Welcome to the American Journal of Sports Medicine's webinar presented in conjunction with the American Orthopedic Foot and Ankle Society. Thank you for joining us. I am Christine Watt, Senior Editorial Coordinator for AJSM, and I will be the operator of the webinar today. Before we get started, I would like to take a moment to acquaint you with a few features. There are options for how you listen to this webinar. If you have any technical difficulties hearing the audio properly, please try clicking the phone call option and calling in for the audio, or switching the speakers that are being utilized. At any time, you may adjust your audio using your computer volume settings. To send a question, use the Q&A feature at the bottom of the screen. When finished, click the Send button. Additionally, you can indicate your interest in a question by upvoting it. Just click on the thumbs-up icon located to the left of the question. Questions you submit are seen by today's presenters and will be addressed throughout the presentation, so please send those questions as you watch, rather than at the end. There is CME available for this online activity. Here are the learning objectives and the disclosures for our faculty and organizers. At the conclusion of today's program, we ask that you complete a brief evaluation to collect CME for this activity. Those will be given at the end of the program in an in-email to attendees. At this time, I would like to introduce our moderator, Dr. Daniel Latt. Dr. Latt is Associate Professor of Orthopedic Surgery and Biomedical Engineering and Director of Clinical Research at the University of Arizona. He is also a member of the AJSM Editorial Board and will be moderating our webinar. And with that, I'll turn the program over to Dr. Latt. Thank you, Christine. Thank you to AJSM, AOSSM, and AOFAS for sponsoring this webinar. And thanks to you all for your interest in spending an hour of your evening with us discussing this important topic. Lateral ankle sprains are among the most common sports injuries, while most heal uneventfully, many do not. In caring for these athletes, we're responsible to decide when they might benefit from surgery, which technique to use, how they can best recover from surgery, and when they should return to play. We've recruited an all-star team to help you find answers to these questions and many more. I'll be moderating the session and facilitating the question and answer period. It's my pleasure to introduce our distinguished panel. Leading us off will be Dr. Ken Hunt, discussing the workup, indications for surgery, and open repair. He'll be followed by Dr. Eric Giza, who will describe arthroscopic repair techniques. In third spot, Dr. Eric Ferkel will explain anatomic reconstruction. And finally, we're truly fortunate to have Dr. Bob Anderson, a legend in sports foot and ankle, tell us about post-operative protocols and how he makes return-to-play decisions. I'll now turn it over to Dr. Ken Hunt for our first talk. Please share your screen, Dr. Hunt. Thanks, Dan. Great. Well, good evening, everybody. It's a pleasure to be a part of this. Thanks to Dan and the group for inviting me. So as Dan mentioned, I'm going to lead off by talking about surgical indications and a focus on open repair. So I want to start by just saying we're talking about the inversion sprain, the lateral ankle ligament injury, but it's not just the ATFL. I'm going to talk about the importance of looking at the CFL during your decision-making for surgery and which surgery you choose. We know that the three ligaments commonly injured in high-grade sprains are ATFL, CFL, and PTFL. The other thing that's really important to be mindful of is the risk factor. So these can be patients who come in and if they've got that variceal, they have a history of multiple ankle sprains, they play on irregular surfaces, you need to pay attention to this to determine whether surgery might be a part of the conversation. Biomechanics are also very important to be mindful of. The ankle is an oblique joint axis, meaning that the anterior part of the talus is actually wider than the posterior part. The implications of that is that when we're dorsiflexed, we're maximizing our tension in varice to the CFL, and when we plantarflex, we're isolating the ATFL. So in a dorsiflexed position, ATFL resists forward motion and CFL resists varice, whereas in plantarflexion, the ATFL is isolated and resisting varice. And that's why these sprains tend to occur primarily in plantarflexion, because that's putting more force on the ATFL, which is typically the first one to tear. The other thing that's important to recognize is the interruption in neural feedback. So with high-grade sprains, patients aren't able to respond in the same way to fire their peroneal tendons, which are a secondary stabilizer. And if this does not address it in physical therapy while recovering from an ankle sprain, you can get the situation where even a small force can cause that sprain because you don't have the ability to protect your ankle. And that's important not only in preventing the need for surgery, but also in post-operative rehabilitation and recovery. Now a common question is, well, how do we predict this? Like, can we look at a patient with a first or second time sprain and predict whether they're going to go on to chronic instability? The answer is maybe, but it's difficult. So a very nice study from several years ago looked at 82 patients who had a first-time ankle sprain, and they got a whole bunch of different tests done on these patients, and then they followed them. And they only actually identified two predictors of developing chronic ankle instability. One is an inability to do a single drop landing and vertical drop jump at two weeks, and the other is a balance deficit at six months or a lower FAM score at six months. Now, that doesn't give you a lot to go on, but there are indicators of when patients are not going to improve after a primary sprain. So what are the indications? Well, obviously chronic instability, meaning they've had multiple sprains, they can't trust their ankle, they don't want to step off curves, they can't return to sport. Associated injuries, interarticular injuries, perinatal tendon injuries that require surgery is an indication to repair the ligaments. It's important to note that the vast majority, up to 90% of patients with instability have some interarticular pathology that might be impacting their ability to improve. And this is why even if I do an open repair, I'll do arthroscopy in each of these to address that pathology. Now, let's talk a little bit about the CFL. So we did a study that was published in 2020, looking at repairing both ligaments versus repairing the ATFL only. And what we found is that if you add the CFL repair in a cadaver model, it increases the stiffness, it reduces medial translation of the subtalar joint, and it has a higher failure torque. So there is a biomechanical advantage to including the CFL in your repair, particularly if it is noted to be unstable. So how do we assess this? Well, I'll do this in the clinic. It's obviously easier to see on the OR table when the patient's asleep, because they're going to be less resistant. But we look for that inversion and medial translation. So you can actually see where there's translation of the subtalar joint in addition to the tibial talar joint. Pereira published a very nice paper looking specifically at subtalar joint instability and how to examine this clinically as well. So what are the open surgical techniques? Well, I have four general techniques in my arsenal. I'm going to focus in this talk on the open repair and the open repair with augmentation. So for me, an open Brostrom is indicated if the CFL is unstable. If it's not, arthroscopic repair is very good for an isolated ATFL. But I like to do the open Brostrom if the CFL is included. Now this is the tried and true procedure. This is the gold standard. It was described in 1966 by Brostrom, modified by Gould in 1980. So this is the gold standard. Now this is my Brostrom repair. I like to use an anchor in the fibula, but you essentially want to isolate the ATFL. And I'll generally do this with the ankle held in neutral and the hind foot held in full eversion. But if the CFL is out, I'm going to retract the perineal tendon and isolate that CFL. It's just that thickening of the capsule is generally very easy to see arising from the distal fibula. So I like to repair both. Now how can you assess this? Basically the tests that I described are going to help you with that. Again, if you do arthroscopy, you can look and see the ATFL and you can look and see if on exam, if the ankle opens up on the lateral side. And if there's no subtalar instability and the CFL is intact, you don't need to repair it. You can just proceed with the arthroscopic repair. So when do you augment? There are a number of techniques that have come out and there's good data supporting them. So for me, it's when there's a lot of tissue laxity, so that Ehlers-Danlos type of patient, if there's poor tissue quality, meaning you don't have enough ligamentous tissue to get a confident repair, or if there's that subtle hind foot varus and you just need a little bit of additional support in your repair in order to ensure healing. So this is the suture tape technique. This is just demonstrating what it looks like to repair the ATFL. And so what I'll do is I'll