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Speaker: Our next presenter is Dr. Adrienne Estes. She is an assistant professor, department of podiatric surgery, medicine and biomechanics at Western University Health Sciences, currently practicing in Riverside University Health System in Southern Cal and she is fellowship trained in reconstructive ankle and limb salvage surgery. So topic that we have after to talk about is minimally invasive lateral ankle stabilization. So please welcome our young doctor. She has not even given the talk yet.
Dr. Adrienne Estes: Thanks to my entourage for your support. So I was always taught whenever you teach at a conference or seminar to this magnitude that you always say thank you. So I just want to say thank you to the chairman of the present series. Thank you for including me. Some of my mentors are in the audience, Dr. Lester Jones is here and Dr. Jared Shapiro who I think just walked out with his little one but I am sure he will come back. But thank you guys for your mentorship. Even all the way as a student, I don't think I am young but I guess in their eyes they think I still am so. Thank you guys for being here. So again, I am Dr. Adrienne Estes. I am going to talk to you today about minimally invasive lateral ankle stabilization. Again, I am from Western University these days. No financial disclosures. So our objective today is we are going to discuss the traditional gold standard versus percutaneous approach when it comes to lateral ankle stabilization. Kind of go through an overview of the surgical trajectory of this procedure, go over some alternatives of where we are kind of going with this procedure and then some pearls that I think are helpful that have helped me to sort of master this and see if it's something familiar for you or something new for you.
So as you know, ankle sprain is a common lower extremity injury, very common if it's a stable injury. They definitely do better with the RICE procedure, the non-operative mechanisms but some of them are obviously vey debilitating, especially in about proximally 20% have been documented that they aren't doing well. They need something more invasive to help them. Refresher of your ligaments, ATFL, CFL, not picture your PTFL that usually rarely involved. Very important that you don't just limit your clinical examination to those ligaments. You have to think of everything because there are lots of injuries that happen from an inversion mechanism as you know. So never forget to look at that in your clinical exam. So obviously, your presentation will be different in an acute versus chronic. Obviously, this is more of an acute presentation and with the picture you will likely not see ecchymosis after the acute phase. But a lot of it's still similar in the sense that you need to make sure that you look at everything related to an inversion injury such as you want to look at that distal fibular syndesmosis, you want to look at the base of the fifth metatarsal ray, you want to make sure you are concerned for an OCD, peroneal tendinopathy etc. A lot of these patients come and tell you, I just don't trust my ankle and if you have been asked them to do a single leg hop, sometimes they just look at you like I can't even know. Your anterior drawer test, your Taylor tilt's they don't trust it. They aren't able to walk. Some of them are still pretty swollen especially at the end of the day. Your diagnostic testing as a refresher, some of these are little outdated and I don't think everyone uses even half of these anymore. I still do stress radiographs. I believe in it because it gives me lot of answers when it comes to subtalar joint instability, especially when you are looking at the CFL; however, it's clinician-dependent I think and it's not very reliable and that's why it's fallen out of favor.
And I even joke about this. If people know Bill Grant, I always joke with him. I sprained my ankle really bad last year and he really wanted to do the stress that. We were at a conference together and he had a fluoroscopy and he was like I want to stress and see. He practically gave me an ATFL injury and we joke about it all the time, but I still use that. Biggest thing I used still is an MRI. I don't use an ultrasound and arthrogram at all. But I like 3T because I think I get pretty superior results. I am looking for more than just ligament injuries and I am also making sure we are looking at all ankle pathology. So let's dive into surgical intervention. That's the whole topic, right? So typically if you have a failed situation it's because these patients are still symptomatically unstable, they are having poor function and when we first do this non-surgically, the reason I am talking about this like little side comment is because it's important for where I am going to go is that we used to think just prolonged immobilization. That's what we did ankle sprain but now we are going into this convention of functional rehabilitation utilizing lace-up braces, CAM boots, early accelerated rehabilitation program and that's important I think when we are dealing with our surgical patients if we create a very stable strong construct for them surgically, so we can get them into that accelerated program so we can avoid that disuse atrophy and that extended rehabilitation time that they sometimes can get into. So about 10% to 30% of our patients with our chronic ankle sprain instability usually fail. So they need obviously something more. So let's dive into little bit of brief history of where we are at with all this. So I try to make this where we were and where we were going and what are questions we still have with all this. So the gold standard today as we know is Brostrom-Gould. And the biggest thing about this to understand is that when Brostrom first started this in 1966, it was about showing that we can repair the ATFL primarily because it still had the same outcomes as you did if you did acutely or in the chronic stage.
