On behalf of AOFAS, I want to welcome you back to the advanced foot and ankle challenging conditions expert teaching course. Today is the final day of this course where we focus on strategies to tackle your toughest cases. Thank you to course chair, Dr. Peter Mangone, along with co-chairs Dr. Errol Bailey and Kelly Hines for putting together such a fantastic course. And thank you to all the faculty for their participation. Before we get started, I wanted to share a few housekeeping items. All faculty will share their disclosures during their individual presentations, and you could also find them within the virtual platform under speakers and disclosures. This course offers a total of 14.5 AMA PRA category one credits. Use the tile on the platform landing page to claim CME at the end of this course. All broadcasts are being recorded and will be available under on-demand recordings on the virtual platform within 24 hours of this broadcast. All on-demand recordings will be available on this platform until October 31, 2022, and then will be available on the PRC to view whenever you like. To send questions to the faculty, please click on the Q&A tab in your navigation bar. You're also welcome to use the chat to communicate with other attendees or faculty, but please be aware that everyone can read what you write in that area. If you experience technical difficulties, please try closing your browser and logging back in the same way you did the first time. Lastly, we want to thank our sponsors of this course, Stryker, Treece Medical Concepts, and Ardalan. You can learn more about these companies by visiting the exhibit hall icon on the platform landing page. I will now turn the program over to Dr. Peter Mangone to get started. Thank you. Thank you very much, Jennifer. First of all, I want to say thank you to the AOFAS staff for the great work they've done to put this on. It is our last day. We've had a great last two days, and hopefully today we'll mirror that. I'll get great information. I'd like to thank my co-chairs, Kelly and Errol, for the work they did to help put this on. I'd like to thank the faculty for donating their time and expertise to help teach all of you out there who are attending. Finally, of course, I want to thank the attendees themselves for being here. We do this to educate you, and hopefully we're able to answer your questions and get good information out there. Education is one of the main roles of the AOFAS, so we appreciate you being here. Our sponsors, once again, are Stryker, Ardalan, and Treece Medical. We'll have a little bit more to say about the next sessions and about the specific sponsorship for those. As far as housekeeping items, if you have questions, we do want to encourage people to ask questions. There is the opportunity to do so verbally if you raise your hand, but ideally most of us are using the Q&A function. If you want to put it in chat, we can also find it there, but if you put it in that Q&A tab at the bottom of your Zoom window, ask questions throughout the time. We may answer some of those while we're in the middle of those talks. On the other hand, I may save them and ask them at the end. We've been trying to get to as many of those, and we've gotten to a lot of them during the last couple of sessions, so hopefully if you've got pertinent questions, please let us know, and we'll be happy to try to advise you. Final thing, for the breakout sessions, there will be breakout sessions between 1 and 2 Central today during the lunch hour. During that time, we'd encourage – we're not going to necessarily have cases to present. We're just going to have faculty in the breakout rooms that you can access via the web platform on the one tab that says breakout sessions, and we'll have a list of the different faculty in the different rooms. There's about six or seven different rooms, depending on the topic, and you can either bounce in and out and listen. If you've got a case that you want to bring, we'd encourage you to bring a case or two to present to the faculty and get that opportunity to interact with the faculty, get their opinions as to what they might do for that particular scenario, and have a good discussion about that for everybody available. Just remind you about that between 1 and 2. We'll probably finish a little early. I might end this first session just a few minutes early because the second session, we have four talks, and we don't want to run over on that, so we might run this one a little bit more quickly and then be able to get to a situation where we have a 5- or 10-minute break before that lunch breakout session starts. I appreciate it, and with no further ado, we'll start into the next two sessions are on ankle instability. Specifically, they're being sponsored by an educational grant from Ardalon, so if you do get a chance to see them at some point at one of our other meetings, or if you can visit, they have a virtual booth here, if you visit their virtual booth on the platform, but also if you get an opportunity at one of our regular meetings to thank them for the sponsorship, that would be terrific. We're going to talk first about lateral ankle instability. For those of you who know, I've done a lot of work in this, and it's really been a passion of mine, but overall, ankle instability overall is something that all the way back from about 2004, I said this is just something that we don't treat very well. We've come a long way, and so we've got three great speakers today to talk to us about different aspects of lateral ankle instability and then four speakers on medial side instability. We'll start with Dr. Gainey and with MIS and open non-augmented repair using the native tissue, so I'll turn it over to her. All right, thank you, everybody. So I have gotten the opportunity to talk today about MIS and open non-augmented repair using the native tissue. These are my disclosures, nothing specifically related to what we'll be talking about today. So we all know that ankle sprains are common. In fact, they're the most common injury that we see in sports, and 10 to 30% of all athletic injuries occur every year. So this is something that we see routinely in our offices. Fortunately, most of these can be treated successfully with non-operative management, but they're not benign, and up to 20% can develop chronic lateral ankle instability, and a third of grade three sprains will have recurrent injuries. When I evaluate a patient, the things that I tend to ask them about this is, are they having instability, pain, or both? Because many times you see an MRI that shows a chronic injury, and really what we want to treat is the instability with the lateral ligament reconstruction. This is an instability procedure, not a pain procedure, so they really take a lot of time trying to tease out where their pathology is and what their complaint is. We all know their physical exam is critical for this. In particular, we want to look at their alignment, because as we know, if they have varus hindfoot, then this may make them prone to recurrent injury, and it may be something that we need to correct at the time of their injury. We all know about the anterior drawer, and I think really important is to compare it to the other side, because we know that there's a difference between laxity and instability. One is physiologic, the other pathologic. So some of these patients just have baseline laxity, and that may affect how you're going to treat them. Radiographs, you can look at tail or tilt. In general, I'm using my physical exam, and then I use this if I feel like it's equivocal or I'm not quite sure. So I rely 90% of my clinical exam of the patient and their history, but then I use this as supplementation if I'm not sure where the instability is coming from. I do tend to use MRI, and again, this is more for preoperative management and for planning rather than the actual decision to operate. I've usually made my decision to operate on them based on, again, their history and their physical, the fact that they've had recurrent injuries that have been refractory to nonsurgical management. And I'm using this to see if there's any intraarticular pathology that I want to address at the same time, because as we know, over 90% of patients with chronic ankle instability will have something intraarticularly. For treatment, I try physical therapy, physical therapy, physical therapy before we send them to the operating room, and I often will ask them, what kind of physical therapy did you have? Because they may or may not have been compliant with it, and they may or may not have had the appropriate physical therapy. And then we want to find out, you know, when does this occur? If it's a senior in high school that only gets to well-playing basketball and has no plan of playing basketball in the future, maybe it's not something that we have to manage. So we want to find out what causes it. Is it something that they could take out of their lifestyle and be perfectly happy, or is this important for quality of life? Once we do decide a patient needs to go to surgery, what do we know? Brostrom-Gould is a great surgery. Patients will ask me about it, and I'll tell them it's one of my best surgeries that I do. It's one of my favorite surgeries to do because it has such a high rate of success. Why? It's anatomic. It's very hard to overtighten a patient's own ligaments. So I rarely see a patient that comes back to me that feels overtight. There's a very low revision rate, as low as 1.2% in a recent systematic review, and 85% to 90% mid- to long-term have excellent results. So it lasts. It's a procedure that you can do once, and you don't have to worry about it stretching out over the long term. We also know that, in general, it's better than the non-anatomic options, although, of course, there are situations where you're going to have to do that, and we'll hear about that later. In comparison, it tends to be a higher satisfaction rate as well as less stiffness. So why do it arthroscopic? I just told you that the Brostrom-Gould is one of our best surgeries. People come up to me and ask me why I do this for something that's already so good. Essentially, it's the same procedure, and I say almost the same procedure, and we'll talk about why it can be different. So it's the same procedure, just through smaller incisions. So hypothetically, could you have decreased pain? Could you have decreased wound healing and decreased swelling after the surgery? And so this is something that we're still teasing out, but these are all hypothetical benefits. So as you can see in this image on the right, you can see the Brostrom-Gould versus the arthroscopic procedure