And I'm going to talk to you about Anclin-Stability. This is collaborative work I've done with Dr. Stone, Takao, and Gilo, an international collaboration. I'll show you as we go here. I do have no disclosures other than I've done some work with ConMed on this. I don't have any royalties, and I just teach this technique under their umbrella in some of their labs. So that's the only real disclosure I have. So this is the problem that we have here. You can see this lady rolls her ankle, quite a severe injury. This is no doubt going to cause lateral ligamentous disruption, maybe some interarticular pathology. So this is a grade three severe sprain. You can see here on the drawer test of the ankle, the ankle completely subluxes out of the joint. So this is obvious laxity. And this will go on to chronic instability. We don't use this technique for acute instability. These are for chronic cases. So indeed, chronic ankle instability is what we're talking about, not acute cases. So what do you do for these? Well, probably a lot of you are doing an anatomic repair, the Brostom-Gould procedure. This is a really good procedure in the gold standard, which we should measure against. So you don't have to stop doing that. Reconstruction techniques are a little more robust. The historic reconstruction have been non-anatomic. You can see some of them here, the Watson-Jones, Christman-Snook, and Evans, and they've all had their problems. So we wanted to move to a more anatomical approach. The question is, is do you repair or reconstruct? For me, if the remnant ligament is insufficient or absent, of course, you can't repair. If it's there and it's robust, I will do a Brostrom. And you can determine this preoperatively with diagnostic imaging and clinical examination. Sometime, if we're doing an open procedure, we'll do it by direct visualization. If the remnant is insufficient or absent, then we'll move right to a reconstructive procedure. We looked at the literature here. This is a review of the literature that we did on open stabilizations, and you can see that the open anatomic reconstruction has grade A or B evidence to support it. So it is probably the best procedure that you can use compared to the open non-anatomic and open anatomic repairs. So this is, of course, if we can do it open and we can do it anatomic, that's great, based on the literature. And if we can do it more minimally, such as here, we all know that less is better. And of course, we've learned this from our colleagues in other areas with the shoulder and knee. So this, we moved to a minimally invasive technique through an international collaboration. And basically, it was a group of four surgeons, myself, Stéphane Guillot from France, Masato Takao from Japan, and Jim Stone from USA. So we worked on the technique we call the anti-roll. A is for ankle reconstruction of the lateral ligaments. So this is the ankle reconstruction of the lateral ligaments, a minimally invasive technique. Now this technique, we've published in four different formats. It can be done open, which is probably the best way to do it if you're starting, do an open procedure to get familiar with the technique. It can be done arthroscopic, percutaneous, and we now just published a hybrid technique. So the AOP and H anti-roll techniques. Now each of these different techniques have their own benefits. We can briefly go through these. The arthroscopic technique is great for concurrent pathology. However, it's technically challenging. It's difficult to master. You really have to know your ligamentous insertions and origins, and it's not as simple as it may sound. We've done many of these cases working on this technique, on the fibula, where we get the origin portions mixed up because of the difficulty to understand the anatomy. So it takes a good arthroscopist to do the anti-roll. The percutaneous anti-roll is easier, and I'm gonna show you how easy it can be when you get familiar with it. However, the fixation is uncertain. You're working through small incisions, and you're not really seeing the fixation of the devices, which you can see when it's open or arthroscopic. And also, of course, the percutaneous is not good for concurrent pathology. You don't address concurrent pathology. So you'll need an MRI ruling out concurrent pathology if you're using the P anti-roll, or at least be clinically sure. And last, the open anti-roll is good for concurrent pathology. It's very easy to master. It's a good starting point if you're gonna do the anti-roll procedure, and you can treat intra-articular as well with a larger incision. The anti-roll procedure was based on anatomic studies. In your bottom right corner, it was a previous fellow of mine, Kintaro Matsui, from Japan, who worked with me for a year, publishing a number of papers in this area. The key contribution that we found in developing our anti-roll technique is based on this Y graph. If you look at the diagram up on the left, you look closely at the ATFL and CFL, you can see that they have separate origin points. This is the way it's commonly drawn, but when you actually look at the anatomy, the second anatomical structure with Dr. Matsui looked at, in many catabolic specimens, you can see they share a common origin site, and this is the key to allowing the anti-roll anatomic Y graph using one tunnel. So we didn't have to use two tunnels in that very stingy real estate on the fibula. The other thing that we looked at was the lengths of these ligaments, and on average, with multiple cadaveric specimens that we published, the ATFL was 15 millimeters wrong, and the CFL was 30 millimeters wrong. Now there is some slight variations for smaller guys like me and other taller guys, but that's the average size, so this is what our anatomic Y graph is based on. So you can see here in this diagram, the anatomic Y graph has a 15 millimeter stem for the fibula insertion point, the tailor insertion point, and the calcaneal insertion point. Between the fibular insertion point and the tailor insertion point, there's 15 millimeters of graft, and between the fibular insertion point and the calcaneal, there's 30 millimeters of graft, and this is how the Y graph lays over in a cadaveric specimen. So the