I'm going to be talking about arthroscopic brostrums, and so the evolving scope of ankle instability. So just, you know, we talked a lot about when to operate, but just mainly when to operate it. Loose bodies, open injuries, high-level athletes where you might want to go early, subacute, you know, generally if they failed, of course, their conservative management, they have lots of recurrent instability, or concomitant injuries that you may find in MRI, which has been a highlight by Ned and others as well. So what is surgery? So you know, I think there's been a rising use of arthroscopy at the time of ankle stabilization. And this study here is showing that, you know, of those surveyed and done, it was close to 96, 97%. I think being at a sports conference here, you know, all of us are familiar with arthroscopy, and I think it's definitely a tool to have in your toolbox to definitely make sure you evaluate things. As MRIs are not 100% sensitive, so even sometimes an MRI may be negative, it's relatively quick if it is negative. But then you can do the drive-through test as Kirk went through, both for the stenosmosis or in the medial side to make sure you're not missing some subtle instability elsewhere. So my setup here for ankle arthroscopy is I like to use traction. I think that makes it a little bit easier to seize all around and get in this little bit of a setup. I think it's worth it to do that in order to make sure you get the evaluation of everything. Again, we talked about the brostrom and the modifications and the techniques of how to do that. And, you know, main thing is when you go in there, you want to make sure you detach whatever maybe remnant scarring is around that area, both for the ATFL and CFL if that's involved. And I do like to involve a sensor retinaculum as well. And so you want to make sure you can pull that up as shown in the figures here. So this is kind of my side, a little bit more of a straight longitudinal incision and pulling those over. And I'm kind of evolving a little more to a knotless technique, but same idea in terms of pulling all that tissue back up to the bone and make sure you're preparing that bed. So again, to start off arthroscopy, if I were doing an open technique, a longitudinal incision and making sure that I'm separating the retinaculum from the remnant tissue here. So make sure you're doing a good dissection separating those two, putting my suture anchors in there, which people are probably familiar with if you're doing using anchors frequently. I use two anchors and then I'm making sure I grab both layers of that tissue, both the remnant tissue as well as the retinaculum. Just some more pictures of it. I think this is a pretty common technique to how people might want to do this to make sure you're getting all that good tissue there and then pulling it back down. So just kind of the steps if you go through briefly in terms of how you do it, you're doing a nice exposure, you're elevating the tissue off the bone, the ligament, scarring the retinaculum, preparing the bone for an anchor, whether that's with a ronger or some roughing with a rasp, you place your anchors and then you're using a suture needle to pass to your ligament, retinaculum, and then you're setting for using a knotless or doing a tying. And for all of us here who do shoulder, so I do a fair amount of shoulder as well, these steps may seem very familiar to you. So it's very similar to what you might do for a shoulder instability. We make sure you have good visualization, using an elevator to lift the tissue off the bone and the labrum and the capsule, preparing the bone for repair with a rasp or a bur, you place your anchors, pass your sutures around and you set your mechanism, whether that's a knotless or tying knots. So the steps are not too different. So if you're familiar with shoulder instability, it's not too far of a stretch to be able to understand the steps and concepts of how to do this arthroscopically for the ankle. And so, you know, a lot of people cite their early studies that it didn't work out very well. And that's true, it didn't. When they did it early on, it didn't work well. People tried some thermal shrinkage as well, which we found for our shoulder students that also didn't work in the shoulder as well. But those are the early studies. But people didn't give up on the shoulder when they came around for vancouver repairs and stuff. Now, it's probably the most common technique, there are a lot of trainees who have never done an open band cart before. And so the kind of evolution of that as our techniques and instruments have improved, you know, very few people will go to an open band cart as a primary procedure. So what are the steps for an arthroscopic one? So the main thing, as it's been highlighted, is making sure you know your anatomy. So there are nerves that have to be aware, particularly superficial perineal nerve branch. And so there's been some great work done in terms of identifying that anatomy and how to be safe. So your landmarks are just a fibula, a superior margin of the perineal tendons, it's kind of the back. So some people also cheat that forward using the posterior portion of the fibula. You want to make sure you're aware where the SPN is as well. So, you know, you can dorsiflex and invert the foot and sometimes that can help highlight that nerve for you. You can use transformation if you're doing arthroscopy to help find that. And that's your superior border. But some people will also cheat that a little bit more posterior, just going off the anterior portion of the fibula. So you're kind of a little bit of a narrower corridor, but a little bit more safer by cheating your safe zone a little bit anterior from