Without further ado, we're going to introduce our first speaker. This is going to be the arthroscopic brostrom. Dr. Peter Mangone is going to talk about this. And Peter, I'm wondering why people aren't all doing this. Can you figure this out and teach us about it? So Peter, come on and tell us about the arthroscopic brostrom. So, one thing I want to mention real quick, I just want to Arthroscopic lateral ligament reconstruction 15 years since patient one. Where are we now? And what I'd like to do is kind of go over with you. Where are we? What what is going on? And as Mark said, why are we not doing this? The good news I have to tell you is that I no longer have royalties So every year for the last 10 years or so when I've gotten up to speak on this I'm always shy about the fact that people think I'm trying to sell something at this point I'm not trying to sell anything and nor have I been for the last 10 years But the idea itself right the idea itself I have passion for and I think it has a role in our Reparmentarium this all started basically as an individual pursuit with myself and George Acevedo Because we were just frustrated with doing open ligament reconstruction after Scoping the ankle and so we kind of worked through this process of figuring out. How can we do this arthroscopically? At the same time what we didn't know is there were about five or six other people And we eventually all got together and we started looking into this further and doing more research talking to each other about 2000s about, you know, how can we do arthroscopic procedures? So what have we learned 15 years later and where do we go from here? So number one, while open Brostrom's work, they definitely All right, and that's backed up by the literature. This is not just an anecdotal thing. So, you know, why is that? Well, is it intra-articular pathology that's going on? It's very difficult when you do a Brostrom it's very difficult to see the medial side of the ankle It's very difficult even to see the central part of the ankle unless you're going to do a really extensile dissection All right. So with that being the case multiple studies So if you're going to do this arthroscopic exam, so point number two is if you're going to do this arthroscopic exam to look at the ankle, right, to identify associated interarticular pathology, then why would you then open it when you can see the ligament and the structures right there to be able to do the procedure itself? So with that being the case, what do we know? Well, we know from the literature that actually arthroscopic procedures, barostrum procedures, do better than many people think, right? Everybody kind of thinks there's no way that'll work, it's not there. The reality is that this is based on the literature. It's not based on my personal anecdotes or some people who do the procedure. The biomechanical data clearly shows it's equal to open procedures with a two-anchor type technique. There's greater than 10, it's now up to about 15 studies in the literature that with greater than 12 months essentially follow-up, all of them in peer-reviewed literature showing that the results are equivalent, if not better, than open procedures, and in many cases better. And here's kind of a list of those publications. In addition, compared to the traditional open technique, the patients have less pain, they have less swelling, they have less incisional scarring, and at least in my practice, and I think it's been shown in some literature, that they recover faster, right? They simply just have less swelling. You can see from these photos here, they have almost minimal swelling. It allows them to get into a brace faster, it allows them to rehab faster. There are several meta-analyses that have been published showing no significant difference between open and arthroscopic techniques, and in fact, in March 2020, an FII article showed better results than open techniques in a head-to-head competition. So again, where are we now? Once you're through the learning curve, the arthroscopic brostrom is also more efficient, right? Instead of having to take down your drapes and re-drape, or put a new drape over the wet drape, and then have to dissect through all this tissue that's been, had water flowing in it, over it for the last, anywhere from 10 to 25 minutes, depending on what you're doing, instead, it's much faster and more efficient for both the surgeon and the patient. My current start to finish time is 8 to 10 minutes to do an arthroscopic brostrom, and that is achievable by the average surgeon if they just learn the technique and go through the learning curve, whereas before, having to take down the drapes, move everything, now I've got to dissect through water-extravasated tissue, find the tissue planes, put my anchors in, tighten up the tissues, and now I have to close, right? The closure for this is basically three stitches when you do it arthroscopically. It's quicker rehab, this video, there it is right there. Why is it quicker? Well, I think it's because we're no longer destroying all the normal tissue to get to the abnormal tissue, right? They not only have less swelling, but you also aren't disrupting all those proprioceptive fibers in that area in order to get down to the abnormal tissue, which is actually the ligamentous tissue. And this is all without augmentation techniques. I'm not using all these augmented procedures, these extraneous type issues. This is just the native tissue in that area. So with that being the case, we know that arthroscopic techniques for lateral, and now even we'll hear about acute medial instability, have been less favorably adopted in the U.S. compared to internationally, without a doubt. It's much more embraced on the international front. So the question is, why is that? We know that it's safe. We know that it's stable. We know that if you get through the learn curve, it's pretty simple to do, and patients oftentimes are very happy with the results. But in the U.S., we're still not routinely performing ankle arthroscopy ligament reconstruction, it's much less popular here than elsewhere. We continue to have more traditional open techniques. Well, I would tell you, when I ask people why is it, well, it certainly can't be because of lack of literature. It can't be because of, quote, poor results. The literature doesn't back that up. It's not time consuming. The learning curve maybe takes a little bit, but most of us are pretty good surgeons. And the patients aren't, I don't think the patients are out there demanding larger open incisions where they have more pain. So what are the reasons that are out there? Well, I think industry drives some of it. There's a large number of foot and ankle providers in the U.S. that don't use a scope very well or don't know how to scope. And so industry favors these open procedures. The U.S. system doesn't pay for the learning curve, right? The two-tiered systems more favored internationally actually favor the learning curve better. In the U.S., you have a CPT code, you get paid the same, whether it takes you 10 minutes to do the procedure or a half an hour or an hour. And if you don't, if you're not willing