However that being said as much as he showed that it was excellent results, they went in and talked about complications but too it was still weaker. So that's where all those modifications started coming into play. When the goal modification came in, that was maximizing the retinaculum but if you see the retinaculum, it's obviously still friable and it provides some support but I would not say excellent support when they tested in terms of strength and it's still pretty weak. When you have a situation where you have a lateral ankle stabilization that's needed but you donât have a lot of tissue to anastomose, obviously, that's where we had those reconstruction cases coming. With tendon grafts, whether it was autograft or allograft or what not, those were coming into play. However, those are also falling out of favor. The reason why is because they are creating a very stiff ankle, stiff subtalar joint, technically demanding. These tendons swell three times the size, so these patients are having a tough time recovering. Using any sort of synthetic material, your anastomosis takes longer. So the recovery time is longer. So that accelerated rehabilitation we talked about isn't on your plate right now. So where do we go from now? Well, the Brostrom-Gould was good and Carlson's team came into it and said what can we do even further? So what they found was that if they resected the ATFL right at the origin at the anterior aspect of that fibula and use drill holes and then reinsert it back in and when patient came in to play, no pants-over-vest and we can shorten and stabilize it. That also was a benefit and I think most people are probably doing that. Lot of people are augmenting your lateral ankle stabilization with some type of suture anchor or even an internal brace. So why are we still not satisfied if we aren't there. Well, I think a lot of it has to do with the demands of our patients for not being met fully. Correct. I mean patients, we're all getting heavier. We have an elite group of athletes that if the Brostrom-Gould isn't strong enough and their demand is even stronger than average patient, we are also not doing them favors.
We have a lot of chronic ligament laxity patients and lot of the older studies talked about that there were poor function on those patients. What else? There was obesity we talked about and these revision cases. What are we supposed to do with the revision cases that aren't doing successful with the original Brostrom-Gould procedure? So we still aren't quite perfect of what we can do for all of our patients. So that's where interference screws came out, suturing screws came out. Interference screws were really all the rage because of that extra support they gave that bone on soft tissue contact. That was really big in the ACL repairs in the knee. They showed it was very, very strong and that's how that trickled into foot and ankle surgery. And then for those of you who know about internal brace is pretty common now. That's an old suture knotted material that you put in that augments to your Brostrom-Gould. And the reason why this has become very popular is because of the strength that it's providing. This is where I think the biggest bang for your buck is to talk about this. This is about 1.6 times better in terms of strength than a native ATFL and about 3.7 times greater than if you did Brostrom-Gould. So that alone I think is a reason to really favor it. So where do we go from here? So now we are getting to the topic of minimally invasive surgery and it's like all the rage. Everyone is talking about this and it's not even just in foot and ankle. It's everywhere. Even general surgery is having fellowship specifically for minimally invasive. It has become a very good marketing tool. Higher patient satisfaction rate. I am going to fix your bunion with this small incision and some of that's really great and validated. The reason why there is so much opposition for it in the past because some people say, oh, this is -- we have been here. We have been down this road. It went away, it didn't work and so no one is going with this now. The problem is those techniques really focused on I am going to do this small incision and sacrificed the goals of surgery, your fundamental principles of what you are trying to achieve for that small incision.
And that's probably why it didn't do so well versus nowadays our challenge is to get the goals of an open procedure and those fundamental is down and then put minimally invasive surgery in that. So for the audience I think there is probably huge range of what you do or may you don't do this at all. But I think it really depends on what your technique of choices, how you are trained, what's good in your hands and I think those are all really good arguments. So you might be open modified Brostrom-Gould and you might even do the internal brace depending on the case. Some of you may be doing augmentation now. You are really into -- you don't have much tissue left. You need something to hold it. You definitely believe in your suture anchors for that augmentation. Our ankle arthroscopy is now unheard of for these cases. They are showing more and more evidence, very validated evidence that these patients need to be scoped because there are so many other associated injuries related to the ankle sprain that we're not treating and that we're focusing that if we fix the ligaments these patients are going to be great. So we aren't doing them the full scope of addressing their etiology of pain. Some people are going to really innovative and doing everything all inside. Arthroscopic Brostrom approach, I was not trained. It was right when we were training this was kind of newest thing. So not everyone that I was even being mentored by did this. So it took a lot of training as I went on in my fellowship to do this. And then we have what I called them [indecipherable] [11:33]. When I was in fellowship training and I am sure you have this as well whether you are in training or not, lot of times your hospital just laugh at you thinking they are going to give you this fun tools. It's innovative, that's great but it costs three times the amount, so you aren't going to get it. So I was fortunate enough to work with my fellowship director as well as Dr. [indecipherable] [11:51] showed me some stuff on what you can do to get the same goal without all the gadgets. You can still get that. So a lot of people are coming up with their own ways of minimally invasive lateral ankle stabilization and they sometimes probably talk about it in papers or even at conferences.
