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Dr. Schoenhaus: Alright, our next speaker is Dr. Benjamin Kamel who is a senior resident. He is actually chief resident in Chino Valley Medical Center and he has a keen interest in education. He does a fair amount of work for Present in writing and evaluation of test questions, etc. And we have asked him to do a life skills lecture -- actually, I am sorry he is doing ankle stabilization procedures, rehab for a quick and safe return to activity. Please welcome, Ben Kamel.
Dr. Benjamin Kamel: Thank you Dr. Schoenhaus. Thank you Present for having me here today. It's a pleasure. It's an honor. Alright, so I am going to talk to you guys today about ankle stabilization procedures and rehab for a quick and safe return to activity. I don't have any disclosures to make. So what we are going to talk about, we're going to review the diagnosis and work up for patients with ankle sprains and ankle instability. We're also going to take a look at the available non-operative and operative treatments that are available for patients with lateral ankle instability and then finally, we're going to recognize the effects of multiple augmentation methods but more specifically I'm going to talk about suture tape and its effects in expediting functional rehabilitation. So to get started, ankle sprains are of the most common injuries in the foot and ankle and when you look at musculoskeletal injuries as a whole, it makes up 20% of those injuries and when we take a look at these patients, we really want to make sure that we are being thorough with our examination. What may seem like such a simple ankle sprain can come with a lot of other injuries as well as what may be a simple sprain could be something that is much worse than just the simple ankle sprain.
There are multiple risk factors that contribute to patients that develop ankle sprains or chronic ankle instability. We have mechanical risk factors such as hyperlaxity, arthrokinetic restrictions or synovial changes. We also have functional risk factors such as impaired proprioception, impaired neuromuscular control or impaired postural control. And it's when our patients develop multiple of these risk factors that they start to develop chronic lateral ankle instability. So when we take a history, we are wanting to question our patients on what the position of their ankle is in when they have their injury as well as the amount of force that was applied during the injury and this is going to help us to identify what structures may be injured and to what degree it may be injured. This study was done out of England. They took a look and made an evidence-based clinical guideline to help grade ankle sprains and what we know as our grading system today. It ranges from grades 1 to 3 and we have mild, moderate, severe and for grade 1, you have a stable ankle with the ability to bear weight and an intact ligament versus your grade 2 where you have some laxity and partial tear in your ligament and then with your grade 3 it's really an unstable ankle that has a complete tear. And this is a mechanical injury. So you have to mechanically stress these ankles. I like to stress all the ankles that I am concerned for instability in the OR, or even in the clinic, I know that it's oftentimes not as accessible in the clinic but it can really be a valuable tool.
With your talar tilt test, you are analyzing these patients in the AP or mortis and you are looking for 10 degrees of a tilt and also with your anterior drawer looking in the sagittal. Sagittal view, you are looking for 5 mm of displacement anteriorly. There have been some research to look at the accuracy of these tests and you can see that the sensitivities of these tests are fairly low and the specificities are relatively high and what this means is if you have a positive test that more than like there is some ligamental injury involved; however, if you don't get a positive test, it doesn't necessarily rule out a ligamental injury. So when we take a look at an MRI if you decide to order a MRI, you can see the different grades. We have ATFL and the CFL and you can see the differences in grade 1 versus grade 2 and grade 3 with the grade 1 being an intact ligament and grade 3 you can see the destruction of the ATFL there with the arrow and -- I can't really point but the CFL there is also destructed. As I had alluded to earlier, you want to make sure when you are taking a look at these patients that you are also looking for other pathologies that might be present. When these patients initially come in, they are swollen, they are in a lot of pain. There may be ecchymosis. So it's hard to really do a thorough examination initially. What practitioners might fall into the trap of is they are out of the acute phase. They are feeling much better and they may miss some other pathology that's going on such as peroneal pathologies like a tear or subluxation and OCD of the talus or Achilles tendon injuries.
