Name: Chronic Ankle Instability Case Presentation
Uploaded: 2026-05-18T00:00:00Z
Channel: Arthrex

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Kaitlin Neary, MD (Boise, ID), shares her surgical approach for chronic ankle instability patients using DX Knotless FiberTak® anchors and the InternalBrace™ ligament augmentation repair.&nbsp;
 
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

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VID1-009094-en-US | A | Chronic Ankle Instability Case Presentation

Kaitlin C. Neary

Surgeons presenting one or more clinical cases

Chirurg:innen präsentieren einen oder mehrere klinische Fälle

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Cirurgiões que apresentam um ou mais casos clínicos.

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Chronic Ankle Instability Case Presentation

Speaker  Hi I'm Doctor Caitlin Neary. I practice at Catalyst Orthopedics in Boise, Idaho. And I'm going to present a case of a patient that I saw with chronic ankle instability. This was a 32 year old female. She was a previous division one soccer player. So as a result really had a history of recurrent sprains. Over the course of many years. She was now a popular physical therapist in town. She'd rehabbed a lot of my patients who had undergone the brostrom procedure, and finally came to me saying she had experienced progressive, debilitating ankle pain and instability and was ready to take care of things after, of course, many years of dealing with recurrent sprains on exam, she had tenderness to palpation really everywhere, anteriorly over her ankle joint line, laterally over the sinus tarsi and the lateral ligaments medially over the deltoid ligament. She had significant laxity with testing of both Atfl and CFL, with a positive drawer test, positive clunk test during testing of atfl, and really had a significant amount of subtalar instability due to the laxity of her CFL. She had no peroneal tendon pain, no peroneal tendon instability, but did have anterolateral ankle pain with cross leg exam and applied external rotation, which of course cues us into a possible syndesmotic injury. I obtained an MRI which revealed a few findings. First and foremost, she had chronic tearing of both Atfl and CFL as well as her deltoid ligament. There was questionable chronic syndesmotic injury with increased edema on T2 imaging within the distal tibiofibular joint, which of course brings high suspicion for us in osmotic injury that may be subtle in nature. Speaker  She also had peroneal tenosynovitis and a mild intra articular effusion. Not all instability is treated the same, although we do see a lot of patients that come to us with chronic instability. They don't all have the same presentation and they don't all have the same pathology. And I think there's a lot of considerations to to think through when you see a patient like this. So here are all the things that are going through my brain. When a patient like this comes to my clinic, first and foremost, am I going to use arthroscopy? Am I going to scope the patient? And for me, I think it's important to use arthroscopy with every single patient with instability. The reason being, not only can you evaluate and treat intra articular pathology, but you also can evaluate for subtle instability of the other ligaments aside from your lateral ligaments, including the syndesmosis and the deltoid ligament, which you'll see in this case proved to be really beneficial. The next question is if there is syndesmotic instability, how do you evaluate it? Are you using your shaver up into the distal tibiofibular joint? Are you stressing the ankle? There's a lot of ways to evaluate for that subtle syndesmotic instability. The next question that I ask myself are which ligaments am I going to address? Is it just Atfl only or Atfl and CFL? And I think for all of us, this is a case by case basis. Speaker  The other question is, do you address the deltoid, especially if it's asymptomatic? And I think that that's something that's debated. And I think as the primary stabilizer of the ankle, something that we're learning more and more should probably be addressed. The next consideration is the approach to the ligaments. Do I primarily repair the ligament? Do I augment the ligament with the internal brace. Does this patient require allograft. And of course there are certain scenarios where any of those may make sense, which patients get augmentation. In my clinic, the majority, not all, but the majority of patients get augmented with the internal brace. Because I truly do believe that the lateral ligaments need that Checkrein need that seatbelt to keep it from stretching out, and also allow accelerated rehabilitation without worrying about your repair failing. There's the consideration of your repair construct. Which anchors do you use where? I use two knotless fibre tacks in the fibula with a guide tunnel for the internal brace centered between the two anchors. And then, of course, I doc the internal brace into the neck of the talus at the Atfl footprint, but I think it's important to make your augmentation as anatomic as possible. And then finally, if your syndesmosis is unstable, which you'll see in this case, hers was what do you use? Do you use a tightrope for her instability? Do you use the atfl internal brace and when and where do you use those constructs? So I think there's a lot of considerations that we think through. Speaker  And it's important to note that not every instability is the same. So here you