So let's dive into some literature review to justify the idea of where I am going with this with minimally invasive is a good option, if not at least equal. So when we look at the literature review, the biggest problem is that it came out before a lot of these validated outcomes measurements. So for example Brostrom, they didn't even talk about complications in the original article and they just simply said patients had good-to-excellent results. Same as Gould paper, same thing, didn't mention complications and that's a big deal to not mention that. Carlsen's paper touched briefly on it. His case load was mostly elite athletes and so at least he commented that it was 10% unsatisfactory. Hamilton, the same thing. Meissner [phonetic] touched on this point that some of these patients really need a little bit more stability and support and he commented that they noticed they had a lower outcome, which I think was an important point for them. And then finally, we have some studies that are finally using more validated objective measures [indecipherable] [13:10] in 2011. So are you even scoping your ankles when it comes to lateral ankles stabilization? I am not sure of the audience, but the literature is telling us that there is enough validated evidence to support this and if you notice the trend, if you look at the years on the studies I posted, they are really climbing to say that you really need to start scoping your ankles. It's really becoming a normal and that's probably why a lot of my colleagues who do trauma, a lot of them scope their ankles as well even in trauma cases because of the degree of injury that you can get. Especially, since they are showing that patients without scoping or even up to 20% still not happy because we are solely reliant that if we fix the ligament we fix the attenuation that that's going to be enough, but we aren't dealing with any of the chronic synovitis, potential OCD, peroneal tendinopathy and obviously this is really outside our complicated cases.
I am not really diving into these specific cases that I call them like a zebra and herd of horses where there are these cavus, severely varus, 300-pound people -- obviously, those are very unique cases. This is outside that. But in a typical situation, I think this is pretty validated. So what do I consider successful and minimally invasive if you are going to do it. Well, I think it needs to be reproducible. I think you need to make sure it's mechanically stable and long lasting not just on your table and you test it but functional outcomes of patients are happy. Obviously, the patients are happy as well subjectively and objectively and to really look at postoperative complications, which a lot of the older people do not even touch on. So when we look at things that are small incision, a lot of them will throw out different words. Mini-open, pseudo-open, endoscopic, arthroscopic, minimally invasive. It's all the same idea that it's smaller and you are trying to achieve the same goals as you did with the full-open [indecipherable] [15:02] of the procedure. There is enough literature to show that it is, that it's supported that it's at least equal if not at least effective in function as well as stiffness and strength. And that's important. Now for me because of how I was trained, I was trained with Dr. Shapiro and Dr. Jones, mechanics are very important especially in surgery. So they even did that. They tested this that this is mechanically sound and it definitely had an excellent failure to load rates and that was studied in multiple different situations where they tested it open to the arthroscopy and it's pretty much equal. So I think now it's fun to go into some technical pearls of this procedure. If you never done it or want some ideas or refresher. I think the goal is pretty simple. We want it to be reproducible, simple, easy, that you don't need any accessory portals and it's just to the point, I got it. Do I think this is a high learning curve? I would say yes. Do I think it's worth it? I would say, heck yes.
So when you look at this, it all comes down to understanding your surgical anatomy and I think it's interesting. If you ask someone to try and operate blind that's they feel like that's crazy. You need to see everything. But a lot of times in surgery, you aren't so lucky to always feel everything. You really have to understand everything in space and that type of confidence is how you are going to get successful with this. So the biggest thing is understanding your safe zone and Dr. Jorge Acevedo, great guy, really dived deeply into understanding how to approach this with minimally invasive technique. He taught me a lot of tricks for this and the biggest thing is mark out your safe zone. And that's a little different than doing your ankle arthroscopy. Markers that we have all learned. The biggest thing is still to find your distal fibula. Mark out your superficial peroneal nerve intermediate branch. Mark out your peroneals and mark out the lateral tubercle of the calcaneus. Now, this is where it's get important. What they did is they did a study and they found about 48 mm-hmm, about 50 mm range that this is your safe zone. So that's really key to follow that so that you don't get a neurovascular injury that we are all scared of when you tell me I can't open anything and I can't see anything. The other side of it is that well if we are going to try and grab that retinaculum, how do I know confidently I grabbed it. If you are telling me I am going to have this small incision up at the ankle, how am I supposed to reach it? So the other part that they did is they found a 15 mm length from the anterior fibula that you draw it out and that's what that line is. If you get your sutures passed that, you can say confidently you grabbed it. And that's important. A little difference of scoping that you do may need for a general scope versus a scoping specifically for lateral ankle stabilization is you have to really focus on the lateral gutter. So if you are spending two hours doing something else with the scope because let's be honest scoping is tough, and it has a learning curve in itself, you really need to maximize your time on the lateral gutter side.
