Arthroscopic reconstruction of lateral ligaments of the ankle (Anti-Roll) via three portals: A new technique

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1 Arthroscopic reconstruction of lateral ligaments of the ankle (Anti-Roll) via three portals: A new technique Kentaro Matsui 1,2, Mark Glazebrook 2,Wataru Miyamoto 1, Ken Innami 1, Masato Takao 1 Department of orthopaedic surgery Teikyo University, Japan 1 Dalhousie University, Canada 2

2 NO CONFLICT TO DISCLOSE Arthroscopic Anatomic Ankle Reconstruction of Lateral Ligaments (Ankle Anti-RoLL) using three portals : A new technique Kentaro Matsui My disclosure is in the Final AOFAS Mobile App. I have no potential conflicts with this presentation.

BACKGROUND Several arthroscopic repair techniques have

2014 We have adopted a open anatomical reconstruction

3 BACKGROUND Several arthroscopic repair techniques have been published for the treatment of lateral instability of the ankle [1-8]. But there were few report about the reconstruction technique [8]. 5. Matsui K et al. Arch Orthop Trauma Surg We have adopted a open anatomical reconstruction technique so far [9]. It showed good clinical results [10]. We have developed arthroscopic technique with these concepts. 9. Takao M et al. Am J Sports Med. 2005

4 PURPOSE Introduce our arthroscopic reconstruction technique for the patient with lateral instability of the ankle. Material and Methods The patients who were treated at our institute from Sep to Jul for chronic lateral instability of the ankle were included. The instability was diagnosed with physical examination and stress radiographs(anterior and inversion stress radiographs using a Telos device.). Subtalar joint stress radiograph was performed to decide whether to reconstruct only the ATFL or both the ATFL and the CFL. (The ankle was rotated 45 degree internally with inversion stress and more than 10 degree of subtler angle was thought as unstable it needs CFL reconstruction [9].) The indication whether the repair or the reconstruction was arthroscopic findings. > Sufficient fiber of ATFL remnant Repair of ATFL > Insufficient fiber of ATFL remnant Reconstruction determined by following

Material and Methods 48 patients were performed the surgery for the LIA in this period. 2 patients were performed the arthroscopic reconstruction. The 2 patients were reviewed.

5 Material and Methods 48 patients were performed the surgery for the LIA in this period. 2 patients were performed the arthroscopic reconstruction. The 2 patients were reviewed. Surgical procedure With 2.7mm, 30 degree arthroscope without traction of the ankle. Debride all the synovial tissues around ATFL. 3 Portals for this procedure M M MM: Medial midline portal As viewing portal for ATFL attachment (both fibula and talus). At just lateral site of tibias anterior tendon.[5] aca L acal: Accessory anterolateral portal As working portal for talus, fibular and calcanea attachment. At cm anterior from the tip of the fibula. [5] ST ST: Subtalar portal As viewing portal for calcaneus attachment of CFL. At sinus tarsi. This portal does not need for ATFL reconstruction.

6 Surgical procedure The 3 Steps of this procedure.[9] Guide wire Guide wire passing thread acal portal Guide wire Inseret a guidewire Over drilling Change at anatomical insertion of the ligament acal portal Guide wire the guide wire to a passing thread acal portal Introduce the graft via acal portal

Surgical procedure Intereference screw 5mm Guide wire Graft Postoperative rehabilitation Surgery 3days 8wks Immobilization ROM exercise Weight bearing Splint Ankle orthosis Off Active and passive

7 Surgical procedure Intereference screw 5mm Guide wire Graft Postoperative rehabilitation Surgery 3days 8wks Immobilization ROM exercise Weight bearing Splint Ankle orthosis Off Active and passive Full wieght Postoperative rehabilitation program :accelerated rehabilitation [10] with short period of splint immobilization. Sports activity was permitted three month after surgery. ROM, range of motion.

8 Case1: 30 y.o. Male ATFL reconstruction Before surgery AOFAS score: 47 fibula After surgery (6m) AOFAS score: 80 fibula graft talus graft interference screw talus graft no complication no recurrence All these arthroscopic views show the step of Interference screw insertion.

9 Case2: 31 y.o. Male ATFL and CFL reconstruction with Anterior ankle impingement Before surgery AOFAS score:69 fibula guide wire After surgery (6m) AOFAS score:90 talus guide wire talus CFL guide wire no complication no recurrence calcaneus All these arthroscopic views show the step of guide wire insertion.

Discussion We have performed anatomic reconstruction of the lateral ligament of the ankle since 2001[9]. The features of this procedure are as follows: 1. A gracilis autograft ( I or Y shaped) 2.

10 Discussion We have performed anatomic reconstruction of the lateral ligament of the ankle since 2001[9]. The features of this procedure are as follows: 1. A gracilis autograft ( I or Y shaped) 2. Inside-out technique 3. Interference screw 4. Accelerated rehabilitation It showed Good clinical result [10]. Karlsson and Peterson score at before and 2 years after surgery 64.1±4.8 (range 57-70) 91.7±7.7 (range ) But it needed 3 to 4 cm skin incision. In this report We have achieved same anatomic reconstruction technique with less invasive procedure. It may result in less morbidity than open procedure? Limitations Case report short term non comparative

11 Conclusion This arthroscopic reconstruction of lateral ligament of the ankle via three portals achieved same reconstruction technique that we had successfully performed with open procedure before. Although further studies are required, arthroscopic technique will likely prove to be associated with less morbidity than open procedure and the equivalent clinical result would be expected as open procedure.

12 eferences 1. Acevedo JI, Mangone PG (2011) Arthroscopic lateral ankle ligament reconstruction. Tech Foot Ankle Surg 10: Corte-Real NM, Moreira RM (2009) Arthroscopic repair of chronic lateral ankle instability. Foot Ankle Int 30: Cotton JM, Rigby RB (2013) The all inside arthroscopic Broström procedure: a prospective study of 40 consecutive patients. J Foot Ankle Surg 52: Kim ES, Lee KT, Park JS, Lee YK (2011) Arthroscopic anterior talofibular ligament repair for chronic ankle instability with a suture anchor technique. Orthopedics 34: Matsui K, Takao M, Miyamoto W, Innami K, Matsushita T (2014) Arthroscopic Broström repair with Gould argumentation via an accessory anterolateral port for lateral instability of the ankle. Arch Orthop Terauma Surg 134: Nery C, Raduan F, Buono AD, Asaumi ID, Cohen M, Maffulli N (2011) Arthroscopic-assisted Broström-Gould for chronic ankle instability: a long-term follow-up. Am J Sports Med 39: Vega J, Golanó P, Pellegrino A, Rabat E, Peña F (2013) All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique. Foot Ankle Int 34: Lui TH. Arthroscopic-assisted lateral ligamentous reconstruction in combined ankle and subtalar instability. Arthroscopy 2007;23(5):554e Takao M, Oae K, Uchio Y, Ochi M, Yamamoto H. Anatomical reconstruction of the lateral ligaments of the ankle with a gracilis autograft: a new technique using an interference fit anchoring system. Am J Sports Med Jun;33(6): Miyamoto W, Takao M, Yamada K, Matsushita T. Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes. Am J Sports Med Apr 10;42(6):

Arthroscopic Broström repair with Gould augmentation via an accessory anterolateral portal for lateral instability of the ankle: A preliminary report

Arthroscopic Broström repair with Gould augmentation via an accessory anterolateral portal for lateral instability of the ankle: A preliminary report Teikyo University Department of Orthopaedic Surgery