doing the same thing. And again, essentially, it's doing the same procedure, just through smaller incisions. What's the downside? Like anything, there's a learning curve. I can tell you it's probably taken me two years to be quicker at doing the arthroscopic Brostrom than it is for me to do the open, and that's because every time I seem to do it, I seem to find something different that I didn't learn the last time or a different problem that comes about. So every time I do it, I write down a new tip or trick I've learned to try to make this go quicker. We worry about the superficial perineal nerve and the perineal tendons, although the data really hasn't shown that this is a higher rate of injury to these, but it's something you have to be very mindful of when you're doing it. And when I said that it's almost the same procedure, this is what I mean. You can't repair the CFL in this procedure. The perineal tendons are right there. So to safely get to the CFL is very challenging when you can't move them out of the way. So this was really my biggest hangup when I was deciding whether to go ahead with the arthroscopic procedure. So I did some digging. Does the CFL matter? If we look at these biomechanics studies, comparing, looking at the CFL and what it does in the Brostrom procedure, you can see that these two graphs here, one showing anterior displacement, the other showing various tilting, shows that there's no difference if you repair just the ATFL in a cadaver model, or if you repair the ATFL and the CFL. Here's another biomechanics study. Dr. Hunt showed us in a cadaveric study of 10 matched paired ankles, some of them with ATFL only, and the other with ATFL and CFL, there was no statistically significant difference in the stiffness, and that ATFL failed at a higher rate. And perhaps this is why the CFL is less important, because it fails at such a low torque and the ATFL holds for longer. So what did I come up with after this? I don't think that the CFL matters that much in most situations. Again, this doesn't necessarily apply to all situations, and I'll talk later about my algorithm and who I choose to do arthroscopically and who I choose not to. So that takes us to the clinical outcomes. So I proved to myself biomechanically that I felt that maybe the CFL in most situations isn't that important to be repaired, and so does that now relate to clinical outcomes? I'll say that these are all retrospective reviews. We don't really have any randomized controlled trials that I could find, so we have to take this for what it is. But we have 62 patients that were retrospectively reviewed, half open, half arthroscopic. And clinically, there was no difference in the VAS scores or the AOFAS scores or the Carlson-Peterson score, and perhaps a little bit sooner to weight-bearing in those patients that were done arthroscopically. Here's another group of matched patients, 52, half with open, half with arthroscopic. These patients had some less pain in the early postoperative period and the AOFAS score at 6 and 12 months, but they had no complications in either. And so when I said, you know, perhaps it's a lower risk of wound healing, that hasn't really borne out either, because fortunately the risk of wound healing is very low in our open procedure as well. Here's another one, 27 patients, again retrospective. And what they found is that it was actually a shorter surgery and lower surgical costs, interestingly, for the open. And as I said, this may be related to the learning curve, and that with time, perhaps the time of the surgery will get quicker and quicker. AOFAS scores and Carlson scores were both great, regardless of the procedure that was performed, and there was no significant difference. Here's another one, meta-analysis. This is where I find that it's important. They did mention that wound complications were less in the arthroscopic procedures than in the open procedures, but that clinically they were very comparable. So what can we come to conclusions here? So they have similar functional clinical outcomes, which again makes sense because they're doing the same procedure, essentially, minus the CFL, when you're doing it arthroscopically. Possibly you have a quicker return to weight bearing. You may have fewer wound complications. And it does ask the question, could the open procedure be quicker and cheaper? Could open be quicker and cheaper? And that's, I think, still yet to be determined. So now here's how I do it. I think what's important is that you mark out these anatomic landmarks in order to avoid those potential injuries to the SPN and the perineal tendons. And I'll tell you, the first one of these I did, I was nervous until I saw that first patient, the first post-op, to make sure I didn't get the SPN. It's something I become less and less concerned about the more I've done and never gotten it, but it's something that I always think about. So I mark out the SPN. I mark out the perineal tendons. I mark out the inferior extensor retinaculum. Essentially, I just use my thumb's breadth distal to the fibula because it's about a centimeter to a centimeter and a half distal to the tip of the fibula. This is really important. Spend time cleaning out the lateral gutter and cleaning off the distal fibula because this is where time can be lost later. And when I say a lot of time, five minutes in an arthroscopic procedure feels like forever, especially when you're letting the resident do it. But I really take the time. I use either a curette or a cautery device in order to clean off the fibula to give myself a good area there and clean out the lateral gutter. Your first anchor, you want to be about a centimeter distal to the ankle joint. And I usually use a wire, and I still do take an x-ray, although I rarely change the position of it. It just makes me feel better to know that I'm in the right spot and that it gives me enough room to put my second anchor approximately. So you drill it, and then you place your anchor in there. And so you can see in the bottom right corner, your anchor in place with the two sutures coming off of it. Now, here is where you lose a lot of time. Beware of soft tissue bridges. I have to tell you, this is where I really lost time when I first started doing this. Because you can see that if you pass your suture passer in a different portal than your sutures are, then you're going to end up catching soft tissue. And you can see that right here, I nearly caught some. Fortunately, it was soft enough that I was able to pull it through. So what I do is I actually watch my passer going through the same hole to ensure that there is no soft tissue bridging between them. I also use a knot pusher to pass it down the stitch to make sure that the two stitches are not twisted over each other. And I think that has saved me a lot of time. So this first pass that you're going to do, you're going to start from inferior. So you can see where that star is in the bottom corner. So you're putting your first anchor in. You're going to pass your first stitch, that most inferior aspect. Then the second one is going to be one above and so on. So now you put your second suture anchor in. And you're going to do this essentially about at the level of the ankle joint about a centimeter proximal to the most distal one that you already passed. So here's where you want to make it. So now that you've passed all four of your stitches and you've caught your IER because you've marked that out on the skin, now you want to pass your sutures through that small incision. You can see that you make a small incision connecting these. Here's another tip. You don't want to cut your own suture. So what I usually do is I actually make this incision when I pass the suture passer through this third hole here so that I know that I'm cutting on metal and so I have low risk to injury to that. So you don't want to cut your own suture when you're doing that. And then once you've done that, then you use your suture passer in order to tie those two sutures together. So here are my pearls. Mark out your landmarks. Know where your fibula is. Know where your SPN is. Know where your perineals are. And then mark out your extensor retinaculum in order to do that Gould modification. Really take your time to clear out the lateral gutter. Start distal. I made the mistake once of passing my two suture anchors first and then trying to pass the sutures and that was a mistake. So start with the first anchor, pass the two, then put your second anchor. Make sure the sutures aren't twisted. Place your knot pusher over the stitch in order to ensure that. And again, biggest time loss is in managing these soft tissue bridges. So make sure your portal is wide. Make sure that you're passing all your passers through the same portal that you passed your stitches through. So here's my algorithm. Where am I now? I would say the majority of my patients I'm doing arthroscopic. And that's primarily for my primary brostroms. My exceptions to this, patients with ligament dyslaxia or people that I think the CFL really is something that I should fix and have to fix. And I'm doing them open. If I'm opening anyway, if I'm doing a perineal tendon repair in my hands, it doesn't make sense for me to do this arthroscopically first and then open up anyway. I think I would lose time doing that. So if I'm opening regardless and I'm doing an open procedure. I also am not at the point in my career where I'm using a suture tape or an internal brace in an arthroscopic fashion. So if I feel like I need more fixation, my high-level athletes, those that are really ligamentously lax, then I'm going to do that open. As well as revisions that I think need to be done with more of an allograft repair. Again, Ehlers-Danlos, I tend to go more with the allograft. And I know we're going to hear more about that. So I'm not going to go into any of that. So thank you for your time. Thank you. Wonderful. Great talk. Appreciate it. It's fun to see others being able to kind of move forward with the arthroscopic techniques, though. Clearly, you know, whatever way you do it, open or arthroscopic, it can be a very effective procedure. But at the same time, there are definitely cases where we need a little bit more. Whether it be because you feel like tissues need more, whether you feel like the patient needs more. There's some sort of augmentation that is necessary in order to really get where you need to go in terms of the patient's ligamentous stability. Hold on a second here. So with that in mind, we will move on now to have Dr. Doty talk to us about augmented repairs and when and how to use these repairs in his practice and in others. Thank