to go through the learning curve to get to that point, then you're more likely going to favor just continuing to do open traditional procedures. The other thing that I think is interesting is in what I've seen in my travels is that many cases, the foot and ankle surgeons doing these arthroscopically are trained more as arthroscopists. They learn arthroscopy of the shoulder, arthroscopy of the knee, they apply the arthroscopy to the foot and ankle, and then they funnel down to being more of a foot and ankle arthroscopy specialist. Whereas in the U.S., we train more by anatomic parts. And so I believe those skills that the international surgeons learn as arthroscopists in the knee and the shoulder translate better into the foot and ankle than they do here in the USA. Whereas in the U.S., they're more traditionally trained in foot and ankle, and then you have to go and become an arthroscopist. And you know, I can tell you, you can do it. I did three arthroscopy procedures in my fellowship and zero arthroscopy foot and ankle procedures in my residency. And I'm up here talking to you today about it as an expert in arthroscopy. So there are ways to learn, there are courses, but it does require patience and diligence. So what's the real reason we don't do it? Probably tradition, right? You know, what is tradition? Well, tradition is something new that's stuck, right? That's really what tradition is, someone once told me, right? So all traditions start somewhere and sometime, and they do disrupt the status quo. So we know that on average, Ron Smith reminded me at a recent meeting, it takes 17 years from the time there's research evidence to the time something reaches into clinical practice. And I would tell you that it's time for us, in the U.S. at least, to really start examining why are we doing what we're doing, you know? And we have to constantly challenge ourselves to move the ball forward in terms of the techniques. What we're doing ourselves for our patients, as well as what we're teaching our next generation of surgeons. You know, so my question is, are we going to live in the past, right, and do these larger open procedures, which if you look in the knee and the shoulder, you know, they're not doing those anymore for those joints. In the ankle, we're still making those incisions. Or are we going to move to the future and start doing things arthroscopically, right? So when you see this patient in your practice next week, who has a medial osteochondral lesion and lateral ankle instability, you know, the question is, what are you going to do? Are you going to start working toward becoming a better arthroscopist to learn these procedures that do work, that show in the literature they work, and do fully arthroscopic procedures? And honestly, are we eventually going to see these arthroscopic procedures even become office-based procedures, like dentistry and plastic surgery is at this point in time? So I would encourage for the arthroscopic profession, you can read about the technique elsewhere. I didn't want to talk about the technique today. You can find that out. But I would encourage you, this is my son kayaking. Kayaking requires you to take the plunge, right? It requires you to trust the process. But you have to practice. You have to have dedication. You have to have courage. You've got to be prepared and have knowledge and skill. But if you do it, you can be successful. Thank you. Bonjour, les amis. Moi, je m'appelle Peter Doak de Belgique, travaillant au Qatar. It's a pleasure to be with you and to introduce the new speaker, the second speaker of the session today. Mark Lacebrook, the host from Canada here, will talk about the arthroscopic assisted percutaneous techniques, and I wonder if it's going to be a tradition that we have to plunge into as well. Well, thank you. And Peter, I agree, this needs to catch on because the shoulder and knee people are way ahead of us. So I'm going to talk to you about a technique that may help you with the learning curve because it's very flexible. These are my disclosures. I am a consultant for ConMed Lymphatech, but like Peter, I'm not making any money off this technique. I wish I could patent a technique, but it's a technique, not a device. These are my learning objectives. I think they're standard things we all want to know. So this is the problem. And you can see that was a bad ankle injury. We know all about this. When it's severe and it fails in non-optive treatment, they go on to chronic instability. This here is a patient with chronic instability and would like to have a better quality of life. So most of us know about the anatomic repairs, the Brostrom, a gold modification. This works. It works open and it probably is going to work better minimally invasive as we do this more. I think reconstruction works as well, and I've looked at some literature to try to convince you of this. Well, how do you decide what to do? Well, most people look at the remnant ligaments. So that's where you kind of get challenged to do something open. You want to see those ligaments. And if the ligaments aren't sufficient, you have to do a reconstruction. I think maybe you can go right to a reconstruction if you want a more robust repair. This is the evidence from one of my publications in literature review. You can see that open stabilization outcomes work well. If you do this open, it works well. And if you look closely, you can see the anatomic reconstruction may have a little bit of data that's a little more high-end data to support that's an open procedure to consider. We all know that less is better. Short guys like me are better than tall guys like Peter. We all know that. And of course, our colleagues have taught us minimally invasive is what patients want and the way of the future. I was part of this ankle instability group that Peter talked about. This is a wonderful group of surgeons from around the world. We're the real, we're the nerds of the foot nerds. All we do is study ankle instability for several days. We did a collaboration with America, France, Japan, and my country, Canada, where we looked at the technique, the anti-roll. A is for ankle reconstruction of the lateral ligaments. So the anti-roll procedure is what I'd like to tell you a little bit about. What's great about the anti-roll procedure, in my opinion, is it can be done four ways. It can be done open, arthroscopic, percutaneous, or a hybrid of the above. We'll go through this. Now which type of procedure you choose is going to have different pros and cons. So you can tailor this to your patients. If you have concurrent pathology, you don't want to do the percutaneous anti-roll. You want to do an arthroscopic or an open anti-roll. If you're just learning this, you certainly want to start with an open anti-roll. The technique is very easy. If you're doing open reconstructions, this is just an anatomic way that you'll find, I'm sure, convenient and may be better for your patients. We'll leave that to you. This technique is based on anatomic studies. The gentleman in the corner, Kentaro Matsui, was a fellow of mine who did some work in Barcelona and really established the ligaments. We