Name: Arthrex Foot & Ankle Innovation for Sports Surgeons
Uploaded: 2014-07-28T00:00:00Z
Channel: Arthrex
Description: Steve Martin, MD, (Clemson, SC) presents current innovations for foot & ankle sports surgeons treating athletes. He describes the surgical treatment for syndesmosis, ankle fracture, deltoid, lateral ankle and Achilles injuries using the Arthrex TightRope® Syndesmosis, Ankle Fracture System and Internal Brace™ Ligament Augmentation Repair.

Foot and Ankle

<p>Steve Martin, MD, (Clemson, SC) presents current innovations for foot &amp; ankle sports surgeons treating athletes. He describes the surgical treatment for syndesmosis, ankle fracture, deltoid, lateral ankle and Achilles injuries using the Arthrex TightRope® Syndesmosis, Ankle Fracture System and <em>Internal</em>Brace™ Ligament Augmentation Repair.</p>

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VPT1-00246-EN | A | Arthrex Foot & Ankle Innovation for Sports Surgeons

Steve Martin

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Arthrex Foot & Ankle Innovation for Sports Surgeons

All right for topics. Go over them very quickly. First one is pronation, exploitation, ankle fractures in your athletes. And even for the guys that are going to the university centers, I encourage you not to pass these off to your trauma colleagues, and I'll show you why in the talk. My background is sports and trauma. It's not foot and ankle, but you'll have a better understanding of the ligaments injury than they do. They get stuck on the bone side of it. And so when you look at what's been done to this point at the level one trauma centers, and in practice over the last 20 years, we have not done a good job with our syndesmotic ankle fractures. We have about a 40% reduction rate. If you do an open reduction of the Syndesmosis. In this particular study, they decreased it down to 1,515% male reduction based upon post op cts. And so in those patients with mal reduction, syndesmosis functional outcomes are dramatically worse. And so we have to do a better job. One of the reasons that we are not doing a good job is the understanding of this anatomic plane of the syndesmosis. If you put a clamp on the syndesmosis and you're not exactly in that anatomic plane, you bring your CRM in and the syndesmosis is still a little bit wide. What do you do? We squeeze a little harder. Right. Well the clamps are already in the wrong position. So if you squeeze it harder, all you're doing is reducing it even further. You're inducing either internal or external rotation of the fibula in that incisura. And so I don't use a clamp anymore in my cases. If you're putting syndesmotic screws and you put those out of plane and you squeeze it all with them, you're now reducing the syndesmosis. And so the problem is, is that in orthopedics and I'm guilty of this over the last, you know, my practice is that we love to think in orthogonals. We love to think parallel and perpendicular. Well the problem and then we have this ankle mortise which is a box. So let's stick this 90 degree box and then let's make everything parallel and perpendicular. Well, all your injuries are rotational. So when you're thinking about the injury, don't think about the mortise and about the box. Think of a circle. That circle is unlocked and then it's progressively opened like a door on its hinge. So here's your anatomy of the Syndesmosis. You look on the left, there's your anterior inferior, big, broad fan shaped ligament that runs about 60 degree angle. You can have a Wagstaffe fracture that we see very commonly over there on the fibula, your caput fracture that you see on the tibial side when you go over to the posterior side of the ankle, same thing. It's very broad based. It has two bundles. It has a more superficial and a deep bundle. And that's important as I show you the injury mechanism. So if you think of it in terms of the biomechanical strength, that posterior is about 40% of the strength, anterior is about 35. And your interosseous membrane about 25%. Your injury mechanism in your athletes, especially the foot, is in pronation there planted and they're changing directions as that foot is in pronation. Then there's an external rotation force applied to it. Depending upon how much external rotation and how much abduction of the talus determines how high up the fracture is. And you'll see it again here. If you'll watch his left foot out of bounds as he plants. And this is the key. When you get a fracture, is the foot's planted in pronation there. Then he's rolled up on and then the big external rotation force. And so the foot is not able to disengage from the turf. And that's the difference between a high ankle sprain and your pronation. External rotation fracture is the inability to the foot to disengage from the turf. And if you'll see back on his x ray, you'll get that kind of reverse fracture line. So when you get an MRI what starts is the medial side. Your deep deltoid is torn. Then your anterior inferior is torn. Most of the time it can be off the tibia or the fibula or mid substance. Then you'll get your interosseous membrane and fibula fracture. And at that point the the fibula continues to externally rotate and it starts to peel the posterior off. And in 90% of the athletes that posterior is an incomplete avulsion. If you look at it arthroscopically. And I'll show you this guy's case, is that the deep bundle is torn right off the back of the tibia, but that more superficial higher up bundle is intact. And the reason that's important is I now have a hinge to work with, and all I have to do is internally rotate the fibula to get my reduction. And that's not about 10% of the time that will be completely avulsed. And I'll show you a case of that. So there is that peel back lesion like in the shoulder of that posterior inferior. And you can see the wavy waviness to that ligament is it's still partially intact, and all you have to do is internally rotate and you'll reestablish that posterior hinge. And so here you're looking from an anteromedial portal that's looking posterior laterally. These osteochondral fragments that are attached to the posterior syndesmosis are there 100% of the time. And so that you can see that that's the deep bundle, the