Hey everybody! Welcome to this months episode of the Ankle Surgery Update – Science guiding treatment! Thank you very much for tuneing in again. We hope you will find the following paper picks interesting. As always, you can find this podcast on all common plattforms and feel free to join us at FuSpruLMU. The picks for this session are:
Hey everybody! Welcome to this months episode of the Ankle Surgery Update – Science guiding treatment! Thank you very much for tuneing in again. We hope you will find the following paper picks interesting. As always, you can find this podcast on all common plattforms and feel free to join us at FuSpruLMU. The picks for this session are:
Hi, everybody, welcome to this month's episode of ankle surgery update science guiding treatment. Thank you so much for tuning in again. We hope you will find the following paper pics interesting. As always, you can find the podcast on all comm platforms and feel free to join us at foods through LMU. The pics for this session are magnetic resonance imaging and outcomes of osteochondral lesions of the tailor's associated with ankle fractures by ch in its gun and colleagues published in foot and ankle International. For the second part, we actually pick two papers and arthroscopic reconstruction in chronic lateral ankle instability. One studies entitled all inside endoscopic and atomic reconstruction leads to satisfactory functional outcomes and patients with chronic ankle instability, by giggle at all published. Casta the second studies entitled arthroscopic assisted versus all arthroscopic ankle stabilisation technique by gofio at all published in foot and ankle International. So let's take it from here. The first study of this episode is entitled magnetic resonance imaging and outcomes of osteochondral lesions of the tailors associated with ankle fractures. By section it's a gun at all published in for the ankle International, concomitant condra lesions and anchor fractures to us is one of the most discussed topics and anchor fracture care right now. Ankle fractures are frequent and often doomed educational operations for residents. But the outcome, especially with increasing complexity is far from optimal. One reason for those inferior outcomes could be untreated into particular pathologies. That's again and colleagues conducted a prospective study on the incidence of osteochondral lesions after ankle fracture treatment The clinical relevance and early follow up 30 patients were treated operatively 26, non operatively 56 consecutive patients with a mean age of 45 plus minus 13 years were prospectively enrolled post operative MRI using a 1.5 Tesla scan were performed in the second month after injury. osteochondral lesions were classified according to handle at all. in patients with an osteochondral lesion that were symptomatic for more than six months. revision surgery was a considered the patient rated outcome was assessed at two months and second year using the eo f as the quality of reduction was rated as an atomic in about 70% of patients. Whereas the reduction the remaining patients was acceptable. No delayed or non union occurred. osteochondral lesions occurred in 35% of patients with a vast majority almost 80% being condra lesions. One patient suffered displays Condoleezza Rice and was treated by micro fracturing six months following the initial procedure. Interestingly, the occurrence of an osteochondral lesion was not affected by the fracture mechanism, the fracture severity per the Dennis vevor or longer hands and classification and unstable syndesmotic injury or the treatment methods IE conservative or operative treatment, but osteochondral lesions occurred significantly more often than patients with an acceptable compared to an anatomical reduction. Let's have a look at the clinical outcome. Although patients with an osteochondral lesions had a significant high i o f score in the second post operative month, no significant differences were observed in the second post operative fear at this final follow up the mean eo f score was 81 plus minus seven points in those patients with an osteochondral lesion and 86 plus minus eight points without osteochondral lesions. Interestingly, they did not find significant decrease for the OCL group p equals 0.026 and a significant increase for patients without an LCL p smaller 0.001 between the second year compared to the second month control.
Unknown Speaker :Thanks, Sebastian. Ankle fractures are common and we strongly believe that osteochondral lesions are a major issue. Actually, several societies already recommend arthroscopic assisted treatment for ankle fractures. Still, recent studies analysing insurance databases showed that just about 1% of patients suffering an ankle fracture are actually treated arthroscopically assisted. To me the greatest aspect about this study is its perspective design. I strongly want to encourage the authors that they further follow up these patients. It does give us the unique opportunity to see the natural course of these intra articular lesions and their effect on the patient rate of outcome. We actually started arthroscopic assisted surgery for more complex ankle fractures several years ago and have published our one year results with 32 patients. At one year follow up the median score was 94 points and the O ma score 90 points. But in contrast to this study by eska and colleagues, did we assess the khandro lesions by direct visualisation during arthroscopy and treated any icrs grade for lesion by micro fracturing? This could explain the difference of about 10 points in a score between the two studies. In our court. 91% of patients had some sort of quandra lesions, but full thickness lesions were observed only in bi and tri malayala fractures at a range of rate of about 40% but not in uni Melia fractures. Sebastian, you said it's kind of I'll use the hippo classification. Do you think this could be a limitation of their studies?
