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Author Reply to “‘Ankle Arthroscopy: No-Distraction and Dorsiflexion Technique Is the Key for Ankle Arthroscopy Evolution’”

      I read with interest the comments of Drs. Vega and Dalmau-Pastor about my recent commentaries.
      • Ferkel R.D.
      Editorial commentary: Ankle arthroscopy: Correct portals and distraction are the keys to success.
      • Ferkel R.D.
      Editorial commentary: Osteochondral lesions of the talus—Are we going the wrong way?.
      Unfortunately, they are dead wrong! They clearly do not know or understand the history and evolution of ankle arthroscopy, and the numerous articles and textbooks I have written on the subject.
      If they think that the dorsiflexion and no-distraction method with large arthroscopes and instruments is the key to ankle arthroscopy, we are going backward, not forward. In 1984, Jim Guhl and I were performing dorsiflexion and no-distraction ankle arthroscopy. We developed the distraction system because we realized that we were missing and not treating a lot of pathology. Noninvasive distraction provides the surgeon the opportunity to see the whole joint, not just part of it. It allows the surgeon to work alone “hands-free” in both the front and back of the ankle.
      • Ferkel R.D.
      • Dierckman B.D.
      • Phisitkul P.
      Arthroscopy of the foot and ankle.
      It is incorrect that the dorsiflexion/no-distraction technique has fewer complications than the noninvasive distraction technique when compared side by side. In addition, the only reason why they advocate a large arthroscope is that they cannot get enough flow to keep up with the shaver using small joint instrumentation. They can solve this problem by having a dedicated inflow that avoids the potential problem of a pump but gives a high flow system that very efficiently irrigates the entire joint. The disadvantage of large arthroscopes and instrumentation is that they are associated with increased rate of cartilage dings and scratches. In addition, it is very difficult to maneuver large instrumentation through the small areas of the ankle joint without inadvertent damage. The only time I use a large shaver is when performing ankle arthrodesis, when cartilage damage is not a concern.
      As I have pointed out numerous times in my lectures and writings, we recommend “relaxing the distraction” and using a 70° arthroscope to work on the front of the joint, and increasing distraction when addressing pathology more centrally or posteriorly.
      • Ferkel R.D.
      Foot and ankle arthroscopy.
      The notion that the courses my colleagues and I have taught for years is not “third generation” is ridiculous. The authors clearly have not attended these courses or have missed their messages. The courses taught by the Arthroscopy Association of North America, American Orthopaedic Foot and Ankle Society, American Orthopaedic Society for Sports Medicine, and others throughout North America and overseas teach “cutting edge,” advanced, newer, as well as basic, techniques so attendees can be familiar and comfortable with all aspects of ankle arthroscopy. The Orthopaedic Learning Center (OLC) in Chicago was started more than 20 years ago, and I am proud that my partners and I at the Southern California Orthopedic Institute were founding members and financial supporters.
      My colleagues and I have put on numerous ankle arthroscopy courses at the OLC, and all techniques are taught there every time. This year's ankle arthroscopy course is October 5-6, 2018, and Mark Glazebrook and I are Course Chairmen. We are excited that one of our Master Instructors is Niek van Dijk.
      AANA. Course 811: New Techniques and Controversies in Foot and Ankle Arthroscopy and Sports Medicine.
      We have always taught all techniques, including his, so that each participant learns as much as possible. For example, arthroscopic ligament reconstruction is not a new technique. Hawkins and I were performing it in the 1990s. However, people such as Peter Mangone and Jorge Acevedo have helped refine and improve these techniques, and these are routinely taught at the OLC.
      • Acevedo J.I.
      • Mangone P.
      Arthroscopic brostrom technique.
      • Acevdeo J.I.
      • Mangone P.
      Ankle instability and arthroscopic lateral ligament repair.
      Both the OLC and Amsterdam Foot and Ankle School courses have contributed greatly to the education worldwide of surgeons interested in ankle arthroscopy.
      It is very narrow minded, immature, and incorrect to infer that the techniques that my colleagues and I have been developing and teaching are wrong and not state of the art. Our methods use all the newest techniques available or that are in development, and the outstanding published results of these confirm the validity of our methods. There is a time and place for different techniques in ankle arthroscopy and a skilled, mature, knowledgeable surgeon understands this and uses it to his or her advantage. Both techniques that have been discussed are not mutually exclusive, but rather, complement each other. Expertise is needed in all the various techniques of ankle arthroscopy to give our patients the best possible results.
      I suggest you attend this year's OLC course in Chicago, and you will understand how inappropriate your Letter to the Editor is. I look forward to seeing you there.

      Supplementary Data

      References

        • Ferkel R.D.
        Editorial commentary: Ankle arthroscopy: Correct portals and distraction are the keys to success.
        Arthroscopy. 2016; 32: 1375-1376
        • Ferkel R.D.
        Editorial commentary: Osteochondral lesions of the talus—Are we going the wrong way?.
        Arthroscopy. 2017; 33: 2246-2247
        • Ferkel R.D.
        • Dierckman B.D.
        • Phisitkul P.
        Arthroscopy of the foot and ankle.
        in: Coughlin M.J. Saltzman C.L. Anderson R.B. Mann's surgery of the foot and ankle. Ed 9. Elsevier, Philadelphia2016: 1723-1830
        • Ferkel R.D.
        Foot and ankle arthroscopy.
        Ed 2. Wolters Kluwer, Philadelphia2017
      1. AANA. Course 811: New Techniques and Controversies in Foot and Ankle Arthroscopy and Sports Medicine.
        (Accessed February 5, 2018)
        • Acevedo J.I.
        • Mangone P.
        Arthroscopic brostrom technique.
        Foot Ankle Int. 2015; 36: 465-473
        • Acevdeo J.I.
        • Mangone P.
        Ankle instability and arthroscopic lateral ligament repair.
        Foot Ankle Clin. 2015; 20: 59-69

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