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

Implications of obesity in patients with foot and ankle pathology

Obesity is a growing problem defined as a body mass index of greater than 30 kg/m². It is predicted that by 2030, 48.9% of adults will be classified as obese which expands surgical risk factors to a broad population while increasing healthcare costs at the same time in different socioeconomic groups. This specific population has been widely studied in multiple surgical fields and published studies have shown the implications in each of these fields. The impact of obesity on orthopedic surgical outcomes has been previously reported in several total hip and knee arthroscopy studies, with evidence indicating that obesity is strongly associated with an increased risk of post operative complications together with higher revision rates. In line with increasing interest on the impact of obesity in orthopedics, there has been a similar output of publications in the foot and ankle literature. This review article evaluates several foot and ankle pathologies, their risk factors associated with obesity and subsequent management. It provides an updated, comprehensive analysis of the effects of obesity on foot and ankle surgical outcomes, with the ultimate aim of educating both surgeons and allied health professionals about the risks, benefits, and modifiable factors of operating on obese patients.

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.

In-Office Needle Arthroscopy for the Treatment of Anterior Ankle Impingement Yields High Patient Satisfaction With High Rates of Return to Work and Sport

PURPOSE

To evaluate the clinical outcomes of in-office needle arthroscopy (IONA) for the treatment of anterior ankle impingement in the office setting and also evaluate patient experience of the IONA procedure.

METHODS

A prospectively collected database of 31 patients undergoing IONA for the treatment of anterior ankle impingement between January 2019 and January 2021 was retrospectively reviewed. Inclusion criteria for this study were patients ≥18 years of age, clinical history, physical examination, radiographic imaging, and magnetic resonance imaging findings consistent with anterior ankle impingement for which each patient underwent IONA and had a minimum of 12-month follow-up. Clinical outcomes were evaluated using the following methods preoperatively and at final follow-up: the Foot and Ankle Outcome Scores (FAOS) and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference and Pain Intensity domains. A 5-point Likert scale regarding patient satisfaction with their IONA procedure was evaluated at final follow-up. Wilcoxon signed-rank test was performed to compare preoperative and postoperative outcome scores.

RESULTS

In total, 31 patients were included in this study, including 18 male and 13 female, with a mean age of 41.7 ± 15.5 years (range, 17-69 years) and mean body mass index of 27.3 ± 5.7 (range, 19.37-41.5). The mean follow-up time was 15.5 ± 4.9 months. The mean postoperative FAOS-reported symptoms, pain, daily activities, sports activities, and quality of life were 79.4 ± 11.9, 82.9 ± 15.3, 83.5 ± 15.4, 71.9 ± 18.5 and 64.3 ± 21.4 at final follow-up respectively. Minimal clinically important difference was achieved by 84% of patients for FAOS pain, 77% for FAOS symptoms, 75% for FAOS Quality of Life, 74% for FAOS sports, 65% for PROMIS Pain Interference, 61% for FAOS Activities of Daily Living, and 42% for PROMIS Pain Intensity. Lastly, 29 patients (94 %) expressed willingness to undergo the same procedure again.

CONCLUSIONS

The current study demonstrates that IONA treatment of anterior ankle impingement results in significant pain reduction, a low complication rate and excellent patient reported outcomes with high rates of return to work/sport. Additionally, IONA for anterior ankle impingement leads to high patient satisfaction with a significant willingness to undergo the same procedure again.

LEVEL OF EVIDENCE

IV, Case series study.

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.

Evaluation of BMI With an All Inside Arthroscopic Broström Procedure for Chronic Lateral Ankle Instability: An Analysis of 113 Patients

The all inside arthroscopic Broström surgical procedure for chronic lateral ankle instability is a minimally invasive procedure that is an option surgeons have when treating their patients. There have not been any studies analyzing the integrity of the repair to patients who have an elevated body mass index (BMI) to determine if the strength of the repair is adequate. We retrospectively evaluated a total of 113 consecutive patients who underwent this procedure. Fifty-nine patients had a BMI ≥30 kg/m²; 54 had a BMI <30 kg/m². Unpaired t tests were performed to determine if a difference in American Orthopedic Foot and Ankle Society, visual analog scale, and Foot Function Index were encountered. Our findings indicate that there is no significant difference between patients with a BMI ≥30 kg/m² compared to a BMI <30 kg/m² who undergo an all-inside arthroscopic Broström procedure for chronic lateral ankle instability. This information may help surgeons decide what procedure options are available when treating chronic lateral ankle instability.

Obesity in Elective Foot and Ankle Surgery

Obesity is a global health problem with significant economic and health consequences. There is very little literature in regards to obesity and its effect on foot and ankle surgery, and to the author's knowledge, there has been no consolidated review on this subject to date. The purpose of this article is to provide a comprehensive review as it pertains to foot and ankle surgery, with hopes of improving surgeon decision making, mitigating risk, and providing better outcomes for patients. A better understanding of the effects of obesity also allows for improved prognostic performance.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

A review of important medical and surgical considerations for obese patients undergoing arthroscopic surgery

Obesity represents a unique challenge in orthopaedic surgery, the impact of which is seen through all phases of injury: in the development of disease, during the operative procedure, and throughout the rehabilitation period. Given the high prevalence of obesity in the United States and around the world, this patient population represents a substantial proportion of patients in need of orthopedic care. The effects of this disease constrain both medical and financial resources. For obese patients undergoing orthopedic procedures, adequate steps must be taken to minimize the risks that occur before, during, and after surgical intervention. This literature review discusses the impact of obesity on arthroscopic procedures, with a focus on procedures involving the shoulder, hip, and knee. The management of obese patients during the perioperative period should address the specific concerns relating to these patients. Obesity is a risk factor for numerous comorbidities, is associated with surgical complications, and is a predictor of poor functional outcomes following arthroscopy. Efforts to minimize the negative impact of obesity on arthroscopic procedures are crucial.

Effect of Obesity on Outcomes of Forefoot Surgery

BACKGROUND

Forefoot surgery typically is elective, so it is important to define risk factors to educate patients on potential complications. The purpose of this study was to determine if obesity is an independent risk factor that contributes to increased complication rates after forefoot surgery.

METHODS

Through a retrospective review of records, 633 patients were identified who had forefoot surgery at one institution between 2008 and 2010. All patients who currently smoked or smoked in the past were excluded to eliminate a confounding factor, as smoking is known to increase complication rates, leaving 427 patients for inclusion, 299 nonobese (BMI less than 30) and 128 obese (BMI more than 30). Medical records were reviewed for the occurrence of complications, including nonunion, delayed union, delayed wound healing, infection, and persistent pain.

RESULTS

The overall complication rate was 9%, with similar rates between obese (10%) and nonobese patients (9%). The only specific complication approaching significance (P = .13) was a higher rate of infection in obese patients (4 % compared to 1%), which could be attributed to the higher percentage of diabetic patients in the obese group. Diabetic patients, regardless of weight, had significantly higher rates of infection (P = .03), with a trend toward higher rates of overall complications and delayed wound healing (P = .08 and P < .06, respectively).

CONCLUSION

Obesity was not shown to lead to more frequent complications after forefoot surgery. Diabetes was associated with significantly higher rates of infection, regardless of weight. Though not significant, there was a trend toward higher rates of overall complications and delayed wound healing in diabetic patients as well.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.