Arthroscopic treatment of patients with anterolateral impingement of the ankle with and without chondral lesions

Arthroscopic treatment of ankle impingement syndrome

Arthroscopic treatment of ankle impingement syndrome (AIS) is a minimally invasive surgical procedure used to address symptoms caused by impingement in the ankle joint. This syndrome occurs when there is abnormal contact between certain bones or soft tissues in the ankle, leading to pain, swelling, or limited range of motion. Traditionally, open surgery was the standard approach for treating AIS. However, with advancements in technology and surgical techniques, arthroscopic treatment has become a preferred method for many patients and surgeons. With improved visualization and precise treatment of the arthroscopy, patients can experience reduced pain and improved functionality, allowing them to return to their daily activities sooner. In this paper, we reviewed the application and clinical efficacy the of arthroscopic approach for treating AIS, hoping to provide a reference for its future promotion.

Arthroscopic treatment for anterolateral impingement of the ankle: Systematic review and exploration of evidence about role of ankle instability

BACKGROUND

Arthroscopic debridement is a common surgical treatment for patients with anterolateral impingement (ALI) of the ankle. Although they often have a history of ankle sprain, information regarding the role of ankle instability in ALI is limited. The aims of this review were to: 1) assess the clinical outcomes of arthroscopic surgical treatment for ALI of the ankle; and 2) review the data regarding anterior talofibular ligament (ATFL) injury and lateral ankle instability in patients who underwent arthroscopic surgery for ALI.

METHOD

A literature search of Pubmed and EMBASE was performed. Studies that met the following inclusion criteria were reviewed: (1) human clinical studies investigating patients who underwent arthroscopic surgery for ALI; (2) results with at least one scoring system with minimum follow-up of six months. The quality of each study was evaluated using the Oxford CEBM tool to assess the level of evidence and the grade of recommendation. The data of patient characteristics, intraoperative findings and clinical outcomes were extracted.

RESULTS

Eight articles were included in this systematic review, all of which were graded level 4 with grade C recommendation. In total, 203 patients with a mean age of 32 years (ranging from 11 to 74) were analysed. AOFAS score was used in 6 studies and scored 90.1 on average at follow-up. Two other studies used original scores. One study reported arthroscopic findings of the ATFL and another study reported on residual instability after surgery. New ankle sprains during follow-up period were reported in 8.3 to 20.0% of patients in 4 studies.

DISCUSSION

This review showed good clinical results of arthroscopic debridement with a grade C recommendation. Reports regarding arthroscopic observation of the ATFL and residual instability after surgery were lacking. Further investigation of what we are still calling "ALI" should be made with higher level of evidence focusing more on ATFL injury and its effect on clinical outcomes.

Ankle Arthroscopy Procedural Volume Is Low Among Graduating Orthopaedic Surgery Residents

Purpose

To evaluate graduating orthopaedic resident case volume and variability for ankle arthroscopy from 2016 to 2020.

Methods

The Accreditation Council for Graduate Medical Education surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents was assessed. Arthroscopy procedures of the leg/ankle were categorized. The average number of cases performed per resident was compared from 2016 to 2020 to determine the percent change in case volume. The 10th, 30th, 50th, 70th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability.

Results

There was no significant change in the average number of leg/ankle arthroscopy cases from 2016 to 2020 (6.2 ± 5 [range 0-35] vs 6.1 ± 6 [range 0-76] P = .732), despite a 19% increase in the average number of total leg/ankle procedures performed over time (168.4 ± 47 [range 55-414] in 2016; 200.8 ± 57 in 2020 [range 67-601], P < .001). There was wide variability in ankle arthroscopy case volume among residents. The 90th percentile of residents performed 13 cases in 2020, compared with 5 in 50th percentile, and 1 in the 10th percentile.

Conclusions

Orthopaedic surgery resident exposure to ankle arthroscopy has remained low and highly variable overtime, despite an overall increase in the total number of leg/ankle procedures performed.

Clinical Relevance

Understanding ankle arthroscopy in case volume and variability is important for programs to ensure that orthopaedic residents are gaining adequate exposure to increasingly popular procedures. Orthopaedic surgery residency programs should explore methods to increase resident exposure to ankle arthroscopy.

Outcomes After Arthroscopic Surgery for Anterior Impingement in the Ankle Joint in the General and Athletic Populations: Does Sex Play a Role?

BACKGROUND

Although anterior ankle impingement is a common pathology within the athletic population, there have been limited data evaluating outcomes of arthroscopic intervention and whether patient sex affects treatment outcomes.

PURPOSE

To provide an overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement and to determine if patient sex affects outcomes.

STUDY DESIGN

Systematic review.

