Ankle impingement

Can ultrasound replace MRI in diagnosing causes of ankle impingement in different compartments?

PURPOSE

This prospective study aims to determine the role of ultrasound (US) in diagnosing different types of ankle impingement due to osseous and soft tissue pathologies and to compare the results with magnetic resonance imaging (MRI), which is considered our gold standard.

METHODS

The study population included 90 patients with unilateral ankle pain who presented with symptoms and signs suggestive of ankle impingement. Their age ranged from 17 to 57 years, with a mean age of 33.7 years. Using US and MRI, our cases were classified into bony and soft tissue ankle impingement. They were further classified according to the anatomical compartments affected, into anteromedial, anterior, anterolateral, posteromedial, and posterior.

RESULTS

90 patients were enrolled in this study: 51 males and 39 females. In our study, posterior ankle impingement was the commonest impingement type, while anteromedial ankle impingement was the rarest type, followed by posteromedial impingement. The accuracy of US in diagnosing osseous impingement was found to have the following: sensitivity 70.37%, specificity 100%, PPV 100%, NPV 75%, accuracy 84.31%, and p value < 0.001; meanwhile, the accuracy of US in diagnosing soft tissue impingement was found to have the following: sensitivity 83.33%, specificity 100%, PPV 100%, NPV 87.10%, accuracy 92.16%, and p value < 0.001.

CONCLUSION

US is a good diagnostic tool in bone and soft tissue impingements, with a significant p value of 0.001 for both. US cannot replace MRI as a diagnostic tool, but as a widely available imaging modality, it can save time and cost and allows dynamic imaging.

Continuous detrimental activity of intra-articular fibrous scar tissue in correlation with posttraumatic ankle osteoarthritis

Posttraumatic osteoarthritis is primarily characterized by articular cartilage destruction secondary to trauma or fracture events. Even while intra-articular scar tissue can be observed following ankle fractures, little is known about its nature and molecular events linking its biological activity and cartilage deterioration. Here, we investigated scar tissue's histological and molecular characteristics, and its relationship with localized articular cartilage alterations consistent with early osteoarthritic degeneration. Intra-articular scar tissues from sixty-two patients who underwent open reduction internal fixation for ankle fracture were obtained at hardware removal time (6-44 months after fracture). Histological analysis demonstrated that scar tissue has the nature of fibrosis with fibrous tissue hyperplasia, fibroblast proliferation, and chondrometaplasia. These fibrous scar tissues showed overexpressed pro-inflammatory cytokines and high mRNA expression levels of osteoarthritis-related markers (cytokines, chemokines, and enzymes) compared to the normal synovium. Furthermore, those transcriptional levels were significantly correlated with the grade of talar chondral degeneration. Our findings suggest that following an ankle fracture, the intra-articular fibrous scar tissue exhibits high catabolic and inflammatory activity, which has a long-lasting negative impact correlated to cartilage deterioration in the development of posttraumatic osteoarthritis.

Arthroscopic Treatment of Anterior Ankle Impingement

Arthroscopic reduction of tibiotalar osteophytes results in good to excellent results in the vast majority of patients. Pain is primarily due to synovial hypertrophy and anterior tibiotalar entrapment associated with the osteophytes. Osteophytes may be due to repetitive trauma such as sports, or associated with subtle or overt ankle instability. A minimally invasive approach results in rapid recovery and less risk than open interventions. In cases where anterior osteophytes have coexisting ankle instability and in many cases ancillary procedures such as ankle stabilization are performed.

Posterior Ankle Impingement

This article is devoted to managing posterior ankle impingement syndrome and its management using endoscopic to arthroscopic surgical instrumentation. The authors explore the critical anatomy, pathogenesis, and clinical examination. Operative techniques, including the approach, and instrumentation used, are outlined. The postoperative protocol is discussed. Finally, a literature review is provided, which also defines known complications.

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.

Clinical significance of the anteromedial talus osteophyte in anteromedial ankle impingement in chronic lateral ankle instability

PURPOSE

The aim of this study was to evaluate the relation between anteromedial ankle osteophytes (AMAO) and anteromedial ankle impingement (AMAI) in chronic lateral ankle instability (CLAI) through visualization and quantification.