can see what I did first and foremost started out with arthroscopy. And there's no question that syndesmosis is unstable. You can see there's significant anterior to posterior translation of the fibula in the sagittal plane. You can also see that that four millimeter shaver is easily inserted up into the distal tibiofibular joint. So for me, that's the answer I need. I knew I needed to fix the syndesmosis. Here's the construct I use for the fibula for my broström procedures. You can see the internal braces located centrally with a knotless fiber tack on either side. Once the fiber tacks have been placed here, I'm using a reverse mattress fashion through the Atfl to really give a nice cuff of tissue. Get a nice repair where you can bring the entirety of the ligament back down to the fibula so you can see those sutures being passed in this portion. Now here's the tensioning. And so you pull the working suture through the locking mechanism. Then you take the repair suture. And as you slowly do tight small little tugs, you can see in slow motion just how much of that cuff of tissue is advanced onto the fibula. It's really quite remarkable how much advancement you can get of the tissue, and how even of a repair you can really get. Speaker  Here's another example where you can really see the advancement of the tissue back up onto the fibula. I think that's the beauty of the anchor is you get a much more biomechanically sound repair. Now, I've placed the internal brace anatomically over the atfl and saved the tails. And this is an easy way to use your internal brace not only to augment the atfl, but also augment atfl. So I'm marking, drilling and tapping into the tubercle of the tibia, marking the laser line on the anchor to make sure that I tension appropriately. And you can see now I've docked the tails from the fibula into tubercle of the tibia to give a nice augmentation of the anterior inferior tibiofibular ligament or atfl. So it's a great way to stabilize both your lateral ligaments, your atfl as well as your atfl. And of course, don't forget the deltoid. It's the primary stabilizer of the ankle and important for rotational stability. So you can see here using the knotless fiber tacks medially. Once again you get a really nice cuff of tissue being advanced up onto the medial malleolus. So the next considerations for me revolve around the internal brace and the use of the internal brace. I think the first consideration is the utilization of the internal brace in our practice. And I think that of course, every surgeon is different, and we all look at every patient and decide whether or not this is something that they would benefit from. Speaker  But for me, I use it for every single patient. I think that everybody has the same right to accelerated rehabilitation. They have the same right to a successful outcome, and they have the same right to access to innovation. And this is an implant that truly can accelerate rehab and improve the success rates long term. And so I believe that every patient should have access to that. And it's something that I use for the majority of my patients during Brostrom procedure. There are some tips and tricks and challenges with the internal Brace that I think we're all aware of. I think the biggest thing is the tensioning. You want to make sure you do not over tension the internal brace, because that can cause pain and other problems. But at the same time, you don't want to under tension the internal brace because you then render the implant ineffective. It doesn't provide that checkrein or that seatbelt. So for me, not only do I use the laser line in the markings on the anchor itself to help with tensioning, I really focus on position of the foot. I think that's the most important thing. So I keep the foot in neutral, eversion and inversion and 10 to 20 degrees of plantar flexion at that position. That's where the atfl is at maximum stretch. That's when you want to protect it. Speaker  That's where it's at. When people sprain the sprain their ankle and tear their atfl. So I keep the foot in that position. And when you have the foot at that position, you really can't overtension the internal brace. It won't let you. But what's nice about placing it in really secure with the foot in that position is when the patient brings their foot up in dorsiflexion and eversion, the internal brace becomes loose and doesn't cause impingement. Anterolaterally. The final consideration is post-operative care and what our protocols look like, and I think there are a lot of questions around this. Here you can see an example of my protocol for the first week. I make everybody rest. I place them in a splint, keep them non-weight bearing strict elevation, let their incision get some good early healing. But after a week I allow them to start walking in a boot. I allow them to start physical therapy and give them an ankle brace and tell them it's kind of self-guided, self-directed therapy. From there, I don't have any restrictions after a week and then have them follow my protocol with their physical therapist. The ultimate goal is full recovery somewhere between 9 and 12 weeks. And that's what I quote my patients. And we know that's probably pretty accurate. Based off the study published by Collin et al, in Foot and Ankle International. And so the goal is always by three months to have patients back to full activity.

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Chronic Ankle Instability Case Presentation

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