METHODS

A systematic literature search of the MEDLINE, Embase, and Cochrane databases was performed during August 2019. The following combination of search terms was utilized: "ankle," "impingement," "talus," "osteophyte," "arthroscopy," "surgery," "procedures," and "treatment." Two reviewers independently performed data extraction.

RESULTS

A total of 28 articles evaluating 1506 patients were included in this systematic review. Among the studies, 60% (17/28) and 14% (4/28) assessed anterolateral and anteromedial impingement, respectively. Good to excellent results were reported after arthroscopy in patients with anterior ankle impingement, with a success rate of 81.04%. All studies that evaluated functional outcomes (16/16; 100%) cited improvements in American Orthopaedic Foot & Ankle Society scale, visual analog scale, and Foot Function Index. The average complication rate was 4.01%, with the most common complications being mild nerve symptoms and superficial infection. The most common concomitant pathologies included synovitis, osteophytes, meniscoid lesions, and anterior inferior tibiofibular ligament injury. Four studies (15%) failed to report sex as a demographic variable. Only 7 (25%) studies included analysis by sex, with 4 (57%) of these demonstrating differences when comparing outcomes by patient sex. When compared with male patients, female patients exhibited higher rates of traumatic ankle sprains, chondral injury, and chronic ankle instability associated with anterior ankle impingement.

CONCLUSION

Our systematic review demonstrates that arthroscopic treatment for anterior ankle impingement provides good to excellent functional outcomes, low complication rates, and good return-to-sports rates in both the general and the athletic population. This study also reports a lack of statistical analysis evaluating outcomes comparing male and female populations. The included studies demonstrate that, compared with male patients, female patients have higher rates of traumatic ankle sprains, chondral injury, and chronic ankle instability associated with anterior ankle impingement; therefore, particular attention should be paid to addressing such concomitant pathology.

Role of Arthroscopy in Various Ankle Disorders

INTRODUCTION

Ankle arthroscopy has come a long way since it was thought, it is not feasible because of tight joint and anatomical characteristics of ankle joint. The same anatomical features like capsular attachment and safe accessory portals are used to access the whole joint even with a rigid arthroscope. Ankle distraction method was routinely used to access the anterior ankle. However, nowadays, anterior arthroscopy is done in dorsiflexion as this increases the anterior ankle joint volume, and thereby easy access to various anatomical structures. On the other hand, intermittent traction is used to access the posterior ankle. Initially used as a diagnostic tool, ankle arthroscopy is now used extensively as a therapeutic and reconstruction tool. New evidence is published for all inside ligament reconstructions, effective management of impingement syndromes, and osteochondral lesions. The indications are being extended to fracture management and arthrodesis.

METHODOLOGY

This narrative review was performed following a literature search in the Pubmed database and Medline using the following keywords: ankle arthroscopy, portals, ankle OCD, functional outcome. Related articles were then reviewed.

CONCLUSION

Complications rate is reduced with a better understanding of the relative anatomy of surrounding neurovascular structures and tendons with regard to the position of ankle joint. This review on ankle arthroscopy focuses on anatomy, indications, and complications. Ankle arthroscopy is a safe and elegant tool as any other joint arthroscopy.

Three-Portal Approach of Arthroscopy for Anterior Ankle Impingement Syndrome: A Propensity Score-Matched Analysis

Objective

To introduce a 3‐portal approach of arthroscopic for anterior ankle impingement syndrome and to compare this method with 2‐portal arthroscopy.

Methods

From July 2011 to April 2019, a total of 52 patients (30 females, 22 males) with anterior ankle impingement syndrome underwent surgery with 2‐portal approach (anterior medial and anterior lateral approach; N = 26) and modified 3‐portal approach (anterior medial, anterior lateral, and an accessory anterior median approach; N = 26) of arthroscopic were recruited retrospectively after we performed a propensity score‐matched analysis (PSMA). The mean age at operation time was 44.1 years (range from 22 years to 74 years) and the mean follow‐up duration was more than two years (range from 2 years to 9 years). Clinical outcomes of all patients were evaluated according to the range of motion (ROM, dorsal flex angle), the American Orthopaedic Foot and Ankle Society lesser metatarsophalangeal interphalangeal scale (AOFAS), the visual analogue scale (VAS), and the operation time before and after the surgery.