METHODS

Forty-three patients with unilateral CLAI between September 2018 and March 2020 accepted arthroscopic repair of an anterior talofibular ligament (ATFL) and were split into two groups: AMAI (AMAI including intraoperative AMAO resection) and pure CLAI (with AMAO but without AMAI, no AMAO resection). The AMAO protrusion lengths in each direction were measured and compared after all of the ankles were reconstructed. All patients were assessed preoperatively and at 2-year follow-up with ankle dorsiflexion, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and visual analog scale (VAS) score.

RESULTS

Intelligent analysis showed that a large extent of osteophytes was found at the dorsomedial surface of the talar neck in AMAI group. The upper and inner bound protrusion distances of AMAO in AMAI group were greater than in the pure CLAI group. There was no significant difference in anterior bound protrusion distance of AMAO between the two groups. Preoperatively, the ankle dorsiflexion of AMAI group (7.6 ± 1.4°) was considerably lower than that of pure CLAI group (22.4 ± 1.9°) (p < 0.001). When compared to the pure CLAI group, the AMAI group had a substantially worse AOFAS score (62.2 ± 6.7 vs 71.1 ± 9.1; p < 0.001) and VAS score (6.0 ± 1.0 vs 4.9 ± 0.8; p < 0.05). However, there was no significant difference in postoperative ankle dorsiflexion, AOFAS score, or VAS score between the two groups.

CONCLUSION

AMAO is formed mostly on the dorsomedial surface of the talar neck in CLAI with AMAI, and the upper and inner bound protrusion lengths of AMAO were shown to be significantly correlated with the existence of AMAI in CLAI.

LEVEL OF EVIDENCE IV

CT-Based Calculation Model Assists Precise Treatment for Anterior and Posterior Ankle Bony Impingement

OBJECTIVE

Ankle arthroscope is the preferred tool for ankle surgeons to treat ankle impingement. However, there is no relevant report on how to improve the accuracy of arthroscopic osteotomy through preoperative planning. The aims of this study were to investigate a novel method to obtain the bone morphology in anterior and posterior ankle bony impingement through computed tomography (CT) calculation model, use this method to guide surgical decision-making, and compare the postoperative efficacy and actual bone cutting volume with conventional surgery.

METHODS

This retrospective cohort study includes 32 consecutive cases with anterior and posterior ankle bony impingement by arthroscopy from January 2017 to December 2019. Mimics software was utilized to calculate the bony morphology and measure the volume of the osteophytes by two trained software engineers. The patients were divided into the precise group (n = 15) and the conventional group (n = 17) according to whether obtain and quantify the osteophytes' morphology with CT based calculation model preoperative. All patients were evaluated clinically using visual analog scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, active dorsiflexion and plantarflexion angle before and after surgery at both 3 months and 12 months postoperatively. We obtained the shape and volume of bone cutting through Boolean calculation. Clinical outcomes and radiological data were compared between the two groups.

RESULTS

The VAS score, AOFAS score, active dorsiflexion angle and plantarflexion angle were significantly improved in both groups postoperatively. In comparison of the VAS score, AOFAS score, and active dorsiflexion angle, the precise group were higher than the conventional group in the follow-up at 3 and 12 months postoperatively with statistical difference. The difference between the virtual bone cutting volume and the actual bone cutting volume of the anterior edge of distal tibia in the conventional group and precise group were 244.20 ± 147.66 mm³ and 76.53 ± 168.51 mm³ , respectively, there was statistical difference between the two groups (t = -2.927, p = 0.011).

CONCLUSION

Using a novel method of obtaining and quantifying the bony morphology with CT-based calculation model for anterior and posterior ankle bony impingement can help guide surgical decision-making preoperatively and assist precise bone cutting during the operation, which can improve the efficacy and evaluate the accuracy of osteotomy postoperatively.

Posterior Ankle Impingement Syndrome

Posterior ankle impingement is typically seen in athletes, primarily dancers and soccer players, secondary to dynamic and repetitive push-off maneuvers and forced hyperplantarflexion. Posterior ankle impingement results from chronic, repetitive trauma to the posterior ankle capsule, flexor hallucis longus tendon, and/or os trigonum. It is important to perform a thorough workup by isolating and testing the posterior compartment muscles and obtaining proper imaging with radiographs to identify any osseous abnormalities and MRI to evaluate the soft tissue structures. Nonsurgical treatment includes activity modification, physical therapy, and steroid injections.

