Dalhosie University Halifax Nova Scotia Mark Glazebrook MSc., PhD, MD, FRCS(C), Dip Sports Med Associate Professor Dalhousie University Queen Elizabeth II health sciences Center Halifax, Nova Scotia Panel: 35-Year-Old Recreational Basketball Player with Recurrent Ankle Sprain Panel Moderator: Phinit Phistikul, MD 2:08 PM Pro: Reconstruction: Stronger, More Stable Result Mark Glazebrook MD PhD
Mark Glazebrook Disclosure Statement Mark Glazebrook has received something of value in the past 1 year ( ≥ $500.00) or served as a Journal review er from a commercial company or institution related directly or indirectly to the subject of this presentation, as noted below. a = research/institutional support, b = misc. non-income support, c = royalties, d = stock/options, e = consultant/employee f = Journal review er NAME: DISCLOSURE: COMPANY/SOURCE: 1. Glazebrook e Stryker Wright Inc. 2. Glazebrook a,e Ferring Inc. 3. Glazebrook a,e Cartiva Inc 4. Glazebrook ae Smith & Nephew 5. Glazebrook f Foot & Ankle International 6. Glazebrook f JBJS(A) 7. Glazebrook f The Bone & Joint Journal 8. Glazebrook f CORR 9. Glazebrook Past BOD Member AOFAS 10. Glazebrook President Elect/BOD Canadian Orthopedics Association (COA)
Acute Ankle Sprains Inversion injury Lateral 90% Anterior talofibular ligament (ATFL 70%) Calcaneofibular ligament (CFL 20%) Syndesmotic (High sprain) injuries 10% PTFL and deltoid (w ithout #) - Rare
Injury to Ligaments Grade 3 Severe : • Complete disruption • Obvious Laxity on exam and paradoxically less tender • Signal and structural changes on MRI w ith torn ends visible and fluid filled gap
Injury to Ligaments Grade 3 Severe : • Complete disruption • Obvious Laxity on Chronic Ankle Instability exam and (CAI) paradoxically less tender • Signal and structural changes on MRI w ith torn ends visible and fluid filled gap
Ankle Instability TREATMENT Non Operative RICE from Injury Functional Rehabilitation Peroneal Strengthening Achilles Stretching Proprioception Bracing or High Top Shoe w ear Lateral Wedge Orthotic Taping (Ineffective after ~10 min exercise)
Ankle Instability TREATMENT Operative Open (Traditional) Vs Minimally Invasive (MIS) Anatomic Repair Non Anatomic Repair Anatomic Reconstruction Non Anatomic Reconstruction
CAI: O PEN Stabilization Outcomes Level Level Level Level Level Grade of Procedure Total 1 2 3 4 5 Recommendation Open Anatomic Repair 0 6 4 7 4 21 B Open Non-anatomic Repair 0 0 1 0 0 1 I Open Anatomic Reconstruction 1 0 3 12 2 18 A Open Non-anatomic Reconstruction 0 1 4 23 1 29 B Internal Brace 0 0 1 1 0 2 I Total 1 7 13 43 7 71 Conclusion: OPEN ankle stabilization surgery provides good to excellent results
Less is Better!!
Less is Better!!
Less is Better!! THE SHORT GUY is LESS … Better???
Ankle Instability TREATMENT Operative Open (Traditional) Vs Minimally Invasive (MIS) Anatomic Repair Non Anatomic Repair Anatomic Reconstruction Non Anatomic Reconstruction
Dalhousie University Halifax Nova Scotia Tokyo, Japan Canada Minimally Invasive Ankle Stabilization International Collaboration
ESSKA AFAS AIG -since 2013- European Society of Sports Traumatolgy, Knee surgery and Arthroscopy Ankle and Foot Associates Ankle I nstability Group Jordi Vega (ESP) Anthony Perera (UK) Bas Pinenburg (NLD) James Calder (UK) Niek van Dijk (NLD) Mark Glazebrook (CAN) Helder Pereira (PRT) James W . Stone (USA) Numo M. Cortereal (PRT) John G. Kennedy (USA) Jin Woo Lee (KOR) Peter Mangone (USA) Woojin Choi (KOR) Jon karlsson (SWE) Jorge Acevedo (USA) Satoru Ozeki (JPN) Dominic Carreira (USA) Ali Gorbanni (FRA) Masato Takao (JPN) Keneth Hunt (USA) Andy Molloy (FRA) Eric Giza (USA) Siu Wah Kong (HKG) Stephane Guillo (FRA) Thomas Bauer (FRA) Christopher Peace Caio Nery (BRA) Yves Tourne (FRA) (SGP) Fernando Raduan (BRA) Fredrick Michels (BEL) Jorge Batista (ARG) Chicago 2014 Stephane Guillo (Chair) 21 active members Thomas Bauer (Vice Chair) from Europe, North & South America, and Mark Glazebrook (Secretary)
Logical Approach for Rx CIA MIS RECONSTRUCTION 1. Current Literature Review 2. Anatomy Studies 3. Surgical Technique Development 4. Biomechanical Testiing 5. Future Clinical Studies (Safety & Efficacy)
Current Literature Review
Current Literature Available on MIS stabilization Techniques Current Evidence for Treatment of Ankle Instability with MIS?? Minimally Invasive Surgical Treatment of Chronic Ankle Instability: A Systematic Comprehensive Evidence Based Review of Current Literature Kentaro Matsui, Bernard Burgesson, Masato Takao, James Stone, Stephane Guillo, ESSKA AFAS Ankle Instability Group, and Mark Glazebrook