all know that the ATFL may have two bundles, depending on the specimen you're looking at, but what I think is important is the ATFL and CFL come together at a near common origin point on the distal part of the fibula. This allowed us to design our anti-roll with a Y-graft where we have one common origin. So this is the anatomic Y-graft and what's nice about this is the numbers on average for the cadaveric specimens fit quite nicely. The ATFL is around 3 centimeters or 30 millimeters and the CFL, sorry, the CFL is around 3 centimeters, 30 millimeters, and the ATFL is half of that, 15 millimeters. So when you construct your graft, this is how you do it. Now the technique development, Dr. Masato, my good friend, is a champion of the arthroscopic. He is a master of arthroscopy, somewhat like Nick Van Dyck. He is really talented with the arthroscope and that is his, I'm not as good with the arthroscope, I mean I can scope an ankle, so I kind of like the percutaneous technique. The open anti-roll is where you should start. If you're going to do this procedure, do it open, get familiar with it, and then decide if you want to do it percutaneous or arthroscopic. And when you get really good, you can use the scope here and there as you want in a hybrid technique. So no matter what technique you choose, there's five steps. You make the graft, you make the tunnels, and you deliver the graft. So the first step is making this anatomic Y graft. Again, 15-30, that's the centimeters. You bury about 15 millimeters of tendon into each tunnel. So step one, if you're doing this arthroscopic, you're going to use slightly different incisions. You can see that your portals are going to be modified. So if you're doing the arthroscopic technique, you need a midline portal, an accessory interlateral portal, and a subtalar portal. The technique has been published. Step two is make the fibular tunnel. I'm going to show you the way I do it. This is the percutaneous technique. It's important to use live fluoroscopy when you do this technique to be sure you're in the central portion of the bone, right at that anatomic origin site, the common origin site of the ATFL and CFL. Once you get that, if you're doing the scope, you can use a scope picture and you get to see exactly where you're going to put that. What's great about the scope is when you deliver the graft, you can see the screw go in. Your next step is the talus tunnel. Again, you have to know your anatomy here. You're going to be doing this fluoroscopy guided. You want to make sure you hit the ATFL insertion point on that neck body junction of the talus. And then finally, the calcaneal tunnel, which runs about three centimeters on a perpendicular line from the mid portion of the subtalar joint. Once you have these tunnels made, you're just going to deliver the graft through the Y graft delivery site. This is the small incision, probably less than a centimeter, right at the tip of the origin site of the ATFL and CFL. So now we're going to deliver the graft. So here we go. I'm going to put this all together. Let's see if we can run this movie right here. Okay, so I'll walk you through this. This is rather rapid fire. So here we are percutaneously passing our guide wire through the fibula. It's on a 30-degree angle from the long axis. You pass the suture. You've isolated the fibular tunnel. Next, you're passing your guide wire through that insertion point of the ATFL, being careful immediately to avoid the neurovascular structures. You make your tunnel and pass another suture through. Now you have two of the three tunnels isolated. Finally, you do the calcaneal tunnel, which again, on the fluoroscopy, is about three centimeters perpendicular on the midline of the subtalar joint. Now we deliver the graft. You can see the common site for the fibula. The fibula portion of delivery percutaneous is easy. You can actually palpate the fibula and you can really see and feel the graft go in. If you're doing this for your first time, make the incision bigger if you want to be sure. Once you get the graft in, you pass whatever fixation device you'd like to use. I use an interference screw. I pass the guide wire for the interference screw. Then I deliver the interference screw to secure the common Y graft to the fibula. Once we have this done, we then go on to the talus. So as you can see here, you know this screw is in the fibula. You can palpate it. You're going to know exactly where it is. It gets a little more difficult when you do the Taylor tunnel and the calcaneal tunnel. So if you're a beginner, again, I go back to the open procedure may allow you to get the comfort. Next, you take a blunt instrument like a hemostat. You're running this along the lateral wall of the talus and you're exiting out the second portal over by the talus. Remember, the whole graft has to go through the Y graft delivery site. So you need to deliver this delivery suture back through the Y graft delivery site. So you grab a hold of the suture, bring it bring it back to the Y graft delivery site, right at the distal portion of the fibula, like so. A little hesitation for excitement. When you bring this back, you just fix this to the ATFL limb and another interference screw to secure it. So now we have the ATFL reconstructed through 2.5 to 1 centimeter stab incisions. This, you must be very careful. You need a good fluoroscopic projection to show that your guide wire for the interference screw is in the talus. You don't want to put the artheresis screw in here. You want to put in the fixation for the ATFL. So be careful that you get it in the right location. Finally, we're reconstructing the CFL, again passing a hemostat along the lateral wall of the calcaneus. You've got to be sure to be under the perineals. Again, it helps to know your anatomy here. The CFL lies under the perineals. You can palpate the perineals between the hemostat and the skin. Again, you're going to pull this delivery suture back through to your Y-graft delivery site, and then you're going to deliver the Y-graft into the calcaneus with another interference screw. So you can see here, by pulling this through into the Y-graft delivery site, under the perineals, and into the calcaneus, and fix it again with the interference screw. So if you do this technique, you should have three incisions with a small poke hole from the wire out the back of the fibula compared to an open procedure. This is a percutaneous procedure done with a cadaver, and you can see near-anatomic reconstruction of the ATFL and CFL. So why do I use the anti-roll? Good literature support, anatomic design, works for all clinical scenarios, reconstruction or repair. It's robust, which may get the patient back to work faster, and it's versatile. So you have a choice going forward. I urge you to consider minimally invasive techniques like Peters and maybe this. You can decide to repair or reconstruct, open or minimally invasive. My choice is an anatomic reconstruction. I use the anti-roll, and I recommend you consider this. This is how I roll. Thank you very much. Okay, so moving on to my moderator duties, our next speaker is Callum. Callum, come on