put in my sutures, like I'm going to do a standard broach room, and then I like to fasten the suture tape to the talus first. So I'll make a small drill hole, fasten it to the talus, then I'll do my broach room repair with the hind foot held in full eversion. And then once that's done, I'll fasten the fibular portion of the suture tape over the top of the ligament. I don't like to put it into the joint, I like to put it over top of the ligament. So this is what it looks like to split the internal brace. Now what I'm going to show you includes a graph, but I'm meaning to illustrate just splitting that internal brace. So again, we confirm that's a paler instability. We know that the CFL is out. I'm going to put, I'm going to split the suture tape. So I put the center portion into the fibula, and I'll fasten that into place. So you're going to look at that suture tape, and again, I put a graph in this, but I'm meaning to illustrate the suture tape technique. And then once that's in, I'm going to take one limb right under the ATFL, and I'm going to take the other limb right deep to that along the CFL, so that I can split that ligament and use the same anchor point in the fibula to repair or augment both ligaments. So I will do the CFL anchor with the ankle and hind foot in neutral. Very important not to overly evert this. If you overly evert it, it can get too tight, it can get stiff. So you want to put the hind foot in neutral while you're repairing this. And then I'll put in the ATFL limb, and that again, the ankle in neutral and the hind foot in neutral as well. And then I can do my repair. So I've already put the sutures in. So here I'm going to fully evert the ankle, because you can't make the brochure repair too tight, but you can make the suture button too tight. And this is what it looks like at the end, generally very stable and allows you to be much more aggressive with rehab. So there's good data to support this. There are a number of theories out. Probably the best study is this one. It's a comparative with a randomized study looking at an open rostrum versus a suture tape augmented rostrum. And they found a one-month earlier return to pre-injury level of activity with a lower complication rate in the suture tape group. So they suggested that augmentation may support accelerated rehab. We looked at and recently published on data, published literature on suture tape and found, not surprisingly in the ankle, that there's been a significant increase in publications over the past decade or so. So is there a role for acute repair of ligaments? Yes, there probably is for me, and there's good data on this. For me, it's athletes with tissue laxity who have previously failed a rostrum even on the contralateral side and with a hitch of multiple high-grade sprains, or if they have another injury that needs to be addressed surgically. So I think there is a role for this. The data is still coming. Fifteen years ago, no one repaired them acutely. This was, I think, James Collier's article here was a very important one to suggest that, hey, we can get these athletes back quicker and more predictably with an acute repair after a primary injury. So there's a role for it. You just have to give thought to it in your practice. This is my post-op protocol. I put them in a walker boot for four to six weeks. I keep them off of it for 10 days for soft tissue rest, but I start immediate motion. Unless I really need to rest it for some reason, I start range of motion right away because stiffness can be a real problem. And Bob's going to talk more about the return to sport. It's become more milestone-based rather than time-based, but he's going to go into that in greater detail. In summary, lateral inclinability is very common. Outcomes of surgery are good and improving, and the rehab techniques have also improved, which has helped us out a lot. I think the augmented techniques, and some of what you're going to hear today, are helping us to improve outcomes and, importantly, allowing earlier rehabilitation to allow these athletes to get back to the sport more rapidly. I will stop share and hand it back to you, Dan. Thank you. Yeah, thank you, Dr. Hunt, for that excellent overview and introduction to this exciting topic and great thoughts about open repair as well as its augmentation and when and where to do that. That's super helpful. Next, I'd like to have Dr. Giza explain to us about arthroscopic repair, how to do it, when to do it. I want to remind the audience to please post your questions. We have a good question-answer period. Take your questions. If they're really simple ones, we'll have people answer them online. The more complex ones that will be useful for the whole audience, we'll answer in our question-answer period, so please enter those. With that, Dr. Giza, if you can share your screen, and then we'll turn it over to you. I can do. Well, thanks again. Honored to be here with this faculty, and thanks to AOSSM, AOFAS, AJSM for sponsoring this and allowing us to share knowledge. Those are my disclosures. As Dr. Hunt mentioned, the exam's really important, obviously, the interior drawer. One thing that I sometimes see overlooked, and you have to decide particularly to include the CFL, and this is just to highlight or compliment what Dr. Hunt was talking about, I usually have the patients, when I see somebody with instability, I put them prone. You can really get a good look as to how much subtalar instability they have. This is almost like learning how to do a Lachman. I remember when we were all residents, we were like, did I feel that? I don't know if I felt that, but once you do, you can see how there was an endpoint there on the right, but see how the endpoint ends right there? Plus, it forces you to double-check for an osteogonam or any posterior pathology, gives you another look at the peroneals from the other side, so I would encourage you to try that prone lateral instability exam. My algorithm for this, typically, if I'm going to do an arthroscopic brostrom, this is the mild to moderate, and I know we're going to hear later about augmentation and allografts, but I find this very helpful, particularly in the setting of fixing an osteochondral defect. For the arthroscopic approach, obviously, you got to have the proper equipment. You do need to have the experience of doing a lot of ankle arthroscopy and being comfortable with the scope, and going back, looking through the literature, and we won't go through every single case here and every paper, but people were thinking about this a long time ago, as soon as arthroscopy started to become very popular, and this paper was 2009, kind of evolving techniques over time, and then early teens, or whatever you want to call it, started to come out with some pretty good literature. Kaineri and the group down in Brazil showed doing a one-incision double-loaded anchor and getting people back to sport and athletes back to sport at the same level as open techniques. George Acevedo and Pete Mangone published this paper in 2015, kind of showing that it works really well, but there were some complications, and I think that's been the evolution of the technique to really paying attention to the lateral soft tissues. When you compare the arthroscopic to the open, this two-year follow-up showed no difference between the two groups, and another one, same thing, no big difference, so sometimes there's, and I'll show you a couple of indications and reasons why I choose to do this arthroscopic. Dracos and his group at HSS looked at the biomechanics, because, you know, that's obviously an important thing, because we're not dissecting out the tissues the same way you do when you're doing it open, and Misato Takao and Professor Kumai in Japan have talked a lot about how you're actually, when you take it all off as a cuff, you're still including the CFL and really even the inferior extensor retinaculum, excuse me, because it's all kind of pushed together. So, we did a study some years ago looking at 10-match pairs comparing open to arthroscopic. We randomized the pairs, and then we used our Instron. That's obviously, this is an example of the open, and we found really no statistical difference, so that gave me the confidence, and this was back in, you know, the 2012-ish or so when this really started to become more popular, that this is a safe thing to do, and depending on the patient, you can see from this data, they're really very similar pull-out strength. So, as this got even more evolved, you wanted to make sure you had the right landmarks to make sure you could do this safely and not have any problems with injuring any of the soft tissues, including the superficial perineal nerve. So, this study by Christian Ortiz and George Acevedo kind of looked and found what were the safe zones. So certainly want to be cognizant and be thinking of, you know, what does this look like when I'm doing it open and what does it look like from the arthroscopic perspective. And then the IER is usually about 15 millimeters from the fibula. So most of the techniques that you'll read about in the literature, you want to make sure you're far enough away from the distal fibula when you grab this, the soft tissue. So to do this safely, you want to mark out while they're awake in pre-op, have them dorsiflex the ankle and mark out the tendons because sometimes depending on the patient's body habitus, sure you got a, you know, a gymnast, you can