Combined Anterior and Dual Posterolateral Approaches for Ankle Arthroscopy for Posterior and Anterior Ankle Impingement Syndrome

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.

Anterior and Posterior Arthroscopic Treatment of Primary Synovial Chondromatosis of the Ankle

BACKGROUND

Primary synovial chondromatosis (PSC) is a progressive disorder of unknown etiology resulting in formation of multiple loose bodies. If left untreated, it may lead to degenerative changes or malignant transformation to chondrosarcoma.

METHODS

Seventeen patients who underwent combined posterior and anterior ankle arthroscopy within the same operative session and had histologically confirmed PSC were included in this retrospective study. American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score was used to evaluate ankle function preoperatively and at a final follow-up. A 3-question survey was used to evaluate patient's satisfaction at the final follow-up.

RESULTS

In 14 patients, loose bodies were found in both compartments of the ankle, in 2 only in the anterior compartment, and in 1 only in the posterior compartment. All patients had evident signs of synovial inflammation in both compartments. The AOFAS Ankle-Hindfoot score increased from the preoperative median score of 65 (range, 29-90) to 95 (range, 65-100) at the final follow-up. Fourteen patients reported they were extremely satisfied with the outcome, 1 was moderately satisfied, and 2 were dissatisfied. No cases of recurrence of synovitis or loose body formation were noted, nor any signs of malignant transformation during the follow-up period.

CONCLUSION

We believe the risk of recurrence of PSC, which is in close relation to malignant transformation, can be minimized by performing a complete synovectomy of the ankle. Our experience and review of literature makes us believe that ankle PSC should be regarded as a whole joint disorder. Performing a combined posterior and anterior arthroscopic procedure within the same operative session should always be considered in patients with ankle PSC.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

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.

Combined anterior and posterior ankle impingement syndrome with nonunion of Cedell fracture in a 58-year-old female: a case report

BACKGROUND

Combined anterior and posterior ankle impingement has seldom been reported. Cedell fracture, fracture of posteromedial tubercle of talus, is an uncommon and easily missed injury which may elicit posteromedial ankle impingement. The injury mechanisms and management strategies of these two lesions have been reported individually. But the concurrent lesion of both of them has not been reported.

CASE PRESENTATION

We reported a 58-year-old female with combined anterior and posterior ankle impingement syndrome with nonunion of Cedell fracture in whom open osteophytes debridement, fracture internal fixation and posterior talotibial ligament reconstruction were performed. The AOFAS hindfoot score was 90 at 1 year follow-up. To our knowledge, this was the first reported case with anterior, posterior and posteromedial impingement which was treated operatively with an excellent short-term outcome.

CONCLUSIONS

To fully recognize this occult lesion and avoid missing is imperative for reducing the morbidities. We suggest CT and MRI as excellent imaging modalities that can help the timely diagnosis and appropriate treatment for this combined impingement with circumferential lesions.

Operative Approaches to Ankle and Hindfoot Arthroscopy

The role of arthroscopy in the management of ankle and hindfoot pathology management has increased greatly in recent years with the potential for lower complication rates, faster recovery, improved access, and improved outcomes when compared to open techniques. Procedural variations exist as techniques aim to optimize lesion access, decrease operative time, and improve patient safety. Our goal is to summarize the described approaches and patient positionings common in minimally invasive arthroscopic surgery for anterior, lateral, and posterior ankle pathologies. A survey of pathology organized by arthroscopic approach and a review of recent advances in concomitant lesion management may be useful when planning arthroscopic foot and ankle surgery.

LEVEL OF EVIDENCE

Level V, expert opinion.

[Effectiveness of Tang's arthroscopy approach for anterior and posterior ankle impingement syndrome]

OBJECTIVE

To investigate the effectiveness of Tang's arthroscopy approach in treatment of anterior and posterior ankle impingement syndrome.

METHODS

Between August 2010 and September 2017, 92 patients with anterior and posterior ankle impingement syndrome were retrospectively analyzed. There were 58 patients were treated with Tang's arthroscopy approach under floating decubitus (group A) and 34 patients were treated with standard anterior and posterior approaches (group B). There was no significant difference in gender, age, body mass index, side, disease duration, preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score, and preoperative visual analogue scale (VAS) score between the two groups ( P>0.05).The operation time, AOFAS score, VAS score, and Roles-Maudsley score were recorded to evaluated the pain and function of the ankle, and patient subjective satisfaction. The X-ray film and MRI at 12 months were used to observe the ankle impingement.

RESULTS

Median operation time of group A was 50.5 minutes ［95%CI (49.3, 54.6)］, which was significantly shorter than that of group B ［88.5 minutes, 95%CI (76.5, 92.8)］ (Z=-4.685, P=0.000). All incisions in group A healed by first intention; while the incisions of 2 cases in group B delayed healed after debridement. The follow-up time of group A was (54.7±18.8) months, while that of group B was (55.4±17.9) months, and there was no significant difference between the two groups ( t=-0.178, P=0.859). The lateral X-ray films at 12 months showed that the talus process was removed incompletely in 2 cases (3.4%) of group A and 1 case (2.9%) of group B. There was no significant difference in the incidence between the two groups (χ 2=0.014, P=0.699). At last follow-up, the AOFAS scores were 83.1±6.6 in group A and 85.2±6.4 in group B; the VAS scores were 1.3±1.1 in group A and 1.6±1.0 in group B. The AOFAS and VAS scores at last follow-up were superior to preoperative ones ( P<0.05), but there was no significant difference between the two groups ( P>0.05). The median subjective satisfaction score of group A was 2.0 ［95%(1.4, 1.7)］, which was better than that of group B ［2.0, 95%(1.6, 2.2)］ ( Z=-2.480, P=0.013).