Acute Ankle Sprains

Understanding the types of ankle sprains is essential in determining the most appropriate treatment and preventing substantial missed time from sports. Commonly known and recognized is an acute lateral ankle sprain, however, a differentiation should also be made to understand high (syndesmotic) ankle sprains as the mechanism of injury and recovery periods differ between these two types.

Arthroscopic osteoplasty of the medial and anteromedial wall of temporomandibular joint: surgical technique and anatomical considerations

The anterior displacement of the articular disc is the most frequent cause of pathological alterations in the TMJ. Although it is an extremely common pathology, there is no certainty about the aetiopathogenesis of this disease. The main aim of the present report is to describe new anatomical findings that could help clarifying the aetiopathogenesis of this disease and determine a typology of treatment based on the cause of the disease. All the operative records of patients who underwent arthroscopic osteoplasty of the medial TMJ wall in our centre from January 2021 to September 2021 were reviewed and analysed to identify specific anatomical features observed in every procedure. Fifty-two joints were included for analysis in this study. Twenty-two joints were classified as Wilkes stages II-III and 30 as Wilkes stages IV-V. The most common complication observed in our sample was the dysaesthesias found in the temporal and preauricular regions. Other complications observed were frontal branch paresis (n = 2), intraoperative bleeding (n = 1), and postoperative malocclusion (n = 1). The compression of the superior head of pterygoid lateral muscle (SPLM) on the medial bony wall and the consequent muscle atrophy could be key for the aetiology of the anterior TMJ disc displacement. Therapeutic actions on the osseous and muscular component in this anatomical area could improve the outcomes of patients affected by TMJ internal derangement. A meticulous dissection of the fascia of the superior fascicle of the lateral pterygoid muscle allows a remodelling of the bone surfaces with minimal complications.

Arthroscopic Osteophyte Resection for Osteophyte-Induced Popliteal Impingement

Popliteal tendinitis causes lateral knee pain. A cause is impingement of the popliteal tendon by lateral femoral condylar osteophytes. Conservative and surgical treatments have been reported; however, popliteal impingement is a relatively rare disease, and no treatment has been established. Reduction of mechanical stress is important in the treatment of impingement syndromes. The popliteal tendon is an important tissue that contributes to knee stability and, therefore, usually cannot be transected. On the other hand, osteophyte resection may allow the reduction of mechanical stress. Therefore, we describe an arthroscopic osteophyte resection technique for the treatment of osteophyte-induced popliteal impingement. In brief, this technique involves confirmation of popliteal impingement, osteophyte resection using an osteotome, smoothening of the resected area, and confirmation of the resolution of popliteal impingement.

The double posteromedial portals endoscopy for posterior ankle impingement syndrome in athletes

Background

Posterior ankle impingement syndrome (PAIS) may result from flexor hallucis longus tendinopathy, compression of the posterior process of the talus from the presence of an os trigonum, soft-tissue impingement, or a combination of these. Posterior extra-articular endoscopy performed with the patient supine through the double posteromedial portals, with excision of adhesions, excision of the posterior process of the talus or an os trigonum, and decompression of the tendon of the flexor hallucis longus (FHL), can be used in athletes with PAIS.

Methods

Thirty-four athletes with PAIS in whom conservative management had failed underwent posterior ankle endoscopy in the supine position using the double posteromedial portals. The patients were assessed pre- and postoperatively using the American Orthopaedic Foot and Ankle Society hindfoot scale score, the Tegner scale, and the simple visual analogue scale. Time of surgery, return to sports, patient satisfaction, and complications were recorded and analysed. The average length of postoperative follow-up was 26.7 ± 12.6 (range 24 to 72) months.

Results

The mean Tegner activity scale score improved to 9 ± 0.2 postoperatively (p < 0.05), while the mean American Orthopaedic Foot and Ankle Society scale score improved to 96 ± 5.1 (range 87 to 100) postoperatively, with 29 of 34 patients (85.3%) achieving a perfect score of 100 (p < 0.05). The mean time to return to sports was 8.7 ± 0.7 (range 8 to 10) weeks. The complication rate was low, with no superficial wound infections or venous thromboembolism events; only two patients (5.9%) reported pain and tenderness by 3 months after the index procedure.

Conclusion

Posterior ankle endoscopy for the resection of a posterior process of the talus or an os trigonum and decompression of the tendon of FHL is safe and allows excellent outcomes with low morbidity in athletes with PAIS.