out. You're hiding behind the curtains, it's a very dramatic presentation. Oh, he gets the music, excellent. Wow, this is getting, where are the laser lights? So Callum's gonna tell us about arthroscopic assisted, sorry, that's mine, scoping them all. He thinks we should scope them all with an open Brostrom. Callum, if you don't mind, before that, can you, I understand you live near the Queen, can you tell us a little bit about the Queen and what's going on over in Windsor? I will, thanks, Mark. So as Mark said, I'm gonna talk about a slightly different approach. I think it'll be a good counterpoise to the two talks we've heard previously. I don't really have anything relevant to disclose, but I do wanna disclose, as you alluded to, who I am and where I come from, because I come from this area in the UK. The center of my practice is in Windsor, just to the west of London, I also practice in Windsor. I also wanna say just quickly, as the first Brit to stand on stage in this meeting, a big thank you to AOFAS and to Christy Giovanni, who sent the invite out to us as a guest nation, and to Casey Humberd and Daniel Guss, Ken and Mac, who've chaired this session. And it's been a great experience putting the whole thing together. I'm an officer for both us, I'm the chairman of the education committee there, so it's been a great experience putting this program together with them. Back to where I live, strange things are happening in the UK at the moment. Most of the land around where I live and where I work is owned by the so-called the Crown Estate, as they call it, or the Royal Family. And I'm aware that we're in a meeting in Canada, a meeting of Americans, but it's an odd time, and I feel I ought to just sort of say something. We're in a period of national mourning in the UK, and regardless of what you feel about monarchies in general or the monarchy, everybody kind of liked the Queen. So it's a strange time for us all. There are flowers everywhere, everything's been cancelled. Everywhere you go, if you stop in a motorway service station, all the adverts show this kind of Elizabeth to Regina. The adverts have been taken down, the London Tubes, everything. So it's kind of a weird period for us. So we don't know how to behave, so I just thought it would be wrong not to mention it. But life goes on. This was three days ago, also on my patch, if you like, at the BMW PGA. This is Rory McIlroy teeing off on the final round. So life goes on, so I'm gonna get on with my talk now. So we know, I don't think, the first part of the title is Scope Amour, and I think we already know that we should scope amour, really. So Richard Ferkel told us this in the 1990s. This is a nice paper from Kim Slater in Sydney, who broke down the pathology that was found at the same time as arthroscopy for lateral ligament surgery. And the most common pathology is impingement, whether it's bony or soft tissue, and we know that. I just wanna bring your attention to the bottom line here about peroneal tendon pathology as well. I'm gonna come back to that, because 14% in his series needed concurrent peroneal tendon surgery. So I do scope amour, I think, you know, this kind of thing with anteromedial impingement is probably the most common bony lesion it's very easily dealt with at the same time as surgery. So I'm not gonna go against the grain. I feel that we should arthroscope all these patients. But I don't feel we should do the whole thing arthroscopically, so we've heard two excellent talks about the arthroscopic technique. I'm gonna try and justify the combination arthroscopy and open brostrom. So there are a growing number of papers, comparative series. There are kind of small series, 30-odd patients in each treatment arm coming out of arthroscopic versus open. It's a technique, as we've heard, that's been around for quite some time. And there are some meta-analyses coming out as well. This one's only on four papers, but these two from an Austrian group and from a group that Ken Hunt was involved with are on eight papers, and in fact, the last two have seven of the same papers in the meta-analyses. So what do these show? Well, there isn't really a difference in scoring. Outcome scoring, there's a slight difference in AFR score in favor of the arthroscopic technique, but it's really to do with the very high weighting of pain in AFR score, and it's a clinically insignificant difference in pain postoperatively. There probably is a difference in complications, particularly nerve complications, although it's slightly in favor of the open technique, although, as we know, there is a complication rate anyway with the open technique. But possibly what it comes down to, in the literature it seems, is a lower incidence of wound complications in the arthroscopic group. Bottom line, it was returned to sport, and we heard this in the previous talks. Is there any evidence that you get returned to play faster with the arthroscopic technique? Well, what strikes me with the papers is that there's a really long period of immobilization in most of these series, longer in the open groups than the arthroscopic groups, which is kind of imposed by the surgeon and treating physician. Up to six weeks of protected weight bearing, which is not, I think, common practice for most of us. If you look at the bottom study, Matsui et al., who were the only group in all of these series who allowed all of their patients in both techniques to weight bear when they felt they could, there was a three-day difference in favor of arthroscopic technique. So this is a nearly four-month return to play, three days quicker in arthroscopic. So that's clinically insignificant. So we don't have the evidence that it's different. Anyway, what determines return to play? I mean, as I alluded to, I think it's possibly less about surgical approach and more to do with biology and the post-op regime and the rehab in general. So we have to be cautious about interpreting these findings. And I think in some ways there's an analogy with the Achilles debate, the minimally invasive versus open Achilles repair debate, where there are papers favoring either, but I think it probably comes down to rehab protocol, which has the biggest influence on return to play. So we've heard about arthroscopic and we've heard about arthroscopic-assisted. This is a paper I just want to show because it's an excellent slide. It's from the late, great Pau Galano's group in the University of Barcelona, and they have fantastic calibric pictures. So this is one of them. And I think that the point of this paper was to say where you put your suture anchors in the arthroscopic technique. What it also demonstrates is that you're probably catching the superior intra-articular parts of the ATFL with these arthroscopic techniques, and not the inferior part, which has the shared insertion with the CFL. And that's one of the reasons I like the open technique, because you can see that lower part of the ATFL, you can repair that, you can repair the CFL. And importantly, you can perform peroneal tendon surgery, too. If you want to, if you believe in fiber tape, if you believe there is an indication for it, you can do that