Really clean that out, you have to be able to see the distal tip of the fibula. If you don't, you aren't going to be able to see your drill hole and you won't be able to be confident that your anchor is deep in the bone so you have to be able to see what you are doing when it comes to that through the scope. Safe zone, we said I am a big believer to use fluoroscopy in these cases as much as it seems easy to not use a scope without it or to do a full-on open without that you don't need fluoroscopy for this. I would argue I like it, I would like to be confident that I didn't do anything wrong and that I didn't hit the lateral gutter. This is showing that the picture that you can see the two holes in the distal fibula that's about where the marker is about the centimeter up from the distal tip of the fibula, another centimeter up above that. So this is just a bigger picture if you needed something bigger to understand this safe zone idea and what we are watching for. So this is just an example of how you just maximize. You use your anterior medial portal. That's your viewing window. Your anterior lateral portal, that's going to be your working hand. The biggest thing that was hard for me when I tried to do this is you can't see your drill hole. You have to really pay attention and we probably teach this to residents all the time, don't move your hand. Don't move your hand. You really have to scape with the same trajectory because if you mallet in the anchor, it could totally miss the hole and pop out and you wasted the entire anchor and the hospital is mad at you because you wasted and you needed another one. So that's the biggest thing is to really hold firm with your working hand and don't lose your trajectory. So this is just an example of what you are looking for. If you are going to do the drill and some companies have easy markers to follow that you know that you are confidently drilling to the right depth. The biggest thing is when you put in the actual anchor itself to really understand your anatomy. You have to make sure you are turning your hand more lateral so you don't dive into the lateral gutter and also that if you are making sure you aren't so distal that you are drilling all the way pass the distal aspect of the fibula.
You need really good bone. This is just a picture showing you the technique of how to do the suturing. It's hard to describe without a picture that's why I put one in. So how this works is you have to able to do a lot of Suturelassoing and you can do an inside-out or outside-in technique and what does that even mean? That basically means that you are going to start at your ankle and go out past your extensor retinaculum so that's inside-out. Outside-in is just the opposite. The reason why they have two techniques described is I think it's just clinician-dependent. Dr. Acevedo likes outside in because he feels he does not get a soft tissue bridge as easy. I like the inside-out technique myself. I think if you are new to this or you aren't comfortable, you should start there because it's easier to go into something that you already can see and come out through the skin that you are confident through that zone. At least that make sense to me versus throwing through the other way you are bearing and you are trying to find the suture passer through the scope at the same time and try not to damage the articular surface. I think it's just a higher learning curve and if you are little nervous, that would be my suggestion to do that. So let's say you aren't someone who crawls and then runs. You need walking, so I crawl, I walk and then I walk faster and then I run. That's me. So this is a great opportunity for you to utilize something a little bit more comfortable for yourself where you would like to see more but you would like to be challenged to be something a little bit less invasive than you are full on [indecipherable] [21:29] open Brostrom-Gould and internal brace. So this is great. Jorge did the same thing. He just knows clinicians well. He said, I am going to do the same thing the same tools but now on incisions. So the difference is it's now you are just going to make a really small incision at the distal aspect of your fibula. You need to be able to debride it. You need to be able to see the tip of the fibula. All you have to feel for is right where the ATFL is originating. Whether it's attenuated, already torn or what not, make sure you debride it right on the bone just like you do in any other procedure.
You do the same exact repair with the drill guide. The difference is I think it's still easier to do inside-out technique and the biggest thing you have to remember is you have to understand layers. So you throw it through the skin but we still have to pull it back to grab the retinaculum. Well, how do you do that? You are already out of the skin. Well, how it works is that you have to bluntly dissect dorsal to your capsule. All the suture went through onto the joint under the capsule, so you grab that, pop it through the skin, bluntly dissect into your subcutaneous tissue and use whatever blunted instrument you have. A curve hemostat or right angle, some tool that they give you to like grab the suture in the subcu, pull it back because it has the retinaculum with it, secure it like you all know how to do confidently. The foot is dorsiflexed, neutral, slight everted. Now, at that point what I liked about this is that if you feel like you still need an augmentation, let's say on the field you really held the right position, you tight it as tight as you can and you still don't feel confident with your anterior drawer test, I never cut these yet until I am really confident that this is stable because sometimes you still need augmentation because we saw enough studies that it's going to make it even stronger and more supported. So you can still do an internal brace. You can do an accessory portal for the insertion of the talus. You can do a push block or swivel lock and throw the suture up through the bone into the fibula to get more of a bite. So there is certainly other options you can do when it comes to this. You don't have to just stop there. But I think it depends on your comfort level a little bit of where you would go with that. So I think this is a really good topic because we have so many different directions we can go with this to agree or not agree. And I think the biggest thing for those who are pro-open like no, no I donât buy into this, my patients are happy, I am really good at this, it's good in my hands, I have limited my complications to practically nothing versus may be other people in the audience who really believe in medical innovation. They really want to have a good marketing advantage for them.
