Talofibular Bony Impingement in the Ankle

Update on Ankle and Foot Impingement

Ankle impingement syndromes are a well-recognized cause of chronic ankle symptoms in both the elite athletic and general population. They comprise several distinct clinical entities with associated radiologic findings. Originally described in the 1950s, advances in magnetic resonance imaging (MRI) and ultrasonography have allowed musculoskeletal (MSK) radiologists to further their understanding of these syndromes and the range of imaging-associated features. Many subtypes of ankle impingement syndromes have been described, and precise terminology is critical to carefully separate these conditions and thus guide treatment options. These are divided broadly into intra-articular and extra-articular types, as well as location around the ankle. Although MSK radiologists should be aware of these conditions, the diagnosis remains largely clinical, with plain film or MRI used to confirm the diagnosis or assess a surgical/treatment target. The ankle impingement syndromes are a heterogeneous group of conditions, and care must be taken not to overcall findings. The clinical context remains paramount. Treatment considerations are patient symptoms, examination, and imaging findings, in addition to the patient's desired level of physical activity.

Relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis

PurposeThis study aimed to evaluate the relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis. Methods: Incongruent varus ankle osteoarthritis was defined as a talar tilt of more than 4° on standard ankle anteroposterior radiographs. We retrospectively reviewed 30 patients with unilateral incongruent varus ankle osteoarthritis with normal alignment of the contralateral ankle. All patients underwent bilateral weightbearing computed tomography and standing plain radiographs. The talar tilt and the distance between the talar lateral process and lateral malleolar tip were measured from a standing ankle anteroposterior radiograph of both sides. Talar and fibular spurs were assessed on the coronal and axial views of weightbearing computed tomography. After simulating the correction of the talar tilt in varus ankle osteoarthritis, talofibular bony impingement was reassessed. Results: On the varus side, the distance between the talar lateral process and the lateral malleolar tip was significantly shorter than that on the contralateral side (p < .001). Talar spur was present in the varus side of all 30 patients on the axial view of weightbearing computed tomography and in the control side of 10 patients. After the simulation of talar tilt correction, talofibular impingement (overlap) occurred in all 30 patients with a larger extent in the severe talar tilt subgroup (p < .001). Conclusion: Talofibular impingement by lateral gutter osteophytes is closely related to increased talar tilt in patients with incongruent varus ankle osteoarthritis. Therefore, lateral gutter osteophytes should be resected to stabilize mortise and improve clinical outcomes.

Ankle Impingement: A Critical Analysis Review

Ankle impingement presents with painful and limited range of motion with dorsiflexion or plantar flexion, originating from pathological contact between bone and/or soft-tissue structures. Diagnosis is made primarily through clinical examination with adjunct radiographs and magnetic resonance imaging, with care taken to rule out a plethora of similarly presenting pathologies. Arthroscopic surgical approaches bring satisfactory short, mid, and long-term outcomes, with the current body of evidence dominated by Level-IV studies. Minimally invasive techniques offer improvements in time to return to play and complication rates relative to open approaches. Recent advances in the arthroscopic management of ankle impingement include long-term outcome studies, novel prognostic classification systems, and strategies for concomitant lesion management.

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.

Morphological Characteristics of Os Subfibulare Related to Failure of Conservative Treatment of Chronic Lateral Ankle Instability

BACKGROUND

The os subfibulare is usually asymptomatic and found incidentally on radiographs. However, sometimes it may cause subfibular pain and may be associated with chronic lateral ankle instability (CLAI). We hypothesized that os subfibulare could interrupt the talofibular space causing impingement, resulting in chronic pain and functional instability around the lateral malleolus. The purposes of this study were to analyze morphologic characteristics of os subfibulare, and to evaluate the clinical significance of the os subfibulare in patients with CLAI.

METHODS

Between November 2011 and April 2015, 70 patients who had both computed tomography (CT) and magnetic resonance imaging (MRI) among 252 patients who visited our hospital with the symptom of lateral ankle instability were included in this study. The location of the ossicle was classified into 3 zones in reference to the attachment site of the lateral ankle ligaments. The impingement was classified into 2 groups according to the presence of talofibular encroachment. Digital radiographs were used to measure the ossicle width and shape determined by the length and width on an magnetic resonance (MR) image.

RESULTS

The most common shape of ossicles was oval, and the most common location of ossicles was at the anterior talofibular ligament (ATFL) attachment site. Sixty-one percent of patients showed talofibular impingement on coronal MR images. In 48 cases, the dimension of fibula plus os subfibulare was larger than that of the contralateral normal fibula. The larger size and talofibular impingement of the ossicle were associated with greater need for operative treatment in patients with ankle instability.