through the open technique and you can't through, very easily through the arthroscopic techniques. So what about long-term follow-up? We've got lots of papers showing short-term follow-up now of arthroscopic techniques. We've got quite long, long-term follow-up of Brostrom techniques, which is only natural because it's an older technique. It's slightly disappointing in the low rate of revision. It's clearly under-reported. This is a meta-analysis of 11 studies. And I think one of the conclusions was that, you know, it's under-reported in most of the papers. So can we really believe 1.2% revision at nine years? The longest follow-up we've got is 26 years. And this is military recruits. It's an old paper by Josh Bell from 2006. About 90 patients and really good functional results after 26 years. And this is just with a standard, no suture anchors, just repairing with non-absorbable sutures of ATFL and CFL. So putting all that together, this is my philosophy. Here's what I do. I do an open modified Brostrom gourd, which I think is not uncommon, certainly in Europe. Using a suture anchor, I like to repair the ATFL and the CFL, particularly when, in most cases, but particularly when the CFL is lax and various tilt is opening up. And if there's any peroneal tendon surgery or any other surgery, I'll do that at the same time. And I scope every patient. And by the way, we all know the phenomenon of operating through wet tissues after you've scoped the patient. I scope patients after the Brostrom repair. The only exception being if there's an osteochondral lesion I need to get through the ankle to. I need that distraction in the lax joint. But almost every other pathology is at the front of the joint. And I scope them after the Brostrom repair, which I find gets around the problem of tissue dissection. And my rehab is just a splint for 10 to 14 days and then they wait there. And they wait there generally in an ankle brace. If there's concurrent peroneal tendon surgery, I'll sometimes bear them wait in a boot rather than just a brace. And there may be other surgeries that have been performed which would alter that rehab. I tend to use the C-shaped incision, but I sometimes use the longitudinal incision, particularly if I know I'm gonna have to do some peroneal tendon surgery. But I prefer the C-shaped incision because I think the wound complication rate is lower. Although I accept there's a higher risk of pranging the superficial peroneal nerve branches. So you have to be careful about that. We're writing up. We unfortunately haven't written up yet. It's a shame we didn't get this ready in time for the meeting. But this is my series of about 170 lateral ligaments with minimum four year follow-up and a mean of nine and a half year follow-up. And you can see that if we exclude those 7% of non-atomic repairs early in the series, the vast majority I'm doing on arthroscopy, and I said the vast majority of those arthroscopies are at the end of the procedure after the prostrum repair. This is the slide I really wanna just spend a few seconds on. So additional surgery is performed in a third of the patients. So of this whole series, and I'm talking about extra articular additional surgery. This isn't the arthroscopy additional surgery. So as with the series I showed at the start, about 13% of my series needed peroneal tendon surgery. We've got cal costeotomies in there. We've got some fiber tapes when there's a very deficient ATFL or CFL. And we've got some other stuff as well, even subtalar fusion, some revision cases. So the point I'm making is that a third of them need additional surgery in my patients. Those are the people who walk through my door. So finally, here's what I think. I think that you should nearly, and there are some exceptions, always scope with a prostrum. I think I'd agree that the wound complications can be an issue and you have to be careful about that. I think recovery is more dictated by rehab than by surgical technique. I think that you need, I need an open technique in a third of my patients because of the additional surgery in the pathology that walks through my door. And I also think that an ankle, we hear comparisons of shoulders and knees. It's not a shoulder or a knee. I mean, the ATFL is literally just there under the skin. We don't have to die through loads of muscles. So I think comparisons with other joints are potentially unfair. Thank you. Thank you, Clark. And thanks to all speakers so far for sticking to the time so that we can have a vibrant Q&A afterwards. Now on is Christopher Krulen, who will go from lateral to medial and talk us about the arthroscopic deltoid ligament repair. No music? All right, hello everybody. Thank you for coming this early in the morning. My name's Chris Krulen. I'm at University of California, Davis out in Sacramento, California. Here are my disclosures. None are related to this talk. So why do I care about the deltoid? I think somewhat I care about it a little too much, but it's important for control of the talus. It's important in syndesmotic stability. More and more research is showing that. And the kind of tradition of, oh, I don't fix the deltoid, but it's a primary stabilizer of the ankle. So why shouldn't we fix it? I want all of you to start fixing the deltoid more than you probably are. And I think a lot of subtle injuries are often overlooked. And if we fix it, we're gonna avoid chronic medial issues, pain, cartilage injuries, malalignments, or arthritis. If we go back almost 20 years, there was an article in 2004 that showed people who had medial gutter pain. They had a dynamic valgus, as you can see in these pictures. And when they scoped them, all the patients had medial instability and most had a direct repair, but a lot of them also had lateral instability. And at four years, 90% of those patients were doing well. So what does a patient look like in your clinic? They often complain of the medial ankle rolling in or having some medial instability. On exam, you might see like this picture where you kind of see this posterior hind foot valgus, but you don't see it too many toes. And you can test. I find this still kind of to be difficult, but slight inversion of the ankle and then trying to do a drawer for the deltoid are also evaluating the rotational stability of the talus within the mortis and comparing it to the contralateral side. I still think arthroscopic evaluation is the best. This is an obvious deltoid tear. You can see the posterior tibial tendon and the FDL. In these situations, I still do an open repair to really make sure I'm getting both the posterior and anterior components of the deltoid. I still think, so here's a testing the deltoid ligament with the camera in the medial portal. And you can see there's no real instability there. Here's some instability where you see the deep deltoid ligament is injured. You can see that rotational. And I would argue that this would require a repair of that anterior deltoid. So how do I do it? I start with the scope in the interlateral portal to breed the medial gutter. I test translation from there, and then I place the camera into the medial portal and evaluate that