Associations between clinical and imaging findings in posterior ankle impingement syndrome: a systematic review

BACKGROUND

Posterior ankle impingement syndrome (PAIS) is a common and debilitating condition, commonly affecting people who participate in activities that involve repetitive ankle plantarflexion. The relationship between clinical and imaging findings in PAIS has not been established.

PURPOSE

To investigate the relationship between clinical and imaging features in PAIS by reviewing the literature comparing symptomatic patients to asymptomatic controls.

MATERIAL AND METHODS

A systematic literature search was performed to identify all English-language articles that compared imaging features in patients diagnosed with PAIS to imaging in an asymptomatic control group.

RESULTS

A total of 8394 articles were evaluated by title and abstract, and 156 articles were read in full text. No articles compared imaging findings to an asymptomatic control group, thus no articles met the inclusion criteria.

CONCLUSION

This systematic review found no published research that compared the imaging findings of people diagnosed with PAIS to asymptomatic people. Until this information is available, imaging features in people with posterior ankle impingement should be interpreted with caution.

Anterior ankle impingment syndrome is less frequent, but associated with a longer absence and higher re-injury rate compared to posterior syndrome: a prospective cohort study of 6754 male professional soccer players

PURPOSE

To study the epidemiology and return to play characteristics of anterior and posterior ankle impingement syndromes (AAIS and PAIS) over 18 consecutive seasons in male professional soccer players.

METHODS

Between the 2001-2002 and 2018-2019 seasons, 120 European soccer teams were followed prospectively for various seasons. Time loss injuries and player exposures were recorded individually in 6754 unique players. Injury incidence and burden were reported as the number of injuries and days absence per 1000 h with 95% confidence intervals (CIs). Injury severity was reported as median absence in days with the interquartile range (IQR).

RESULTS

Out of 25,462 reported injuries, 93 (0.4%) were diagnosed as AAIS (38%) or PAIS (62%) in 77 players. AAIS and PAIS were similar regarding injury characteristics except for a greater proportion of AAIS having a gradual onset (69% vs.47%; P = 0.03) and being re-injuries (31% vs. 9%; P = 0.01). Impingement syndromes resulted in an overall incidence of 0.03 injuries (95% CI 0.02-0.03) per 1000 h and an injury burden of 0.4 absence days per 1000 h. PAIS incidence was significantly higher than that for AAIS [0.02 (95% CI 0.002-0.03) vs. 0.01 (95% CI 0.005-0.01) injuries per 1000 h (RR = 1.7). The absence was significantly longer in AAIS than in PAIS [10 (22) vs. 6 (11) days; P = 0.023]. Impingement syndromes that presented with a gradual onset had longer absences in comparison to impingement with an acute onset [8 (22) vs. 5 (11) days; P = 0.014]. Match play was associated with a higher incidence and greater injury burden than training: 0.08 vs. 0.02 injuries per 1000 h (RR 4.7), respectively, and 0.9 vs. 0.3 days absence per 1000 h (RR 2.5).

CONCLUSION

Ankle injuries are frequent in men's professional soccer and ankle impingement is increasingly recognized as a common source of pain, limited range of motion, and potential time loss. In our study, ankle impingement was the cause of time loss in less than 0.5% of all injuries. PAIS was more frequently reported than AAIS, but AAIS was associated with more absence days and a higher re-injury rate than PAIS. The findings in this study can assist the physician in best practice management on ankle impingment syndromes in professional football.

LEVEL OF EVIDENCE

II.

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.

Chronic Fracture of the Posteromedial Tubercle of the Talus Masquerading as Os Trigonum Syndrome

Posterior ankle impingement syndrome (PAIS) can be caused by osseous pathology from the posterior aspect of the talus. The commonest cause is an os trigonum, an accessory ossicle arising from the lateral tubercle of the posterior talus. We have observed cases where the osseous impingement is due to a chronic fracture nonunion of the medial tubercle of the posterior talus with unique symptoms, differentiating this clinical syndrome from the more common os trigonum syndrome. These can be readily overlooked on imaging and confused with an often coexisting os trigonum. Awareness of these lesions is paramount to ensure appropriate management and safe surgery. We describe a series of patients presenting to the senior author with this clinical syndrome, discuss its unique clinical and radiological features, and describe our surgical technique.