you, Dr. Doty. Can you hear me, Pete? Yes, we can. Good morning. That was an excellent talk, Lauren. And in light of how Pete opened up the section, I'll try to avoid any redundancy. So I may blow through some of these slides because I think Lauren did a fantastic job of covering some of the basics. And so probably my biggest disclosure is, much like Pete alluded to, I haven't figured this out 100%. I think all of the faculty on the panel are trying to figure out, we have good outcomes with these procedures, but what can we do to optimize our outcomes even more? And if you do enough lateral ankle ligament repairs, at some point you're going to have patients come back into your office two or three years later with another injury. And how can we avoid that small subgroup of patients in those revision surgeries? And so this is where I'm at in my algorithm. These are my disclosures. And so I think it's important to remember, we're all going to see these, the foot, mostly basketball injuries, just based on landing with the foot in a plantar flex position, but also soccer. And with children's sports, as popular as they are now, this is a common place in our practice. And so a lot of patients, ankle sprains every day in our office. It's amazing to me how many patients come in from another orthopedist without weight-bearing radiographs. So I put this slide in. If you're an orthopedic surgeon, please get weight-bearing radiographs on your ankle sprains, so you can look at alignment amongst other things. A comprehensive physical exam is important. I think the most successful surgeons are going to understand when concomitant procedures are necessary, and they're going to address all pathology, like Lauren alluded to. And so I think many of those surgical failures or those acute revisions are necessary because there was pathology that wasn't addressed at the index operation. And so you must touch your patients. You can't just rely on x-rays and MRI. You need to palpate and see where they hurt. It's a quick exam, less than a minute. You start medially, work yourself around laterally, examine posterior for any impingement, examine the perineal tendons, and so pretty straightforward. Again, confirm and diagnose all pathology. Oftentimes, patients may come in with an ankle sprain, and indeed, they do have lateral ankle instability, but they also have syndesmotic injuries, deltoid injuries, avulsion fractures, amongst other things. What's the patient's biggest complaint? Is it pain or instability? It's a simple question I ask every patient, and it helps me to understand what they anticipate they want to gain from the surgery. Do they want 100% pain relief, which can sometimes be difficult to deliver, or do they have ankle instability, which I think is probably the most predictable aspect of the operation? What are their functional expectations? Conservative treatment, I think, is mainstay for acute sprains. If they want to participate in sports, if they want to hike or mow, the surgical algorithm may be a little bit different than someone who's doing extreme sports. They may be able just to wear a brace, put their earphones in, mow their grass, and ignore their spouse, which is generally what most of my patients want to accomplish. Eversion strengthening, physical therapy, surgical versus non-surgical, quality of life interventions. They don't all need surgery. You should never talk your patients into surgery. Generally, most of these patients have had enough sprains that they're going to say, look, doc, I've done all these things. Will you please fix my ankle? And then we oblige. So MRI is important. Again, fluid, anteriorly, posteriorly, we've all seen this. We know what a torn ATFL looks like, and we know what a normal MRI looks like. Make sure you look at the perineal tendons. Make sure you look for posterior impingement. So the reason for an operation in my hands are the patients who say, I don't want to continue living with the pain, or I don't want to continue living with the instability, or both. These are generally young athletes still participating in sports, or then a second demographic of moms and dads who continue to sprain their ankle every month. For me, the surgical algorithm is almost always an ankle arthroscopy. I have a low threshold to evaluate the perineal tendons, if they're tender there, or if they have any change on MRI. Boney debridement anteriorly, a lot of these patients have anteromedial impingement with a large osteophyte. Maybe 5% or so require a section of that to decrease the dorsal medial impingement. And then if there's an osteogonum, if I'm already looking at the perineal tendons, then I'm going to take out any evidence of posterior impingement. And then the reason we're all here to learn about the ligament repair, and that's probably where the most controversy exists. Why do they all need a scope? I think MRI is only partially sensitive for some of these lesions. The syndesmosis may be stable, but it also may be tender just based on synovial reflections and meniscoid impingement lesions. And so you can debride that. You can look at the articular cartilage. We all know that this is more effective to evaluate the cartilage than MRI. Perineal tendons, it's an important part of the treatment algorithm. You have to have functional perineal tendons to protect your repair, or it doesn't matter what type of repair you have. It's eventually going to fail, and the patient's going to develop a cavernous foot. And so synovectomy, most commonplace, there's a tremendous amount of associated perineal tendon pathology that we always look for on MRI. And again, if they're tender, then I'll look at the tendons. A recent biomechanical study suggested that tubularization probably restores more perineal function than resection, even when you're resecting less than 50%. I've always tried to tubularize when possible, but until now, I really had no evidence to do that. So how do we address the ligamentous instability? And so multiple options. And I can kind of tell you where we were, where we've been, and where we are now. And I think it's great that we have some diversity on the faculty on how we treat this, because we all have probably a culmination of our own experiences. And so I do arthroscopic repairs from time to time. In my hands, generally an arthroscopic repair is going to be someone with limited instability, usually a younger patient. And I can think, honestly, younger female, maybe a cheerleader, 16 or 17. No significant radiographic instability, but complaints of instability and functional limitation and just the feeling of giving way. I think for me, that's the ideal arthroscopic repair. Generally, I proceed with an augmented repair. And so the reason for that and how we got there, so we know that just an isolated talofibular ligament repair is probably not as strong as what we had hoped. And so this is looking at patients' return to sports participation pre-injury, and only 58% of those patients were able to return to that level. This is an often quoted study, you've probably seen it a million times. So from that study, there became more and more interest in trying to augment the repair with native tissue and using the inferior extensor retinaculum, which we all learned in residency and probably the most commonplace procedure during our training. And I loved when this article was published because I, as I found myself early in practice, performing Brostroms, modified Brostroms, I kept thinking to myself, this patient's extensor retinaculum, I cannot get it up to the fibula. It doesn't matter how far I dorsiflex. It doesn't matter if I release it distally or if I do, it becomes incompetent. And so this study, I felt really validated the fact that in some patients, you just can't get the extensor retinaculum to stretch up to the fibula. And so what do you do in those patients? And I think, number one, it validated that it's not possible to do that procedure in some patients. And number two, still most of these patients did well. And so, again, it was a good procedure. But what about those patients who wouldn't do well if you couldn't incorporate the extensor retinaculum or that needed a higher octane repair? Those patients are going to fail. And so, again, if you're doing 100 of these every year, then you're going to see five or so that are going to trickle back in and have issues with continued instability, continued sprains, or they're getting out of the bathtub and they roll their ankle. And so what about this list of patients who maybe need more than just a primary repair and you're unable to incorporate the extensor retinaculum? And so that's where the interest in tenodesis procedures, Watson Jones in 1955, Crispin Snook years ago, which perpetuated themselves and probably the most popular was in my generation of surgeons. And maybe because it was easier to perform was the Elmsie procedure. This was Coughlin and Skanks article doing it with autograft. I don't know many foot and ankle surgeons that harvest hamstring autograft anymore. This is the autograft technique, which I used to use a lot prior to 2015. And so that demographic of patients that I was concerned that a modified broster wasn't strong enough, then I would proceed with an autograft. And again, this is a pretty invasive surgery. I look at these pictures now and I think to myself, my God, I'm glad those patients, I think most of them did well, or they ended up either in Dr. Bailey or Dr. Mangone's office. But that's a pretty invasive surgery. And so, and then what do you do when that surgery fails and they tell the autograft out and they've got this scar tissue in these bone tunnels. And so that lended itself to multiple scientists trying to evaluate what can we do better? What can we do different? And the dilemma was with those autograft reconstructions, you had to immobilize long enough for the tissue to begin to incorporate, which we know autograft tissue probably doesn't incorporate for six months. And so it was a long period of casting or non-weight bearing up to six weeks, or even in some cases, I know where surgeons would cast people for three months. And then that landed itself to stiffness. The dilemma was if you move the patients too early, then it landed itself to further laxity. And so, with the traditional brostrom, you wanna move early to avoid stiffness, but then that stresses out the repair and you get this premature failure shown in this study now 10 years ago. Another study 13, 14 years ago, looking at elongation after repair with unprotected motion. And so patients wanna move quicker and surgeons want to move their patients quicker for physiologic healing, but