gutter. This is three years afterwards, showing ongoing stability. When I see this kind of subtle injury, I either do an intermedial kind of open or an extension of my portal, or more and more, I'm doing these arthroscopic repairs. As we heard earlier, the benefits of an arthroscopic repair decrease your soft tissue disruption, you decrease your recovery time, and you can prevent this medial instability, which I think if we could ever have a longitudinal study, would show a decrease in ankle arthritis. There are a couple articles you can refer to. I'm very biased to this one, Mangone is as well. But this paper showed a two centimeter safe zone between the saphenous vein and the posterior tibialis tendon of where you can place your anchors and your sutures. So it's a relatively safe area. The Koreans, a group from Korea also did a study. They have some excellent pictures as well to show you. And then finally, Horty Vega published an article looking at an all-inside technique, both medially and laterally. So again, so here I am from the anterolateral portal, cleaning the deltoid ligament, cleaning that area, showing some peel off. And then I test again from the antermedial portal, showing that rotational instability. Here's placing an anchor from, through that antermedial portal into the medial malleolus. You can also do a more percutaneous where you create an accessory portal and pass your anchor through that portal and your sutures. Here's passing the sutures with a nitinol loop to pull the sutures and pass them around. Here's using that nitinol suture with the anchor coming through the portal. And then you pass your suture. So here I am, we don't need the volume, but passing it out. And then I'm passing the suture back in. Hopefully no bad words are said. And then you see here, here's the suture being pulled. This is a knotless suture, which I'm using more and more in my arthroscopic techniques so it just makes it a lot easier. I don't have to tie any knots. Pulling that suture through, and then here I am pulling it tight, holding it tight, holding the foot in an inverted kind of neutral position, tying it. So then here's before and after. So you can see how solid that repair is. I no longer have any of that rotational instability. Here's another one. So it's not as strong as the previous, but it's still significantly improved compared to what I had. So in summary, I think the arthroscopic deltoid evaluation is an important skill, along with doing an arthroscopic repair. And you can see that there, which is pulling on that suture, tightening up that deltoid. So it minimizes our soft tissue dissection and speeds up your rehabilitation. Thank you. Okay, so if any of you have any questions, we'd encourage you to come to the mics and ask questions to our speakers. We're gonna look at the poll results too, questions from the poll. So you have an opportunity to answer these. Our team in the back is working on this. This is our first time trying this, so bear with us. In the meantime, if we have a question, over here, number four. Thank you. Mark, everyone, great talks. I guess my question is this. I've been doing ankle arthroscopy all along, and I do more what our British colleague does. I deal with all my intra-articular pathology. I do an open brostrom. I could deal with my peroneals. More importantly, I put an internal brace in, fiber tape, whatever we wanna call it, 98% of the time now. Why do I do that? Because I'm allowing people to weight-bear immediately, move immediately. So I think it comes down to, if we're doing it arthroscopic, what's your rehab protocol? Are you letting them move day one? Are you really letting them weight bear day one? And do we not need the internal brace? Or are you simply protecting them longer? If everyone can go through their rehab and try to justify to me why we would do all arthroscopic and not use suture tape. Or if you know a way of doing arthroscopic and minimally invasive suture tape, let me know. Thanks. Peter, you seem to be minimally invasive with your technique. Why don't you tackle that? Thanks, Steve. Appreciate that. Yeah, my response to that is I just use an external brace like I always have. And so I feel very comfortable with my repair in the operating room. If I don't feel, I also want to make sure people know, I don't never do an open procedure. There are patients that I do open procedures on where I don't think they're good candidates for arthroscopy or an arthroscopic reconstruction because their or an arthroscopic reconstruction because their tissue quality is not good enough. And I'll do an allograft or something like that. Or if they have a massive perineal tendon tear. But when I do my arthroscopic technique, when I leave the operating room, if I'm not stable when I leave the operating room, I'm not leaving the operating room. Once they're stable, then I protect them. I'll splint them initially for the first five to seven days until they come back. Once they come back, the nice thing is now I can put them in a, I just put them in a lace-up ankle brace. And I let them do 50% weight bearing for the next week to two weeks. And then I let them go to full weight bearing at that point in time. Now, full weight bearing isn't full activity. But I tell them they need to wear their brace. As long as they're wearing their brace, to me, they're as protected as using an internal brace type structure. It's just an external brace. And so I've found that those patients can do well. When I used to do open procedures, I couldn't put them in an ASO or a strap brace quickly because their incision hurt too much. And so typically, they ended up in a boot. And to me, that's worse because then you're not doing protected range of motion. And they end up with less tissue quality development over the next four to six weeks. So in the poll, we see that most of our colleagues use the combined open repair and scope. So that will be interesting, Clark, to discuss. But maybe we can go first to colleague number three there at the mic for another question. This is a question for Dr. Gley's book. How far up the fibula do you find the common? How far from the styloid do you find the common origin of the ATFL and the CFL? So if you refer to the paper published by Kentaro Matsui, my name is on it as well, he'll give you the exact location based on cadaveric studies. But as a general rule, we measure it with a goniometer and cut it with an ax in orthopedics. If you go to the very tip of the fibula, the very bottom of the fibula, the ATFL and CFL come off just anterior to that. If you go too high up the fibula off the tip, your CFL is going to have to come around the fibula. So it's almost on the tip, erring slightly anterior. That's your common origin point for the ATFL and CFL. So just the hair, anterior, and cephalad to the tip. Correct. Thank you. Colleague at the mic number two, please. Hello. Hi. Andy Goldberg from London. Can I just say thank you to all the speakers for fantastic talks on a really important subject, in particular to Chris for addressing the elephant in the room. I've got a large series of these medial injuries. And what I think is interesting