posterior inferior syndesmosis. And in these young athletes I scope all of these. That's another reason for you guys to be doing it instead of the trauma guys. They don't like to have a scope in their hands. And I think the scope is very valuable. You're documenting Osteochondral injuries. You're pulling out osteochondral fractures very, very commonly that are going to be loose bodies. I do multiple stressing, both fluoroscopic and arthroscopically. You know, midstream in my repair to make sure I'm getting a stable, rotationally stable ankle. This in It's in the interest of time. So after he gets plated, the TightRope a very easy device to put in. I view this as an internal brace of my interosseous membrane. Remember, that was 25% of my syndesmosis. If you're going through the plate, here's the Arthrex lateral locking plate. You can go about 30 degrees off axis of the plate. And that's why I don't use a guide pin in that situation. I go straight with the drill. You just you pass your suture through. Pull your implant through to the other side. And I usually do bring CRM in and confirm that I've set that button on the other side. You can toggle your sutures to help do that. So here he's splitting the two to get the button to toggle. And then you pull back and you can lock it. And I confirm with CRM. As you're tensioning. I don't always use the little hemostat that you see here, but you want to sequentially tension one, then the other one and the other because the sutures will bunch up just a little bit. It never causes a problem. You just kind of work it down and then all the way down. And as you can see with this plate, the button does fit all the way down into the device, which is important, which I'll show you here in just a second. And so what I add to that is a repair of the anterior inferior syndesmosis. I'll either put if it's an avulsion, I'll put an anchor in and put a suture into it. What I'm doing now is an internal brace. You saw the internal brace and some of the other other talks. It's two SwiveLock, two FiberTape between it. There'll be an extra suture on one of the swivel locks that I'll do my repair with. So I'm repairing and internally bracing the anterior inferior. And then I'm getting complete rotational stability of the ankle. And on your athletes that's important. And so there's just a repair with a that's a SutureTak anchor. At ten weeks he was doing He was already back to our outdoor track. He runs a 100 meter. I don't take credit for his speed. When we look at the fracture set, it does all work together with the TightRope. It's built around the TightRope. You have that 35 degree cutout in the plate so that you can drill off axis in that anatomic plane that we talked about before. The scallop plates allow you to put a TightRope outside of the plate as well. If you want to get the more rotational control by putting your two TightRope at a 30 degree axis. You have all your plate options both laterally and medially. And so you basically you have one fracture set. Then you have your TightRope, you have some anchors InternalBrace, and you have everything that you need to get rotational stability of your ankle fractures. The problem when the button doesn't fit into the device is that you can get friction against the plate with your suture, and actually have a suture failure that probably indicates that you didn't have didn't have rotational stability as well. And this is a case just from a couple of weeks ago. This was actually a motorcycle accident. And he had a huge medial abrasion, full thickness, and didn't want to do any medial surgery at all, didn't want to repair his deep deltoid, didn't want to do anything on the medial side. So I actually put him lateral decubitus, draped all that out, did a quick scope of the anterior, a single anterolateral portal just to make sure my hinge was intact. There is his internal brace so he has no other fixation of his syndesmosis other than an internal brace. And then on the video. So here's the fracture here plate. Here's superficial peroneal nerve. It's actually starts outside of the fascia. So it's a little bit of a variant comes down and about 4 to 5cm above the tip of the lateralis which is right there. It splits into three major two major branches intermediate and dorsal medial branch right there. Army. Navy. Here is our repair of an internal brace of our anterior inferior. There's the ligament. Here's the internal brace. Just slight. One hemostat underneath. Tension running diagonally at the 60 degree angle of the normal anatomic anterior inferior syndesmosis. You can see now when we externally rotate. No motion at the syndesmosis. And when we look at our reduction, you can actually see your lateral talus. And you can anatomically look that your reduction is anatomic. You can do an anterior posterior shuck test which shows you the stability of the syndesmosis. So here's the last case on the ankle side. This is a soccer player. Now he's lost his posterior hinge. A little more difficult situation. And you have to spend a little more time making sure your syndesmosis is right and reestablishing the hinge and I do it. This is from a little over a year ago, and I actually do more of the internal bracing now. But he gets his scope. We confirm the injury, we do the stress testing, we fix his fibula, do an open reduction and repair of the syndesmosis and repair the anterior inferior couple trans osseous TightRope to do the interosseous membrane and the posterior hinge. And actually, this is an internal brace of the deep deltoid. And I have a little bit different technique on that now, but you're looking at repair or internal bracing of all the elements of the injury, starting all the way over to the medial side and both your anterior and posterior syndesmosis and your osseous membrane. So you're working on all the elements of the ligaments injury. And so here he is at ten weeks. He's full weight bearing. He's walking to class with no brace. He's got more than 12 degrees of dorsiflexion. He's doing in-line jogging and he wants to play soccer. I didn't clear him because he wasn't one of our collegiate athletes and he hadn't rehabbed adequately, but he was he was doing well. And so this concept of an