So then our next speaker is Mark Dracos. He is homegrown. He did his residency here, did a fellowship in sports here as well, and then did a foot and ankle fellowship, so he's the perfect speaker to talk to us about two topics. Ligamentously unstable ankle and also OCDs in the talus, and then we'll have a question-answer session. And so Mark, we got till 15 minutes. We can get through it. All right, so I'm going to talk about ankle instability and then OCD lesions. The two are related and and we'll go over it. All right, so I have nothing to disclose. So let's talk a little bit ankle instability. So ankle sprains, as you guys know, are really common. There are about 30,000 of those injuries every day. It's the most common reason people come and see me. It's very common in basketball as well as other sports. So things you may get asked. Ankle sprains most commonly involve the ATFL. 65% of the time, it's an isolated ATFL injury. CFL, NTFL about 20%, the syndesmosis about 10%, and deltoid is the rarest of the ligaments that's involved. What usually happens is the ankles plantar flexed and you have an inversion type of injury causes rupture of the ATFL. One of the reasons for this is the anatomy of the talus. As you guys know, the talus is wider anteriorly than it is posteriorly. So if the foot plantar flexes, it's narrow. There's more space and then the ATFL becomes more at risk. With the ankle in the neutral position, the CFL is more at risk. An isolated CFL injury rarely ever occurs. And when they ask you or when the injury mechanism is an external rotation type injury, that's when you start thinking about the syndesmosis or a deltoid type injury. So what are risk factors for ankle sprains? Inappropriate shoe wear, irregular playing surfaces, cutting activities, a cavus foot, tarsal coalition, basketball and football, generalized ligament dyslexia, and of course previous ankle sprain is probably the most common risk factor for another ankle sprain. How do we evaluate that? The anterior drawer test. It's basically like a Lachman test of the ankle. You do this with the ankle in about 10 degrees of plantar flexion. 0 to 5 millimeters of translation is normal. Yeah, anything more than that or up to 10 millimeters is considered abnormal. The Taylor tilt test is also something you can use. This is where you're applying a various stress to the ankle. This is more indicative of CFL. So the anterior drawer is really a test for the ATFL. This is more of a test for the CFL. I will tell you that this test is much less sensitive and specific though because there's some sub-Taylor involvement as well. So the sub-Taylor motion accounts for some of the inversion of the of the foot and ankle. So you're going to want to compare this to the other side. So syndesmosis injuries. This is tenors to palpation well above the ankle. So the two common tests that they'll ask you how to test for syndesmosis are the squeeze test. That's where you take your thumb and your hand and you grab around the tibia and fibula and you squeeze. You're putting tension on the syndesmosis and this is a heterotopic ossification after a syndesmotic injury. So again, when you have a syndesmosis injury, it's going to be above your joint line. Those usually tend to have a prolonged recovery as well. Ankle sprains, there are multiple different classifications which do have some prognosis in terms of how long you want to return to full activity. In terms of treating them, I would argue that there's not a huge difference though in terms of the classifications. Meaning even if you have a complete tear of your ATFL and CFL, you're going to want to treat these patients conservatively. So if you get asked in a test, oh, there's a complete rupture, you still go with conservative management. So that involves the rice protocol, rest ice, compression, elevation. And the other thing that they will ask you is in terms of rehabbing ankle sprains is proprioception training, okay? You lose some of this proprioceptive feedback once you sprain your ankle, which makes you slightly more likely to get a second ankle sprain. So proprioception training is one of the important things in the rehab, which you may get asked about. The other thing that you may get asked about is that if you're going to do some strengthening, perineal strengthening is important. There are studies that show that once you've sprained your ankle, there's an increased perineal latency, which means the perineal tendons aren't firing as quickly as they should be, which can contribute to, again, further ankle sprains. So that's something else that you want to consider doing in terms of rehabbing these patients. So despite, when do we get chronic ankle instability? So despite appropriate initial management, about 10 to 20 percent will develop persistent ankle instability. And this usually involves a stretching out or an attenuation of the lateral ligament complex, and people will complain of recurrent ankle sprains. Now, there's an important distinction between anatomic and functional instability. So functional instability is the subjective feeling of giving way during exercise. And this is really the proprioceptive or lack of proprioceptive feedback. So ligaments will actually heal. The ankle will be stable to a physical exam, but the patient complains that the ankle's given out of it. It's a proprioceptive or lack of proprioceptive feedback. That's functional instability. True anatomic ankle instability, you can demonstrate