And really when I have a patient with this type of pathology, I want to be absolutely convinced that they do not have a tarsal coalition. Now with these patients with tarsal coalition, it's the lack of internal rotation in that subtalar joint that makes them prone to lateral injuries. And you also want to take a look at varus hindfoot alignment and this is important because this can be a contributing risk factor one, but two, when it comes to preoperative considerations you want to make sure that you are addressing this issue. If not addressed, you may be not helping your patients with having the most successful outcome that they possibly can. If you have gotten an MRI and you are looking for a sprain, you might as well look to see what's going on with peroneus, so I briefly demonstrate. Here you can see with these animations correlating with the MRI. You have a normal peroneus brevis that sits in between the peroneus longus and the fibula. And with injury, you may have some compression and with repetitive injury, you will see that they might have a partial split tear or also known as the cashew sign. And then they could also have a complete tear as you can see here. I don't want to belabor this point but I think it's definitely important to discuss OCDs when it comes to ankle sprains and instability as it can occur in a quarter to a third of the time. Non-operatively, according to Zinger inc., et al, these patients can do well 40% of the time becoming asymptomatic and not having much issues with it, but it's the other patients that go on to have some symptoms later on that need to be treated operatively and depending on the size of your lesion, you want to consider bone marrow stimulation or a transplantation of an allograft.
So nonsurgical treatment continues to be the treatment of choice to begin with these patients. You could have a patient with a grade 3 tear and treat them nonsurgically and they can still heal and go on to do well. You want to think about this in three phases. So you have your acute phase, patients are swollen, they are in a lot of pain and this is more treatment with supportive care, rest, ice, compression, elevation. And once they have come out of the acute phase, moving them onto more of a functional rehabilitation, working on their strength, their flexibility, and then until they can get to the point where they can go back to the field or the court or just the activities of daily living. So I have patients oftentimes when they have an acute tear, they will ask, well, doctor it's torn or if they have a broken bone, well, it's broken. Doesn't it need to be fixed? I think that's intuitive thought but the literature maybe saying otherwise and this randomized control trial done out of JBJS in 2010 took a look at this and they found no significant difference in ankle scores and functional outcomes with or without surgery. Surgery was associated with decreased prevalence of re-injury and increased risk of osteoarthritis. This meta-analysis done in 1999 found similar results with no significant difference with or without surgical repair; however, interestingly they found that secondary surgical repair had comparable results to a primary repair. So if you are afraid that you are going to be burning some bridges by not treating these patients surgically initially, then this study says otherwise.
And that's ultimately what we are afraid of is these patients have an ankle sprain and as Dr. Schoenhaus mentioned earlier today with the TC ligament, if it's injured, it becomes elongated and it will heal in elongated position. Same with these lateral ligaments. They can heal in an elongated position and this leads to instability and ultimately intraarticular damage with synovitis, chondral damage or OCDs. And when all those fail, we have to consider surgical treatment. Now there are a lot of surgical treatment options today but we didn't get to where we are today out of nowhere. Maybe I have gotten this from Dr. Shapiro but Dr. Gallay, so more history coming. Dr. Gallay in 1913 sacrificed to peroneus brevis to use in his paralytic club foot patients for lateral ankle stabilization. This has had many indurations since then with the Chrisman-Snook and the Evans procedure. It wasn't until 1966 when Brostrom came up with the implication of the ATFL, which was later modified by Gould, which used the lateral portion of the extensor retinaculum. You want to think about the current treatment options in three categories; you have anatomic repair, anatomic ligamentous reconstruction, and nonanatomic ligamentous reconstruction. So we will start with the anatomic repair, which we know as our Brostrom procedure. As I mentioned before, it is a midsubstance lubrication of ATFL and with the Gould modification, which is augmenting that primary repair with the lateral portion of the extensor retinaculum. You can also perform the Brostrom procedure with an arthroscopic technique. This is beneficial in your patient population with significant comorbidities.
You are afraid to have a huge incision or they just don't want to have a huge incision. And as this can also lead to good result, it also has a high learning curve. So it is difficult to perform. Generally, the Brostrom procedure does well; however, it doesn't always do well and you want to make sure you consider your patients that have had previous failures, hyperlaxity or over 10 years of symptoms as this has been associated or has been considered a contraindication for this procedure. Very briefly, to do this procedure using a bump underneath the ankle or hip as you see fit, but just to be sure not to use your bump underneath your heel. This can create a pseudo anterior drawer and you can be inappropriately fixing your ankle in an anterior drawer position, which would not be good and you would not have successful outcomes. Couple incisional approaches. If you are concerned about any peroneal pathologies, you may want to consider the posterior hockey stick incision or even if you are not concerned about it, an anterior J for exposure of that distal fibula. You want to carry your dissection down, mobilize the extensor retinaculum, make a periosteal incision, expose the distal fibula and you can use a variety of options whether you are going to do a primary repair or using suture anchors for your fixation or even suture tape, which I am going to talk about later with the internal brace. And you want to make sure you repair these in a neutral and slight eversion position. As I have mentioned before, you can use ankle arthroscopy for your repair; however, if you are afraid to do the procedure with arthroscopy, which I will understand because I myself don't have that experience but you may want to consider using arthroscopy just for the sake of looking at the intraarticular surface.