technique development, again, the arthroscopic anti-roll is the technically challenging one. This is the favorite procedure of Dr. Takao, and I think he's reaching about 100 of these procedures that he's been doing and we're studying in Tokyo. The percutaneous anti-roll is more my favorite operation because it's a little easier and less demanding. However, each of these different procedure has their benefits, as we already looked at, and you'll have to use what's best for yourself. The open anti-roll, again, a great place to start because you can see the fixation more and more using a combination of either of these procedures, whichever you want, and the most hybrid type would be the arthroscopic and the percutaneous combined, and we'll go through an example of that. So regardless of which technique you choose, there's five straightforward steps here. The first step is to construct your Y graft. The second is construct your fibular bone tunnel, then your tailor bone tunnel, finally your calcaneal bone tunnel, and deliver the graft. It really is that simple, it's not that hard. So here's step one, and we already went over the dimensions of the Y graft. If you are gonna be doing this arthroscopic, you're gonna be using different portals than you would for a standard arthroscopy procedure. So here you can see, we use accessory interlateral portals and a subtailor portal on your left. For the percutaneous, it's basically three stab incisions over the tunnels that you're gonna be fashioning. So here we are, this is an example of the percutaneous technique. So you can see we're constructing our fibular tunnel. This is done with a patient in the lateral position. You use a pin to get the exact anatomic origin of the common ATFL and CFL point on the distal tip of the fibula. You gotta be sure that when you pass this guide pin through the fibula that you're in the middle of the fibula on both lateral and anterior projections. If you do a hybrid procedure, you can see right here, this is having a look inside where you're looking at the arthroscopic location of the ATFL. Your next step, again, this is percutaneous, using the scope as you wish if you're doing a hybrid technique. This is the anatomic insertion point of the ATFL. That dot on your X-ray there, slide B, is exactly where the ATFL inserts. So this is a long guide pin that we're looking at on its long axis to show that we are in the exact location that we want this to be in, and you construct the portal there. And finally, step four is your calcaneal tunnel. This is much more straightforward, and the real estate is a little more generous, so we use a larger tunnel here and a larger interference screw to fix this. You have to be careful of the sertal nerve. It lies right over the insertion of the CFL on the calcaneal wall. So here you go. Once you get your three tunnels constructed and have them isolated, you can deliver your Y-graft through these three tunnels. And this is what it'll look like. You've got a minimally invasive procedure with three incisions and a small poke hole from the wire at the back of the fibula. And in this cadaveric specimen, you can see that it's near anatomic reconstruction of both the ATFL and the CFL. So I'll just run this video to quickly show you the whole procedure in its entirety. This is the percutaneous technique. We're passing the guide pin through the fibula here, making our bone tunnel 30 millimeters deep, six millimeters in diameter. You pass a single thread through it to isolate that tunnel. Next, your tailor tunnel across that tailor neck. This is all with fluoroscopic guidance, of course, to be sure you have your anatomic insertions and origins correct. Again, you're passing another passing suture through this tunnel to isolate the tunnel. Finally, your calcaneal fibular tunnel in the calcaneus with a third suture. Here we are delivering the Y-graft into the fibula. You can see here, when you're doing it percutaneous, you don't actually see it go in the bone. You just see it pass through the skin. Usually we put a guide wire in that tunnel for the delivery of the interferon screw prior to inserting the ATFL Y-graft. So in this technique, you can use whatever fixation device you want. I've had a number of people tell me that they're using different types of fixation. We're using the interference screws. So right here, this is not too difficult because the fibula is very subcutaneous here, and you know that you're in the fibula, and you know that your Y-graft is secure in that fibula, and you can see it disappearing. If you're uncertain, you can just open that incision a little bigger, and in the open procedure, you'll have a much larger incision, and you can see the whole technique. If you're doing this part, the percutaneous part, so what we're doing here is we're passing a hemostat through the delivery site at the fibula, and out a second portal along the tailor wall. So you run that hemostat right along the lateral wall of the talus. Then you take the delivery suture that you passed through the tunnel earlier, out through the delivery site. So it's a little bit of shuttling here because this delivery suture is gonna be the actual suture that pulls your ATFL stem through the talus. So you'll see here, we just pass this back through and attach it to the ATFL stem subcutaneously. Now this part is probably the hardest part of the procedure. You wanna be sure that you have your guide wire through the tailor tunnel, and when you deliver this interference screw with your ATFL stem in the tunnel, you really can't see it. So it's a bit of a leap of faith to know that you've got that stem in and you're putting that interference screw in the right position. But again, if you're starting out with this, an open procedure, you can see the whole show. Last is the CFL limb. You can see again, we're passing a hemostat along the lateral wall of the calcaneus. It's gonna come out through the portal here and pass it through. So with that, you have a percutaneous procedure done with the Y-Graft. And that is it. Thank you very much. That's fantastic work, lots of basic science.

ankle instability

minimally invasive technique

anti-roll procedure

ankle reconstruction

ligament origin points