in that last case where you could see it still having some laxity and external rotation, how important do you think the distal attachments are? So the attachment onto the talus and the tibial spring. Yes. There we are. Get closer. Like this? So I think it's the same thing as the lateral side. We seem to ignore the attachment to the navicular on the medial side or to the spring ligament. Same thing with any insertions into the talus. Typically, what I've found is that they're fine. And just imbricating that tissue on one side or the other is adequate enough. And so I think the biggest challenge that I find is how much tissue do I actually take when I pass those sutures? Usually about a centimeter from the malleolus is where I'm passing that suture, maybe a little bit more. And I think when I see a little bit of that residual laxity, like in that last one, I think I just didn't take enough tissue and repair it. Like I underappreciated the laxity that was there. So I don't really pay attention to those distal insertions. But maybe we should. And maybe that's one reason suture augmentation of these repairs has been helpful, because we're now, we just avoid it by adding another suture. Yeah. I think the same question that applies on both sides. There's very little attention to the distal end. Any attachment of two things has an origin and an insertion. And both ends can be injured. Yeah, just a quick comment on that. I think one area that we, sorry, one area where we still don't totally have it on the medial side is that combined injury, that spring ligament and deltoid ligament. And obviously, there's some confluence there. They kind of overlap. And I think some of those patients actually have some spring ligament pathology that we don't pick up on. And that right now, at least so far, that's more difficult to address through the scope. I think to me, in my hands, that's better done open. But I think we're still in that process of, I'm glad we're paying attention to the deltoid, because we've been noticing it for a long time. But we still have a lot of work to do to figure out the pathologies combined, isolated. Thanks to Dr. Hinterman and all his work, he's done a fantastic job. And so we just need to continue that tradition forward to look at it further and try to better define what needs to be repaired and in what order and when. So looking forward to the answers in the next conference. The colleague number three, Mike. Thank you. Stuart Miller from Baltimore. Dr. Krillin, again, with the deltoid reconstruction, can you address using suture versus allograft for reconstructing the deltoid? Yes. So there are techniques for the allograft. I think you basically have to have an almost absent sleeve of tissue there. The deltoid is quite thick, and there's quite a bit of tissue there. So I think that it's not really needed often. I think there's enough there to repair. I think one challenge in more of the chronic injuries is sometimes the bones have malaligned. So doing bony procedures are sometimes needed, like a small shift of the calcaneus or even a cotton to reinforce the bone. To reinforce that tissue. And sometimes if you don't and you just rely on your soft tissue repair, it'll fail again. I just want to highlight, when we're talking about these operations, remember, I know we all know this, but I hear it mixed up all the time and it gets confusing. Repair is where you take the native ligaments and either advance them or tie them together. You're kind of restoring the normal anatomy. Reconstruction is where you take some sort of graft, whether it be biological or not, and substitute the ligament. So please keep repair and reconstruction straight. Dr. Daniels, I know you're working on an arthroscopic total ankle replacement. You have a question about this? I do lots of scopes, Mark. So it's more of a request than a question. I mean, this has been a great technique session. And if you recall, 30 years ago, everybody got a peroneus brevis transfer. And it really worked well for stabilization, but we know all the problems with that procedure. Then we moved to split peroneus, and then we moved to the crisp and snook, a more anatomic repair. And very little talk about the medial side. Now we're moving back to the fact that it's maybe OK just to do an arthroscopic reconstruction, the ATFL only. No mention about the medial side. We hear some excellent technique lectures. I mean, this is about half a dozen times I've seen your technique lecture, Mark, which is really good. And then the last one is we hear how important the deltoid is. Where I'm really confused is clinically, who do I choose for all of these three excellent procedures? I mean, when is the ATFL alone good enough? When do I have to worry about the CFL, like your technique? And when do I have to go to the medial side? This is where I'm really confused. Technically, I can do all these things. But as far as our patient care is concerned, where are the indications for which procedure? And I really think we should be spending more time on that right now, getting a treatment algorithm in place, than talking about the technique. That's a great question, Tim. The cart may be before the horse. And I think when you look at the literature, I think there's a paucity of these kind of algorithms to discuss when and why we should be doing which side and which ligaments. If we break it down a bit, we could start with Peter. Peter's technique is, for the most part, Peter, ignoring the CFL. I'm wondering if you could comment on whether we should be paying attention to the CFL, or if the ATFL repair is enough. Well, yes. I mean, my technique, definitely, we don't go after the CFL. And mainly because, ideally, I get the infaric stentor retinaculum. It's attached to the perineal tubercle. And it helps to control the calcaneus, much like the open Brostrom-Gould technique. But at the same time, I will argue my technique is, I'd say, relatively simplified. It was kind of an early technique. I would hope that over the next 10 to 15 years, all the young people in the room would actually make that better. And there are better techniques. I think Jordi Vega's technique is great. And there are ways to do this. So I agree with Tim. Ankle instability is, in my opinion, completely under-recognized. I think we're recognizing it more in the last 5 to 10 years. But I knew, 20 years ago, I was like, this is a problem nobody's addressing. And we only addressed it if somebody came in and said, I rolled my ankle. And all those patients you see at age 50 that have arthritis probably had ankle instability. And that's the reason they have arthritis at 50 instead of 80. And so the more and more we can call attention to this and figure out, how do you figure out, which patients do I fix? Which patients do I don't? That is the next generation's question. And I think that's something to look forward to. So while we're not even sure whether we should be doing the CFL or not, we don't have good evidence for that, now we're jumping to the medial side. Dr. Krulin, I'm wondering, is medial instability and lateral instability separate entities, and it's one or the other? Or are