see everything really easily, but if you got a, you know, football lineman, it may be a little bit harder once they're asleep to be like, oh geez, where's the, where's the tibia here. So, and then the other thing I do is invert the foot and really find that SPN. And I mark it out. That was with the dots right there. And for the arthroscopic technique, you can see, I mark out the perineals too, when you can feel them so that you're making sure you're not going too far back. Patients to supine, obviously these people are unstable. You don't need distraction. And then you can address any intra-articular pathology such as an osteochondral defect. Some of the companies have some like commercial little fat pad retractors, or you can even just take, you know, any, any kind of thing and put it in front of the, the fat pad. And that kind of pulls everything away. And then you're protecting the neurovascular bundle. If you want, I like to use the, the underwater electrocarotid to clear the soft tissues. That's one of the big things with doing this. You have to really make sure you can see what you're doing in that lateral gutter. Otherwise the tissues start to fall in on you and then you're, you're hopping on the struggle bus and you don't want to be there. So I really make sure I mobilize the soft tissues. You can see I have an elevator here. I'm getting all my finger on the perineals and I could, I can, I'm feeling that I'm getting everything mobilized. So it all comes up as a cuff. You don't want to just have the anterior tissues. You you place your, your first anchor, which you can see there. And then it first couple of times you do it, you really got to drop your hand. You're getting as far down on the fibula as you can see. And if you're worried, you just, you know, take it back, take the drill out and say, okay, I'm in the fibula. And then you place your anchor, as you can see here, it's going in. And then the sutures are there. And I, and I like to actually do that, that, that picture had both anchors in. I like to do one at a time. So you put the first anchor in and then you pass your sutures and you can see that coming through. And then here you are, you're just pulling them out from the side. And then, and then I've found over the years that putting the second anchor in after you pass the first makes it a lot, a lot more simple. So then you're looking at that and then pull up on the tissues and make sure you have really captured a good cuff of tissue. And if you then look at the joint, you can actually see the talus kind of coming back up and you know, you have a good repair. Then you just make a little perk incision and capture the sutures and then time down in eversion and neutral. So here's a little pre and post exam. It's, it's really solid. At one point early on, I was a little worried. Sometimes you'd go back in and you'd be like, yeah, this thing's solid, but geez, I can still see some suture there. So I work with Tom Clanton in the group. You can still see a little space, you know, between the sutures and the fibula. So, you know, obviously double row has been shown in lots of different literature, including shoulder that it's stronger. So we actually did a cadaver study with, with Dr. Clanton out of Vail and showed that you actually will get 40% more surface area. It's not necessarily stronger, but you can see the difference between the standard tie. And then that area B where you can see running, you just run two of the sutures up under the skin and put it in as a double row, do a little mini incision in the lateral fibula. People often ask me, Hey, what about if you have an OCD? And actually this is one of my main indications for doing an arthroscopic brostrom is to say, Hey, look, I got this OCD here. I have to address that. However, you're going to, I usually do clear the interior scar, prepare the fibula, get everything ready. Go back, get my, pass my sutures first, get that all ready to go. Then turn back round, whatever kind of intra-articular repair you're doing, whatever you're using allograft, autograft, what have you. Then I, once I'm sure that's down, I have my fiber and glue or whatever you're doing it. Then you just remove the scope, tie the sutures and you're done. So here's, here's somebody at five weeks. I I'm, I'm with Dr. Hunt. I usually have him in a brace, but this is a California college student who was like, Oh, I feel great. She walked in for a five to six week appointment. Here's somebody at 10 weeks, feeling stable, doing his thing. There's some other techniques. I showed you mine are the one I like to use. There's been a number of other Patriot papers. Some people do it all inside. Mark Glazebrook and Masato Takao and company have showed how you can even do this. If you're going to use a cadaver or a hamstrings autograft, you make a little Y and you can do this all arthroscopically. And then my good friends in Chile, Manuel Pellegrini, Giovanni, Christian they have an all like a knotless all inside technique that you can check out where, where they pass the sutures underneath with no knots. So thanks very much. And hopefully this was, was educational for everyone. Thank you, Dr. Giza for that fantastic overview of the arthroscopic treatment of a lateral ankle. We'll then move on to our third speaker. Dr. Eric Ferkel is going to tell us about anatomic reconstruction and we'll turn it over to you. All right. Thanks, Daniel. And thanks to ALSM and Dr. Owens for having me on today. This is the, I feel fortunate to be amongst some incredible colleagues here. I've been asked to talk about allograft reconstruction for lateral ankle ligament instability. So it's been kind of alluded to ankle injury and the epidemiology of it is really one of the most common injuries for sports medicine injuries that we're going to come across, whether the NCAA athlete, the high school athlete, or the professional athlete is one of the most common causes of acute injuries in volleyball. And one of the leading causes of time loss in American football epidemiology, if you know, is the lateral ankle ligament injury accounts for approximately 90% of ligament as injuries in all of sports and 11% of injuries seen in the professional league in the premier league in soccer, 77% of those were actually lateral ankle ligament instability. So you look at the spectrum of the repair for, to address lateral ankle ligament instability, starting to think about functional instability that Dr. Giza just discussed using arthroscopy, when you move to surgery, you think about arthrobrostrum, suture repairs, Dr. Hunt mentioned possibly adding an augment. When you have severe instability that's failed, perhaps you got to jump to another option in this case, allograft or autograft. So the problem here is now you have recurrent instability. Patients possibly fail the previous surgery. Maybe the ATFL, CFL tissues are too thin, too weak, too elongated. And so in this case, I think in my mind, thinking about doing an allograft reconstruction is going to be the best option to address this chronic lateral ankle ligament instability, CLAI. And so when you have these indications that I look at where you have significant ankle laxity with a 10 degree difference in Taylor tilt compared to the contralateral side, previously failed reconstruction, generalized ligamentous laxity, a BMI greater than 30, heavy athletes or laborers, or poor picture quality noted during interoperative evaluation. For me, this is a great indication when there's two or more of these to jump to doing an allograft reconstruction. We want to ask ourselves, is allograft similar to the native intact ATFL? There's a great study by Dr. Clanton's group in Vale 2014 did address that question and they did show that an anatomic reconstruction when done anatomically, which is important, of the ATFL with an allograft demonstrated similar stiffness and strength to the native ligament at time zero in these cadaverica models. So the question is, anatomic reconstruction with an endograft, well, when we use it best for the failed reconstruction, as I mentioned, inadequate tissue and the quality of the secondary reconstruction may be inadequate. So the study Dr. Clanton also showed that when you have this biomechanical validation of similar to the native tissue, we can then say to ourselves, well, if we do this anatomically, are we going to have a better outcome? So this is another review that did show and agreed with this study that showed an anatomic repair was more favorable than doing a non-anatomic teneodesis reconstruction for these chronic instability patients. Is there an optimal graft? So this is another question, especially around the world where maybe allograft isn't a great option for some patients. In this study, which is a meta-analysis of 29 studies, autograft versus allograft, it actually showed that when measuring the patient's subjective satisfaction scores, there wasn't a difference between autograft and allograft in the reconstruction of the lateral ligaments in these chronic lateral ligament instability patients. Both graphs were associated with postoperative Carlson-Peterson scoring superior to 80 points and a similar rate of patient satisfaction. So takeaway from this study was that you can use autograft or allograft and both had really good outcomes. So I just want to go through my technique on anatomic lateral ankle ligament reconstruction using a tenon graft. In this case, I prefer to