Patients want small incision. They don't want stiffness. They want to master this and so I think the challenge for both of us in both groups would be that you don't sacrifice small incisions over the goals of your surgery. So really make sure that when you look at these studies, they are asking these questions so that you feel you are making a confident decision in what you are doing and for me, I think that it's validated, meaning you are looking for justified equal strength, effectiveness, mechanical stability, better correction, same or better functional long-term outcomes. So where do we draw the line and how do we decide? Are we getting the principles down for what we are trying to gain out of open? Or we just really wanting to push this minimally invasive? Well, I think the biggest thing when we look at the literature is this functional outcome measurable? We talked about that and do we have enough evidence to support that? You in the audience were like oh, I have seen this before. It's not going to be again. This will eventually die out. These innovations may backfire and those are valid points because we are still in the infancy of this newer technique when it comes to minimally invasive but it's not because we are old fact when it was used to. This is new approaches with minimally invasive technique and it still just as strong. So we will go through some articles to make you more confident in that decision. So I think it's important that we still talk about open procedure because they are validated enough. The revision rate when they did a systematic review is only 1.2%. That's pretty good with an eight-year followup, pretty good, but there is also plenty of studies that show these patients are doing really well when you aren't doing it open. Some of them have mentioned the complication rate is about the same, if not a little bit higher and I think that probably has to do with I think the surgeon and their technical skill-set. I think that because it's such a higher demand to master this, it probably is pretty tough and complications happen. So I think we need more studies to really see if that's true or not. But even Dr. Rigby's team, they found no difference. He does open and he does close and he really now only does all inside.
He is happy with it. They are happy. He can weightbear them early, accelerate rehabilitation program, less swelling, less scarring, less pain and patients are rehabilitating a lot faster. They also looked an internal bracing with this with open with all inside. They were also statistically significant. Vega's team, all they have write about this minimally invasive very effective. Patients are happy and [indecipherable] [26:24] group looked specifically at radiographic outcomes, meaning they stress tested it to see if it handled it pretty much the same as open. Do we have enough evidence? I think it's important that we talk about the things that maybe outside of the clinical and literature review of is this good mechanically. I think the reality of medicine is politics and cost that's I have to deal with that. I am sure a lot of people do and so they was a study that talked about that. It's definitely a higher cost unfortunately because a lot of the equipment you are using for this is disposable. You don't have to use it if you have a different approach or maybe you only have to use some of it. You do need a higher skill-set and I would say a lot of the articles say it's potentially shorter. I would agree with your skill-set getting stronger, but I think it's definitely longer in the beginning until you feel more comfortable because people will say I can open this up, see it be done in 30 minutes versus scoping you still trying to find the joint in 30 minutes. So it does take more time to master this. When we look at the rates of complications, they are still not confident. If they are at least lower, but at least most of them say they are about the same and I think we need more long-term studies not because minimally invasive isn't nothing new but because these particular techniques that have been described are really only in a few years, but so far they are showing promising results, especially when we look at the biomechanical studies, Acevedo's group and Giza, they did tons of this with failure to test load on all types of things. They compared it to the original strength of an open Brostrom and open Brostrom-Gould and one with an internal brace, all inside, open.
They did it all and it really was comparable and I think that's really valid to say that this is pretty good. So I would say for 2018 where are we now when it comes to lateral ankle stabilization. I would say that we definitely see a lot of ankle arthroscopy. I scope all my ankles. I think open ATFL, CFL and [indecipherable] [28:23] is definitely used with suture anchors. I don't think many don't use that. At this point in time, most, I would think all are doing the retinaculum reefing. I think that there is enough evidence to suggest that it is least equal and it is least safe to be able to do this minimally invasive technique. So my take-home for you is that I think it's just as effective based on all the studies that I have shown and probably more climbing. So thank you, appreciate it.
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