CONCLUSION

Arthroscopic treatment of anterior and posterior ankle impingement syndrome through Tang's approach can shorten the operation time, simplify the procedures, and obtain good effectiveness and patient satisfaction.

A literature review of the complications following anterior and posterior ankle arthroscopy

INTRODUCTION

There is a wealth of studies reporting the complications of anterior and posterior ankle arthroscopy. The aim of this study is to summarise and review the complication rate(s) associated with both anterior and posterior ankle arthroscopy, as described in the literature.

MATERIAL AND METHODS

The authors carried out a comprehensive review of the literature up until March 2018. An extensive search of the MEDLINE, Cochrane library and EMBASE databases was undertaken using the following keywords: complications of ankle arthroscopy, anterior ankle arthroscopy, and posterior ankle arthroscopy.

RESULTS

A total of 107 papers were identified and 55 were deemed appropriate for analysis. The overall complication rate of ankle arthroscopy was found to be between 3.4- 9%.

CONCLUSIONS

No life threatening complications were identified in the literature with both anterior and posterior ankle arthroscopy. The commonest complication after anterior and posterior ankle arthroscopy is superficial peroneal nerve injury and temporary Achilles tendon tightness, respectively.

[Mid-to-long term outcomes and influence factors of postoperative concurrent chronic ankle instability and posterior ankle impingement]

OBJECTIVE

To investigate the mid-to-long-term efficacy of patients with chronic ankle instability combined with posterior impingement syndrome after 3-9 years of follow-up, and to analyze the influencing factors.

METHODS

From February 2010 to December 2015, 46 patients underwent concurrent lateral ankle ligament repair with posterior ankle arthroscopic surgery at the Institute of Sports Medicine, Peking University Third Hospital. The patient was first placed in a prone position and underwent arthroscopic debridement for the posterior impingement. After finishing the posterior arthroscopy, the surgeon and assistants first translated the patient to the affected side, then turned to the healthy side, and changed the position to the supine position. During the turning over, another assistant held the arthroscope and the instrument to ensure that it was sterile and could be used without replacement. The anterior ankle arthroscopy was operated if necessary and the lateral ankle ligament repair was anatomic repaired with anchors. The 42 patients were followed up, including 26 males and 16 females. The average age was (28.9±10.0) years. The patient's clinical symptoms, joint stability, mobility and motor function were compared by questionnaire and physical examination. The preoperative and postoperative visual analogue scale (VAS) scores, American Orthopaedic Foot and Ankle Society (AOFAS) scores, Tegner scores were compared, and the clinical scores and the patient age, gender, height and weight were compared. The correlations between body mass index (BMI), preoperative duration, surgery duration, and cartilage injury were analyzed.

RESULTS

The mean follow-up time was (71.8±22.8) months. The postoperative VAS scores (1.0 vs. 5.0, P<0.001), AOFAS scores (92 vs. 80, P<0.001), and Tegner scores (6.5 vs. 2, P<0.001) were significantly superior to the preoperative levels. The excellent and good rate was 97.6%. The postoperative VAS score (t=2.719, P=0.10), AOFAS score (t=-2.853, P=0.10), Tegner score (t=-3.443, P=0.001) and time to return exercise (t=2.814, P=0.008) were negatively correlated with the patient age, and the postoperative VAS score was negatively correlated with cartilage injury (Z=-2.195, P=0.028).

CONCLUSION

The mid-to-long-term clinical outcomes of the chronic ankle ligament instability combined with the posterior impingement were good. The age of the patients was negatively correlated with the clinical outcome. The combined cartilage injury could aggravate the postoperative pain.

A Preliminary Study of Ankle Single Photon Emission Computed Tomography/Computed Tomography in Patients With Bony Impingement Syndrome: Association With the Visual Analogue Scale Pain Score

Both osteoarthritis and impingement syndrome are the disorders commonly observed in sports medicine. However, failure in pain alleviation by surgical intervention introduces challenges in the diagnosis and decision-making for orthopedists. Hybrid single photon emission computed tomography/computed tomography (SPECT/CT) provides both functional and structural information of ankle pathology. The purpose of this retrospective study was to evaluate whether bone tracer uptake by ankle SPECT/CT is related to the lesion type and visual analog scale (VAS) pain score for patients with osteoarthritis and bony impingement. Fifty individuals with chronic ankle pain who underwent pretreatment ankle SPECT/CT were included in the current study. The median follow-up period was 2.5 (range 1.8 to 3.2) years. The lesion types were categorized by the positions of anatomical changes and bone tracer uptake. The VAS pain score was recorded 2 weeks before and 1.5 year after surgical intervention. Twenty-nine (58%) of 50 patients had osseous impingement. Among them, 16 (55.2%), 4 (13.8%), and 9 (31%) patients had anterior, posterior, and both types of ankle impingement, respectively. The uptake grade of bone tracer was significantly related to the lesion type of ankle impingement (p < .001). The VAS pain score was significantly correlated with bone tracer uptake before treatment (p < .001). Bone tracer uptake was related to the lesion type of impingement detected by SPECT/CT and was confirmed by surgical findings. The VAS pain score was significantly correlated with the bone tracer uptake. Preoperative ankle SPECT/CT may be helpful to clinically correlate the VAS pain score in the pre- and postsurgical periods for patients with osteoarthritis and bony impingement syndrome.