Causes of delayed diagnosis of posterior ankle impingement in the pediatric and adolescent population

PURPOSE

The purpose of this study was to identify and characterize various causes of delay in the diagnosis of posterior ankle impingement syndrome (PAIS) in pediatric patients.

METHODS

IRB approved prospective study of patients under 18 years who underwent arthroscopic surgery for the diagnosis of posterior ankle impingement after failed conservative treatment at a tertiary children's hospital. Radiographic findings were compared with an age-matched control group. Descriptive and inferential statistics were employed.

RESULTS

47 patients (61 ankles), mean age 13 years, had an average 14 months delay in diagnosis of PAIS from the initial presentation. 33 (70%) patients had seen multiple medical providers and given other diagnoses. 9 (19%) patients participated in ballet or soccer, and 16 (34%) patients had unrelated associated foot and ankle diagnoses. 25 (41%) of 61 ankles did not have pain on forced plantar flexion; all 61(100%) ankles had tenderness to palpation over the posterior ankle joint line. Radiographs were reported to be normal in 37/52 (71%) ankles, while MRI report did not mention the diagnosis in 20/41 (49%) studies. There was a significant difference in the MRI findings in the patient population when compared to the control group. Indication for surgery was failed conservative treatment. All 61 ankles had posterior ankle impingement pathology confirmed visually during arthroscopy. At average 15 months follow-up, there was significant improvement pre- to post-operatively (p<0.001) for both pain VAS (6.9-0.9) and AOFAS ankle-hindfoot scores (65-94).

CONCLUSION

Multiple clinical and imaging factors can lead to delayed diagnosis of posterior ankle impingement. An increased awareness about the features of PAIS is needed amongst medical providers involved in treating young patients.

Endoscopic resection of a localized tenosynovial giant cell tumor causing posterior ankle impingement in a 15-year-old athlete: A case report

Tenosynovial giant cell tumor (TGCT) is a systematically benign but locally aggressive lesion arising from the synovium, tendon sheath or joint bursae. Even in athletes, soft tissue tumors may be the underlying reason or a component of posterior ankle impingement, although the most common mechanism is forceful and repetitive plantar flexion. In this article, we present a case of localized TGCT in a 15-year-old female patient presenting with symptoms of posterior ankle impingement. The preferred technique for treatment was complete local resection via posterior ankle endoscopy. The patient returned to sports at three months and no recurrence was observed on the last follow-up at the first postoperative year. Although rare, soft tissue tumors should be taken into consideration in posterior ankle impingement in athletes. Such benign soft tissue tumors in the posterior ankle can be treated safely and effectively via two-portal posterior endoscopic approach.

Prognostic factors in ankle sprains: a review

Ankle sprains are one of the most common musculoskeletal injuries, being the most frequent musculoskeletal trauma among athletes.

Most of these injuries are successfully treated conservatively; however, up to 70% of patients can develop long-lasting symptoms. Therefore, understanding prognostic factors for an ankle sprain could help clinicians identify patients with poor prognosis and choose the right treatment.

A suggested approach will be presented in order to positively identify the factors that should warrant a more aggressive attitude in the initial conservative treatment.

There are some prognostic factors linked to a better recovery and outcome; nevertheless, prognostic factors for full recovery after initial ankle sprain are not consistent.

Cite this article: EFORT Open Rev 2020;5:334-338. DOI: 10.1302/2058-5241.5.200019

Delayed diagnosis of posterior ankle impingement in pediatric and adolescent patients: does radiology play a role?

BACKGROUND

Posterior ankle impingement syndrome (PAIS) results from the pinching of anatomical structures in the posterior part of the ankle.

OBJECTIVE

To identify the possible role of imaging in the delayed diagnosis of PAIS and identify key findings on imaging to suggest PAIS in pediatric and adolescent patients.

MATERIALS AND METHODS

Data were collected prospectively in patients younger than 18 years of age who underwent arthroscopy after being diagnosed with PAIS. Imaging was reviewed retrospectively by two radiologists, compared with findings in literature and an age-matched control group, and correlated with arthroscopic findings. Pre- and postsurgical Visual Analogue Scale (VAS) pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted.