the back and a little bit posterior from the front. And then your sensor retinaculum is approximately about 15 millimeters from the distal tip of the fibula here. So starting out for arthroscopy, most of us are doing that anyways. So you're going in there and checking your drive-thru signs, checking for any chondral injuries at the same time. So you've done that and then you're going to prepare the bed, as you might for a shoulder. And then you can put your anchors in and then you can use a suture passer from the outside in and grab your sutures, make sure you're incorporating everything. The key is making sure that you're staying within the safe zone and that you are involving that inferior retinaculum as well. So making sure that's where, kind of that 15-millimeter mark, you're passing your suture passer up and through here, making sure you're incorporating all that in a very similar passage. I use a suture lasso, but you can use any kind of suture and passer devices you want. And there are trademark ones that can make it a little bit easier as well. So does it work? So there's some work done for biomechanics stuff by several studies here as highlighted with different cadavers showing that they are equivalent, particularly if you're isolated for ATFL. Some clinical studies as well showing that there's a reduced swelling, there's less post-operative pain and higher pain satisfaction, and potentially ability for early rehab since they have less swelling early on. In terms of recurrence rate, as we mentioned, nothing is foolproof. So if they're open, depending on the studies that you look at, there is a range of recurrence, somewhere between 5%, 10%, 13%. Arthroscopic ones, if you're looking more at the recent data, so it ranges from 0% to 10%. But if you're looking more at the recent data, in the 2014 to 2017, if you accumulate those, there's about a 5.3% recurrence rate. Complications, so the big one that everyone takes a highlight is the nerve injury of this because you are kind of being close to that, doing some volume passes potentially. But as you can see, comparing these two between open and arthroscopic, if you're looking at superficial nerve injuries, they are a little bit higher. That could be a product to alerting curve and make sure you know where your anatomy is and everything like that. But there is a slight increase to that, so that's something to be aware of. And so I've been moving through a knotless construct, similar to how I do for the shoulder. And so just kind of briefly how that would be done. I put my anchor through my anterior lateral portal, center anterior lateral portal. It typically come with three sutures. You have a passing suture as well as your set sutures. And so what you do is you pass up forward, and you have your suture lasso come up through your, pull it out through your anterior lateral portal, and you grab your passing suture. And so you pull that down this way. And now you have your suture out distal. And so that comes out this way. Then you pass your next suture pass. And the nice thing about this suture pass is that both ends have a loop. So you can just pull it back up the other way. And so now your free end that's sitting over here, you pull it back up this way and out through your portal. And then you set your sutures as you would potentially for a, just like you would in the shoulder. And then you can do that arthroscopically. So when do I offer this? So it's evolving. I'm trying to incorporate this into my practice now. I'm not doing this for my young contact high level athletes. Kind of using this more for my weekend warriors, recreational athletes, a little bit older, what are their goals, how quickly do they need to get back. I haven't really changed my rehab protocol yet. My rehab protocol has been the same as I'm trying to gain some more experience in terms of how these people recover. And so I offer it. When I presented them, I offered them a similar timeline and stuff. So that's kind of how I've been incorporating it. It's definitely not my necessary go-to yet, but somehow I've been trying to work it in. So again, think about your athlete. You know, who is it that's going to be out there? Or is it maybe potentially a former athlete who talks about football a lot and how he used to be on the lines? So quickly about time to return to sport. So you know, there's some great studies that was highlighted earlier in terms of how quickly potentially if you do some augmentations, getting them back as quick as four weeks or six weeks. But on average, it takes somewhere between three to four months to return from a standard ankle stabilization. Another study that kind of broke down a little bit more, time to return to personal training, to return to team training, back to full play. I guess it was in the soccer population. So I think ankle sprains, you know, as are very common. Conservative management is a mainstay. It's been highlighted by others. Browse from the goal modification is still, I think, the open procedure is still the gold standard. I think arthroscopic techniques are emerging and we're still learning from them. There are some out there who are doing it for all their athletes. I've talked to them where they said they'll do it even for a professional athlete comes in. They're going to do arthroscopic as their go-to. But there is definitely people who are pushing the limits on that. And I think that's something that we're going to continue to understand more and learn from about that. So I just want to thank my staff. And just a quick one slide for that and my references. So from here, I guess I'll have the...

arthroscopic brostrums

ankle instability

ankle stabilization

ankle arthroscopy

suture anchors