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Patrick Mahomes Ankle, Chet Holmgren's Foot, And Minimally Invasive Surgeries for the Foot & ankle



We recently had Dr. Anthony Yi on the podcast. We talked about many injuries of the foot and ankle including the recent Patrick Mahomes high ankle sprain and the impact on his play and return to 100%. We also discussed the Lisfranc injury and the implications for athletes such as Jimmy Garoppolo and Chet Holmgren. This one was a fun one. Check it out anywhere you get your podcasts.


Dr. Anthony Yi

Foot and ankle surgery specialist

USC undergrad

Keck Medical School

University of Washington Ortho Residency

Fellowship trained at Harvard Brigham and Women's Hospital


If you would like to see Dr. Yi check out his website here

Follow him on IG @anthonyyimd




Full Transcript of the Podcast


Zach Smith: All right. We've got Dr. Anthony Yi on the podcast today, he is a foot and ankle surgery, specialist. And you've got an oppressive resume. When you read through, I'm like, man, you've basically checked off all of the coolest schools to go to the USC Undergraduate School. The CAC Medical School at USC University of Washington, trained, ortho residency. And then to top that all off, as if that was an impressive enough, you did the fellowship at the Harvard Brigham and Women's Hospital. Which is funny because every time I pull up a protocol it seems to come from Brigham and Women's Hospital. So I know they're doing a lot of great things in surgery and in rehab. So welcome to the podcast.

Anthony Yi: Oh, thanks so much for having me and I'm excited to be here and very flattering. But, you know, I'm very grateful to have had the opportunity to train with some awesome mentors and all those places certainly.

Zach Smith: Yeah. And and so, to jump right into it. You know, we had kind of messaged a little bit earlier today and and I wanted to get your thoughts because there's a lot of injuries that are happening currently and we're gonna drop this podcast ASAP because I want to talk about some, some injuries that, you know, some other people may have had that are listening to the podcast or maybe going through right now. And, you know, we kind of mentioned Patrick Mahomes. Did you see the video of the mechanism of that injury?

Anthony Yi: Yeah. So a pretty violent, you know, twisting injury to the ankle with a lot of weight coming down on it. So that's fairly classic for what is being reported as you know, a high ankle sprain. So what is the high ankle sprain? You know in distinction to the classic ankle sprain that we talk about or a lower ankle sprain, the mechanism and and the structures that are injured as is the biggest distinction. So with the more common ankle sprain, we often have people turning or twisting their ankle inwards or maybe misstepping off of a step. Or maybe they're on turf running around and they twist their ankle. And this is a little bit more of a lower in energy in general and with injuries to a different set of ligaments than what we generally talk about. When it comes to a higher anchor, ankle sprain, Higher angle. Strings are generally a little more. Higher energy with the ankle in an up position and violent twisting in order outward. And what happens is that? There's a series of ligaments, there's three main ones that make up what we call the cindasmosis, or basically a series of really strong ligaments that connect the tibia or the shin bone to the side, skinny bone, or the fibula, and you can have an injury to any one or more of these in combination that can end up, you know, with the with the high angle frame. And when you have a sprain as, you know, it it's generally referring to when one or more. Those ligaments is at least partially torn if not, you know, fully torn.

Zach Smith: And I was surprised by by the the level of his injury and how bad that looked and then his ability to continue to play. And then even play in the next game to walk me through a little bit from like your perspective. When you're doing an evaluation of that ankle and trying to figure out, you know, is it gonna be able to play, you know, and I know there's some surgical techniques that might come involved. What walk me through, kind of the different levels of of injury and then kind of the indications for treatment and, and how you can see that.