RESULTS

Thirty-eight patients (20 females, 18 males), 51 ankles, with an average age of 12.9 years had an average 18-month delay in diagnosis. Twenty-seven of the 38 (73%) patients had previously seen multiple medical providers and were given multiple misdiagnoses. Radiographs were reported normal in 34/47 (72%) ankles. Thirty patients had magnetic resonance imaging (MRI) and findings included the presence of an os trigonum/Stieda process (94%) with associated osseous edema (69%), flexor hallucis longus (FHL) tenosynovitis (16%), and edema in Kager's fat pad (63%). Although individual findings were noted, the impression in the MRI reports in 16/32 (50%) did not mention PAIS as the likely diagnosis. There was a significant difference in the MRI findings of ankle impingement in the patient population when compared to the control group. Surgery was indicated after conservative treatment failed. All 51 ankles had a PAIS diagnosis confirmed during arthroscopy. At an average follow-up of 10.2 months, there was improvement of VAS pain (7.0 to 1.1) and AOFAS ankle-hindfoot scores (65.1 to 93.5).

CONCLUSION

PAIS as a diagnosis is commonly delayed clinically in young patients with radiologic misinterpretation being a contributing factor. Increased awareness about this condition is needed among radiologists and physicians treating young athletes.

Hindfoot endoscopic release of the posterior ankle capsuloligamentous structures improves ankle dorsiflexion range, function and pain in patients with painful limitation of ankle dorsiflexion

Objective

To evaluate the effect of arthroscopic release of the posterior capsuloligamentous structures on ankle dorsiflexion and function in patients with painful limitation of ankle dorsiflexion.

Methods

A prospective consecutive case series of 13 adult patients with painful limitation of ankle dorsiflexion were included. None had clinically relevant gastrocnemius, soleus or Achilles contracture. Patients with anterior bony impingement or ankle degeneration on CT scan were excluded. All patients underwent combined anterior and posterior ankle arthroscopies with resection of posterior capsuloligamentous structures and the posterior fibulotalocalcaneal ligament. Ankle range of motion was assessed 2 years postoperatively. Foot and Ankle Outcome Scores (FAOS) were used to assess functional outcome.

Results

The median patient age at surgery was 26 years (range 19–44). At 2 years postsurgery, the ankle dorsiflexion range had increased by 15 degrees (range 0–25, p<0.0001). FAOSs completed at a median of 44 months postsurgery (range 26–72) significantly improved. Median improvements were 19 points for pain (range 6–67, p=0.0004), 14 points for symptoms (range 0–36, p=0.0005), 15 points for activities of daily living (range 6–35, p<0.0001), 45 points for sport (range 20–55, p<0.0001) and 50 points for quality of life (range 13–62, p<0.0001).

Conclusions

Hindfoot endoscopic release of the posterior ankle structures, including the posterior fibulotalocalcaneal ligament, is an effective technique for improving ankle dorsiflexion range in patients with painful limitation of ankle dorsiflexion.

Level of evidence

IV.

Combined Anterolateral, Anterior, and Anteromedial Ankle Impingement in an Adolescent Soccer Player: A Case Report and Review of the Literature

A unique case of combined anterolateral, anterior, and anteromedial ankle impingement in an adolescent soccer player is presented in this article. To the best of our knowledge, this is the only report of circumferential, massive, anterior ankle impingement in children described in the literature. The importance of proper diagnosis and treatment of such a lesion is illustrated in this case report. We also emphasize that clinical examination combined with 3D computed tomography scan reconstruction is an excellent and cost-effective imaging modality that can help with the diagnosis of anterior ankle impingement. Finally, open surgical treatment showed excellent results in an elite athlete.

A flexion osteotomy for correction of a distal tibial recurvatum deformity

Aims

There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure.

Patients and Methods

A total of 39 patients (12 women, 27 men; mean age 47 years (28 to 72)) with a distal tibial recurvatum deformity were treated with a flexion osteotomy, between 2010 and 2015. Nine patients (23%) subsequently required conversion to either a total ankle arthroplasty (seven) or an arthrodesis (two) after a mean of 21 months (9 to 36). A total of 30 patients (77%), with a mean follow-up of 30 months (24 to 76), remained for further evaluation. Functional outcome, sagittal ankle joint OA using a modified Kellgren and Lawrence Score, tibial lateral surface (TLS) angle, and talar offset ratio (TOR) were evaluated on pre- and postoperative weight-bearing radiographs.