they intimate related? Do we need to study both these concurrently? I would say that they're probably more related to each other than not. A lot of the articles that Horty Vega writes about, they discuss the micro-instability. So as you buy into the idea of micro-instability, you see more and more deltoid instability as you scope the ankle for a scoped lateral leg. Rarely does someone have isolated lateral or medial instability. I myself have it from a basketball injury. But that idea of having medial instability and isolated valgus deformity from a deltoid or spring ligament injury is very rare. But I think every single patient that is getting a lateral ligament, you should evaluate that deltoid ligament. I'm probably over-repairing deltoid ligament instability, but I would rather be on the side of over-repair because there's really no downside. But I do agree with Tim in that there is no real diagnostic measurement of medial instability. In the ankle, medial instability is obviously a different animal when you look at the lateral ankle versus the medial ankle. We have numbers to evaluate syndesmotic instability, but we still don't have measurements or numbers to evaluate lateral or medial instability when we're scoping the ankle. Yeah. We were given some five more minutes time to tackle some more questions. So colleague at the mic number two, please. Thank you. Sergio Vela from Colombia for Christopher. How many anchors do you use? And if you use two anchors or more, would you decide to use one or more anchors? I typically use one anchor. And I've found that, especially with a knotless anchor, you can just take a larger sleeve of tissue, so about a centimeter of tissue. If I'm not happy, and I try to get that anchor a little more down where the tibio spring and the tibio navicular insert kind of a common point between the two. If I'm not happy with that, then I will place another suture or another anchor slightly more up on that anterior surface of the medial malleolus to get more of that tibio spring, or sorry, tibio navicular component to tighten that up. But usually I can get away with just one. If you need to go more posterior, Jorge Acevedo is very good at creating a separate accessory portal to place another anchor into that colliculus between the, or the intercollicular groove. And he'll place another anchor there, and then pass that through for a more posterior repair. We have Dr. Magid, mic number one. My name is Magid from Qatar. Could I ask, as a bandit believes, if you have acute scenario with multiligamentous injury, the medial, the deltoid ligament, and the lateral ligament has gone, how you go around adjusting the tension on the medial side and lateral side? Because in the lateral side, you need to avert the ankle when you tension it. And the medial side, so how do you go around that? You wanna answer that? I can answer it too. I think it's interesting, these multiligament injuries, and we don't really know much about them, do we, in the literature, there's not much said about them. And it's quite, not an uncommon scenario when you perform an acute MRI on a patient who's injured their ankle and everything lights up. One of my problem with this is I don't really know the significance of the individual ligaments lighting up. So what are we treating? I mean, so I don't, I'm not specifically answering your question in terms of differential tensioning. I'm kind of bouncing it back and saying, what do we know about multiligament injuries and should we be repairing them all? I mean, we don't do, in the UK as a whole, we don't do acute lateral ligament repairs in every patient. We put them through a rehab program, right? And then we treat the instability or the micro-instability who complain of pain with laxity. But I don't know what we're treating with the deltoid ones. Yeah, I would agree, I would agree. Yeah, on an acute basis. I think when I do perform medial and lateral arthroscopic techniques, typically I just, I try to look at the foot first and see what kind of foot it is. So if it's a foot that's more of a pes plano valgus type orientation, I'll maybe over, I'll kind of tighten up the medial side a little bit more than the lateral side, right? So I don't pull them into more valgus. On the other hand, if it's more of a cavus type foot, I'll tighten up the lateral side first before I do the medial side. But I do try to not overly evert or invert either side when I'm doing that. And I don't know that I have a specific tension or technique other than, you know, I tell people all the time, my partner's in the room somewhere, tell Shannon, Jim Samarka used to say to me, Pete, when we get done, it better look like a foot. And so that's kind of my guide is it better look like a foot and function well. And that's kind of the techniques I use. I just think we're not there yet. In the ACL, they talk about tensioning the position a lot. We're just not there yet. So that's great topics for future research. We're striving for anatomic now, best we can. Dr. Johnson, you'll have the last question of the day. We're running out of time. Thank you. Thanks, and thank you. I really see the value in scoping some of these ankles and except for using it as a technique, how many of the panelists feel that, boy, if I wasn't there looking at this arthroscopically and managing this intra-articular problem, this patient would have a problem long-term? I mean, I'm not sure that scoping out a little synovitis and this and that is really a game changer. So how many of you really believe that being there is really important on every case or whether you can be more selective on your physical exam and decide who you need to scope and don't? Okay, let's just do this quick to finish the session. And we're gonna start from the bottom up to the top. Scope them all or MRI investigations prior is enough. I scope them all, but I often think exactly what you're saying because if you go back in after a scope, there's a ton of scar tissue again from violating the joint. Next, quick answer. Scope them all. Do we make a difference by doing it? I don't know, but the chance of making a difference is enough because it's a minimal thing to add into your procedure. Peter? I scope them all and I think it does make a difference. If you look at the studies, the studies would say, even the study column put up there that had that long-term follow-up, 10% of patients still had a problem with open procedures. And I can tell you arthroscopically, that's not been the case. In the literature, there's less post-operative pain and problems if you scope them. And I scope most of them, but do rely on the MRI in a good old-fashioned clinical exam and history to decide what the patient needs. So with that, I'll thank you all for your attention and wonderful questions. Thank the speakers for keeping on time and my co-panelists. A great opening session. Thank you very much. Thank you.

ankle arthroscopy

arthroscopic brostrom procedure

ankle ligament reconstruction

arthroscopic techniques

faster recovery

better outcomes

arthroscopic assisted percutaneous techniques

ankle instability

deltoid ligament repair

treatment algorithms