the problem is you're starting to stretch out the repair. And so based on the surgeon's need really to improve their success long-term and to avoid that small percentage of failures, based on the athlete's need and desire to get back to sports faster, and based on these orthopedic device companies looking at the high volume of patients undergoing ligament reconstruction, and really the opportunity monetarily to make financial gains, there was a lot of interest in this in the past five to 10 years. And so you start to see these papers trickle in with a standard or modified brostrom, and then this, quote, augmentation type procedure. And so what you see is these studies that are showing accelerated rehabilitation protocols with the same outcomes and really trying to show improved outcomes, improved success. And so this is two of the more popular early studies with some well-known authors looking at, again, 81 patients returned to full weight-bearing in nearly two weeks, returned to sport at 80 days. And so ideally augmentation in this scenario would lead to earlier mobility so you could rehabilitate the patients faster, which we know is gonna lead to more organized tissue remodeling, less post-operative pain from immobilization to avoid that cast disease, earlier return to activities, so return to sport, return to work, increased patient satisfaction which lends ourselves to perpetual success as surgeons. We all want our patients to be satisfied. And then it just made, for me, it made me feel better. I was doing the allograft reconstruction on those that I was concerned about, super invasive. I felt like I was able to confidently repair these with an augmentation, avoid those bone tunnels, avoid the need for allograft, actually driving down the cost some from what I was doing in worrisome patients and made me feel better. And a lot of us, again, a culmination of our own experiences, I felt like I was doing something better. There are multiple companies now that are interested in this space based on the financial gain. These are the two companies that I'm most familiar with, the Flexband Solo, the kit from Arlon, and then the internal brace. And so, again, I think products are, well, accepted within the foot and ankle community and multiple other products that are available depending on your interest level. So look, again, it's not a difficult procedure to perform. And so I'll generally take down the ATFL, a sleeve of tissue. And once you've elevated your sleeve of tissue, I usually start by plugging into the talus, plugging the augment into the talus, and then doing my Brostrom repair in a typical fashion with suture anchors, and then at the very end, plugging in the augment over top of the repair into the fibula. And so another study, looking at high demand military population, 96% of those patients could single leg hop, single leg heel raise at six weeks. So earlier functional rehab. So what do I expect during recovery? For me, I like to splint my patients for two weeks to avoid wound problems. I have a lot of smokers. I have a lot of non-compliant patients who like to live on coats and hot dogs and donuts. And so wound problems for me are something I try to avoid. At two weeks, if they come in and their wound looks good, they're placing a cam boot, allow them to begin weight bearing and start physical therapy with range of motion, eversion strengthening. At six, we're taking them out of the boot and placing them in a brace for conditioning, sport specific PT and walking on uneven ground. A return to sports, I think it's all dependent on the case and the athlete. It's easy to get up and show the one or two cases where we had a patient go back at six, and I think six weeks or so, and you can push the limitations. I think I prefer to operate on athletes at the end of the season. So there's less pressure on trying to get the athlete back to sport. I prefer to take it slow, but there are those specific cases and scenarios where there may be an important game or playoffs or a championship that the athlete may otherwise never get to experience again. And I think this gives you the ability to fine tune and tailor your rehabilitation depending on the sport and depending on the athlete and depending on the level of accepted risk that you as a surgeon and the athlete want to accept during rehabilitation. And again, boosting your confidence to do that. So another good study looking at augmentation versus standard Brostrom, return to previous activity level and previous play activity level. Again, faster in the augmentation group. Also the augmentation group had fewer patients who had to drop out of the accelerated rehabilitation protocol. And so, and then again, complications. Again, I think it's safe to augment. I don't think you really burn any bridges. So who do I augment in? Nearly all my patients, honestly. Anybody that I do an open repair in, probably the exceptions to that would be a young athlete with a low BMI, with functional instability where I might consider an arthroscopic repair. And for me, that's probably fewer than 5% of my patients. Number two, if I have a young, that same patient, I think of a young lady I operated on this week who had an ankle dislocation after an accident and acutely based on the degree of ligamentous damage and the loose bodies, I scoped her ankle and did a primary repair. And again, her tissue, her injury is less than two weeks. And just based on the nature of that injury and the degree of inflammation, I don't know that an augment is necessary. But 95% of my patients get an augment. I don't think that that's affected me in a detrimental way. I think that most repairs are non-anatomic, even those repairs where we say it's a modified brostrom, it's truly a sleeve of tissue that often incorporates the extensor retinaculum, which is probably non-anatomic, albeit I still think a good thing because it incorporates the subtalar joint. A traditional brostrom, as I discussed, may not be enough octane for most patients. And then rehab, our patients expect to rehabilitate faster and it's not difficult. So I think the literature would suggest that there is a difference now and that's been borne out. There's evidence to support it. I think over-constraint with some thought during the surgical procedure and the technical aspects, you can avoid over-constraint with some tricks. It definitely takes a few extra seconds, if a minute. And then I think we always have to be aware of costs, but it's certainly costly to have failures, certainly costly to have repeat operations. And then if you're accustomed to doing something more invasive, such as an allograft or a lengthier surgery for more difficult patients, then perhaps this is actually a cost saver. And so just some things to think about and thank you for your time this morning. Thank you, Dr. Doty, great talk. Yeah, we definitely have seen a trend toward accelerated rehab and how do we do that best in any joint? And so I think that the augmentation possibilities continue to grow and can hopefully, like you said, it's not about do people do okay, but can we even make it better? So we'll see how things go as time goes on. And so now I hope, Elizabeth, I hope your son's game went well. They're playing in the state championship today, so hopefully it went well, but we're gonna have Elizabeth Martin talk to us now about what happens in those 5% of cases that you've been in practice a while, that patient comes back and it's always a terrible feeling when you go in to see them and it's been 10 years since you operated on them. You don't even remember you operated on them and then you walk in and you talk to them and you see the scar on the side of their ankle and you do their ligamentous instability and they're kind of pretty lax and you go, oh yeah, well, who did your surgery? And they said, you did, Dr. Mangone, like 15 years ago. And you kind of go, oh, geez, okay. And that's always a little bit of a wake up call. There's a certain percentage of patients that show up like that. So Elizabeth's gonna teach me what to do when that happens. All right, thank you so much. My son's team won. So they're now the state champions and next weekend they're going on to, yeah, they're going on to out of state to compete in regionals. So it's super exciting. So anyway, let me just open my presentation and share my screen. Let's see. We good? Yep, I think we can see it. Okay, great. So expanding on the last two talks, we're not gonna rehash technique because a lot of the techniques you're gonna use in the revision situation are the same or similar to what you use in primary. But we're gonna talk about it in more of an algorithmic way, sort of when to do what and what to think about during each step. Of note, there is not much data here on revision stabilization. Mainly, I think, because it's pretty rare to fail. And so much of the data is in primary, but there's a few studies looking at revision. So, oops, sorry, blew through my disclosures, nothing relevant to the talk. So we're gonna start with a case and this is actually not one of my initial patients, but she, 22 year old female, she comes into my office with an acute ankle sprain. She was running, she inverted hard. And, oh, by the way, I had a surgery on my ankle three years ago. So we got x-rays and I hear her x-rays. So you'll see relatively neutral-ish alignment. She's got some metallic anchors in the fibula, maybe a little bit of sort of bony lysis, a little bit to the lateral aspect of the anchors. Hard to tell, but these are her initial images. So after you go through the, oh my God, she failed her ligament reconstruction, you're freaking out. So what do you do next? So the acute patient is different than the chronic patient and this patient, treat it like a regular old severe sprain, just because they failed their, they sprained through their revision doesn't mean they're definitely gonna need another surgery. So take a step back and I recommend treating these like a severe sprain. Again, there's not much data on what to do in the acute revision patient. Typically with that acute injury, it's more of an early postoperative failure. Typically the chronic, the people you see who are further out are more of a chronic microtrauma type case. But so typically these are earlier, closer to the index procedure. And I usually treat them like a severe sprain. For these, I do not hesitate to immobilize them potentially in a cast or in a boot just to give those ligaments a chance to heal. Rarely worry about sort of stiffness in these patients by casting them. So if they come in instead and are chronic, hey, my ankle ligament got done 10 years ago and just