Anthony Yi: Yeah. So in general, you know we you know in the medical field like to try to have a grading system for how severe injuries are. And you know, I don't love putting things into categories as often not so clear but on one end of the spectrum, the most mildest you know form of injury you can think of the ligaments being stretched but not necessarily torn. And then on the other end of the spectrum, you can think of the ligament being completely torn, and then there's everything in between. So we generally categorize them as one grade, one grade, two grade three. So then that, in that manner,

Anthony Yi: In terms of things that I like to establish when and seeing a patient with this type of injury, one getting the story, you know, if there's film of it. Like if you're a high profile player like Patrick Holmes, you're gonna have some videotape with that laying eyes on that tape to see exactly what happened what the mechanism of injury was. And then directly just getting your hands on the patient. Taking a feel seeing where it's painful? Doing specific maneuvers. For example, there's something called a sydesmosis, squeeze test. So literally trying to in your hands, squeezing the tibia and fibula to see if that elicits pain, overlying, this and dismosis There are other different special tests that you can perform during the physical examination as well. And then the other on the other.

00:05:00

Zach Smith: Yeah. No, that makes sense. And and I think that's probably the advantage of these NFL players is. You know, they've got X-ray usually on site at the at the stadium. So they can at least get an idea that we're not gonna put this guy back in the game with a fracture in his leg. And then, you know, obviously, they're probably just taping the heck out of that thing to make sure that at least his ankle isn't rotating at the at the lower end as much that you know, maybe it won't put as much stress on on that. But really that it's funny because like high ankle and low ankle. The general public seems to not probably understand the difference because it is it is kind of confusing and so the the low ankle, you know, it's kind of as you said right where the foot connects to the ankle and then this is up in a little bit s*** up into the shin. How high up into the shin are people typically feeling the pain of that of that high angle spread?

Zach Smith: Yeah, yeah absolutely. And so with that once you know obviously Patrick Mahomes he's He's able to play. He didn't to me, didn't look as mobile as he normally is, didn't have as good of plant. Not honestly, frankly, I was pretty surprised. They didn't have an MCL injury on top of and maybe he does and and they're just like the the Thai ankle sprain is worse. Maybe you got a low grade, but the way he got landed on was definitely also could have been hey MCL mechanism in my eyes too. But he obviously didn't need surgery, but there are some surgeries to repair these correct? Like the, the tightrope. And and those can you kind of talk about that a little bit?

00:10:00

Anthony Yi: Two bones, but also allows for some motion to mimic and what we normally have. So if you imagine two strong metal buttons and a really strong suture in between, holding those two bones in the correct position, but at the same time, allowing for a very small amount of motion, that's that's normal between the two, the tibia and the fibula I generally try to use this method unless there's an obvious reason not to use it, because I fall a little bit more into that camp of thought, that argues for, you know, maintaining what our bodies normally do. So on a physiologic basis, there should be some motion. So this the suture button device allows for that. it also does a nice job of

Anthony Yi: Giving Stability to the Ankle Joint While it's excuse me, the sydesmosis join while it's while it's healing. Some situations,…

Zach Smith: Yeah.

Anthony Yi: where, I might be in lean towards a, screw would be if there's an associated fracture. The fibula that's heavily, comunuted, meaning it's into a lot of different small pieces and I need more fixation for fixation of that as well. Or if the bone quality is just really not where we need it to be. Those are some examples of situations where I might use a screw. But, you know, I lean towards more of that suture button fixation that you're referring to, just because it allows for some physiologic motion.

Zach Smith: Yeah. Yeah, that makes sense because in the PT world what we think about is, you know, if you take, if you take movement from one area, it's gonna pass that force to somewhere else. And so, because it's gonna limit, you know, one thing it goes to somewhere else. So that makes sense. And I've seen that I've seen some patients with that. It seems like a pretty good result. So, yeah, I've been pretty happy with the patients. I've seen that have had the tightrope done, so kind of going off of the sports injuries, another quarterback, those kind of in the news. And right now, one of the top prospects in the NBA Chet Holmgren,

00:15:00

Zach Smith: Jimmy Garoppolo is injury was reported as a Lisfranc injury. And it's good timing because I saw you just you just did a post on Instagram with kind of the signs and symptoms of Liz, Frank injury. You know, we hear it a lot. I think a lot of people don't really well understand what it is and it's fairly common in sports. At least he walk us through what the Liz, Frank gain injury is and then kind of the the treatment for that.