use a semitendinosus allograft reconstruction. Like I said, you can use autograft as well as you would like. Typical Brostrom approach. Obviously, if you have a previous incision, sometimes you're going to be handcuffed to that previous incision. I like to use a bioteneodesis screw as well. In this case, we're going to be doing both the allograft as well as the typical Brostrom at the very end of this case, which I'll show in a minute. The key is you want to really capture the joint, but you also want to avoid over-tightening. The ligament that I understand will probably stretch out over time is that crepe elongates. So here's a case of a 42-year-old female pickleball player. I'm sure we're seeing all these patients in our clinic these days. And I like to use a telos, which is a device we have in our x-ray booth, to put stress of approximately 10 to 15 decanewtons on the ankle. And here you can see the left versus the right side here, where obviously there's significantly greater tailor tilt. Also, you're checking to see their stability in clinic, and you can do it via fluoroscopy if you don't have the telos machine in your office. As Dr. Giza just alluded to, should you scope the ankle first? Absolutely. A lot of studies showing concomitant pathologies, such as osteochondral lesions or loose bodies, and you don't want to miss those if you're addressing this injury. Technique, again, exam under anesthesia, arthroscopic assessment for concomitant pathology. That's the arthroscopic approach. And then you're looking for here is your initial is going to be your evaluation of the tailor neck there. Make a 5 by 5 millimeter diameter, a 17-long tunnel drilled into the telos and then drilled into the fibula as well. In this case here, some telos allograft was then used for ligament reconstruction. Each graph was approximately 14 centimeters in length. You do a crack-out whip stitch on your allograft, and then you drill, again, your ATFL drill hole is about 10 millimeters superior to the tip of the fibula and about 18 millimeters above the sub-tailor joint. And then you identify your CFL drill hole about 13 millimeters from the sub-tailor joint at 120 degree angle from the fibular shaft here. And at this point, I'll take a device that allows you to really rasp that tunnel to avoid any sharp edges. You can thread it out as well. And you want to make sure that there's no risk of tunnel blowout and making sure that you're really center, center of the fibula when you're doing that coronal plane to avoid that tunnel blowout. And then you over-drill the four millimeter and the five millimeter drills, and then to allow those tunnels to converge. You then pass the semitendinosus into the telos and you fix it into the telos with the biotinodesis group followed by the graft insertion into the fibula from anterior to posterior. And you can see the passage there into the fibula as well. Next, you go down to the calcaneal incision, just posterior to perineals, obviously care to avoid an injury to the neurovascular and you want to get the perineals out of your way. And then you pass the wire from lateral to medial across with again, care to avoid injury on the medial side of the neurovascular structures. The wire is an over-drill to create that 5.5 by 25 millimeter tunnel. And you can see a nice little drawing here, which shows that. And then the graft is passed, making sure that the ankle is placed in that neutral position there. And then fixating it with a biotinodesis screw while the hind foot is reduced, usually with a 5.5 by 15 millimeter screw into the calcaneal tunnel. At this point, you then complete your typical brash and gold reconstruction, and you can use either suture anchors. You can do a side to side reconstruction and bring that back again, ensuring to avoid that the anchor, the ankle, and it's up to their motion are stable, but unrestricted. When we look at this study that was done by Dr. Ferkel Senior, Dr. Dierkman in 2015, showing 71% return to play and at a previous activity level when using this technique. Another study done in 2010, again, showed that you had the contact mechanics of the normal and sectioned ATFL brash, but there's, when you restore these anatomically, you had no decrease in forces compared to the native ATFL. Another study using the semi tendinosis allograft reconstruction did show 81% improvement in stability. And only five patients had residual functional instability. Finally, I wanted to show this study, which did look at high return to sports in 2022 by KSST. Patients had a high return to sport, high return to work rate in high risk patients, which meant patients with at least ligamentous hyperlaxity or insufficient native tissue and or high demand athlete. So at 63 months, excellent results we're seeing in this study for these patients. Postoperative management for me is non-weight bearing in a splint initially converted to a cast from week one to week three, and then begin weight bearing in a boot at week three post-op. I like to begin blood flow restriction therapy usually around 10 to 14 days post-op. Dr. Anderson will touch on in a moment here, talking about functional rehab and testing before return to play. So just want to also give a quick shout out for a course that Dr. Hunt is going to be the chairman of next month. It's sponsored by AOFAS and Instacost in Boulder, Colorado. If you log onto AOFAS.org backslash sports, it's going to be a phenomenal meeting with Dr. Anderson as well. Going to be lecturing there and some phenomenal speakers, Dr. Giza in Boulder, Colorado, April 18th to 21st. So I just want to give a quick shout out to that and send it back to you, Dan. Thank you very much. All right. Dr. Perkel, thank you for your fantastic presentation. That was a awesome overview of this complex technique. I think we all, your photos were fantastic, got a really good sense of the procedure. We'll move on to our final speaker. It gives me great pleasure to welcome Dr. Anderson. Dr. Anderson is going to be telling us about post-op protocol and return to play decision-making. And it's really great to have this talk as part of this webinar. So thank you, Dr. Anderson, and turn it over to you. Great. Thank you, Dan. And it's a pleasure being with you. I appreciate the invitation to be here Dan, can you see everything and hear me okay? Yep. Looks great. Okay. Very good. Well, so we heard wonderful talks on how to do the surgery. What about getting these guys back to play? So I have nothing to disclose as far as it concerns this particular talk. You know, we talk about, you know, surgery. We also have to talk about your post-op recovery. I think it's as important as the surgery itself. And it's something you need to put together when you're a patient pre-op, not post-op. You've got to educate them on the risks, the balance between healing time and protecting the repair, avoiding atrophy, scar, arthrofibrosis. And then of course, what I like to do is I like to count backwards. When do they have to get back? When is their goal to be back playing? And I try to go back and say, okay, we got three months, four months, five months. Let's see how aggressive we need to be with your post-op recovery and rehab. When you talk about post-op recovery being as important as surgery, this is a team approach. You have to have everybody involved from your trainer to your rehab specialist, strength and conditioning coaches, the head coach has to be on board, as does the player himself and his family and other members around him. I think it's really important that before you can get to the post-op recovery, you got to create the right expectations. These people, these athletes need to know that everything heals better with more time. And unfortunately, time's not always on your side when it comes to managing the elite athlete. There's pressure from multiple parties. Will he return? When's he going to return? Will he have the same talent? What are the risks? You really need to talk to the player. You need to understand the player's psychology. What's behind all this, not just from a physical, but from other little issues that may be going on. So you really have to function as a psychiatrist. You have to listen, educate, obtain and offer additional opinions. You really need to keep in mind that that player is a patient. He's your patient. It's okay to be a team supporter, but not a fan of the player himself. You have to really maintain perspective from a health perspective and do what's right in the longterm, really not cut any corners just to get into back to play quicker. You also have to understand that recovery and return activity depends on what is the edge of your part, how much surgery is actually done. As you all know, a fracture in osteotomy may heal much differently or quicker than a ligament does. And a ligament may heal much better or different than a tendon will. So all these things are very important as you start putting together your post-op recovery plan and return to play. There's other considerations too. There's numerous factors that influence a specific date for actual return and its documentation. There's a season schedule. Some seasons have longer downtime than others, and you've got more time to get these guys back. And then, of course, what about the talent level? What talent level does your particular athlete have? What about scholarships, even at the high school level or redshirt in college? And then, of course, what's