recently it's been given out more. I also treat those patients like they've never had a ligament reconstruction, meaning take that step back. Say, hey, have you tried PT? Have you tried bracing? Maybe they just need a little bit of dynamic stabilization in addition. The overall failure rate after primary reconstruction is sort of buried in the literature after sort of more contemporary Brostrom type procedures. It's closer to that sort of 1.2 range. That was a recent meta-analysis. So again, we don't have a lot of data because many of these patients just do so well. So back to this patient. So you cast her, she continues to be unstable. So then what? So basic principles for your revision or your failed patient. First of all, confirm the diagnosis. Just because the patients say that they're having instability, as you know, this doesn't mean they necessarily are having lateral ankle instability. It could be that they're having pain impingement, or sorry, pain inhibition. It could be that they're having some mechanical symptoms within the ankle that are causing that feeling. So confirm that diagnosis, and that's on your good physical exam and potentially on stress radiographs. I don't always get stress radiographs for my primary, but I do in a failed ligament reconstruction, especially because that whole concept of subtalar instability potentially can elude as well. Also make sure your patients are rehabilitated. Worst case scenario, you give them some good prehab before surgery. And I think the critical piece of this whole revision talk is to determine the cause of failure after you've determined that in fact, they are still unstable. Since so few of these fail, typically there is a reason for that failure. And if you don't address that reason in your revision, the chance of it succeeding is not as great. So then execute your plan. So first of all, is this truly recurrent instability? Symptoms, objective instability, is it their perineals that are unstable? It can be several other things. So use your very good physical exam to help you. Check their strength. I always MRI image my recurrent instability patients preoperatively, not to look at the ligaments because really you're just gonna see a ball of scar, but to look for concomitant pathology, to look at those perineals, to look at the cartilage and to see if there's potentially something else that is clouding the picture. So again, the key part, why did this fail? So there are many reasons that this could fail. Maybe it's just bad luck, just a bad injury. Is it potentially surgical technique, biologic or patient factors, or maybe alignment of the patient? So in terms of surgical technique, this is more common in the acute setting, just didn't quite get the repair right the first time. This is pretty uncommon. Alternatively, maybe it just wasn't the ideally selected procedure for that patient, but surgical technique, again, is pretty rare. And if it's technique related, it's usually more acute. So biologic factors, hypermobility hasn't been shown to actually predispose to ankle injury or instability, but it may predispose to failure. And there's literature supporting that. And like Dr. Gainey mentioned earlier, you wanna make sure you're really examining both sides and that you're not assuming that laxity in the operative side is a failure. It may just be their baseline. So in terms of alignment, this is critical. So, and this alignment difference can happen anywhere along the axis. And so you need to be very diligent in your examination of this and try to figure out if their alignment's off, where is it coming from? So you can truly address that. And sometimes hind foot rigidity, potentially like a coalition can contribute to recurrent instability, just increasing that sort of lever arm heading medially. So this is a patient who walked into my clinic with persistent instability in his 60s. And, oh, I did not even include a foot film, but he actually on standing really had quite a bit of varus alignment through his heel. And looking at his tibia, maybe the plafond is heading a little medial. So this is somebody that I would recommend getting sort of full length standing films on to see, is it more than a foot? You know, is it more than just their ankle and their hind foot alignment that's contributing to this? In terms of patient factors, high BMI activity, you know, crushing your ankles or maybe even under rehabilitation after the primary procedure. So in terms of consideration for the revision setting, you know, like any revision, you wanna equip yourself with the op note if possible and really think about where the incisions are. Where are the anchors? Where are the tunnels? Are you gonna have to change your position of any of your fixation to try and, you know, maintain appropriate bone stock, mainly in the fibula where you're, you know, you have little or smaller real estate to begin with. And this is always fun when you, you know, the patient comes in and they have these crazy incisions that you have to work around. So, you know, how do you pick which approach to choose? So we've talked about sort of more minimally invasive, more anatomic, non-anatomic. How do you pick when the revision setting? So the rule of thumb, I think, is usually do something different. Don't do the same exact thing that was done the first time and expect it to succeed. Kind of like, you know, Charlie Brown kicking the football or like the, you know, Einstein definition of insanity. You wanna do something different unless there is a really, really good reason that that initial procedure failed. Now I say this, but they're actually, and you know, the literature is bad if I'm quoting a, you know, an abstract from the annual meeting that hasn't been published yet. But there was a very small yet unpublished series looking at 26 patients with revisions. And actually 15 of them, half of them had a revision brostrom and did quite well. Now the abstract doesn't mention whether it was augmented or not augmented. So it may, you know, potentially be irrelevant, but maybe you can do a primary brostrom for these patients. Other studies are mixed. Some showing that it's, you know, it had good results. Others showing that it was a higher failure rate. But my rule of thumb in these is don't do the same thing. Don't do the same thing again. You're just, you know, you're setting yourself up for potential failure and you don't wanna revise your revision. So in terms of surgical options, so should you do a repair? Should you use the native tissue with or without augmentation? And then I bolded the with, because this is a case for where really, I think augmentation is warranted once you've failed once. Do you reconstruct? And if so, do you use allograft, do you use autograft? Do you do non-anatomic or anatomic? And do you realign? Do you augment the mechanics? Another question is, do you scope these patients? I routinely scope these patients for numerous reasons in terms of common pathology with chronic and recurrent ankle instability. I scope all of them. I think you can make the argument if they're having no inter-articular pain and the MRI is okay not to, but really with these, I don't want another reason for them to fail. I don't wanna wonder if I had done a scope, would I have found something that's causing this post-operative pain that they're now complaining of? So how about doing a brostrom and suture tape augmentation? So for this in the revision setting, I think this is an excellent procedure when the tissue is robust enough that you could repair it. Keep in mind, you may need to pivot intraoperatively. If you notice intraop that the tissue is not appropriate for this, you may need to pivot and switch to a graft tape procedure. The benefits of doing it, as we've spoken, faster recovery, I think the times that it makes the most sense to do this are in the case of sort of the bad luck patient where they just had a really bad injury and the tissue's pretty good. If there's a concomitant alignment issue and you're correcting that alignment at the same time and you're really, that's you think what the most likely cause of your failure was. Perhaps an athlete getting back to play somebody that you want to rehabilitate faster would be a time to do this. Like any revision, have plan to be ready. You can't just say, yeah, I'm going to do a brostrom and assume the tissue is going to be good because it really might not be good enough to do so. And you need to have other options available for yourself. There is some evidence. This is like the one or two things where there's actual evidence behind it but there is evidence. One paper looking at 30 patients who were revised with a brostrom with suture tape. One of those patients failed and was revised to an allograft but the remainder of patients did quite well. So there is evidence to back up doing this as a revision procedure and you can do it open or you can do it arthroscopically as well and use your suture tape arthroscopically as well if that's within your wheelhouse. You have to keep in mind that with any revision brostrom procedure there is an increased potential for nerve injury whether you do that open, whether you do it arthroscopically it's something to really consider. So I honestly, I do my revisions open. I don't try to minimal and basic these. So in terms of when to do allograft, when to do autograft. So if concerns about the tissue integrity, any hypermobility, if the ligamentous tissue is attenuated or BMI, I tend to make my tunnel not like this picture shows. I tend to make mine more from inferior to superior to make sure I'm really above where that SPR comes out approximately. But again, you can use allograft, you can use autograft, most commonly hamstring. There's a relatively recent AJSM paper looking at using hamstring, allo or auto for, and they looked at about 30 patients. Half of them were revisions and they noted that the revision patients, none of them did as well as the primary. And the question there is, is it because it was a revision procedure or is it because that those patients had patient factors that were leading to them needing a revision? Is it because they were hypermobile to begin with? Is it because their BMI was larger or their alignment was off? We don't know. But I think it's reasonable to tell your patient, hey, there's a chance that this revision procedure may not be as, doesn't have the success rates of native. And then there's a question of whether to do sort of where to put your fibular tunnel, whether to do one tunnel, two tunnel, especially in the revision setting. If you have anchors in the fibula, you need to work around those when you're putting in