Current Evidence MIS Approaches to Ankle Stabilization . Surgical Total Level Level Level Level Level Grade of For or Technique Papers I II III IV V Recommendation Against MIS Non A 0 0 0 0 0 0 I NA Repair MIS Non A 6 0 0 1 2 3 C For Reconstruction Arthroscopic 19 0 0 0 12 7 C For Repair Arthroscopic 6 0 0 0 1 5 C For Reconstruction
Current Evidence MIS Approaches to Ankle Stabilization . Surgical Total Level Level Level Level Level Grade of For or Technique Papers I II III IV V Recommendation Against MIS Non A 0 0 0 0 0 0 I NA Limited Evidence to Support MIS for Rx of Ankle Instability!! Repair MIS Non A 6 0 0 1 2 3 C For Further Studies Needed !!1 Reconstruction Arthroscopic 19 0 0 0 12 7 C For Repair Arthroscopic 6 0 0 0 1 5 C For Reconstruction
Anatomy Studies
Boney Land Marks ATFL & CFL Foot Prints Bony landmarks available for minimally invasive lateral ankle stabilization surgery : A cadaveric anatomical study Kentaro Matsui Xavier Martin Oliva Masato Takao Bruno Pereira Submitted Moto Gomes for Kentora Matsui MD PhD Publication Teikyo University Martinez Lozano, Tokyo Japan ESSKAAFAS Ankle Instability Group, Mark Glazebrook Spanish/Catalonia Collaboration
Boney Land Marks ATFL & CFL Foot Prints Methods: 12 lower extremity cadaveric specimens • Detectability of the tubercles tested: • Palpation • Fluoroscopy • Distances from tubercles to the footprint centers • Tubercles not detectable: Provide an alternative means of localizing ATFL and CFL footprints using alternative landmarks.
Precise Anatomy of ATFL & CFL Traditional ATFL & CFL Anatomy… Not Precise!
Precise Anatomy of ATFL & CFL ATFL ATFL & CFL partially share a common origin Site
Surgical Technique Development
International Collaboration Dalhousie University Halifax Nova Scotia Tokyo, Japan Canada “A nti RoLL” A nkle R econstruction o f L ateral L igaments
Ankle Reconstruction of Lateral Ligaments Anti RoLL Evolution from Open To MINIMALLY INVASIVE Percutaneous “A&P Anti RoLL” OPEN Anti RoLL Submited New Arthroscopic Surgical Technique for Ankle Instability: Percutaneous Arthroscopic Reconstruction of Lateral Ligaments (Percutaneous Anti ROLL) Mark Glazebrook, James Stone, Masato Takao, Kentaro Matsuie and Stéphane Guillo ANKLE INSTABILITY GROUP
Arthroscopic Anti-RoLL A Anti RoLL
Percutaneous Anti-RoLL P Anti RoLL Accepted for Publication New Arthroscopic Surgical Technique for Ankle Instability: Percutaneous Arthroscopic Reconstruction of Lateral Ligaments (Percutaneous Anti ROLL) Mark Glazebrook, James Stone, Masato Takao, Kentaro Matsuie and Stéphane Guillo ANKLE INSTABILITY GROUP
Surgical Technique 5 STEP PROCESS 1. Anti-RoLL Y-Graft Construction 2. Fibula Bone Tunnel (ATFL-CFL) 3. Talar Bone Tunnel (ATFL) 4. Calcaneal Bone Tunnel (CFL) 5. Anti-Roll Y-Graft Delivery & Fixation New Arthroscopic Surgical Technique for Ankle Instability: Percutaneous Arthroscopic Reconstruction of Lateral Ligaments (Percutaneous Anti ROLL) Mark Glazebrook, James Stone, Masato Takao, Kentaro Matsuie and Stéphane Guillo ANKLE INSTABILITY GROUP
Surgical Technique Construction of the Anatomic Y Graft Step 1 1. Anti-RoLL Y-Graft Construction (Dr Masato Takao Technique)
PERCUTANEOUS Anti-RoLL FIBULAR PIN PLACEMENT A B Step 2 Fibula Tunnel ATFL & CFL D C Origin Site
PERCUTANEOUS Anti-RoLL TALAR PIN PLACEMENT A B Step 3 Talar Tunnel C D ATFL Insertion Site
PERCUTANEOUS Anti-RoLL CALCANEAL PIN PLACEMENT Step 4 A B Calcaneal Tunnel CFL Insertion Site C D (Approximately 15mm posterior to the anterior edge of the posterior facet and about 15mm inferior to the joint line.)
PERCUTANEOUS Anti-RoLL Y Graft Passage and Fixation A B Step 5 Y-Graft delivery site Anti-Roll Y-Graft C D E Delivery & Fixation
PERCUTANEOUS Anti-RoLL Final Anatomic Allograft Construct ATF L CF
Biomechanical Testing
University of Barcelona Medicine-Anatomy Biomechanical Testing Collaboration Xavier Martin (Barcelona, Catalonia) Masato Takao Satoru Ozeki (Tokyo, Japan) Mark Glazebrook (Halifax, Canada)
Biomechanical Studies (ONGOING) Using Cadaveric Model Investigate Tensile forces during ankle ROM on: Normal Intact Ankle Ligaments Anti RoLL Reconstruction
Future Clinical Studies (Safety & Efficacy)
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