Because what you can with arthroscopy, you may not be able to see with your open repair. So consider using arthroscopy whether to use it for your fixation or just for diagnostic and intraarticular treatment purposes and then move on to your open repair. And unfortunately, Brostrom is not always enough as much as we would want it to be. You have to consider with your generalized ligamental laxity patients or high demand athletic patients or your patient who are overweight, another option. So this is when I would consider using an anatomic ligamentous reconstruction using allograft or autograft. You can reconstruct the lateral ligaments using tenodesis screws. Again, like I mentioned before using this in revision or heavier athletes or hyperlaxity. And then finally, we have the nonanatomic ligamentous reconstruction group, which I had mentioned before. We have Watson-Jones, the Evans and Chrisman-Snook, which are all different variations of sacrificing the peroneal tendons to reconstruct the lateral ligaments. Historically, these have not done very well. They have been associated with a lot of complications with sural nerve problems, over tightening and recurrence. So which one is the best? I always wanted to know which one is the best. I just want to do this one and that's it. But this is a meta-analysis that was done recently in 2018. They had seven randomized controlled trials and they concluded that there is not enough evidence to choose one procedure over another. It's unfortunate. But they did make some other conclusions, which is that there are limitations to using dynamic tenodesis screws. The nonanatomic repair is associated with a lot of complications, the modified Brostrom no matter which way you do has been associated with good outcomes and then you should consider an anatomic repair with allograft or autograft for your chronic lateral ankle ligament laxity patients.
So you may want to augment your repair. If you do a Brostrom, you might want to augment it and there are multiple options with grafts, anchors, additional anchors if you have already used some, suture tape or freeze-dried human dermal collagen scaffold but for the sake of time, I am going to use just talk about the suture tape. So why add suture tape? The goal is to allow an athlete a quicker return to play without comprising short or long-term results. So what's the science behind this? I mean there has got to be a reason why we are advocating this to our patients. So this is a study that took rats and sectioned the Achilles tendon and repaired them. And what they have done, you can see that there is a sham controlled group on the left, the ambulatory group on the middle and the suspended healing group on the right. And they had them ambulate at three and seven weeks and you can see in the middle bar graphs the ultimate load to failure in the ambulatory group was higher than that of the suspended group. Now, the suspended group would be equivalent to that of what we do with our patients when we place them in a cast, although sometimes I wish we can suspend our diabetic patients when we want them to be nonweightbearing. So if we take a look at an electron micrograph, we take a closer look, the ambulatory group, you look at the collagen fibers which are more similar to that of the controlled group than the suspended group.
We can see that the suspended group, the collagen fibers are in disarray and they are not very organized, which you would imagine won't lead to a good functioning ligament. This is another study that took a look at the ultimate load to failure of a native ATFL in compared to that of a fixated with a Brostrom ATFL and you can see that the native ATFL's ultimate load to failure was 150 Newton and you compare that to no matter which way you did the Brostrom where it was a primary repair or with the suture anchor that the ultimate load to failure was 75 Newton. So half of that of the native ATFL. This is another study, which is a cadaveric study. They sectioned the ATFL and they repaired them and cyclically loaded the studies and you can see that when the ATFL repair was unprotected and cyclically loaded that there was a significant difference in the amount of elongation in that ligament, which as Dr. Schoenhaus mentioned before with that elongation will come other issues. Oftentimes, here this from my attending or other surgeons that all of my lateral ankle stabilization procedures do well. While this study done by me fully was a long-term study that looked at nine-year follow-up of ATFL repairs for chronic lateral ankle instability and surprisingly it's not 100% but it's 58% of patients that practice that return to their pre-injury level, 16% had changes to a lower level but still active in less demanding sports and then 36% had abandoned their active sports participation, although they were still physically active. So I may not be doing as well as we think.