Results

During the follow‐up period, both two groups indicated significant improvement in these function scores. Clinical assessment showed that for the 2‐portal approach of arthroscopic the total average of AOFAS scores were significantly increased from preoperative 59.91 ± 5.281 points to postoperative 76.18 ± 1.471 points (P = 0.02), the VAS scores were significantly decreased from preoperative 7.64 ± 0.924 points to postoperative 4.18 ± 0.982 points (P = 0.04), and the dorsal flex angle was significantly increased from preoperative 12.27° ± 6.467° to postoperative 21.36° ± 3.931° at the last follow‐up (P = 0.035). However, for the 3‐portal approach of arthroscopic the total average of AOFAS scores were significantly increased from preoperative 48.64 ± 9.646 points to postoperative 79.18 ± 6.555 points (P = 0.015), the VAS scores were significantly decreased from preoperative 7.82 ± 0.751 points to postoperative 2.64 ± 1.629 points (P = 0.01), and the dorsal flex angle was significantly increased from preoperative 13.64° ± 7.775° to postoperative 20.45° ± 6.502° at the last follow‐up (P = 0.045). There were no significant differences among the dorsal flex angle, the AOFAS scores, and the VAS scores between the two groups at the last follow‐up (P > 0.05). Although the operation time of the 3‐portal approach of arthroscopic (74.82 ± 18.395 min) was longer than that of the 2‐portal approach of arthroscopic (92.55 ± 27.153 min), the difference was not significant (P > 0.05).

Conclusion

Both the 2‐portal and the 3‐portal approach of arthroscopic provides almost the same satisfactory clinical outcomes for anterior ankle impingement syndrome, but we strongly suggest the 3‐portal approach of arthroscopic which can supply greater joint contact area to treat advanced impingement syndrome for a good result.

Outcome Comparison Between Functional Ankle Instability Cases With and Without Anterior Ankle Impingement: A Retrospective Cohort Study

Functional ankle instability (FAI) and anterior ankle impingement (AAI) are likely to occur simultaneously. Nevertheless, how AAI affects ankle instability remains largely unknown. This study aimed to assess patients with FAI + AAI and those having FAI without AAI after arthroscopic synovectomy combined with the modified Broström procedure. Patients with chronic ankle instability who underwent surgery at the Huashan Hospital of Fudan University (China) from January 2010 to December 2015 were reviewed. Propensity score matching was performed (FAI + AAI: n = 86; FAI without AAI: n = 43). Ankle function was assessed by the American Orthopedic Foot and Ankle Society (AOFAS) and the Meislin criteria at 3 months, 1 year, and final follow-up. In the FAI + AAI group, AOFAS scores increased from 52.6 ± 7.2 to 78.6 ± 8.2, 84.2 ± 6.4, and 83.6 ± 11.3 at 3 months, 1 year, and last follow-up, respectively (p < .001). In the FAI without AAI group, AOFAS scores increased from 64.3 ± 10.5 to 85.2 ± 8.6, 91.4 ± 7.9, and 90.2 ± 9.8 at 3 months, 1 year, and last follow-up, respectively (p < .001; all p < .05 for differences between the 2 groups at each time point). The 2 groups showed similar scores based on the Meislin criteria (p = .38). Hypertrophic distal fascicle of the anteroinferior tibiofibular ligament showed lower AOFAS scores (all p < .05). Patients with FAI with or without AAI had improved outcomes with arthroscopic synovectomy combined with the modified Broström procedure; however, patients with combined FAI and AAI showed a relatively poorer outcome in comparison with those suffering from FAI alone, probably because of hypertrophic distal fascicle of the anteroinferior tibiofibular ligament.

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.

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.

Effect of obesity on arthroscopic treatment of anterolateral impingement syndrome of the ankle

The present case series study was performed to evaluate the effect of obesity on the arthroscopic findings and the functional outcome after arthroscopic treatment of anterolateral impingement syndrome of the ankle. The study was conducted on 36 patients (26 were classified as obese [body mass index ≥30 kg/m(2)] and 10 as not obese [body mass index <25 kg/m(2)]) who had previously undergone arthroscopic treatment of anterolateral impingement syndrome of the ankle. The arthroscopic findings and demographic features were recorded. The patients were examined postoperatively at 6 and 12 months postoperatively, and AOFAS scores were obtained. Our data showed that obese patients had the same arthroscopic findings as nonobese patients, except for chondral lesions. At 1 year of follow-up after performing arthroscopy, the presence of obesity had no effect on the functional outcome of arthroscopic treatment of anterolateral impingement syndrome of the ankle.Obesity has no effect on the effectiveness of arthroscopic treatment.

US in ankle impingement syndrome

Ankle impingement is a common condition occurring secondary to sprain or repeated microtrauma. Clinical symptoms are chronic pain located in the affected region and limited range of ankle motion. There are three types of ankle impingement syndrome: anterior impingement, which can be subdivided into anterolateral, anteromedial and purely anterior impingement; posterior impingement, which can be subdivided into posterior and posteromedial impingement; and calcaneal peroneal impingement which is secondary to planovalgus foot deformity. This paper evaluates physiological and clinical elements of these three types of ankle impingement syndrome as well as the role of ultrasound (US) imaging and US-guided treatment.