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IC 108-2022: Ankle Instability in the Athlete: Con ...
Ankle Instability in the Athlete: Controversial Is ...
Ankle Instability in the Athlete: Controversial Issues (4/5)
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I live in Vail, Colorado, so thank you everyone for coming to visit us here in Colorado. Ingrid, one of our fellows here from Norway, she came a long way, so thanks for coming and hanging out with us this morning, everyone. I am a consultant for Arthrex, so please keep that in mind, I guess, as we work through this. I wanna start with a case example. I was charged with talking about timing of surgery and also potential augmentation. This is a case example from my practice. Saw an 18-year-old female high school senior track and field athlete. She presented nine days after a severe inversion sprain. She was in a boot and in crutches. She's quite good. I'll sort of go through what she's ended up doing subsequently, which is kind of fun. But she had a positive anterior drawer, she had a tailor tilt, and she was rock-solid stable on the contralateral side. So as Dr. Amendola alluded to, we wanna check the other side for some internal controls. Here's a slice of her MRI. I'm really showing the ATFL with a lot of edema in it, a lot of subcutaneous edema there laterally, and a lot of thickening of that ATFL, probably some partial tearing off of the talus. She said, well, I'm competing in the state championships in five weeks, and I need to go to school. I'm gonna be a freshman next year, and this is really important to me. What are we gonna do? So we have a lot of options here that we can think through. We can cast her for a little while. We can immobilize her in a boot, as she's been doing. We can start some functional rehab. We could try to fix it. Or we could fix it with some augmentation. So what I did was one more week in a boot with a night splint. I like utilizing a night splint for these acute ankle sprains, because I think if you're in a boot all day, that's great because you're held in dorsiflexion. That shortens the ATFL so it can heal in an anatomic position. But if you spend seven, eight, nine, 10 hours at night with a foot plantar flexed, the ATFL is going to be elongated. It's gonna heal in that elongated position. So I use the same night splint that I use for rehab and clinic, or they can get them on Amazon for plantar fascia, but I take the wedge out of it. So the plantar fascia will kind of push them all the way up into dorsiflexion. I like to just hold them in neutral, and it's just a blue plastic wedge, or a blue plastic L that holds them in neutral at night. So we got her back in the five weeks. She won the 100 meters and the 300 meter hurdles, and then set a state record in some of the relays. She has since gone on, I use this with her permission, this is her back then. She's gone on to win multiple titles in the SEC in track and field, and she came back, which was terrifying, with a navicular fracture, a navicular stress fracture, which was really stressful, and she wants to be out doing this stuff. But we got her back after that, so that was also fun, but a talk for a different day. So in terms of anatomy, Dr. Amendola touched on this. Palgolano did wonderful dissections. These are open access, so if you search Palgolano and Ankle Anatomy, these were published in open access journals. He unfortunately passed away at a very early age, but he was a beautiful anatomist from Spain. And you can see, as Dr. Amendola alluded to, number eight and number nine are the ATFL and the CFL. Always good to see them up close like that. So I treated this patient without surgery. Was that the right thing to do? Here's a current concepts review from JBJS in 1991. This is a meta-analysis, so to speak, a review article of 12 randomized controlled trials. In reviewing this, again in 1991, they recommended a short period of protection with tape and bracing, and then early physical therapy and range of motion, and said do surgery later if you ever need to do surgery. Here's a randomized controlled trial from 2003 in JBJS British, a follow-up of eight years. They noted that operative intervention led to less residual pain and less functional instability, so there's a vote for perhaps early surgery. And then we go to a Cochrane review in 2014. This is probably the largest study, 20 trials, and the study failed to demonstrate any benefit to early surgery over conservative treatment, and there was a recommendation for a randomized controlled trial, which we have not gotten to, and I've not been able to find anything on that. But this is basically giving us the groundwork for treating this conservatively, certainly at first, as Dr. Amendola alluded to. So when do we fix these acutely? Well, certainly in open injury. If you're in there washing something out, that will happen very occasionally that you have some tearing of the skin laterally, go ahead and fix some things. If you have a loose body on imaging and something you need to do arthroscopically, let's go ahead and fix it, because we're there. If there are other injuries, so if there's a perineal tendon dislocation, which can certainly live with a bad ankle sprain or a lateral ligament injury, and you're already there, let's go ahead and fix the superior perineal retinaculum along with the lateral ankle. And then the question is, as we looked at, a lot of these studies are from five, 10, 20 years ago. Is there some benefit to a modern surgical technique? Are we better at this? You know, ANSEF's really quite good at preventing infections and we've gotten quite good at this. So perhaps we can be a little more aggressive in treating these folks acutely. But if not, as I alluded to, we immobilize them for seven to 10 days and start early functional rehab, starting with balance and proprioception. Once you're making some gains, we start with strengthening and work them through that functional rehab program. So there's limited evidence for early repair, but it may be appropriate in certain circumstances. So I want to transition a little bit to a lateral ligament reconstruction model and our rationale for perhaps augmenting that and why we are there. So Dr. Steadman and Dr. LaPrade at the Steadman Clinic really created a pyramid and kind of a way to think about doing musculoskeletal research. First, we needed to find the relevant anatomy. We need to design an anatomic reconstruction. We need to then test it