Surprisingly, patients don't like casts or maybe unsurprisingly. So no matter what procedure it is that I am doing if a patient requires a cast, I am always thinking when is the soonest that I can get this patient out of a cast in the safest way. So let us hear to this conundrum. On one hand, we have the study, which we looked at the rats where they were ambulated sooner and they had better ultimate load to failure than that of the suspended group and then on the other hand, we had the study with the cadavers that were cyclically loaded and there is a significance in elongation when they were unprotected. So what do we do? This is a study that was done by Vane et al and similar to the findings of the previous study by Kirk et al, the native ATFL was found to have ultimate load to failure of 150 Newton comparing that to the 75 Newton of the Brostrom with anchors. But then when they added suture tape as an augmentation that they found that the ultimate load to failure was up to 250 Newton. Now, there may be a misconception that this higher than 150 Newton of ultimate load to failure may be overtightening; however, if you fixed the patient in proper position and you are allowing functional rehab early that these patients won't really have overtightening but they will just have a stronger or higher ultimate load to failure. This is a traditional rehabilitation guideline done by the University of Washington for patients that are postop lateral ankle reconstruction and it's a long rehab process. For them it's four months and it's four phases. And so very briefly, I am just going to just talk about what they suggest, which is phase 1 is mostly protecting that ankle for that first six weeks with partial weightbearing and not much range of motion.
Phase 2, they are allowed to ambulate a little bit more with a little more range of motion. No inversion and still no eversion but there is active and active assisted plantarflexion and dorsiflexion. Moving on to phase 3, which is around two and half to three months, they are now moving into more full weightbearing and more range of motion and strengthening exercises. And then finally, phase 4, three and half to four months they are starting to do more sports specific-type activities and only after this point are they returning back to sports. So here is a protocol that I would recommend. If you have used the suture tape augmentation and you feel comfortable that you have secured your patient, day of surgery these patients are in a splint or a CAM boot. Two or three days later, they are coming back to the office and we are doing a wound check and if they are not already in a CAM boot, then I am putting them in a CAM boot and they are being weightbearing as tolerated. I make sure that the patient is coming out of that boot everyday to do dorsiflexion, plantarflexion and even eversion. I am okay with eversion but just to make sure that the patient is not doing any inversion. By week 3, they are coming out of the CAM boot into an ASO ankle brace beginning formal physical therapy at this point. By week 6, we are doing sports specific training in hopes that by two and half to three months that these patients are back on the field as opposed to after four months. There is not a lot of literature about using the suture tape augmentation but one of the studies here by [indecipherable] [0:24:03] done in the Foot and Ankle International in 2018 took a look at 89 patients that were all athletes and the followup average was around a year.
And their return-to-play was 12 weeks at 90% of their injury level. So another study, which you may be wondering, can I use something other than an anatomic reconstruction with allograft and autograft. Can I use the suture tape with my Brostrom for generalized ligamental laxity and according to this study by Dr. Cho out of Korea, you absolutely can with 28 patients that were followed for over two years. They used this technique and only one patient had recurrence of their instability. And finally, this study, which is not yet published, however, I have read reports about it. They have 154 subjects that were enrolled with the power analysis of 61 in each group. They are comparing the Brostrom repair in both groups one with and one without suture tape augmentation. Both groups are receiving the same postoperative rehab for postoperative protocol and their primary outcome is subjected to self-reported time to return to pre-injury level of activities. So I am interested to see when this one comes out and I am sure that there are more to come. So in conclusion, chronic lateral ankle instability can occur because of mechanical and functional limitations. It is important that you do a thorough examination to make sure that you are looking for not only the severity of their injury but looking for other concomitant pathology such as tarsal coalition or peroneal pathologies or Achilles. Anatomic repair techniques continue to be the gold standard for operative treatment and suture tape can help lead to quicker and safer return to play. Again, these patients are not using casts but they are weightbearing sooner. They are going into more of a functional rehabilitation status sooner, less swelling, which leads to less pain and more successful outcomes. So I know you could be anywhere else on a Friday night but you choose to be here and I appreciate your attention. Thank you.
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