on physical exam or a stress test. So this is the, basically, the x-ray equivalent of the two physical exam tests that I showed before. So you have your anterior drawer down here, and your tail or tilt here. So in theory, when you do a tail or tilt on a normal patient, they shouldn't move, okay, or at most move five degrees. Ankle instability has been classified in the literature as greater than 10 degrees of opening with a varus stress, or five degrees greater than the opposite side. Similarly, with, on a lateral x-ray, ankle instability has been classified as translation of a centimeter or greater at the widest portion of, or the furthest distance between the talus and the tibial plafond, or five millimeters greater than the opposite side. Even when patients do have chronic instability, I would argue that functional rehab is still the first line of treatment. So if you get a question where they say patients have multiple ankle sprains, if they haven't failed physical therapy, that's probably your answer. You should probably send them back, or they should at least be given one course of physical therapy to see if they can improve their proprioceptive feedback and perineal strengthening. The surgery is indicated when, despite rehab, they still continue to have ankle sprains. And the other thing you can consider is if they have recurrent effusions, bad sprains, or sprains that involve potentially injury to the cartilage as well, those are issues which may require surgical evaluation or surgical stabilization. So how do you fix these? The Brostrom-Gould, or the Brostrom-Gould modification is the mainstay of how to fix these. He originally advocated a mid-substance repair of the ligaments. The advantages of doing this is that no normal tissue is sacrificed. There's not a tenodesis effect. There's no donor site morbidity. And you preserve tibiotailor and subtailor motion. Okay. So it's really an imbrication. So what happens is that in chronic ankle instability, you're not going to find two frayed edges or two ends of ligaments that are just kind of hanging out in space. What happens is they all heal, but they heal attenuated. So when you're doing an anatomic or a Brostrom repair, what you're going to be doing is you're going to be incising the ligaments and imbricating them, advancing the tissue. Okay. So most often these ligaments are stretched and attenuated. They're not, you're not going to see two torn edges. This is just a catabaric example of what I'm talking about. This is a right ankle. Here's your fibula here. Okay. The red arrow is pointing at the ATFL. The green arrow is pointing at the CFL. So what you're going to do is you're going to make an incision. Okay. In this case, we fix it with suture anchors. We can do it with just sutures or suture anchors. And you're advancing this tissue to imbricate the tissue and close down that lateral sided ankle instability. I'd also tell you that the ATFL and CFL are really just thickenings in the capsule here. I advance the whole thing as a layer. But this is kind of your standard treatment for chronic ankle instability. It's a imbrication or advancement of the local ligament tissue. There are non-anatomic augmented repairs. I would argue that a lot of these are historic. I doubt you're going to get asked about these at this point. These include the Evans, Watson, Jones, and Christmas Snook. This is basically where they took the perineal tendons and used that as local tissue to advance through the fibula. Some of these had problems including subtalar stiffness and arthritis. But the advantage to them is they may be useful if there's no local tissue available. So for instance, if there's really no lateral ligament complex, you can use some of these tissues. If there's no, I would argue now the best thing to do for chronic instability, if you don't have any local tissues, using graft. So use a hamstring allograft or a hamstring autograft. And basically what you're doing is through some combination of drill holes, you're going to reconstruct the lateral ligamentous complex. So both the ATFL and CFL. Important thing to remember is chronic ankle instability usually has a high association of concomitant pathology. So there's about a 95% chance it's intraarticular pathology. This is kind of a list of all the things that can occur with chronic ankle instability. But the most common thing you're going to see and going to get asked about is a cartilage osteochondral lesion of the talus. Okay. I'm going to talk about that in my next talk. You also get soft tissue impingement perineal tendon tears usually about 10 to 20% of the time. And again, you can have other ligaments injured as well. Last but not least, I just want to talk about the syndesmotic injury. So this is an injury not just to the syndesmosis but also to the deltoid. What I would argue is that if you have instability to where the talus is not congruent underneath the tibia, you're going to need to do something to fix that. So most high ankle sprains or syndesmosis injuries, you still have a congruent joint. However, you know, if you see something like this where you know that you've torn at least the syndesmosis and deltoid here, you no longer have a congruent joint, you're going to need to do something to reduce the joint and basically reduce the tibia underneath the overuse of talus underneath the tibia. All right. That's it.

ankle instability

osteochondral lesions

ATFL ligament

ankle sprains

proprioception training