and allow for early range of motion. So I'd like to kind of work through how we've done that or how they did that at Steadman Clinic. Much of it was done before I was there. This is a JBJS article that Dr. Clanton and Dr. LaPrade worked on defining the anatomy. This again has beautiful pictures. This is an example of that. What was found in this study is that the ATFL often has two fascicles, and you can see those two fascicles there, but very precisely anatomically defined so that we have access to that. And then it was defined also radiographically. So if you lose your way intraoperatively and you want to make sure where you should put your tunnels or put your anchors, you can see that. And that was done also at the Steadman Clinic. So we've defined the relevant anatomy, which was great. Now we need to find an anatomic reconstruction. Luckily, that was already done by Dr. Brostrom as Dr. Amendola alluded to. This was in 1966 and defining an anatomic repair of the lateral ankle ligaments. This can be done as this image shows just with suture mid-substance or with anchors onto the fibula as many people choose to do now. Those are both acceptable ways of doing it. So we have our anatomy. We have our anatomic reconstruction. Now we need to test the reconstruction. So Norm Waldrop, he's usually at these meetings. I haven't seen him yet because it's early on the first day, but one of the other Vail Fellows completed the first biomechanical comparison of an intact ATFL and combining and adding or also testing a Brostrom repair. As you can see here, the intact ATFL has a strength of about 160. I call it 150 because it's easy number to remember in terms of strength, but the Brostrom is only at 68 newtons. So we define the anatomy. We looked at the reconstruction. We tested the reconstruction and unfortunately, it doesn't look like it's strong enough. So that led us down the path of trying to find something a little better for our Brostroms to allow for early range of motion. That concept came from Gordon Mackay in Glasgow, Scotland. He had the concept or the idea of augmenting the Brostrom with something that is termed an internal brace that is a trade name. It is not an artificial ligament, but it's a check rein or a seat belt. A seat belt stops you from progressing too far if you're in a car accident. And a check rein on the horse is that strap running from the horse's head to its back. And the horse can move its head left and right and up, but it can't drop its head and in certain horsing circles, equestrian circles, that's considered what the, you don't want their head to drop. So that's the idea of a check rein and that's what that is. And so that's the idea of the internal brace. So the internal brace can be placed over your Brostrom repair. Here we place an anchor into the talus. We continue with our Brostrom style lateral ligament repair. Here we are placing our second anchor. Sorry, I'll show you what it looks like finally here. And that is a heavy suture placed in a little bit of laxity compared to what your repair has done to act as a check rein or a seat belt. So as we talked about, we need to test this. We need to know if this is any better. So this is an AJSM article from 2014, also from the Steadman Clinic. Here's what it looks like being tested in the lab. And this shows us that, I'll sort of put your attention to the left graph, that the intact ATFL is around 150 Newtons and you have, with the augmentation alone and the Brostrom with augmentation working to the right, much more significant ultimate failure in terms of Newtons. So the take-home points and what I try to remember is that the intact ATFL is around 150 Newtons. The Brostrom repair gets you to 50 or 60. And then if you get your Brostrom repair with augmentation, you're up over 150 Newtons. So you have significantly more strength. That should allow us to rehab patients early and that's what we're starting to see. So we defined the anatomy. We looked at a reconstruction. We tested it and found a good, strong repair. And now we can allow early range of motion and push folks through. So where are we in terms of testing this in the literature? 2016, this is a biomechanical study in cadaveric specimens. 18 specimens were looked at in a KSSTA article. And in fact, the augmented repair was stronger in terms of the angle of failure. So it was much stronger when they torqued the ankle. When we look at human outcomes, 2021 retrospective study by Kevin Martin, who's an active duty military guy. He did a Brostrom repair with the augmentation in 93 active duty folks. At six weeks, he, 96% of them could do a hop test and one was noted. He did an accelerated rehabilitation program. He did two weeks in a splint, two weeks weight bearing as tolerated in a boot and then got him into a lace-up ankle brace and started elliptical training and sort of running him through it. So it was slow-ish for the first month and then push them up. And by six weeks, they were really doing quite well. And then we have an even better study, theoretically a randomized prospective study of a modified Brostrom versus the Brostrom with augmentation done by a couple of guys here based in the United States. Average return to activity was 4.2 weeks. Most of their patient reported outcomes were better, four of six, and there was no significant difference in complication rate. So in this 120 patients or so, there were no difference in complication rates. So with that, I think we'll do probably questions at the end, Brian, if you wanna keep things rolling and then we'll do some panel and questions later.
Video Summary
The video is a presentation by a consultant for Arthrex, who shares a case example of an 18-year-old female athlete with a severe ankle sprain. The speaker discusses various treatment options and their outcomes, including immobilization, functional rehab, surgery, and augmentation. They highlight the importance of early range of motion and propose using an internal brace for augmentation of the Brostrom repair. The speaker presents research on the strength of different repair methods and discusses the positive outcomes and accelerated rehabilitation for patients who underwent the augmented repair. The presentation concludes with studies supporting the effectiveness of the modified Brostrom repair with augmentation.
Asset Caption
C. Thomas Haytmanek, MD
Keywords
ankle sprain
augmentation
Brostrom repair
rehabilitation
research
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