your tunnels. And there was actually a recent biomechanical study looking at if you do two tunnels versus one tunnel, if you do it more anatomic, where the tendon comes out sort of more where the native CFL is, if that biomechanically is better and they didn't find any difference biomechanically. So I think particularly in the revision situation, make your tunnels where you need to to get good bone purchase. And in terms of local autograph, this can be a very powerful tool in the revision setting. So particularly in somebody with a higher BMI, a high demand athlete, the big consideration with this is that it may cause subtalar stiffness depending on how you do your procedure. So the most common sort of current one for, oops, sorry. Current one for these is the split brevis. So taking about a third of the anterior aspect of the peroneus brevis and then weaving it through. This picture shows one option of kind of bringing it through the calc and then up through the fibula and into the talus. Taking this graft instead and bringing it more anterior and putting it from the fibula and just anchoring it into the fibula is an alternative way. And that's the procedure Bob Anderson's group published on in higher demand athletes. That affords you the ability to get that sort of restraint from the brevis to use local native tissue, but not actually lock up the subtalar joint. So if you wanna use that procedure just to run anterior and wanna kind of limit your subtalar stiffness, you can do that procedure and just anchor it in this direction. Can you see my mouse? No, cool. It just anchored in this direction. Great, up to the fibula. Now, if there's a patient that actually has, that you want subtalar stiffness, so if they have either subtalar instability or if it's somebody that you're not worried about adding subtalar stiffness, for example, somebody with a coalition, you may want to, if you choose this procedure or any procedure, use that connection into the heel and really make sure that you're getting as much stiffness as possible. There's also an option, I've never done this procedure of using a fibular periosteal flap that you take from Proximal and fold down distal over. And you can also combine that with an inferior extensor retinacular flap bringing up Proximal. That's a sort of local tissue option as well. There's a recent FAI study looking at that where they had nine year followup of those patients. And they actually did, most of them did quite well, although four of those patients actually had relatively catastrophic complications. And it was a small study of about 20 patients. And so two of them had sort of necrotic skin edges that took a very long time to heal. One of them had severe CRPS and then the other one had a bad nerve injury. So the patients who did well, did really well, but four of them had pretty severe complications. And to use that procedure, the surrounding tissues have to be quite good. So the other question, so when should I augment mechanics? So if they're in the revision setting, be aggressive in correcting. You don't want the revision to fail. You want to give your patient the best chance to succeed possible. But you do have to think about, you know, how severe is the deformity? Is it relatively subtle and I'm kind of just looking for a reason? Or can the patient afford the extended recovery? And somebody like a high-level athlete, there's a picture of Steph Curry's ankles, can they afford that time to recover? And if not, you may consider just supplementing with either kind of a protective lateral post-orthotic or protecting with bracing post-surgery. But, you know, in general, in the revision setting, certainly err toward augmenting mechanics unless there's a very good reason not to do so. How about dealing with the anchors? I think the most important thing is really evaluating and making sure that whatever bone stock you use is going to be good and be able to maintain whatever fixation you want to put in there. So if you're using allograft, you know, you can put your tunnel above the anchors, more A to P to get yourself more bone. I use pre-op CT if there's any concern about where the anchors are, if there's any type of lysis or bone loss around sort of non-metallic anchors. I think CT is very helpful for that so you can really plan where it makes sense to put augmented fixation, particularly in the fibula. So in this patient, the patient has, it appears plenty of good bone stock, you know, proximal to those anchors, potentially some lysis there. So I would definitely get a CT in this patient to see if that was, you know, actually true lysis or just, you know, something about the x-ray. And then there's plenty of room kind of coming out in this direction if you wanted to allograft. And then if you wanted to do suture tape, you know, getting a good sense of what the, what this fibular bone quality looked like to see if you have enough room to truly put your, to put some type of fixation there. And then lastly, in terms of alignment, really, really scrutinize the alignment. I know I said it like 15 times, but very important. Weight-bearing CT, if you have access, can be very helpful to look at foot deformity to try and plan if you want to do a calcaneal osteotomy, if you feel like you might need to do a dorsiflexion osteotomy of the first ray, and also to look at sort of the plafond alignment, consider leg length films if needed. And you can either, if the tibial osteotomy is needed, as Dr. Doty talked about yesterday, you can do a dome, you can do a wedge, you can do whatever's needed to sort of correct that the same way you would for, you know, ankle arthritis. And I mentioned earlier as well, if stiff or a coalition, you may need more restraint. So consider a split brevis or suture tape down to the calc. So in general, the algorithm, you know, start with your conservative treatment, even if it's a recurrent case, make sure you confirm that diagnosis so that you are treating the problem, because instability, that complaint can mean a lot of different things. Determine the reason for failure, the absolute critical component, scrutinize the alignment and be aggressive about treating it. Be prepared to pivot interoperatively. And I typically will immobilize these patients longer than the native, even if I'm doing an augmented suture type procedure. You don't lose much by immobilizing longer, but you give those soft tissues longer to heal. And if you have published, or if you have results on this topic, please publish because there's very little out there. So thank you. Here's a picture of my son's baseball team. This is my little guy right there. And then just so my other son doesn't feel bad, there's my little guy. So anyway, thank you so much for your attention. I appreciate it. Thank you very much. Three great talks. There are, there are a couple of questions we can go to, kind of go across the panel with each of these, and then we can go to the case studies. So one of the questions talks about kind of subtalar instability. So, you know, how do you assess that interoperatively, whether you're open or closed? Is it, you know, I guess, do you use fluoro interop? Do you do it just by feel? So, you know, how do you guys address from a subtalar instability standpoint? We'll start, I guess, with Lauren and we'll just go through the line, Lauren, Jesse, and then, and then Elizabeth. So I think first I have to have a clinical suspicion based on their exam. I mean, I think that the CFL and the subtalar instability is me more an inversion issue than a anterior drawer issue, but I think that's where your stress radiographs are helpful. I'd prefer to know that going into surgery, especially because that would determine whether I'm going to do it open arthroscopically. So I think that's something I would get the stress x-ray on to rule that out ahead of time. Agreed. And sometimes when you're, you're looking at your tailor tilt, you can see that even though it's anecdotal, a tremendous amount of motion through the subtalar joint and inversion where you have that large lateral gapping. The other thing I would say, if you're doing a, if you're breeding posterior, you're evaluating the perineal tendons, if the CFL looks extraordinarily redundant, you can just use your pickups to test it a little bit, and you can imbricate the CFL, even though it may not be incorporated in your anterior repair. And I agree with all the speakers, it's generally not. And so just reef up that tissue posterior. And it's amazing oftentimes how horizontal the CFL actually is. And for that reason, I think probably the most important thing is if you're doing an open lateral repair, trying to incorporate that entire cuff of tissue off the anterior fibula. And even the, if you can bring the extensor retinaculum up without tearing it and making it too tight, just so you can incorporate the subtalar joint with every repair, even if you're doing it secondarily. Because I think we all agree one of the reasons for failure is probably continued subtalar instability. Yeah, I don't have too much to add, except that I always, and I always stress my ankles after I do the ligament repair, because number one, if it's going to fail with me just twisting it, I want to know that in the operating room. And number two, if there's some other, you know, degree of instability, then you can figure it out there as well. But I don't have too much to add, but that's for me in my practice, I always check after my repair. There's one question about how do you see subtalar instability on stress rate of gas? I think those are outlined in the book, but basically you can see kind of lateral train. I'll just answer that lateral translation with the tilt testing. If you take x-rays, you can kind of see where the subtalar joint will translate medially, or you can see it with anterior drawer. And again, drawing landmarks, you can identify if the posterior facet is kind of translating forward relatively. I will say that, you know, just as an add-on, I like to use, I think we're going to migrate here, and I like to use hind foot instability as a, I think it's a better term than ankle instability, because really I think it's in many cases a combination of both of those joints. And some, some people have more isolated ankles, some people have isolated subtalar. I think the vast majority of people who have lateral hind foot instability kind of have a combination of both. And I think that's why you really, in most cases, need to address both, except if you have maybe a very high level athlete that, that you're trying to preserve some sort of specific function because of their elite status. Other than that, I think