Results

Postoperatively, the mean score for pain, using a visual analogue scale, decreased significantly from 4.3 to 2.5 points and the mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly from 59 to 75 points (both p < 0.001). The mean TLS angle increased significantly by 6.6°; the mean TOR decreased significantly by 0.24 (p < 0.001). Radiological evaluation showed an improvement or no progression of sagittal ankle joint OA in 32 ankles (82%), while seven ankles (18%) showed further progression.

Conclusion

A flexion osteotomy effectively improved the congruency of the ankle joint. In 30 patients (77%), the joint could be saved, whereas in nine patients (23%), the treatment delayed a joint-sacrificing procedure. Cite this article: Bone Joint J 2019;101-B:682–690.

Evaluation of the Prevalence of Os Trigonum and Talus Osteochondral Lesions in Ankle Magnetic Resonance Imaging of Patients With Ankle Impingement Syndrome

The prevalence of os trigonum and osteochondral lesions of talus (OCLT) have been presented in different prevalences among different groups in the literature for the patients with ankle impingement syndrome. Our main objective in the study was to determine the possible relationship between the impingement syndrome and the prevalence of os trigonum and OCLT in specific groups. The presence of anterior ankle impingement syndrome (AAIS), posterior ankle impingement syndrome (PAIS), os trigonum, OCLT, and the location of OCLT were evaluated in a blinded manner on magnetic resonance imaging from patients clinically considered to be diagnosed with ankle impingement syndrome from January 2014 to July 2017. The patients were separated into specific groups according to the confirmation of their clinical diagnosis of ankle impingement syndrome on magnetic resonance imaging . A total of 333 patients were included. The prevalence of os trigonum was found to be 1.3% in patients with PAIS(-) AAIS(+), 7.7% in patients with PAIS(-) AAIS(-), 63.3% in patients with PAIS(+) AAIS(-), and 81.1% in patients with PAIS(+) AAIS(+) (p < .001). The prevalence of OCLT was found to be 41.3% in patients with PAIS(-) AAIS(+), 23.1% in patients with PAIS(-) AAIS(-), 18.3% in patients with PAIS(+) AAIS(-), and 27% in patients with PAIS(+) AAIS(+) (p= .005). Our study showed that, for patients with isolated PAIS and AAIS combined with PAIS, the prevalence of os trigonum was 63.3% and 81.1%, respectively, which is more common than previously reported. For patients with isolated AAIS and PAIS, the prevalence of OCLT was 41.3% and 18.3%, respectively. Of the OCLTs combined with ankle impingement syndromes, 87.1% were medially located.

Management of foot and ankle injuries in pediatric and adolescent athletes: a narrative review

In this review, we focus on the treatment of injuries to the foot and ankle in the adolescent athlete. While many injuries in the adolescent foot and ankle are similar to or overlap with their counterparts in the adult population, the anatomy of the adolescent ankle, especially the presence of growth plates, results in different injury patterns in many cases and calls for specific management approaches. We discuss the unique anatomy of the pediatric patient as well as the diagnostic evaluation and treatment of common injuries in the young athlete.

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.

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.

Talar insufficiency fracture complicating ankle cheilectomy

Ankle cheilectomy as surgical treatment for anterior ankle impingement has high rates of procedural success and low rates of complications when performed before the onset of significant osteoarthritis. We present 3 patients who developed insufficiency fractures of the talar neck following cheilectomy for anterior ankle impingement. Due to the high risk of avascular necrosis associated with displaced talar neck fractures, the recognition of talar insufficiency fractures by the radiologist can aid in the timely diagnosis and initiation of intervention. Because radiographic findings of stress fractures often require weeks to manifest, maintaining a high index of suspicion in the postcheilectomy setting allows the radiologist to suggest appropriate further imaging when appropriate.

Effect of a novel mobilization with movement procedure on anterolateral ankle impingement - A case report

This case report describes a 50-year-old male who presented with right anterolateral ankle pain managed unsuccessfully with rest, medications, bracing, injection, physical therapy, and massage therapy. Clinical diagnosis of anterolateral ankle impingement was based on concordant symptom reproduction with palpatory tenderness and a positive lateral synovial impingement test. This case report is a potential first time description of the successful management of anterolateral ankle impingement utilizing a novel Mulligan's mobilization with movement procedure (consisting of internal rotation of the distal tibia) and taping with immediate improvements noted in pain, range of motion, and function. The patient was seen twice a week and was discharged after four treatment sessions. A follow-up after 4 months revealed that the patient was pain free and fully functional.