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Nov 22, 2023 27 likes •372 views

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

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SLIDE 1

e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

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.

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SLIDE 2

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

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SLIDE 3

NAT URAL HIST ORY OF CHRONIC ANKL E INST ABIL IT Y

L

  • 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.

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SLIDE 4

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

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SLIDE 5

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 .

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SLIDE 6

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.

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SLIDE 7

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

  • 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 t a nd Ankle Surg e ry 1998
  • L
  • ng 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 t a nd Ankle I
  • nt. 2001
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SLIDE 8

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

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SLIDE 9

+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 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

  • 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
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SLIDE 10

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

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SLIDE 11

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? ? ? ?
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SLIDE 12

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

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SLIDE 13

e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

  • 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!!.

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SLIDE 14

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

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SLIDE 15
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SLIDE 16
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SLIDE 17
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SLIDE 18
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SLIDE 19

e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

GRAVIT Y T E ST : NE GAT IVE

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SLIDE 20

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

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SLIDE 21

L a b ib , Sa me h A., a nd Ha rris S. Slo ne . "Ankle Ar

thr

  • sc opy for

L ate r al Ankle Instability." T

e c hniq ue s in F

  • 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.
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SLIDE 22

e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

  • 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

  • ve me nts
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SLIDE 23

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

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SLIDE 24

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

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SLIDE 25

e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

  • Sig nific a nt impro ve me nt in

AOF AS, VAS, a nd K a rlsso n sc o re s in b o th g ro ups a t fina l fo llo w-up

  • No diffe re nc e in AOF

AS, VAS, K a rlsso n sc o re s o r a nte rio r tra nsla tio n a nd ta la rtilt b e twe e n 2 g ro ups a t fina l fo llo w up

  • All-inside a rthro sc o pic mo difie d

Bro stro m re pa ir sho uld b e c o nside re d in pa tie nts with la te ra l a nkle insta b ility

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SLIDE 26

DON’T MISS: CHRONIC INST ABIL IT Y + NONUNION DIST AL F IBUL A AVUL SION

  • 7/ 60 o f Bro stro m’ s
  • rig ina l se rie s.
  • Bo ny a vulsio n o f AT

F L inse rtio n

  • Usua lly in Ado le sc e nts

a nd yo ung a dults

  • Os Sub fula re
  • Usua lly E

xc ise b ut ORI F fo r la rg e pie c e re sto re s sta b ility.

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SLIDE 27
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SLIDE 28

POST BROST RÖM PROCE DURE RE HAB

  • Ca st Splint No n-we ig htb e a ring

fo r first 2 we e ks. Wa lking b o o t fo r ne xt 2-4 we e ks

  • Pa rtia l we ig htb e a ring until

we e k 6 a fte r pro c e dure

  • Ge ntle ROM e xe rc ise s sta rting

a t we e k 4 avo iding inve rsio n mo tio n until 6-8 we e ks po st surg e ry

  • Be g in stre ng th pro g ra m a nd

pro prio c e ptive pro g ra m a t we e k 6 o nc e o ut o f wa lking b o o t

  • Running a t we e k 12 if full ROM,

no rma l stre ng th a nd g o o d ne uro musc ula r c o ntro l. No c utting o r pivo ting until 4 mo nths po st surg e ry

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SLIDE 29

e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

T AKE HOME CONCL USIONS

  • Ana to mic Ankle L

ig a me nt Re c o nstruc tio n is Be st

  • Ankle Arthro sc o py is a n inte g ra l pa rt o f

a nkle insta b ility Surg e ry

  • Arthro sc o pic Bro stro m is e q ua lly

e ffe c tive in L a te ra l Ankle I nsta b ility tre a tme nt with le ss c o -mo rb iditie s.

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SLIDE 30

References:

  • Cottom JM, Rigby RB. The “all inside” arthroscopic Broström procedure: a prospective

study of 40 consecutive patients. The Journal of Foot and Ankle Surgery. 2013 Oct 31;52(5):568-74.

  • Hintermann B, Boss A, Schäfer D. Arthroscopic findings in patients with chronic ankle
  • instability. The American journal of sports medicine. 2002 Mar;30(3):402-9
  • Labib SA, Slone HS. Ankle arthroscopy for lateral ankle instability. Techniques in Foot &

Ankle Surgery. 2015 Mar 1;14(1):25-7.

  • Li H, Hua Y, Li H, Ma K, Li S, Chen S. Activity Level and Function 2 Years After Anterior

Talofibular Ligament Repair: A Comparison Between Arthroscopic Repair and Open Repair

  • Procedures. The American Journal of Sports Medicine. 2017 Apr 1:0363546517698675.
  • Yeo ED, Lee KT, Sung IH, Lee SG, Lee YK. Comparison of all-inside arthroscopic and open

techniques for the modified Broström procedure for ankle instability. Foot & ankle

  • international. 2016 Oct;37(10):1037-45.
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SLIDE 31

e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

OUR NE W E MORY SPORT S ME DICINE CE NT E R/ AT L ANT A HAWKS

  • Emory will serve as the official

sports medicine provider for the Atlanta Hawks

  • 90,000 square foot training and

sports medicine center

  • First NBA practice facility to be co-

located with a sports medicine center occupying 30,000 sq. ft.

  • Regional offices in John’s Creek,

Dunwoody, Smyrna, Spivey Station and Stonecrest

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SLIDE 32

e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

E MORY SPORT S ME DICINE CE NT E R

  • 28 exam rooms and 2 radiology

suites

  • 3 Tesla MRI scanner
  • Peak Performance Project (P3) will

also be housed at the new facility

  • 3D motion capture and force plates
  • Indoor and outdoor pools
  • On-site blood/sweat testing and

analysis for nutritional deficits

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SLIDE 33

e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

T HANK YOU

WWW.DRSAML ABIB.COM

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SLIDE 34

e mo ryhe a lthc a re .o rg / o rtho e mo ryhe a lthc a re .o rg / o rtho

  • He nnrikus e t a l pe rfo rme d a pro spe c tive , ra ndo mize d c o mpa riso n o f

mo difie d o pe n Bro stro m pro c e dure with Chrisma n-Sno o k te c hniq ue

–

Go o d to e xc e lle nt sta b ility in mo re tha n 80% o f pa tie nts fo r b o th pro c e d ure s

–

Bro stro m pro c e d ure sho we d g re a te r Se fto n sc o re s a nd re po rte d sta tistic a lly sig nific a nt d e c re a se in c o mplic a tio ns c o mpa re d with the Chrisma n-Sno o k pro c e d ure