internal brace, as we apply it around the foot and ankle with ArthroBrostrom repairs, with our anterior inferior syndesmosis, our deltoid and our spring ligament is that is that we add the internal brace, which is a very simple device, two swivel locks with FiberTape and I am protecting the repair. I'm not substituting for the repair. I'm not substituting for the biology. The biology is still there. I'm protecting it from the extremes of stress strain to allow the biology to heal properly. And so when you look at ArthroBrostrom repair, and this kind of gives you the concept of an internal brace, ArthroBrostrom repair is done exactly the same as you would before two anchors on the fibular side after you've pulled up your anterior talofibular ligament. Swivelock. In between the two anchors. Loaded with the FiberTape was a 3.5 SwiveLock, and right off your tubercle on your talus. You say you do your standard ArthroBrostrom, and then in this case, a 4.75 SwiveLock and that becomes your glide modification of ArthroBrostrom. And by doing that, that very simple addition to the technique. Here's a study by Clanton American Journal of Sports Medicine just this year. Look at the improvement in your failure. Newton's with the standard rostrum with anchors versus your native atfl versus ArthroBrostrom with anchors and internal brace. And so that allows that patient to earlier rehab earlier, get more aggressive with what they want to do and protect the repair. And so the key though is the biology still needs strain. If you want that ligament or tendon to heal properly. Wolff's law still has to apply. So the internal brace is not replacing it. And so the tension that you put on and there's some technical ways to do that is important. You're not over tightening. It's just like the mpfl that Pat was talking about is that I'm just putting it to the point that it's tight but not over constrained, and that's important. And last, just talking about the percutaneous Achilles tendon repair system or the SpeedBridge. When you look at the Achilles tendon and there's been multiple meta analysis of this and this most recent one in our journal in 2012, they looked at ten studies that qualified if they were treated non-operatively with functional early functional rehabilitation. They had basically equal results, including rerupture versus surgery. Surgery carried a higher risk obviously from wound complications standpoint. If they didn't have functional rehab then the the Nonoperative group did not do as well. And so what if I can give you a technique which eliminates the wound complications, allows the functional recovery in a more accelerated fashion, restores the length accurately. We're going to have a better result. The problem is we haven't had a way of doing that consistently because of the wound complications. The posterior ankle, the skin doesn't have a lot of pliability. Swelling works against you. Big long incision. It's relatively hypovascular. So if we can do it, minimally invasive if we've got a younger, more active population. A technique that restores length limits wound complications, allows rehab, and lowers the rerupture rate. And that's what the parse device does. So this is a Gordon McKay which you've seen previously with the Achilles tendon. Speedbridge. This is sped up. So I definitely he may operate this fast I don't. But what I'm showing you basically is the ease of the device. And so you start with a small transverse incision. You split your pair of tenon. The device slides inside the pair of tenon so that these sutures are all inside that pair of tenon. Two small incisions down on the calcaneus. You're putting two swivel locks in so you drill and tap. So this is no different than you're doing rotator cuff surgery, in essence. It's a curved banana lasso. You're going up through that through that distal piece. So I'm not passing any other suture. They're all going down through the distal tendon. Up through. And you confirm that you can feel it as it passes. And so there's not this big conglomerate suture not right at the right at the repair. So there's no knots in there. So from a vascular healing standpoint your tension. You see he passed point a little bit to get the appropriate tension. And then you put your two swivel locks in. So all you're attempting to do is restore length with stable fixation. Then you can close your pair of tenon. I think it would. It's helpful to add your platelet rich plasma at that point for your healing. As soon as you close the tenon, then you're injecting within the tendon sheath. So all that, all those sutures are within the within the tendon sheath. There's no knots, and you allow adequate healing. So when you're looking at tensioning, this is out of one of the Academy's devices. I do prep the other leg there in prone, prep the other leg, put the knee at 90 degrees and marry the resting tension of the other ankle. As you're putting this the first SwiveLock in. And this is one of his cases. And we can talk about level one evidence all you want to. But if you see cases like this, it makes you at least think of maybe we're on to something here. This is one of the athletes that was a bobsledder. Here he is in the left slot, eight weeks after repair with the technique that you just saw. Pretty stout fellow. Eight weeks. And here he is at 15 weeks in the Olympic trials for the bobsled. [00:18:54] What? What do. You want? So I think your common theme with all of these four topics really is this ability to protect my repair. So with the pronation, rotation, ankle fractures, immediate rotational stability of the loaded ankle, the TightRope plus the internal brace, the anterior inferior. And it's eliminated my need for any syndesmotic screws. I haven't used a screw in over seven years except for the diabetic peripheral neuropathy situation. The all inclusive ankle fracture set, which marries to the TightRope, and the internal brace and the internal brace technique for me, for the ArthroBrostrom, for the spring ligament with the posterior tib tendon reconstruction. And lastly, that Achilles tendon SpeedBridge with the pars device. Thank you.

Arthrex Foot & Ankle Innovation for Sports Surgeons

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