Unknown Speaker :That is a great point. Hence, the classification by hapless is a broad classification for osteochondral lesions. This classification grades as follows. type one a condra lesions type two A and B are cartilage injuries and bony fracture with or without bony edoema. Type three and four are detached, bony fragments displaced or non displaced and type five or subchondral cysts, but the vast majority of lesions observed but that's going at all were camera lesions just as we did, but these were not further subclassified you introduced our study in which we did differentiate the observed camera lesions by the icrs classification. Using this classification, we were able to show that full thickness cartilage lesions thus lesions that necessitate treatment are more common and by and try Malila fractures. Maybe the authors should for the next follow up study differentiate the condra lesions per the icrs classification or what do you think
Unknown Speaker :I fully Agree, but I would like to address one more general point. I think we both agree that we are not too happy about the way the term osteochondral lesions is used. Most authors is done in this study also use this term osteochondral lesion inconsistently to me when talking about ankle fractures, we should talk about intra articular pathologies. These include loose bodies, soft tissue lesions, condra lesions, and osteochondral lesions osteochondral lesions to me are different entity compared to conroe lesions. Moreover, their treatment is completely different. Whereas non displaced fragments can be treated non surgically displaced fragments necessitate early surgery and re fixation therefore these are rather treated as fractures. There is one more thing I would like to briefly discuss the author's use plain radiographs to classify their fractures and to assess the quality of post operative reduction. To us, we must ask for preoperative CT scans, not only to safely classify these fractures, but also to make a sound treatment plan. One study actually compared preoperative planning based on radiographs and on CT scans. If I remember correctly, planning on CT scans resulted in a change in the treatment plan in about 20 to 30%. Finally, we also conduct post operative CT CT scans whenever we address on this market instability. In case we do a bony relaxation of the poster and or Andrew send us Moses we conduct unilateral CT scans in case of a purely dementias as soon as more instability. We even conducted bilateral CT scan to assess the reduction of the fibula into the tibial notch.
Unknown Speaker :Thank you very much chance. As stated Initially, I believe that the biggest value of this study is its design and natural history study. This means it does investigate The cause of a disease in this case osteochondral and quandra lesions without any intervention, I believe both of us are very excited to see five year results. This might give us a distinct idea on how patients with or without an osteochondral lesions progress over time. Furthermore, it again does highlight the frequency of intra articular pathologies in ankle fractures.
Unknown Speaker :Thanks Sebastian for the nice sum up. But there's one more thing I would like to state that's kind of treated a patient with the six months old osteochondral lesion by micro fracturing, they did not present the images of this case and therefore, we do not know the actual morphology of the lesion. But in case of an actual chronic osteochondral lesion, one it should address the bony defect as well as the cartilage. In this case, we prefer to do an emic but this is a whole new discussion.
Unknown Speaker :Thanks, Hans. That is an important comment. And the whole topic of chronic as well as acute treatment of osteochondral lesions does most likely for more than one Episode, but let's have a look at the next two papers we chose for this episode. Both deal with us with Copic repair for chronic lateral ankle instability right
Unknown Speaker :before your start with a paper presentation Sebastian chronic lateral ankle instability is a topic that fits well to the first paper. In chronic lateral ankle instability. Accompanying khandro and osteochondral lesions are well accepted for my understanding the discussion on doing an arthroscopic or open stabilisation for chronic lateral ankle instability is not closed, but the mass majority of researchers and colleagues agree that due to the high frequency of intra articular lesions, any patient treated for chronic lateral ankle instability should be scoped prior to the stabilisation. But now please present the paper to us.
Unknown Speaker :Thanks for this comment hands and just to ensure you before we start, both papers did a thrust up prior to the procedure. But let's see what we actually picked the first of the two papers. I would like to present is entitled all inside endoscopic anatomic reconstruction leads to satisfactory functional outcomes in patients with chronic ankle instability and was just published in Casta. There are multiple open arthroscopic techniques described for anatomical reconstruction and chronic lateral ankle instability. The authors presented in 2016 a new technique in brief, they use aggressive tendon autograft, which is fixed to the taters and calcaneus and tension through oblique fibula tunnel using a suture button system and the current study, they want to evaluate the functional results and complication rates using this technique, with a minimum follow up of 24 months 34 patients were included in the retrospective study all underwent all inside endoscopic anatomic reconstruction of the atfl and CFL in the technique described by the authors in 2016. The records are screened amongst others for complication rates and the patient rated outcome was assessed using the eo FHA score carsen score and the anchors tivity score. The prompts were assessed at a mean of four plus or minus 1.6 years after surgery, the overall complication rate was 18%. One patient was re operated for hematoma and five had removal of the fibula cortical fixation device. Because of discomfort, the prompts assess should go to excellent results. The eo f score improved from 60 to 94 plus minus six points, the Carson score from 49 to 87 plus minus 10 and 97% of the patients returned to the same ankle activity score as preoperatively. The authors concluded that the technique grants satisfactory functional results at a minimum of 24 months, but the high rate of implant removal calls for improvements of the design or positioning of the fibric cortical fixation device. The second