Anthony Yi: Yeah, absolutely. So Liz, Frank injuries are as you pointed out. Can be fairly common in certain populations, especially those who are putting a lot of stress on their feet. And what it refers to is the list frank ligament or or joint. So they're in the middle of the foot. You have you know, five metatarsal bones. So just like your hand, if you're flipping over sort of towards the middle of the long, skinny bones, those are called the metacarpals in your hand, in the foot. They're metatarsals. And in between the second metatarsal and another bone called the medial cuneiform. It's just right in the middle of the foot on this side towards your big toe.

Anthony Yi: There's a really big strong, ligament called the Lisfranc Ligament and it has several components to it. So the list frank injury. Can it can be fairly diverse and it can refer to a lot of different variations of injuries but basically what it is is a fracture and or a dislocation or ligament injury in the middle of your foot and you can imagine if someone's coming down with a lot of force with their toes pointed down towards the ground, there can be a lot of force that's transmitted right to the middle of your foot and can cause a fracture or a dislocation or both.

Anthony Yi: And classically again. It's when someone puts a lot of force down through their foot with their point, the toes pointed down, there's often what we call plantar, ecchymosis, or fancy words for just saying, bruising on the bottom of the foot. This injury is unfortunately, a can unfortunately be missed fairly easily if you if any, you know, patient or athlete that comes in with pain. In this region, you should

Anthony Yi: Really have a high suspicion for it and really do a thorough work up including X-rays and and even what we call weight-bearing x-ray. So having the patient put as much weight down on the ground with that foot and even the other side so you can have a comparison so you can make measurements to to really make sure you're not missing this injury. And the reason we don't want to miss it is that if it goes untreated it can cause a lot of problems. It it can lead to pain, difficult to using that foot and then down the line. problems with with arthritis settling in earlier than we'd hope for

Zach Smith: now the other definitely makes sense and it's an it's been an interesting one to watch because like I mean the foot injuries in general like for for NFL MBA, seem to be the most detrimental, a lot of guys get, you know, A A knee injury acl tear meniscus and you're basically know they're gonna come back. We've seen so many people in sports that have been sidelined for long periods of time with like just nagging foot injuries. And it seems like that diagnosis and then treatment becomes so important. I mean, I can think back to a lot of past players like daringly Fat and Ben Roethlisberger. Maurice Jones, drew like there's a lot of big time athletes that have had this have injury and so you know, from your perspective on on like a fairly significant one, Are you going to repair this with the same? I know you can use suture button and maybe is there, is there that still like that kind of controversy between suture button and and like, putting screws for these ones as well.

Anthony Yi: So there there is a bit of controversy. I think the main two options being one would be open reduction, internal fixation just a fancy way of saying that, we're going to operate on the foot set, everything into the correct place, and use the combination of either screws or plate and screws to hold everything in place while they heals. The second option.

00:20:00

Zach Smith: And you. And then you're removing those afterward.

Anthony Yi: Sorry, go ahead. It sometimes not not always having to be the case. But again some Surgeons will lean towards removing those at around the four to six months. After the initial surgery, once things have healed with the idea again of there is a small amount of motion going through those joints. And if you put a plate across that joint in a mobilize it you're eliminating that and then also

Anthony Yi: In young really high demand athletes and just not wanting to have that that plate or screw break over time because that can cause issues. and then in terms of the other odd main option,…

Zach Smith: Yep.