the average person just doesn't want to sprain their ankle. They really couldn't care less whether you call it subtalar or ankle instability. They just don't want to walk outside and quote, sprain their ankle, whether it's their subtalar joint that goes or their ankle joint. So, so I would, I would encourage everybody to kind of see it from, from that perspective. A question here about functional instability. Do you, you know, first of all, what do you define that as, Jesse? And then, and then do you oftentimes treat that non-operatively, operatively? I treat them, you know, it's exactly what you said. The patients come in and they say, every time I walk outside, I sprain my ankle. And so whether it's functional instability or it's objective on radiograph, I really treat them all the same because objective instability with tailored tilt, I'm still going to give them an opportunity to rehab, depending on their overall functional expectations. And some of those patients may do fine if they say, look, I just wear a brace when I go hiking, otherwise I don't need anything. And so then they just have to determine is, is surgery, the risk of surgery and the time off worth any benefit. And so for functional instability, it would be someone in my practice, typically someone who has giving way without any objective radiographic evidence of instability. You can argue about the MRI findings. Again, those patients are still going to get an MRI, but typically you're going to see less pathology. I still think they can benefit from a modified Brostrom procedure. And that may be one of those patients where Lauren is, is probably the arthro arthroscopic repair may be a great decision in that patient. I think there's been some work done from Spain, looking at Geordie Vegas, done a fair amount of work, looking and seeing if, if maybe some of these quote functional instability patients are in fact isolated tears of the superior band of the ATFL where they, they, they have some laxity because of that, but they still have negative quote testing. So I think that's something to consider. I think the other thing that I'll just tell you that I do for these patients is, and is, is core strengthening. I think there's a tremendous amount there's somebody, I think Elizabeth showed that picture of Steph Curry. You know, I think he's really brought to light the role of core strengthening in and glute strengthening in ankle and lower extremity injury and stability. It's really brought it to light. And so I make sure that all those patients who have quote functional instability that show up in my practice, they all get core strengthening and, and go through hopefully about three to six months of glute, especially glute strengthening. And it's amazing the number of patients who will get better after they have that. So all right, for Lauren and, and, and Elizabeth, I know Jesse kind of talked about his augmentation stuff. What do you think about just using one of these augmentation devices and not doing anything to the ligament, right? You just go in, you make an incision and you take one of these augmentation devices and you just throw it over top of the native tissue, which is stretched out. You put it in place and out, out the door you go. What do you think of, of that in patients who maybe complain of instability, but yet they have negative, you know, they, again, you do laxity testing and maybe they don't feel that super lax, but yet they're complaining of this instability, any role for that? I don't, I mean, I think of the internal bracer that augment as, you know, any sort of hardware, right? It's going to fail eventually if you're relying on it solely. So to me, you have to do something to, I mean, essentially it should be secondary to your body remodeling something. So your body has to heal something or that's going to fail. So to me, I think that that's going to cause problems, stress shielding we talk about. And I think eventually it's going to fail if you don't do something to repair their ligaments. Elizabeth, how about you? I don't have anything to add. I a hundred percent agree with that. I mean, really, we should be using that as a check brain and not as the, not as the primary source of stability. So if you're just laying it over top, I don't, I think it's just going to fail. All right. I've got one question before we go to, to the cases real quick. Those are the cases from the audience or those are the questions from the audience. I'd like to know how soon do you get an MRI scan on an acute ankle sprain? What is your paradigm for getting an MRI? Let's say absent your, you know, patient comes in, you're not concerned that they may have some occult stress fracture or some perineal dislocation. You know, they're not, you know, but they're kind of a routine ankle sprain, maybe grade two, grade three. At what point do you consider getting an MRI and why? Because there's really not a lot in the literature on that. And I always am interested from my panelists on ankle instability, you know, when you pull the trigger. I mean, for, for me, if it's an athlete that I'm trying to return to play, I may get it sooner just because if they have any type of chondral injury, I'd want to know that sooner. In the absence of any sort of red flag signs though, like that you're thinking something else, perineals I typically will let them try PT. And if they either get worse with PT or if they plateau after a good course of PT, then I'll get it in the absence of sort of red flag signs. I don't think it's ever changed my management. You know, patients will come in with them. But I agree. I mean, when I get it, it's because something seems unusual, like not, not like a typical sprain. So if everything is pointing towards, you know, soreness at the ATFL, soreness at the sinus and the perineals, but, you know, in some swelling, you know, to me, even the times when I think it's a little bit more extreme than I expect, again, MRI, it shows the same thing. And it's, it really hasn't changed my management of these patients. So I'd say rarely if once, you know, the patient's parents wear me down every once in a while. No, we parents, Jesse, what about yourself? Ditto. I don't see a reason for that. Yeah. I, um, uh, no insurance company will pay for it. It's interesting. Yeah. I see. I I'm gonna say I, I usually it's two to three months for me, at least they have to show me they're not getting better. Uh, but it's interesting. The number of people who come in and of course, you know, once they get the, once they get the ankle MRI that shows they have a quote, torn ligament, they're like, why aren't you going to fix it? Uh, and, and so it's just amazing to me. And there's really not good work that's out there in terms of, you know, we've got all this work on, you know, when do you get a spine MRI, you know, with back pain, you know, things like that, but there really is very little on how on that with ankle sprains and given the number of ankle sprains and the number of MRIs that I see of patients who have come in from, from those it's, it's amazes me. So, uh, um, all right, I'm going to share my screen here and throw up a couple of, uh, cases real quick, and then we'll, we'll get out of dodge and go on to the next, uh, topic here. So yes, go right ahead. Can I ask a question to the other panelists? Because this is something that I've always wondered about the idea of using the perineal tendons to supplement a repair. Never made sense to me because that's your secondary stabilizer. So why are we sacrificing their perineal? So I'm curious if you guys have, you know, that whole, you know, and Bob Anderson does it, who's like the guy, right. But it's never really made sense to me to take half of your brevis and use it when you need it. So I'm curious what you guys think about that, or if you do it or what you found in clinically. I agree with you, Lauren. I mean, I can't, you can't argue with Bob's results and his wisdom, but I did, I don't do it. It doesn't make sense to me. Yeah. You know, I totally agree too. I presented the data in my revision talk, but it's not a procedure I use. Um, for the same reason, I feel like it just feels wrong to take it. Now, I think the thought is if you leave two thirds of it intact and the part that you're kind of, that you're taking, you know, it's like, you're still sort of moving it sort of along the same trajectory, but I don't know. It feels weird. It feels weird. Uh, it, and it doesn't make sense. Yeah, there, there are, there are some studies that show that the brevis will, will hypertrophy over time. But, um, but I agree, I don't use it. I think, you know, Bob has great results, but so did, you know, Elmsley and some did, so did, you know, uh, Watson and Jones and, you know, they, they all make the ankle stable. The issue is what happens long-term, you know, and are you really doing, is it, is it best from an anatomic perspective? So I think that's, uh, um, I think that's a reasonable question to ask. So hold on one second. Let me, uh, let me pull up. I'm going to take that down because it's, it's going crazy on me again here. Hold on a second. Let me pull that, that PowerPoint back up and see if I can open up my, uh, my share screen here and share screen. There we go. That's got it. Good. All right. Everybody see me. Okay. Yep. Good. All right. So the first case actually from, uh, Lauren, uh, you want to go ahead and present it? Sure. So, um, this is a woman that presented to me 51 years old, um, very reasonable apirin, um, chronic ankle instability. And what's really interesting about her is that she has, um, I don't know that it was ever given a name, but congenitally, she actually only has four rays. So interestingly, she only has apirinus longus cause she has no base of a fifth to attach the brevis to. So she has one, uh, tendon over there. She has congenital loss of her ACLs and she was actually very active to the point where she was running marathons. She can't really do much on uneven ground, but able to do anything flat, but then she had, she gets these flare ups of pain and instability. Um, you can go on to the next one. So, um, her exam in her alignment is relatively good. Um, she has challenges with single leg heel raise. So she has lateral instability and then medial hind foot pain. Um, her range of motion is fine. Um, certainly instability, um, both on inversion, um, and with the anterior drawer and her strength is overall relatively good. So, uh, her x-rays, you can see she has essentially ball and socket ankle, but again, she's very active and her, her, um, goals are very reasonable. Um, she doesn't necessarily need to return to running again, but