Unknown Speaker :paper was published at foot and ankle international in entitled f horoscopic assisted versus all arthroscopic ankle stabilisation technique by goofy and they use two different endoscopic methods. The first technique, the so called metho scopic. Brostrom procedure to suture anchors are being placed arthroscopically into the anterior aspect of the distal fibula. The four sutures pass through the skin in a safe zone between the perennial attendance and the dorsal cutaneous nerve. Finally, they are shuttled percutaneously through an additional incision and tied the second technique they are fo scopic all inside ligament repair is performed through three portals. In brief, the Taylor atfl remnant is augmented with a fibre wire and fixed to the distal tibia using a push lug anchor. The author's included 39 consecutive patients 20 of which were treated by one surgeon using the arthroscopic procedure and procedure. The remaining 19 patients were treated by another surgeon using the arthroscopic all inside ligament repair technique. Both groups did not differ per demographics or follow up time. The author's again assessed amongst others the complication rate and the patient rated outcome using the FA score and the boss. Significant more complications are cured in the endoscopic Brostrom group. 40% of the patients in the endoscopic grocery group suffered a complication for patients reported plantar flexion deficit of more than 10 degrees compared to the contralateral side. Three patients suffered a transient Noire it is off the superficial apparently on nerve and one patient required anchor removal because of a prominent suture not only one patient, which equals 5% suffered a complication in the arthroscopic all inside ligament repair. This again was a plantar flexion deficit. For the clinical outcome scores. No significant differences were observed between the two techniques at an average follow up 1.7 years after the surgery, the A or FA s score was about 92 points and then boss one point on an 11 item Likert scale. The authors concluded that both techniques are suitable options, not the arthroscopic procedure and procedure had a considerably higher complication rate.
Unknown Speaker :Thank you, Hans for this nice presentation. But let's talk about a few general limitations. Obviously, the first study was retrospective with all the associated limitations, but the authors apparently have a clinical protocol in place in which all patients are scored preoperatively. For the second study, it remained unclear to me whether it was prospective or retrospective. One limitation both studies is that the authors do not report on concomitant intra articular pathologies. But for the second study, this could be explained as the presence of a tailor osteochondral lesion was an exclusion criteria identified By MRI, which again, we know it's not 100% sensitive, and why we were recording the podcast, we actually had a discussion on the different repair techniques, could you maybe outline the three predominant repair techniques?
Unknown Speaker :Thanks, Sebastian. So, we distinguish three different repair techniques, namely the non anatomic reconstruction, the anatomic reconstruction, and the direct repair. For all these three, we have ethosce kopaka techniques and open techniques. In general, the reconstruction is based on augmenting the ligaments using mainly tendons, while the direct repair uses the scar tissue and the ligament remnants to augment and fix the stability of ligaments. Thank you very much.
Unknown Speaker :I think I got it. The first study use a non anatomical reconstruction they harvested the graceless tendon from the ipsilateral On the obviously affecting a knee or a side of the body that would not have been affected if we would have done an anatomic repair. Overall, they report a return to previous activities of 97%. That sounds pretty high to me.
Unknown Speaker :Yeah, that's pretty astonishing. Actually, fact we have two aspects. It's not only the donor site morbidity, but it's also the result at the ankle itself. Because previous studies showed by transplanting a ligament to the ankle, you will change the kinematics of the ankle, and therefore a lot of previous studies showed inferior results for any reconstruction method against the direct repair. This is why the vast majority of authors nowadays consider the direct repair the gold standard, and the authors, as you stated are reported return to previous activity level of 97%. That's even for studies performing and direct repair. Outstanding. So I do not have a good explanation how they came up with these really good results.
Unknown Speaker :Let's have a look at the horoscopic broaster procedure that is the predominant procedure we perform for our first cases, not for revision, but for the first Gulf. He had all reported a complication rate of 40%, which is considerably high. We have not done the math on our cases yet. But I would assume that if we reserve temporary superficial peroneal nerve and our riders in about 20% of the patients, that's something we would be aware of, do you think the study is going to change our procedure?
Unknown Speaker :That's a good point and I fully agree with you we have not systematically followed up our patients. But still we would have recognised such an really high complication rate, I'm sure. And we did not observe either the high superficial peroneal nerve injuries nor the high rate of limited range of motion. So maybe It's a technical aspect which might lead to this really, really high complication rate. I still believe that we should stick to the arthroscopic poster, but we will definitely will be more aware for the range of motion and this kind of limitation in the future.
Unknown Speaker :Maybe we're not aware enough of plantar flexion deficit. And this might be a limitation for certain sports groups that necessitate maximum plantar flexion, such as delayed answers. And maybe in the future, we should have a look at the old insight technique for certain cases as those reports were really promising as well.
Unknown Speaker :Thanks, everybody for listening to this session of ankle surgery update signs guiding treatment. We hope you enjoyed it as much as we did, and we hope you all will tune in next time. As always, you can find us on almost all podcast platforms, and feel free to follow us on foosball