Anthony Yi: oh and then going back to answer your question with the Search button that that is A option, an option. Let's see. Probably a little less popular option, not as proven in the literature, but it can be used in certain situations. So i the idea being very similar, you know, using the suture button fixation to hold the bones in the correct position, and then letting it heal. And then the second main option is fusion. So the The Lisfranc injury generally spans across a joint. so, The idea of being providing stability by getting those two bones to diffuse together a bond together, be one. So that comes at the sacrifice of eliminating, a joint. However with the idea that it's it's rock solid, once it fuses together, there was a recent study a couple years ago a fairly well done study that suggested that the results suggested that in the case of a purely ligamentous Liz, Frank injury, so no fracture on top of it that patients might be doing better functionally with effusion as compared to doing the open reduction internal fixation route. I, I think it's

Anthony Yi: It's hard to say that one is overwhelmingly better are very clearly better than the other. So in my practice, I generally try to factor in a couple of things. One being, you know, the age and activity level of the patient.

Anthony Yi: The other factor being again. These these injuries can be highly variable especially in terms of how much bony involvement are there. For example, if the joint is is destroyed or broken into many small pieces and it's not necessarily reconstructible, I may lean towards a fusion for example because just fixing a joint that's gonna become arthritic. Anyways, is probably gonna leave the patient with some pain and stiffness either way. So and that situation likely lean towards a fusion, for example, but like the case in my post that was a young active individual who Whose joint looked great on the CT scan and it was mostly a ligamentous excuse me there wasn't there was a fracture but the joint was pretty well preserved. So, you know, I discussed the options with the patient and we ultimately decided to go down the route of fixing it with plates and screws with taking them out after everything, it healed.

Zach Smith: Gotcha. Yeah, and that seems like like you said, it's it's so dependent on what you've got. I was reading a paper earlier today before we jumped on what not a paper, but like kind of a report in there saying of the 28 NFL players that had this injury between 2000 and 2010.

Zach Smith: I was thinking about with, like, Jimmy Garoppolo versus like Chet Holmgren, it seems like he'll probably be out for the rest of the season. Jimmy Garoppolo said he was starting to practice this week. Potentially, if you, they would have been able to make the Super Bowl, he would have been available as a backup, but there would have been obviously certain risks. And I'm sure these risks for you're talking about here,…

Anthony Yi: and,

Zach Smith: where it's like the area might not be fully healed. You're putting a lot of pressure on the fixation. I'm not even sure if he had the surgery. Are you aware if he had it repaired or not? Jimmy Garoppolo?

Anthony Yi: I don't, I believe he did not. I'll be honest, I don't know, but especially with the faster timeline like that. It was probably one that fell into more of the stable category, not requiring surgery, but but still taking time to heal like the timeline that you mentioned.

00:25:00

Zach Smith: Yeah. No, that makes sense. Um, I want to move on to to some minimally invasive, ankle surgery, stuff because this you know, when I first talked to you on the phone we you know we kind of discussed some of this and it's an interesting topic because you know you hear a lot of spine surgeons and they like to advertise minimally invasive surgery and obviously if you if you're a consumer, you know, and you hear Oh you want the really invasive surgery or the minimally invasive surgery, most people are probably gonna opt for the minimally invasive surgery. So walk us through some of the minimally invasive surgeries that you do and then it actually perfectly pairs into what one of my what one of my pts was asking about and asking if you did the pars Achilles repair and I believe that's one of your surgeries is it not

Anthony Yi: Yeah, yes, I happy to talk about that. So minimally, basic surgery. It's actually, you know, one of my favorite parts of practice something. I'm personally very passionate about, but as a concept, it's it's the goal of performing safe effective surgery through incisions that are small as possible. With the goals of less pain and and getting the rehab process, jump started sooner than with more open technique. So minimally, invasive surgery, the main

Anthony Yi: tools and the toolkit are like for example arthroscopy which is using a small camera to put inside a joint and using special instruments to perform surgery through small incisions rather than a larger incision with it with And then, the another important tool is the minimally invasive burr. So this is something that

Anthony Yi: Has been a really fun to use in my practice. Mostly, I've really enjoyed using, but basically if you imagine a small burr on the order of a couple millimeters and there's different shapes and sizes for what whatever application you're trying to use it for But it's bins at low rpm so it doesn't generate too much heat, but it's still is powerful. It has a lot of torque so you can actually still cut bone with it, but if you were to run it and just put it on your skin, it would not tear your skin. It doesn't even cut the hair like on your forearm, if you put it on there. Um, but if, if you put it in the right application and in the right pressure, it's still powerful enough to to cut bone. So just as an example, for example, for a bunion correction, you know, most patients have heard horror stories about friends or personal stories of bunion surgeries. In the past of having abundant corrected and and the recovery process being pretty gruesome and bad. But with with this newer technique with the minimally invasive bunion correction, I make a series of very small incisions. Each only requiring using one or two stitches, I can use this burr to perform what's called an osteotomy. So a controlled cut of the bone to change the shape of the bone and then you screws to fix and hold it in place and it's been a game changer, you know, in terms of recovery, I let patience start walking on it, the day after surgery in general with the special stiff shoe called the post-op shoe And that's a huge acceleration and recovery compared to, you know, more traditional techniques, where you're waiting, six plus weeks to start putting weight on it. So and then to answer your question about Achilles repair,

Anthony Yi: So yeah, so I I use a minimally invasive technique for that as well. So the incision that I use is probably on the order of around two to three inches long, so pretty small and and I use a special instrument that I can insert around the tendon and and I can pass sutures through the tendon on both sides and repair it. Um, you know, traditionally many years ago, the way that we repaired Achilles tenant ruptures was to put a pretty big incision across the entire rupture. Find the ruptured clean it up and, and repair it. And, you know, those big incisions definitely make you lose sleep at night and because that area doesn't get great, blood supply. And so wound, healing complications and infections are very real risk.

00:30:00

Anthony Yi: but with the newer techniques of being able to use special instrumentation to, Perform incisions through much smaller and excusing perform surger through much smaller incisions. I think it's been it's sort of a wonderful in terms of the decrease in wound, complication rates, less infection and and then getting into that end, you know getting rehab going.

Zach Smith: Yeah. I mean, that's what that's kind of what? I'm, I haven't actually never seen anyone that's done yet. Done the PARS Achilles repair, but I'm looking at the pictures of it. It's pretty incredible. Like the size of the of the incision comparatively to, you know, I'm looking at your website. What's different comparatively to like, what? I typically see where someone's got a full zipper going up the entire back of the Achilles. And I think from like a rehab perspective to some of that incision impacts mobility and, and whatnot. So, pretty cool to be able to, you know, go in there and get get that done through. Just the. And that is that what they call the par system, the one that you have

Anthony Yi: Um so the pars system is is through a company named Arthrex. I don't have an affiliation with them with the, you know, make good products and but I actually use a different variation that's not affiliated with any company. Actually, it's a technique that I learned. In fellowship, but there's there's an instrument.

Zach Smith: Just a brand name or something like that is what the kind of horrors. and,

Anthony Yi: Yeah exactly exactly in different in some different companies have different variations of it. But basically, I can again an instrument that's fairly commonly used in operating room and and I've modified it. So I got a big fine rod bender. And this is technique that someone mentors taught me and fellowship that I continue to use.

Zach Smith: Oh, wow. That's that's pretty cool. I love the like the ingenuity of some of these. I think, you know what? Some people don't realize they're going to surgery is like, not every surgery is the same. And then you know, surgeons like yourself who have like these specialized skills and have created, you know, new tools to help them get more successful results. It's pretty interesting, I've been reading about and I've seen a patient a couple patients with this. Have you ever seen the The Syndesmosis Bunionectomy, Do you have any thoughts, or any any information on that? Because people are kind of activities with with the same kind of, it's not like a button and suture, but it looks very similar.

Anthony Yi: Yeah, so you're exactly right. It's actually just a smaller version of the suture button fixation that you use for this syndismosis injury. And the idea is

Anthony Yi: Some of my mentors again in fellowship were big proponents of this and put out a pretty well done research. Study on it as well, but the idea behind it is that the center of the deformity, why not attack or try to correct the bunion through right. Where the center the deformity is and that's done by changing the position of the first metatarsal. So as you know bunion is when the big toe starts to point towards the smaller toes in an often accompanying it, the first metatarsal bone can also start pointing the opposite way.

Anthony Yi: So the idea behind it is to put this suture button so one is going to be on the first metatarsal and others going to be on the second metatarsal and basically squeeze those together to bring that first. Metatarsal over to where it should be. And that and that corrects the the big toe as it swings over as well. Um, So I have I don't use that too much for my practice, because I've had really good success with the the minimally invasive technique that I described. Um, and I really enjoy, you know, letting patients, you know, start the weight bearing and rehab process early on. So I haven't found a need necessarily to do it through this technique, but, but I did use this technique throughout my fellowship training and I think it's

Anthony Yi: I think in certain patients is certainly a reasonable consideration, but but I haven't had to resort to using that technique too much in my own practice currently, because of found really good success with the minimally invasive technique.

00:35:00

Zach Smith: Yeah, like that that you're able to weight bear people earlier because that's that's one of the things that people don't want after surgery is like, Do I have to be on one of those knee scooters or on crutches for like, six or eight weeks? And I know this one, you're able to bear a little bit of weight, but it is very limited because I think there's a concern for second metatarsal fracture. That happens with this right with that with the other verse.

Anthony Yi: Yes. So with the suture button, fixation of the tightrope correction the bunyan, there are cases of second metatarsal fractures and Second terminal, stress. Fractures also and and one of the things when we, when I looked through, some of the studies and talked to, some of my mentors who did did this technique a lot was

Anthony Yi: The technique is really important so in terms of so you do have to put a wire across the first and second metatarsals and then you drill over those wires and then you put the future button across and so the placement of that wire is very important so that can contribute to stress fractures. So the technique is very important.

Zach Smith: Yeah, no, I think that's that's a, that's a great point to make in. And, you know, for anyone listening that's, that is dealing with an ankle or foot injury, if you want to see Dr, Yi and your local to the Greater Seattle area, or even if you want to fly out here and see one of the top specialists in the country. Dr. Yi practices at the orthopedic specialist of Seattle, we'll kind of link up your website. Anthony Emd.com. You can also find them at the orthopedic specialists of Seattle website. I've been really loving the content, you've been posting. I've been been watching everything you post. I have the alerts up on your posts. I'm seeing everything Anthony EMD on Instagram. Is there. Anyone anywhere else you want people to be able to find you through listening to this podcast? They're interested in getting um, some some info from you.

Anthony Yi: Amazing. Mainly my website, you know, that I try to keep that pretty up-to-date. And then if I have interesting cases and you know, I'll be sure to continue to post those.

Zach Smith: Awesome. We appreciate your time, I will link up all those places in the show notes here and then we'll get this up pretty fast so that people can hear about how these Super Bowl will be impacted by the Patrick Mahomes injury.

Anthony Yi: Awesome. Well thanks for having me is awesome talking with you Zach.

Zach Smith: Yeah. Thanks Dr.

Zach Smith: All right. And according there. Appreciate you coming on doctor you. That was awesome.

Anthony Yi: Yeah, that was a lot of fun. Thanks for, thanks for having me, you know?

Zach Smith: Yeah, maybe if there's anything else like in the future of someone, you know, gets a foot and ankle injury or we want to come and talk on about stuff. We'll keep in contact via text and stuff and then if anything pops up, that's like big. Like the Patrick Homes ones are pretty pretty relevant topic for the upcoming, you know, Super Bowl. So that was fun. I appreciate and…

Anthony Yi: Yeah. For sure,…

Zach Smith: enjoyed your time on on the podcast.

Anthony Yi: thanks for having me.



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