CONCLUSION

The morphologic analysis of the os subfibulare revealed that there might be impingement of the talofibular space by the ossicle in some patients. We suggest that morphologic characteristics of the os subfibulare should be considered when selecting treatment options in patients with CLAI and os subfibulare.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Arthroscopic debridement of anterior ankle impingement in patients with chronic lateral ankle instability

BACKGROUND

The aim of this study was to determine the functional and radiological outcomes of arthroscopic treatment of anterior ankle impingement (AAI) in patients with chronic lateral ankle instability (CAI).

METHODS

All patients with CAI between June 2012 and May 2015 were invited to participate in this investigation. All of them accepted open modified Broström repair of lateral ankle ligaments and were divided into two groups: AAI group (with anterior ankle impingement) and pure CAI group (without anterior ankle impingement). All of them were followed up using American Orthopaedic Foot and Ankle Society Score (AOFAS), Karlsson Ankle Functional Score and Tegner activity score. Ankle dorsiflexion was also examined. X-ray examination was applied to investigate anterior tibiotalar osteophytes.

RESULTS

Finally, a total of 60 patients were followed up at a mean of 37 ± 10 months, including 22 patients in the AAI group and 38 patients in the pure CAI group. Preoperatively, the AAI group had significant lower AOFAS score (62.9 ± 11.7 vs 72.9 ± 11.1; p = 0.002) and Tegner activity score (1.5 ± 0.8 vs 2.1 ± 1.0; p = 0.04) respectively when compared with the pure CAI group. The ankle dorsiflexion of the AAI group (13 ± 2.1) was also significantly lower than that of the pure CAI group (26.2 ± 2.1) (p = 0.001). However, there was no significant difference in the AOFAS score or the Karlsson score or the Tegner score or the Ankle dorsiflexion between the two groups postoperatively. The postoperative X-ray images demonstrated complete osteophyte resection in all patients, and no recurrence of osteophyte.

CONCLUSION

The functional outcome scores and dorsiflexion had significantly improved postoperatively. Combined treatment of chronic ankle instability and anterior ankle impingement produced satisfactory surgical outcomes in patients with CAI accompanied by anterior ankle impingement symptom.

Fibulocalcaneal Impingement in a Growing Child With Otherwise Asymptomatic Talocalcaneal Coalition

Subfibular impingement has been described in patients with flatfoot. It possibly occurs with valgus deformity associated with talocalcaneal coalition. We observed symptomatic unilateral fibular impingement initially on the left foot of an 11-year-old female with an otherwise asymptomatic bilateral talocalcaneal coalition. From the age of 8 years, she had complained of pain around the left fibular tip. Magnetic resonance imaging showed a partial talocalcaneal coalition. At 10 years of age, it was questioned whether the pain was related to the coalition. However, imaging of the asymptomatic right foot also showed a talocalcaneal coalition, with the coalition in both feet appearing equal. Additionally, the peroneal trochlea appeared particularly prominent, more so on the left than on the right foot. Therefore, the symptoms were suspected to have been caused only by fibulocalcaneal impingement owing to a relatively long fibula. Subperiosteal shortening of the fibula was performed at when she was 11 years old. A bed for the peroneal tendons was created around the remaining epiphysis of the fibula, and the fibular ligaments were reattached with Arthrex^® anchors (Arthrex, Naples, FL). At 14 months postoperatively, the patient was free of pain with unrestricted movement, although the follow-up imaging studies showed complete bony fusion on the medial aspect of the coalition between the talus and calcaneus. Approximately 1.5 years after surgery, our female patient at 12.5 years old complained of the same problems on her right foot, definitely occurring only around the fibula. The same procedure was performed as she had undergone on the left foot. At the last follow-up examination, she was asymptomatic 2.5 years after the initial surgery of the left foot and 11 months after surgery on the right. Talocalcaneal coalition can cause moderate to severe hindfoot deformity, leading to fibulocalcaneal impingement. Hence, treatment should be determined accordingly.

Arthroscopic Treatment of Ankle Arthritis

Ankle arthritis can be broadly classified as primary arthritis (nontraumatic degeneration) or secondary arthritis (post-traumatic degeneration). A good understanding of the anatomic features and presentations associated with each will assist the surgeon in determining the best course of action for each patient. Many variations of both primary and secondary arthritis can be treated conservatively; however, there are many times when conservative therapy is not adequate. In these cases, ankle arthroscopy may be considered before a joint fusion or replacement. Here, the authors discuss the common types of ankle arthritis, their presentations, and treatment success with ankle arthroscopy.

MR Imaging of Impingement and Entrapment Syndromes of the Foot and Ankle

Impingement is a clinical syndrome of chronic pain and restricted range of movement caused by compression of abnormal bone or soft tissue within the ankle joint. It usually occurs following a sprain injury or repetitive microtrauma causing haemorrhage, synovial hyperplasia, and abnormal soft tissue interposition within the joint. MR imaging is particularly valuable in being able to detect not only the soft tissue and osseous abnormalities involved in these syndromes, but also a wide variety of other potential causes of ankle pain and instability that also may need to be addressed clinically.

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.