she just wants to be able to walk on the beach without her ankle turning on her and go for walks on flat ground and just, you know, get through the day. Um, so there's her, her lateral x-ray, um, there, and then you can see, um, a lot of fluid in the ankle joint, essentially, I mean, not much for an ATFL, um, and then just a lot of fluid around all of her tendons there. Um, and there again, it's, you have that kind of defect, um, on the medial, uh, distal plafonts. I wanted to see if she had an OCD, but overall surprisingly no real arthritis in the ankle. So really instability, number one, and then medial ankle pain kind of posterior tip pain, uh, number two. So curious what you guys would do. All right, Elizabeth, what do you think? So, you know, there's so much you could potentially do with this case, but I think that, you know, the question is, I guess, what, what should you do? Um, uh, I mean, if truly sort of lateral instability is the main, um, complaint, I think you could consider, let's see, kind of see. So her, her hind foot, it's hard to, can you bring up the x-ray? Yeah, sorry. Just to look at her lens. Okay. Um, so her hind foot doesn't look, you know, you know, like it's way off, you know, medial. So I, I probably wouldn't do anything with that. I think is, is she also, is the deltoid okay? Yeah, her deltoid, um, she, again, she's not, I mean, her pain seems to be more posterior tip, honestly, um, than deltoid pain and she's not, you know, she guards a bit. So, um, she had a great exam when she was on tranastasia, but you know, when she was, um, awake, you know, certainly lacks, um, more anterior dorsal ligaments. Yeah, right. So, I mean, I think you could, you could consider doing a ligament reconstruction, um, on the patient with her, if her, you know, ligaments are quite attenuated, you know, I, this is something I w I would augment if you did an isolated, uh, lateral, uh, reconstruction. And then with the, yeah, I mean, if it's more posterior tip pain, you know, I'm, I'm not sure I would really, at least based on this, I don't know that I would do anything for the posterior tip. I don't know. I mean, it's, I don't know, Lauren, this is tough. I mean, if, if instability truly is the main issue, then I, you know, may do a scope and just do a sort of an augmented lateral ligament. Um, at least with that, if her deltoid seems to be okay, it's not like you're, you know, worried too much about the shape of the ankle with that. I don't know. Maybe that's what I would do. I don't know. What would you guys do? I'm glad you asked Liz first. If I could just flounder around, cause this is hard. It's hilarious. True story. I actually have this exact patient and same deal kind of ball and socket ankle. And just like any patient they get because of the, if you look at the x-rays, I think there's four foot varus. And so she's, and she's got high foot valgus a little bit. So she's getting some strain through her post tip, but the problem is she's got no lateral ankle ligaments. And so I think exactly what Liz said, you could scope her ankle, you could repair her lateral ankle ligaments. And I think that would help. Um, and the patient I did, she, it was the same deal, her post tip hurt. So I ended up doing, even though it's counterintuitive, I did a medial slide on her calc, um, and it helped her post tip pain. And I did something to stabilize her first ray. Um, and so I guess to Liz's point, you have to examine the patient and see truly where what's her biggest disability. Is it ankle instability or is it post your tip pain from her flat foot, or is it both? And then do you want to try to address both simultaneously? Yeah, I, I, I would, I think you, I think you, I would probably address both in some way, shape or form. You can see on this MRI that that calcaneus, the subtalagent almost looks like it's a little bit laterally translated. And so there is some medial side instability, whether it's instability because the deltoid is incompetent, or it's because the post tip is giving way spring ligament, or if it's the, like I said, the medial columns unstable. So basically they're getting a forefoot driven hind foot valgus type of, of process there. Um, but what'd you end up doing Lauren? So I did a, um, scope, uh, Brostrom with augmented repair and stability. I mean, she's happy. She's walking on the beach again. Um, I ended up opening her up immediately cause she was, it's hard to see on here is that her medial mal itself is super prominent, um, and rubs on everything. So I was going in any way to kind of shave it down her deltoid. It was very redundant. So I did a medial Brostrom too, and then just kind of debrided her poster tip. Interestingly, she's actually, that's, that was two years ago. She's actually coming back because the poster tip is bothering her again. So now I'm deciding what to do. So thank you. Yeah. Check that medial column out. All right. All right. And this one, um, quick, you get your opinion on, uh, so 55 year old multiple ankle sprains between ages 18 and 25 occasional ankle sprains really has, doesn't have a lot of pain, but he comes in saying he has this kind of laxity, um, neutral heel alignment as a grossly positive answer drawer. Um, so, so here you can see on the, just the standing weight bearing radiographs looks like this when you do stress views, this is what it looks like. So, so, you know, what do you tell this patient? Yeah. We we've kind of talked about, there's been more work over the years of, yeah, well, does ankle instability cause arthritis, right? You know, do you, you know, obviously I don't think we're going to run in and operate on this patient right away or do anything like that, but what are you telling people about ankle arthritis and instability? Do you say, Hey, we're a brace when you go out and do things and, um, but you're at risk for this. You know, do you bring them back maybe every couple of years, get an X-ray, uh, you know, do you just, where, where are you guys at when it comes to, let's say the patient's 35 with this instead of 55. Um, are you kind of, I don't want to say prophylactically treating people, but watching them more carefully because of some of the things that we've seen doing the total ankles and the number of people who really have instability as their source of, um, of ankle arthritis. So to me, I think, I think it's a hard answer. And I always tell patients, you know, people that come in with varicose ankle arthritis, um, is usually because they had multiple ligament injuries. That being said, we don't know the number it takes to, for that to happen, but I think, I don't know. I mean, I, I usually think more of instability events rather than just, you know, so if they're not rolling their ankle, if they're not having instability events, but, you know, once a year they sprain their ankle playing basketball, I think that's a different than somebody three or four times a year that are, you know, have to brace themselves and put themselves in a boot. So I'm basing it more on the frequency and the severity of it. And I think that if it happens only during certain things, I say, you know, wear a brace when you're mowing the lawn. Um, if that's when you feel it and then otherwise I don't think too much of it. So I mean, just my feeling, if it's three or four times a year, I get a little nervous about it, but I have no basis for that. I agree a hundred percent. I tell all my patients, as long as you're not re-spraining your ankle, you're probably not doing any more damage. Uh, but I'm inclined to believe, even though I still tell them that I've become more and more inclined to believe that just like the knee with an ACL, even some of these patients, when they run, they don't sprain, but their ankle shifts more than physiologically normal and they hurt. And so they're getting pro-inflammatory factors and who knows what degree of cartilage wear they're getting. And I think it's hard to quantify and doesn't really change our management, but I agree with Pete and Lauren. I think it's there. Um, it's just, it's again, I don't, it's not worth prophylactically treating in my opinion. Is it the same or different? No, I mean, same. I think it's so hard because we see people, you know, oftentimes when we see them, it's too late, you know? And so I think, but I think in, at least in my practice, I feel like most of the people who are coming in with sort of that chronic ankle instability picture aren't coming in like, oh, I, this is only a little bit of a problem for me. I feel like maybe it's just my practice, but I'm seeing more people that are having kind of more of an issue than just so this happens every so often. Um, so I feel like I, I maybe am talking more about surgical reconstruction, but, um, but I, I think, I think that there might be more of a role for it, honestly, than we think. And then we realize, um, but I, you know, now that you're sort of bringing this up, I'm like, man, maybe, maybe we should be doing this more. Well, and I think that the people that come to you with the ankle arthritis, so are these old guys that played ball and they just strapped it up and went back in and play like, you hear their stories, right? They'll tell you the glory stories of, of their heyday. And I think that we're better about treating it and stabilizing and rehabbing than we used to be. And I don't know if that's going to make a difference for them developing arthritis. Well, I I'll throw it out there from the standpoint of this is for you guys, you young, young panelists and faculty members to figure out, you know, I think that's, that's going to be the great thing is to figure out, you know, which, and try to figure out which of these patients with laxity at age 25, 30, 35 are going to result in that patient at 55, who has that various ankle and, and ends up with a total ankle replacement. And which of the patients are going to be like this person who has ankle laxity, but doesn't necessarily have arthritic changes. And I don't, where I said, we don't know that yet, but I'm sure there's, there's going to be ways for us to figure that out. And that's what I'm going to task you guys to do during your careers is to figure that out. So, all right, we'll we'll stop there on this session and you'll hear the thing about stopping recording, just stay on the session and then we'll go to the.

advanced foot and ankle challenging conditions

ankle instability

minimally invasive repair

open non-augmented repair

augmented repairs

revision stabilization

ligament reconstruction

chronic ankle instability

physical therapy

surgical technique

diagnosis confirmation

revision surgeries

preoperative imaging