their ambition as far as draft is concerned? And then you also have to understand a little bit about the player motivation, if there's any secondary gains that may be a factor as well. The other thing I've learned is you can't treat a pro player athlete patient like you do a college or high school player. There's a lot of business considerations that arrive at the pro level, especially in the established veterans. You've got contract fee agencies, personal injury policies. So, again, you just have to understand it's just a different game. Unfortunately, with the NIL, we're changing some of the college in that regard, too. There's more medical legal concerns for all of us, even managing the college after perhaps the next will be our high school athlete. So, with that said, with that introduction, let's talk about lateral ankle ligament reconstruction. Again, you heard great talks, and you heard each speaker give a little bit about his own protocol, and that's what it is. It's basically very individualized from surgeon to surgeon and patient to patient. So, in general terms, this is my post-op protocol for a lateral ankle reconstruction. I go two weeks, not weight-bearing a splint after they leave the operating room. I take the splint off right around that two-week mark to get their sutures out and then advance them to a walker boot to start range of motion. If I somehow am managing an osteochondral lesion, I'm using some kind of cartilage implant, I address an unstable sinus mimosas with some fixation, I may go non-weight-bearing for four to six weeks instead of the usual two weeks. But again, it's important, as the other speaker said, initiate that dorsiflexion and plantar flexion early on. You can also do some isometric posterior tip and perineal tendon strengthening at about three, four weeks. You just don't want to stretch out your repair. At four weeks, if the wound's sealed, I go ahead and get them into Alter-G in the pool, do some hydro works. I try to get them to advance to a shoe by eight weeks. I hold off on rotational activity until 10 weeks, and I do expect to start field work at about 12 to 14 weeks with some kind of brace protection. I usually do recommend that our athletes use a brace for games and contact for upwards of six months post-op. Now, I will protect or immobilize longer in certain individuals. Those that have an increased BITEN score, if they're Ehlers-Danlos, Marfans, what Eric just talked about, an allograft weave, it's a tendon, it's not a ligament. I may go a little bit longer with my immobilization so I don't stretch it out early. And, of course, revision surgery is another situation where I'll go a little bit slower with my range of motion and progression. I think it's really important for all of you, no matter what kind of protocol you want to institute, you have to concentrate on perineal tendon strengthening, posterior tibial strengthening, particularly if the medial side has been addressed, proprioceptive re-education, and eventually, finally, is your plyometric exercises. What we do tend to find is if you've got somebody who's got post-op dysfunction, it's usually secondary to insufficient rehab. So, you need to go back and see have they completed all the appropriate steps. So, with that said, let's just talk a little bit about return to play. What does it mean? It could be return to activity, return to sport, return to participation. Return to play is a very confusing term because it's really not actually the return to game play as most people utilize that term. It's a guess. It's a very nebulous term. It's one we probably shouldn't use. It shouldn't be used unless you're going to use it in this regard. So, if you truly wanted to find return to play, it should be the safe return of the athlete to competition, either practice or games with no restrictions placed. And it should include consideration of the risk of re-injury and or compensatory injury. So, what about return to play? Can you go open a book and find out exactly how to do it? Unfortunately not. The literature is very sparse when it comes to helping you with the return to play criteria. There's no protocol to follow. There's nothing validated out there. It's all anecdotal. It's pretty much all level five. Again, there's consensus opinions like this one in British Journal of Sports Medicine. There's expert opinions that are in the literature about how to get somebody to return to play. There's this system review on criteria-based return to sports decision. But again, it's not evidence-based criteria. So, if you're looking for literature to help you, sorry, it's not there. You're sort of on your own. And basically, you have to do what works for you. And that's where just experience come into play. So, there are some things that you can do. I think the first thing I want to share with you is that I don't determine return to play. That's not my role. That's not a physician's role. I think it's our role to orthopedically clear that athlete to advance the functional recovery program. This is not a cop-out. My responsibility is to determine the healing progress, the status. Are the ligaments stable? Are the fractures or osteotomies healed? Is it safe to progress further? Another thing, don't talk to the media. Don't voice your opinions on return to play. Let the head coach and let the head trainer do the talking. If you are asked by those gentlemen to provide an estimate, I always try to overestimate. I think it protects you as a surgeon but also the player as the patient. My new answer these days are to say, listen, we're going to reassess this person's progress at six weeks and give you a better idea of when return to play may be feasible. So, that's another way to do it. Just a little bit of a – be a little vague to start with. Return to play decision-making, it's like rehab. It's a team effort. Stay close with everybody. You need to communicate and, again, inform everybody around that player or patient of your concerns and potential risks and stand your ground. Really, don't give in. Don't give in to those that yell a lot. Injuries and surgeries take time to heal, particularly ligament injuries like this one, or ligament surgeries. You've got to consider long-term considerations. Understanding, too, that if there are issues or complications, that tends to fall directly back on you as the provider, as the surgeon. I think it's also important not to make the care of the athlete and his post-op recovery and return to play an ego thing. Try to get someone back quick to make you look good as a physician will eventually bite you. The same thing is true on the other end. Don't let the athlete make return to play an ego thing. Educate the athlete on what's best long-term. What are the risks and implications if he tries to get back too quick? And then, can you adequately protect him from further or recurrent injury and compensatory injury when he does go back? Return to play criteria, I'm sorry, but it's difficult to find. There are no absolute contraindications to participation that exist out there. There's a significant pressure to use approaches that are outside the box, and decisions are made basically case-by-case that oftentimes vary subjectively. So, what kind of things can you do in the office setting? Well, it's still the good old simple objective test, toe and heel walking, the 25 hop test, the 25 single limb heel rise test. Those things still can be utilized and still help to at least get you in the ballpark of when you think that person might be ready to get back. Now, you also have other things provided to us with our whole thought about group effort. I use my trainer, my physical therapist, strength and conditioning courses, and all the resources and parameters they have with them looking at motion and plyometrics and proprioception, durability, endurance, conditioning. So, all those things are important. If I get an athlete that has reached a hurdle, he's reached a plateau, he just is stuck at a certain level and can't move on, then I think biodex testing is very helpful to look for strength deficits and whether he's progressing or not as it compares to the contralateral. So, again, something else you might want to use. Return to play determinations, there's a lot of functional assessment plans that have to be in order. These are provided by most professional and college teams. The doctors should review these. They're very detailed. They're very systematic. They're very specific and individualized. But it is something you need to be aware of that these functional recovery plans are out there and they need to be adhered to on a gradual basis. Now, fortunately, with return to play criteria determination, we do have technology at our disposal. Some more objective criteria is now available. One of it is the computerized treadmill that looks at heel strike and load shifts. Another is the DARI health data. This is one that a lot of the NFL teams are using now, where basically you do baseline computerized functional assessments. You put it on the cloud, and then if somebody has an injury, you can utilize this, you can bring it back, and you can judge how they're doing in the recovery process by, again, comparing what they're doing now compared to what they did at their baseline. So, again, something we're utilizing a lot of that is very valuable. And then, of course, lastly is the GPS. This is wonderful for on-field work. This is a real-time assessment