a Bro stro m-Go uld pro c e dure Pa tho lo g ic intra -a rtic ula r finding s – in 95% o f the ir pa tie nts. I ntra -a rtic ula r pa tho lo g ic • fe a ture s a sso c ia te d with c hro nic la te ra l a nkle insta b ility with a hig h fre q ue nc y

GOL D ST ANDARD - 2017 • Dia g no stic a nd T he ra pe utic Ankle Arthro sc o py • Do o pe n AT F L + CF L imb ric a tio n with no n a b so rb a b le suture +/ - Anc ho rs • T ie suture s with the a nkle in ne utra l • Adva nc e the I nfe rio r E xte nso r Re tina c ulum to the dista l fib ula pe rio ste um (3- 4 Suture s) • Splint Ankle in Ne utra l/ E ve rsio n • > 90% impro ve me nt in multiple studie s • Arthro sc o pic Sta b iliza tio n? ? ? ?

ART HROSCOPIC ST ABIL IZAT ION • Pe rc uta ne o us Sta ple Ha wkins RB, Clin Po d Me d Surg , 1994 • Suture Anc ho rs K a shuk e t a l, Clin Po d Me d Surg , 1994 Ne ry e t a l. F &A I nt. 2013 • T he rma l Shrinka g e Be rle t e t a l, F &A Clin N Am 2002 Ma io tti e t a l, Arthro sc o py 2005 • Arthro sc o pic Bro stro m Ac e vido & Ma ng o ne ; 2011-2015 Co tto m e t a l, JF AS 2013 L a b ib e t a l, T F AS 2015

Ankle L ig a me nt Re pa ir K it • Pe rc uta ne o us Suture Pa ssing Burks & Mo rg a n AJSM 1994 • AT F L re pa ir a nd I nfe rio r E xte nso r Re tina c ulum a ug me nta tio n • CF L re pa ir is q ue stio na b le ? = CASPARI RE PAI R OF SHOUL DE R!!. • e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

T e c hniq ue : Minima lly I nva sive Sma ll Jo int Sc o pe • Sma lle r inc isio n tha n • a n o pe n Bro stro m T re a t intra -a rtic ula r • pa tho lo g y a nd re pa ir the la te ra l a nkle insta b ility simulta ne o usly, with minima l inc isio ns Po te ntia l fo r le ss pa in • a nd swe lling

GRAVIT Y T E ST : NE GAT IVE e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

Pro spe c tive study o f 40 pa tie nts tre a te d fo r c hro nic la te ra l a nkle • insta b ility (JF AS 2013) 27 fe ma le s, 13 ma le s, me a n a g e 45.6 ye a rs – Me a n fo llo w-up o f 12.13 mo nths – F a ile d c o nse rva tive tre a tme nt with c o ntinue d pa in a nd insta b ility – Asse sse d pre -o pe ra tive ly with AOF AS a nd VAS fo r pa in – Ankle a rthro sc o py with ‘ a ll inside ’ Bro strum te c hniq ue • Cha ng e s in pre -o p to po st-o p pa in sc o re s sta tistic a lly sig nific a nt – VAS pa in sc o re impro ve d fro m 8.2 to 1.1 – AOF AS sc o re impro ve d fro m 41.3 to 95.4 – Syno vitis in a ll 40 pa tie nts, DVT in o ne pa tie nt, ne uritis o f inte rme dia te do rsa l c uta ne o us – ne rve in o ne pa tie nt E xc e lle nt sta b ility o f la te ra l a nkle lig a me nts, ne g a tive a nte rio r dra we r a t fina l fo llo w up – Me a n inte rva l to we ig ht-b e a ring po st-o pe ra tive ly wa s 20.2 da ys – PT initia te d 4-6 we e ks po st-o pe ra tive ly – e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

a b ib , Sa me h A., a nd Ha rris S. Slo ne . " Ankle Ar thr osc opy for L ate r al L Ankle Instability. " T e c hniq ue s in F o o t & Ankle Surg e ry 14, no . 1 (2015): 25-27 . T e c hniq ue De sc rib e d • Mild to Mo de ra te , CF L ? • Re tro spe c tive re vie w • 14 Pa tie nts with g o o d • Clinic a l re sults @ 12 mo ns AOF AS sc o re a ve ra g e 93 • 2 ys fo llo w up. 1/ 14 • re mo va l o f suture kno t. 1/ 14 a nc ho r irrita tio n. •

Co mpa re func tio n a nd a c tivity le ve l • fo llo wing a rthro sc o pic vs. o pe n re pa ir o f AT F L in pa tie nts with la te ra l a nkle insta b ility 60 pa tie nts b e twe e n Ja nua ry 2012 a nd • Aug ust 2014 23 a rthro sc o pic , 37 o pe n re pa ir – Ope n mo difie d Bro strum re pa ir do ne in • c a se s whe re a rthro sc o pic re pa ir wa s no t fe a sib le AOF AS sc o re , K AF S, a nd T e g ne ra c tivity • sc o re No sig nific a nt diffe r e nc e be twe e n me thods – Sta tistic a lly sig nific a nt impr ove me nts – e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

F a vo ra b le o utc o me s fo r a rthro sc o pic re pa ir • – Simila r po st-o p func tio n a t minimum 2 ye a rs fo llo w up – Me a n AOF AS sc o re inc re a se d fro m 69.3 pre o pe ra tive ly to 93.3 pre o pe ra tive ly a t a me a n fo llo w-up o f 40 mo nths in the a rthro sc o pic g ro up Minima lly inva sive te c hniq ue • – No c urviline a r inc isio n o ve r la te ra l ma lle o li – Pre ve nts injury o f b lo o d ve sse ls a ro und the AT F L – F a c ilita te s va sc ula riza tio n o f the re pa ire d AT F L . Sho rte ns o pe ra tive time • F a ste r re c o ve ry • – No re po rte d la te ra l a nkle insta b ility po st-o pe ra tive ly e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

Pa tie nts ra ndo mize d into 1 o f 2 g ro ups • 25 a ll inside a rthro sc o pic c o mpa re d to 23 o pe n mo difie d Bro strum re pa ir – pa tie nts AOF AS, VAS, a nd K a rlsso n sc o re s use d to a sse ss o utc o me s • Ante rio r ta la rtra nsla tio n a nd ta la rtilt a sse sse d • ra dio g ra phic a lly I nc lusio n c rite ria • Giving wa y, pe rsiste nt pa in, ina b ility to re sume pre -injury le ve l o f a c tivity – >6 mo nths Outc o me s me a sure d 6 we e ks pre -o p a nd 6 mo nths po st-o p, • fina l fo llo w-up 12 mo nths po st-o p e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho