Anterior ankle bony impingement with joint motion loss: the arthroscopic resection option

A Smaller Tibiotalar Sector Is a Risk Factor for Recurrent Anterolateral Ankle Instability after a Modified Broström-Gould Procedure

BACKGROUND

Several demographic and clinical risk factors for recurrent ankle instability have been described. The main objective of this study was to investigate the potential influence of morphologic characteristics of the ankle joint on the occurrence of recurrent instability and the functional outcomes following a modified Broström-Gould procedure for chronic lateral ankle instability.

METHODS

Fifty-eight ankles from 58 patients (28 males and 30 females) undergoing a modified Broström-Gould procedure for chronic lateral ankle instability between January 2014 and July 2021 were available for clinical and radiological evaluation. Based on the preoperative radiographs, the following radiographic parameters were measured: talar width (TW), tibial anterior surface (TAS) angle, talar height (TH), talar radius (TR), tibiotalar sector (TTS), and tibial lateral surface (TLS) angle. The history of recurrent ankle instability and the functional outcome using the Karlsson Score were assessed after a minimum follow-up of 2 years.

RESULTS

Recurrent ankle instability was reported in 14 patients (24%). The TTS was significantly lower in patients with recurrent ankle instability (69.8 degrees vs 79.3 degrees) (P < .00001). The multivariate logistic regression model confirmed the TTS as an independent risk factor for recurrent ankle instability (OR = 1.64) (P = .003). The receiver operating characteristic curve analysis revealed that patients with a TTS lower than 72 degrees (=low-TTS group) had an 82-fold increased risk for recurrent ankle instability (P = .001). The low-TTS group showed a significantly higher rate of recurrent instability (58% vs 8%; P = .0001) and a significantly lower Karlsson score (65 points vs 85 points; P < .00001).

CONCLUSION

A smaller TTS was found to be an independent risk factor for recurrent ankle instability and led to poorer functional outcomes after a modified Broström-Gould procedure.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Anterior Ankle Impingement Syndrome With Spur Fragmentation: Is It an Os Talotibiale?

Background

Bone fragments are often found in ankles with anterior bony impingement. However, whether they are detached osteophytes or accessory bones remains unknown.

Methods

Among the 66 continuously enrolled cases of ankles with anterior bony impingement, 32 had a fragment located at the anterior margin of the tibia. The cases of posterior impingement, lateral instability, osteochondral lesions, or free bodies simultaneously treated were excluded. The enrolled subjects were classified into 2 groups: ankles without (group A) and with remarkable spurs (group B). The patients' backgrounds, location of the fragments, clinical scores, and other parameters required to resume sports were compared. The Japanese Society for Surgery of the Foot (JSSF) ankle rating scale was used to evaluate preoperative and postoperative ankle conditions, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) was used to evaluate postoperative sports abilities.

Results

Eight (seven subjects) and 11 ankles were classified into groups A and B, respectively, and the mean age of the 18 patients was 25.4 (range, 16-37) years. No statistical differences in patient backgrounds or fragment sizes between the groups existed. In group A, the fragments were located on the lateral plateau in 7 of the 8 ankles, whereas in group B, their locations varied. The patients were followed up for a median of 48 months (range, 24-168). No complications were observed. The postoperative JSSF and SAFE-Q sports activity scores were significantly higher in group A than in group B (P <.01 and <.001, respectively). The postoperative term to return to their original sports activities was significantly shorter in group A (P < .05).

Conclusion

Anterior bony fragments of the ankle without a remarkable spur were located at a specific site, and the results of arthroscopic treatment were better than in those with remarkable spurs. Such a fragment may be called an os talotibiale.

Level of Evidence

Level III, retrospective cohort study.

Clinical and Radiological Mid-to-Long-term Outcomes Following Ankle Arthrolysis

BACKGROUND

The aim of this study was to evaluate the clinical and radiographic success of arthrolysis surgery and the risk of progression of osteoarthrosis at the ankle joint.

MATERIALS AND METHODS

In a retrospective clinical and radiological study, with a minimum follow-up of 24 months, the pain level and quality of living were evaluated.

RESULTS

Following arthrolysis of the ankle joint, 16% of patients required ankle fusion within 2 years. Women had a higher quality-of-life in terms of Foot Function Index. Younger patients scored higher in both quality-of-life and function scores. Radiographic osteoarthrotic changes and the specific follow-up interval did not correlate with clinical outcome.

CONCLUSION

Fewer than 20% of patients required ankle fusion. Female gender and young age had a positive impact. Preoperative radiography and the postsurgical interval are poorly predictive for the progression of osteoarthrosis.

Prevalence and location of bone spurs in anterior ankle impingement: A cadaveric investigation

Anterior ankle impingement (AAI) results from repetitive microtrauma leading to pain and decreased dorsiflexion due to spur formation and synovial hypertrophy. Information about the prevalence of anterior spur formation in a large population, and the individual contributions of the talus and tibia to osseous impingement, is limited. A total of 670 ankle specimens from 344 individuals (n = 111 females, n = 233 males) aged 20 to 40 years at the time of death were examined. Matching tibia and talus were opposed and any spurring causing impingement was recorded. Spur locations were measured and ratios calculated to allow for inter-specimen comparison between: (1) medial-to-lateral and anterior-to-posterior spur location versus dimensions of talar neck width, and (2) medial-to-lateral spur location to dimensions of distal anterior tibial width. Differences in spur prevalence in relation to sex, race, height and age were identified by univariant and multivariable statistical analyses. Bony impingement was observed in 21% (n = 72) of specimens, with bilateral involvement in 8% (n = 27). For ankles with AAI, spurs were seen on the talus only in 61%, on the tibia only in 14%, and on both the tibia and talus in 26%. Spurs were significantly more prevalent in males (P = 0.001) and with increasing specimen age (P = 0.002). There were no significant differences related to specimen height or race. Spurs were predominately located on the anterolateral talus (78%) and the anterolateral portion of the distal tibial margin (80%). AAI was present in 21% of young osseous specimens and was significantly more prevalent in males and with increasing specimen age. Clin. Anat. 31:1144-1150, 2018. © 2018 Wiley Periodicals, Inc.

Does antero-lateral ankle impingement exist?

Antero-lateral ankle impingement syndrome (ALAIS) is a well-established clinical entity that is a common consequence of ankle sprains. Injury to the anterior talo-fibular ligament plays a key role in the genesis of ALAIS. Arthroscopic antero-lateral synovectomy is the standard of care. However, this treatment approach may deserve to be challenged, as it does not include any procedure on the ligaments, despite the presence in some patients of lateral rotational micro-instability of the ankle, without objective laxity. Consequently, we reviewed current data on ALAIS and its links to ankle instability, from the dual perspective of diagnosis and treatment.

Arthroscopic Taloplasty for an Anterolateral Snapping Ankle

Anterior ankle snapping syndrome is rare. Snapping of the extensor digitorum longus due to attenuated inferior extensor retinaculum and snapping due to hypertrophied or low-lying peroneal tertius muscle have been reported. We reported a new mechanism of anterolateral snapping due to a hypertrophied talar head. Anterolateral snapping ankle can be revealed by active dorsiflexion and plantarflexion of the ankle with the foot inverted. Foot inversion will tension the inferior extensor retinaculum and uncover the dorsolateral prominence of the talar head. The dorsolateral prominence of the talar head will snap over the proximal edge of the inferior extensor retinaculum. This technical note reports the technique of arthroscopic contouring of the talar head via extra-articular ankle arthroscopy. We named this technique arthroscopic taloplasty.

Ankle impingement

Ankle impingement is a syndrome that encompasses a wide range of anterior and posterior joint pathology involving both osseous and soft tissue abnormalities. In this review, the etiology, pathoanatomy, diagnostic workup, and treatment options for both anterior and posterior ankle impingement syndromes are discussed.

Ankle Impingement Caused by an Intra-articular Plica: A Report of 2 Cases

Entrapment of soft tissues in the anterolateral gutter of the ankle can cause impingement. When symptomatic, patients complain of chronic ankle pain exacerbated with dorsiflexion. Symptoms of instability and a history of recurring ankle sprains are common findings. Plain radiographs and magnetic resonance imaging may assist clinicians in identifying associated pathology. We present 2 cases of ankle impingement occurring in the setting of equivocal examination and imaging findings. In both cases, arthroscopy revealed a likely congenital, intra-articular plica.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case Study.

Arthroscopic Treatment for Anterior Ankle Impingement: A Systematic Review of the Current Literature

PURPOSE

To provide a comprehensive overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement.

METHODS

A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was performed. Studies that met the following inclusion criteria were reviewed: studies reporting outcomes of arthroscopic treatment for anterior ankle impingement; studies reporting on more than 20 patients; a study population with a minimum age of 18 years; and studies in the English, Dutch, German, Italian, or Spanish language. Two reviewers independently performed data extraction. Extracted data consisted of population characteristics, in addition to both primary and secondary outcome measures. The Downs and Black scale was used to assess the methodologic quality of randomized and nonrandomized studies included in this review.

RESULTS

Twenty articles were included in this systematic review. Overall, good results were found for arthroscopic treatment in patients with anterior ankle impingement. In the studies that reported patient satisfaction rates, high percentages of good to excellent satisfaction were described (74% to 100%). The percentages of patients who would undergo the same procedure again under the same circumstances were also high (94.3% to 97.5%). Complication rates were low (4.6%), particularly with respect to major complications (1.1%). The high heterogeneity of the included studies made it impossible to compare the results of the studies, including between anterolateral impingement and anteromedial impingement.

CONCLUSIONS

Arthroscopic treatment for anterior ankle impingement appears to provide good outcomes with respect to patient satisfaction and low complication rates. However, on the basis of the findings of this study, no conclusion can be made in terms of the effect of the type of impingement or additional pathology on clinical outcome.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II and IV studies.

Arthroscopic treatment in split depression-type tibial pilon fracture

Treatment of tibial pilon fractures is complicated and often very invasive. Partial fractures with a depressed component raise the question of the choice of surgical technique. Minimally invasive surgical reduction under arthroscopic guidance appears to be a promising alternative in this type of fracture. We describe a technique for arthroscopically assisted treatment of a split depression tibial pilon fracture.

Anterior ankle impingement: diagnosis and treatment

Anterior ankle impingement is a common clinical condition characterized by chronic anterior ankle pain that is exacerbated on dorsiflexion. Additional symptoms include instability; limited ankle motion; and pain with squatting, sprinting, stair climbing, and hill climbing. Diagnosis is typically confirmed with plain radiographs. Nonsurgical management includes physical therapy, strengthening exercises, activity modification, bracing, and anti-inflammatory medication. Although arthroscopic treatment is sufficient in some patients, most require an open approach to address related pathology. We advocate aggressive range of motion as well as weight bearing postoperatively. Further study is needed to confirm current understanding of anterior ankle impingement and to better define treatment options and prevention strategies.

Update on anterior ankle impingement

Anterior ankle impingement results from an impingement of the ankle joint by a soft tissue or osteophyte formation at the anterior aspect of the distal tibia and talar neck. It often occurs secondary to direct trauma (impaction force) or repetitive ankle dorsiflexion (repetitive impaction and traction force). Chronic ankle pain, swelling, and limitation of ankle dorsiflexion are common complaints. Imaging is valuable for diagnosis of the bony impingement but not for the soft tissue impingement, which is based on clinical findings. MR imaging and MR arthrography are helpful in doubtful diagnoses and the identification of associated injuries. Recommended methods for initial management include rest, physical therapy, and shoe modification. If nonoperative treatment fails, arthroscopic bony or soft tissue debridement both offer significant symptomatic relief with long-term positive outcomes in cases that have no significant arthritic change, associated ligament laxity, and chondral lesion.

Use of a static progressive stretch orthosis to treat post-traumatic ankle stiffness

Background

Chronic ankle stiffness can develop for numerous reasons after traumatic injury, and may adversely affect patient gait, mobility, and function. Although standard physical therapeutic techniques typically resolve this stiffness, some cases may be recalcitrant to these measures, making it difficult to restore range-of-motion. The purpose of this study was to evaluate a static progressive stretch orthosis for the treatment of chronic ankle stiffness.

Methods

Twenty-six patients (26 ankles) who had chronic post-traumatic ankle stiffness were studied. The patients began treatment at a mean of 47 weeks (range, 6 to 272 weeks) following their initial injury using a static progressive stretch orthosis. A patient-directed protocol was used for 30 minutes per day, 1 to 3 times per day, until the range-of-motion was considered to have plateaued. Mean treatment time was 10 weeks (range, 3 to 19 weeks). Treatment duration, range-of-motion, and complications with the device were assessed.

Results

The overall mean improvement in motion (combined dorsiflexion and plantar flexion) was 17 degrees (range, 2 to 44 degrees). There was a mean improvement in dorsiflexion of 9 degrees (range, -2 to 20 degrees), and a mean improvement of 8 degrees of plantar flexion (range, -10 to 35 degrees). There were no reports of numbness or skin problems.

Conclusions

The outcomes of this study suggest that a patient-directed treatment protocol using a static progressive stretch orthosis was an effective ancillary method for the treatment of chronic post-traumatic ankle stiffness that was refractory to standard physical therapy techniques.