of rehab efforts and recovery, looking at durability, looking at endurance, and, again, what most college and professional teams have at their disposal now. So, again, even with all this great technology, once an athlete passes all testing and can demonstrate pre-injury levels of output, the risk of the decision to return to play still has to be shared. The player, his family, and the doctor all have to be involved with good communication and very good documentation before that person does come back and play. So, lastly, unfortunately, post-op protocol and decision-making for return to play on the lateral ankle reconstruction, is there a formula to follow? Unfortunately not. I think all of you should use resources that are available wherever you are. Don't get trapped on estimates. Do what's best for your patient and consider their long-term health first and foremost. That should be your major priority. We have a lot of work to do in this area. Unfortunately, our decision-making for return to play has no validated programs. This is a paper I recently helped Tom Clanton with and others, and we went through all the literature and found there is nothing validated out there to help us in this arena. So return to play remains largely undefined, and, unfortunately, we still don't know when return to play is not safe. So, again, we've got a lot of work cut out for us. Hopefully, with time, we'll get there. Thank you very much. Thank you, Dr. Anderson. That was incredibly informative. I want to thank the panelists for their fantastic presentations. We now have our question-answer period. I think since we have 10 minutes, we can run over by a little bit, I've been told. I'm going to start out with a quick case. I know nobody likes to show their complications, but this is one of mine, and I want to see what you guys all think about maybe what I should have done differently initially. Did I choose the right initial surgery or things I should have thought about? So this is a 21-year-old woman patient of mine. She came to see me shortly after her motor vehicle accident. I treated her nonoperatively initially with a short period of mobilization and then brace and physical therapy. She'd done that for five months. She didn't improve. She had persistent pain and instability with ADLs, despite having done the things I talked about. Her MRI showed she had complete tears, ATFL and CFL, and she needs to use her ankle. She stands for work. So this is her instability exam under Floro. I'm going to go to the next slide. So I took her to the OR in March 21, did ATFL and CFL, a suture-anchor-based open repair. She had an uneventful post-operative course, but she never felt stable. MRI showed a persistent absence of her CFL. Not the most impressive tail or tilt, but not terribly different than prior to her initial surgery. What do you guys, anybody want to hazard what they think? So, Dan, this is probably a tissue quality thing. If there's not good ligament tissue on the follow-up MRI, then even if that was repaired primarily, it may not have had the biology to really remodel. So in this case, if she's still clinically unstable and it's impacting her life, which it sounds like it is, what I would do is what I demonstrated, which is an allograft reconstruction with a suture tape augmentation. So that gives you the material, the tissue with the tendon, which will remodel into ligament, and the suture tape augmentation, which gives you a little bit more oomph, if you will, so it doesn't stretch out. That's probably what I would do. Yeah, Dan, I would do the same. I'd do allograft reconstruction because I'm concerned about just the available native tissue you can use to reconstruct with. So I think the other point here is, why does she have pain? So I guess the question is, why does this person have pain? Because usually ankle instability itself is not a pain generator. It's a functional disabling one, but it usually is a pain generator. So I'd also be concerned here not only about her recurrence of the feeling of instability, but also the pain generator. Where's it coming from? MRI shows she has a flattening of her peroneus brevis, but not a tear. And I think some of her pain was associated there. I guess the other question is, in this more high-energy injury, this is a surgical accident, whether anybody would consider having done allograft or something else at her initial procedure, even though she doesn't have that much laxity. I mean, there's certainly some, but a lot of functional instability. No, I think it's a reasonable approach for any of these initially with the outcomes that we know are so good for primary repair, however the ways we all talked about doing it this evening. But certainly, yeah, moving to allograft for this afterwards. And I agree with Dr. Anderson. I think one of the things that I like to do in these revision situations for the pain and whether you have, you know, your repeat MRI, I like to get a CT scan because sometimes I find like, you know, if there's just a little edema, you know, on the tailor dome or what have you, sometimes they do have a small subchondral crack or what have you that you can't see that volume averages out from the MRI. And then the other thing to consider is, you know, is their subtalar joint painful, right? So a selective injection, and I tend to in younger folks, I like to do, send them for an ultrasound-guided injection, either of the ankle or the subtalar joint, not with cortisone because they're young. I like to use Tordol mixed with the long-acting and short-acting lidocaine. And then I tell them, hey, write down how it feels at three hours, three days and three weeks. And if they have significant pain relief from either one of those injections, don't do them at the same time, then you may have to address some, you know, kind of focus on when you're doing this, you know, directing towards some type of intra-articular pathology, which is scarring, whether it's an osteogonum or just posterior impingement or an FHL stenosis or something like that. Great. All right, let's go on to the next slide. So I did what you guys suggested, allograft, tunneled allograft reconstruction and examined her peroneus prebis. It was a little flattened but not torn, so I didn't do anything with that. And then, next slide. And then, unfortunately, she comes back. I think this is now like five or six months after our reconstruction with what looks like this serious tunnel expansion and persistent retromalleolar pain along the peroneus prebis. Another MRI shows she's got now a split tear of the prebis and tenosynovitis of the longest. So I thought, do you guys ever see this tunnel expansion? And what do you think about, you know? What kind of anchor or screw was used? So it's sort of the standard kit with, you know, I guess it's, you know, biotinidesis screw on the type set up on the talus and on the calcaneus, and then there's a small screw in the fibula to prevent the two sides from, you know, going to a washroom. So pretty standard. This is definitely a tough problem, Dan. Tunnel osteolysis there is something that, you know, obviously you see that with ACLs. And in terms of release from my workup on this, I would get a CT scan as well as an MRI, and then think about possibly two staging this. The other question is, you know, what's going on with her bone quality? Why is there an expansion? Is there a need to be getting a metabolic workup on her as well? For the patient to see what's going on with that, just so you can prevent this in the future too. Yeah. I mean, on the positive side, she didn't have any instability at this point. It's mostly perineal tendon pain. You know, it's a little bit of asymptomatic widening. So I go on the next slide. So I took her to the back to the OR, examined her perineal tendons, and repaired that flattened perineus brevis. And there was some scarring of the longus, and then bone grafted this tunnel. I guess any unfortunate jury style we'll see. So far she's been doing well. You know, so this was back in August. The only thing I consider adding at this juncture is, you know, when you re-scope it, and obviously get a comparison view to the opposite side, it doesn't look like her, you know, her deltoid's necessarily unstable. But a lot of the folks in Europe talk about this micro-instability. Meaning like, yeah, of course, we're always focused on the lateral side. But is there, if you do like a Hinnerman test intraoperatively, is there just a little bit of laxity in that deltoid? You know, because they've been unstable for so long. They beat up the deltoid with so many inversion injuries. And then that anterior portion of the deltoid is slightly unstable, and then it just keeps edging away at your lateral instability. So just something else to consider. It doesn't look like that's the case here, but just for the audience to be aware of that, that some of these chronic cases do have an element of deltoid instability as well. Yeah, great. Well, thank you, guys. We can come back to this. Let's take some of the questions from the audience. I have, this one is of particular interest to me from a non-attendee. How do you address subtalar instability? I know, Dr. Gizzi, you showed us how to examine for subtalar instability. What do you do different when they have true subtalar instability and not just isolated anterior drawer tail or tilt? Well, my favorite ligament, even though I did a sports fellowship and the entire body is the CFL, because it's so awesome. Um, cause it has this broad expanse. And so when I do, um, all my open brass rooms and stuff, I always kind of dissect down and, and find the CFL. Um, so, um, I always repair that even in folks who, you know, do or don't, but certainly when I know that, uh, I'm, and I think Dr. Hunt and I are in the same camp, um, that the CFL is, is a big primary stabilizer of, of the entire lateral ligament complex. So that, that, that's sort of the, what's sort of my mantra is just that pretty much everybody's going to have it and, um, you got to fix it. I would agree with that. I would just add that, you know, the subtalar joint is stabilized by the CFL, but there are other stabilizing ligaments of the subtalar joint that can get injured with high grade sprains. There are reconstructive techniques. I'll admit I've never done them because I think reconstructing the CFL as Eric pointed out is, is effective enough. And the other, uh, the other ligaments can sort of remodel during the recovery process. Um, but it is, it's more than just the CFL, the subtalar joint. Um, so it's important to be mindful of that, not just with hilting, but with internal rotation of the foot, uh, and with that medial glide test, um, because that, that's sort of isolating the other ligaments. That's right. And then remember part of the reason I think the, the, the Gould modification was, was, you know, such a great advance is that, you know, there's, there's three bands of the inferior extensor retinaculum that, that come down and insert just, just lateral to the interosseous talocalconeal ligaments. And that's why pulling that up also adds to said, said, you know, stability. I've got a question for, for Eric since, uh, since Dan said we can go a little bit long. Um, I, so I'm curious about this, the, the, you know, so George Acevedo wrote a very nice paper on arthroscopic ligament repair and says in there, you do not need to repair the CFL, but I realized that, that the technique that he uses includes the extensor retinaculum. And as you just pointed out, Gould added that and the extensor retinaculum does attach to the calcaneus. So you're technically stabilizing the subtalar joint if you are including the extensor retinaculum in your repair as Gould described. So do you, Eric, feel that if you're doing an arthroscopic repair to include the retinaculum that you don't have to address the CFL surgically? Yeah. And that I, I struggled with that for a long time. And that's part of the reason I wanted to do that. Those in it, you know, the, the cadaver studies on arthroscopic versus open, because, um, there, there was a big debate, um, between, um, young, uh, between Kim and Masato Takao, like, uh, you know, between Korea and Japan. And then, you know, there were papers published by the Koreans saying if you just do the ATFL and then Masato did this really elegant anatomic study showing that if, if, if you take everything off as a cuff, you're including the CFL. I just like to, a lot of times it scars down to the lateral wall of the calc. So I just like to, to elevate it off and I, and I'm fairly aggressive. Like I showed in a video tonight of, of getting my elevator down there and really getting it off the lateral wall of the calc, and then I, I take a grabber and make sure when I pull all the tissue up that I'm, that I'm getting everything there. So I feel like when I do my arthroscopic ones, um, that I'm accomplishing something very similar to what I do for, uh, when I do it open. All right. Let's, uh, let's see if we can get through a couple more of these questions. Uh, about, uh, get it, you get an MRI in every case of chronic ankle instability. Show of hands. Yeah, I think so. It's just the same question. You know, should you scope every one of them? And I, I agree with the other speaker said, as I, I would highly recommend you scope before you do your reconstruction as well. There's a lot of interesting things you'll find as well as the need to assess the medial side, because we know that a lot of these lateral ligament instability patients also have combined medial. And if you don't address the medial instability, you'll have a higher failure rate of your lateral repair. Um, it's interesting. Uh, I might be the only person who doesn't scope, uh, routinely then these, how do you guys deal with the fact that the tissues are all indurated when you go to, when you go to, if you go to do an open repair after a scope, I mean, it's, uh, like operating in jello. Well, I, I use a small scope. I mean, Bob, I don't know if you do too. I use the two seven or sometimes, uh, the one nine and I run my, my flow pretty low, like 30, 30. Um, just so you don't get a lot of extravasation. I, I, I always am a promoter of, of education, but if my fellow or resident has taken too long and I start to see the, the soft tissue, I'm like, you're done gravity flow, gravity inflow solves that really. Um, cause it's a, it's pressure related rather than a specific force that the pump would have. But yeah, low, either low, low pump force or gravity flow. And then as, as Eric said, be, be efficient. Like don't, don't stay in too long. Um, yeah. Yeah. I would echo that. And I was like the, the, the famous John Wooden quote, which is to be quick, but don't hurry, you know, some move, move efficiently and effectively in the ankle and, uh, just getting, getting it out. All right. Um, let's see if there's a couple more of these that we have, um, have not yet answered, um, based on, uh, trends and latest, uh, data, would you, uh, repair all acute complete tears shown in MRI? And you brought that up. Yeah, I would say no, not all of them. I mean, I have a very specific criteria. I don't think it's unreasonable to do an acute repair in some circumstances, but not, not routinely cause that that's going to be pretty much, I mean, that'd be a half of our basketball team, you know, I mean, like you're, you're going to see an injury on the MRI every time. And so I think that the standard is still to rehabilitate. Now, if they've got one of those risk factors, the subtle various, I had an athlete when I was at Stanford that had, um, just chronic instability on one side. And we finally Victor. And then the other side, she sprained and she's like, I said, your first sprain, she said, yeah, but I don't want to go through that when I went through on the other side. And so we just fixed it acutely. She had tissue laxity. And so I think there, there are circumstances when it's appropriate, but as a rule, no, I wouldn't repair it just because I see it torn on, on the MRI. I think that's a good point to bring up because as, as Dr. Anderson mentioned, you know, there's different levels, right? Like, so, so you have your high school athlete. I'm not going to repair them acutely. We have one of our professional soccer players and the pressure's on, they, they tear it during preseason. Those are the ones that consider, and that's what James Calder, you know, published on for the, the premier league soccer players, but with, as we all know, and everybody in the audience knows with the advent of EMR and my chart and all the things being released, the patients are like texting your, or whatever, my charting your nurse saying, oh my God, all my ligaments are out. What do I do? And so it's managing expectations as Dr. Anderson said, I was like, look, your kid's an 18 year old and they're, they're not a professional athlete yet or ever. So let's, let's do what we're, you know, the standard care. And then those who, who hit that higher level as, as Bob mentioned, then, then it's a different consideration case by case. Yeah. Can I ask a question? I have a question for Bob, actually. I, so, you know, your perspective was so spot on and so great. Do you think that, you know, so historically, you know, this is a five to six month injury, but the more recent data definitely shows earlier recovery. Like, you know, we publish a paper showing that in the literature, it's a five month return to sport with the limited metrics that are available, but we're routinely seeing people at 10, 10 weeks, three weeks, getting back to sport as you, as you defined it, is that, do you think a function of the rehab techniques or the surgical techniques, because both have really improved in the last 15 years, but where, where do you see, what do you see as primary? No, absolutely. I think it's both. I think that, you know, I think more and more of us that do the, you know, the higher level, more elite athletes are, are augmenting our brostroms which I think allows for a little bit more aggressive early rehab without that fear of stretching something out. So I think that's helped, but yes, I mean, I think the technology behind return to play criteria, gauging how it's done has improved dramatically with the evolution of GPS, particularly. I think we can now get these guys back where, okay, they're ready. Not only are they ready on the side they've injured and they're recovering from, but knowing that they haven't compromised their other extremity. That's still our biggest fear is compensatory injuries. The contralateral leg injuries. If they come back and we think, okay, your ankle looks nice and stable. You're ready. You feel great, but the whole body's not there. And so that's where these new technology, these more objective measurements can. I think Rick can really help us a lot, but you're right. We've gone from six months down to three, three to four months, I think, for most of these reconstructions. No. Um, all right, let's do a couple of more, uh, questions. Can you bring that back up my post-op protocol? Cause I think I differ significantly from when I saw everybody else do. And I, and I'm curious as to why I know I'm the only person who does acute casting, uh, of patients. Um, but, um, but the thing is that, uh, a cast is stable enough that I can get patients walking right away. I guess a boot is too. Um, but, um, so I was going to ask the question of weight bearing immediate weight bearing or non-weight bearing and why, because we're not really affecting the weight bearing surface of the ankle. Um, and if you keep them from going into varus or valgus in a boot or a cast, um, you should theoretically be able to get them walking. Why the, uh, period of, uh, non-weight bearing in a splint or a boot, uh, and, um, uh, and then also, uh, when, when, when do you allow people to resume activities in a, in a brace, if there is a, is a, if there is a sort of standard time, I know we talked about some of that. I think that's, that's a great thing. And, and that's why I'm really, uh, I feel like this is a fantastic discussion because, you know, most of the times we're at meetings and stuff, we're just talking about surgery, but, but this is the, the, the real meat of the matter. And, um, again, I I've always been very aggressive. I used to be more aggressive when I was a fellow with Martin Sullivan, who was, who was one of Bob's first fellows, Bob, your first fellow, or one of your first fellows, um, first one. And, um, uh, we, Greg Lundin and Chris Cronin, I published paper, Marty would just do immediate weight bearing and, and, uh, side to side aircast, you know, the old green, green and white splint. Um, and I found I had, you know, some of these athletes are like, Oh, they, they told me I could walk. So I'm going to go to, uh, you know, go to UC Davis football player. I'm going to a frat party tomorrow night and whatever. So you, uh, I, I keep them non-weight bearing, put them in a splint for two weeks, uh, but then I don't do a boot. I actually get them into, just as you mentioned, Dan, like if we're going to keep them from spraining, um, you know, by having them in an aircast splint, maybe they're using their crutches for help and they're getting back into the training room. Um, I I'm okay with that. I'm not a huge fan of the boot unless I'm doing an allograft, unless they have a, um, unless they have a, uh, you know, an OCD or something like that. So I'm a little bit more on the aggressive side. If I feel like this, the soft tissues are pretty good because, um, you know, some of these athletes will just stay in their boot and, and then, you know, they come back and they're like, well, you're supposed to come out and be aggressive with range of motion. Another great thing that Dr. Anderson mentioned, I mean, we all are working with, you know, at least D one schools, even if it's not a D one school. You know, most people now alter G and these, these, uh, underwater, um, you know, treadmills are, are much more common now. Um, so I think that's another key thing is, is telling these folks that at three, four weeks, once we're a hundred percent sure the wound is healed, that you get them, you get them in there and get them, get that back so they can start, you know, the, as, as we know, the proprioception takes almost four months to come back, but as those ligaments are, are rehealing themselves, um, they, they start to regain a sense of proprioception. Eric, how long are you waiting to allow them to go? The therapists go inversion, eversion. Is it three weeks or six weeks? That question. I mean, I think it just depends, but most of the time it's, it's six weeks in terms of like, I don't mind him doing band exercises, even at two weeks inversion, eversion, especially if you're using augmentation or what have you, because, you know, um, Lou Shone's paper was from years ago, kind of showed that, Hey, it will stretch out if you're not protecting it. But now we have something that's internally protecting it, no matter what company you're using or what have you. So as long as they're, they're just doing muscle activation, I think it's okay. You know, my concern about immediate weight bearing is twofold. One is that dependent edema. I think they do. Yeah, I think it leads to some noncompliance and as far as how much they're up on it, and then they get edematous and I think I worry about my soft tissue healing. I worry about the, the formation of any kind of sinus tracks because I've done scopes and all these people. And that's the worst thing in the world is to get a sinus track problem. Uh, the other thing is pain. If it, if early weight bearing precipitates pain that I tend to find that I'm playing catch up. And so I really like to just keep them off for 10, 14 days and let them rest and elevate it. I said, let that icing go through the splint and then, uh, uh, not having weight bear immediately. Yeah, I agree. A hundred percent. I, I do the two weeks cause I had some, you know, just some, some wounds and, and stuff just because it's, it's really hard to any pressure on the side. Yep. And, and related to that, Dan, you know, I find that patients tend to do a little more than you let them. So if you tell a patient non-weight bearing, they're probably going to put their weight on it, but they're going to be careful if you tell them, Hey, you can walk on it, you know, all bets are off because it's harder for patients, I think, to restrict themselves, especially when they don't have a lot of pain, the incisions are small. And so I think it's, it's just to sort of protect from what I call the knucklehead factor, just people who will overdo it. So you give them a little bit and they're going to take a little bit more. So I, I just, I'm more conservative, give them less for all the reasons Bob mentioned. When you guys let them return to play. Um, and we know that's somewhat variable depending on the athlete, but do you have them return to play in a brace and how long do you have them use the brace for six months? Like I mentioned, I don't know what everybody else is doing. Yeah, I do. I do brace or tape for a season. So basically six to seven months post-op, um, is when they can discontinue it. You know, one of my, my, in, in, in Bob's lecture was great. Cause it's, you know, it's all about managing expectations with a lot of these athletes, whether they're, you know, their mom claims are the next best thing or whether they're actually on their way to the NFL combine. Um, the, the interesting thing is to just kind of like manage their expectations from the beginning before the surgery. And this was something I learned from Burt Mandelbaum, who I did my sports fellowship with, and he's like, you know, they're going to walk out of office and, and if they're higher level, like Bob mentioned, you got agents, you got coaches, you got trainers, you got parents, you got family members. So Burt would break it down very easily. And this was mostly for his ACLs was six, six, four. So six weeks of healing in motion, six weeks of rehab and four to six weeks of restoration means like a lot of those athletes remember this six, six, four, and they go back and tell coach, Hey, six, six, four. And so that, that rehab, you know, the restoration phase, which is four, and this is mostly for, for soccer players, um, was that, you know, between three and four months they're rehabbed, but they got to restore themselves. And some of them will come back at four or five months and someone will be at that, that six month phase. But at least it allows you to, as, as Dr. Anderson mentioned, that kind of little bit of wiggle room where you say, Hey, it could be six, six, six, but they just remember it. I found that the athletes and athletes, families and parents and coaches remember that those numbers. Great. Well, I think, uh, it's close to six 20. I think we're going to have to wrap it up soon. Um, we can shop, stop, share screen. I know, uh, but I, uh, I truly appreciate, uh, all the panelists, their expertise and the fantastic talks and answering all the questions. Um, and, uh, I know this webinar will be available, uh, for, for viewing afterwards. So I think this is a great repository. Um, I know Christine is there some additional, uh, messages, uh, some wrap up from, uh, AOSSM. Uh, Yes, Dr. Lott, thank you. Um, I'd like to give a big thanks to our panelists and presenters for their work on tonight's webinar. On behalf of AJSM, AOSSM and AOFAS, we hope you enjoyed this webinar and that you were able to attend other educational programs coming up and thank you attendees for your participation, especially if you're interested in CME or would like to view the recording of this webinar. Please go to education.sportsmed.org, log in, click my resources, and then click the course title. You can then complete the evaluation for CME or view the recording, which will be available by Friday. This information will be emailed to you in 24 hours, so please don't worry about remembering it all. We thank you again for your participation and have a great rest of your night.

lateral ankle ligament injuries

surgical treatments

open repair

arthroscopic repair

anatomic reconstruction

tailored treatment

post-operative recovery

return to play decision-making

post-operative protocols

brace use

personalized approach