Current concepts in ankle arthroscopy

Foot and Ankle Surgery: Common Problems and Solutions

Participation in sports activity has increased significantly during the last several decades. This phenomenon has exposed orthopedic sports medicine surgeons to new challenges regarding the diagnosis and management of common sport-related injuries. Arthroscopy is becoming more commonly used in many of the surgical procedures for these injuries and carries the risk of complications. Wound and nerve complications make up the bulk of complications in most procedures. This article describes these complications associated with the common surgical procedures related to foot and ankle sport-related injuries and how to address and prevent them.

Open and arthroscopic surgical anatomy of the ankle

Ankle-related complaints are among the most commonly encountered problems for musculoskeletal clinicians. Ankle pathology is widely variable, including, but not limited to, fractures, deformity, infection, oncologic diseases, neuromuscular conditions, and arthritis. While nonoperative management with activity modification, bracing and/or shoe modifications, and medications is usually indicated as first line of treatment, surgical intervention may become necessary. A thorough understanding of the complex anatomy and biomechanics of the ankle, and in particular, the potential neurovascular structures that may be encountered, is important to reduce complications and obtain good surgical outcomes. The purpose of this review is to discuss the most common open and arthroscopic exposures to the ankle with a focus on surgically relevant anatomy for each approach.

Osteochondral lesion of the talus: prognostic factors affecting the clinical outcome after arthroscopic marrow stimulation technique

The treatment of symptomatic osteochondral lesions of the talus (OLT) has difficulties and limitations caused by the poor regeneration of articular cartilage and the limited access to the ankle joint. It is important that the surgeon understand the causes of failure as well as the factors influencing the results of arthroscopic treatment of OLTs. The presence of such a risk factor may encourage surgeons to find new treatment strategies as well as counsel patients differently.

Current concepts in the diagnosis and treatment of osteochondral lesions of the ankle

Osteochondral lesions of the ankle are a more common source of ankle pain than previously recognized. Although the exact pathophysiology of the condition has not been clearly established, it is likely that a variety of etiological factors play a role, with trauma, typically from ankle sprains, being the most common. Technological advancements in ankle arthroscopy and radiologic imaging, most importantly magnetic resonance imaging, have improved diagnostic capabilities for detecting osteochondral lesions of the ankle. Moreover, these technologies have allowed for the development of more sophisticated classification systems that may, in due course, direct specific future treatment strategies. Nonoperative treatment yields best results when employed in select pediatric and adolescent patients with osteochondritis dissecans. However, operative treatment, which is dependent on the size and site of the lesion, as well as the presence or absence of cartilage damage, is frequently warranted in both children and adults with osteochondral lesions. Arthroscopic microdrilling, micropicking, and open procedures, such as osteochondral autograft transfer system and matrix-induced autologous chondrocyte implantation, are frequently employed. The purpose of this article is to review the history, etiology, and classification systems for osteochondral lesions of the ankle, as well as to describe current approaches to diagnosis and management.

Arthroscopic-assisted fluoroscopic navigation for retrograde drilling of a talar osteochondral lesion

Level of Evidence: V, Expert Opinion

A cadaver study on preserving peroneal nerves during ankle arthroscopy

BACKGROUND

Ankle arthroscopy is an important diagnostic and therapeutic procedure, but neurovascular injury remains a disadvantage. By understanding the anatomy of the superficial peroneal nerve (SPN) and deep peroneal nerve (DPN) the risk of nerve injury can be minimized.

METHODS

Thirty-four lower limbs from 17 cadavers were dissected to find the safest anatomical points easily during arthroscopy.

RESULTS

There was a single branch of the SPN in eight of 34 specimens (23.5%); type 1), two branches in 18 (52.9%; type 2), three branches in six (17.7%; type 3) and four branches in two specimens (5.9%; type 5) at the level of the talocrural (TC) joint. The closest SPN branch to lateral border of the TC joint was 14 +/- 8.4 mm. There was no branch of the SPN or DPN medial to the extensor hallucis longus tendon in any specimen. The DPN bifurcation was 6.5 mm proximal to the TC joint in a single specimen (2.9%) and 14.5 +/- 5.5 mm distal to TC joint in 26 specimens (76.5%). In four specimens (11.8%), the DPN bifurcation was at the same level with the TC joint. In three specimens (8.8%), there was no bifurcation of the DPN.

CONCLUSIONS

From this study the anatomic landmarks defining the medial midline portal are safely away from the SPN and DPN and their respective branches. Clinical studies are needed to define its safety during ankle arthroscopy.

CLINICAL RELEVANCE

This study proves that the medial midline portal is the best portal for the anterior arthroscopic procedures.

Prospective study on diagnostic strategies in osteochondral lesions of the talus

Our aim in this prospective study was to determine the best diagnostic method for discriminating between patients with and without osteochondral lesions of the talus, with special relevance to the value of MRI compared with the new technique of multidetector helical CT. We compared the diagnostic value of history, physical examination and standard radiography, a 4 cm heel-rise view, helical CT, MRI, and diagnostic arthroscopy for simultaneous detection or exclusion of osteochondral lesions of the talus. A consecutive series of 103 patients (104 ankles) with chronic ankle pain was included in this study. Of these, 29 with 35 osteochondral lesions were identified. Twenty-seven lesions were located in the talus.

Our findings showed that helical CT, MRI and diagnostic arthroscopy were significantly better than history, physical examination and standard radiography for detecting or excluding an osteochondral lesion. Also, MRI and diagnostic arthroscopy performed better than a mortise view with a 4 cm heel-rise. We did not find a statistically significant difference between helical CT and MRI. Diagnostic arthroscopy did not perform better than helical CT and MRI for detecting or excluding an osteochondral lesion.

Arthroscopically assisted treatment of ankle fractures: arthroscopic findings and surgical outcomes

PURPOSE

Malleolar fractures have been reported to be associated with a poor prognosis even when the anatomic reduction is complete. Soft tissue injuries such as damage to the cartilage and ligaments, soft tissue impingement, and the existence of free bodies within the intra-articular space account for this poor outcome. In treating fresh malleolar fractures, an arthroscope is used at our institution to confirm anatomic reduction on the articular surface and treat intra-articular injuries. This study evaluated the arthroscopic findings and surgical outcome for fresh malleolar fractures.

TYPE OF STUDY

Prospective case study.

METHODS

The subjects were 105 patients (105 joints) who had experienced malleolar fractures and had undergone surgical fixation between January 1996 and May 1999. Arthroscopy was used to confirm the fracture line, cartilaginous damage, presence of detached cartilaginous fragments in the articular space, ligament damage, and diastasis of the distal tibiofibular joint. The cartilaginous damage was treated using shaving, and the free cartilaginous fragments were excised. Diastasis of the distal tibiofibular joint was treated using distal tibiofibular joint fixation, using a screw. Fracture fixation was conducted after anatomic reduction had been confirmed using fluoroscopy and arthroscopy.

RESULTS

Cartilaginous damage was noted in 21 patients, among whom 13 were treated by shaving and 8 underwent cartilaginous fragment removal. Fixation of the distal tibiofibular joint was conducted in 8 patients. From a postoperative radiographic evaluation, a good result in 100 cases and a fair outcome in 5 were confirmed. The clinical results were good in all, and no postoperative complications or pseudoarthrosis were noted.

CONCLUSIONS

The use of an arthroscope during treatment of malleolar fractures enables diagnosis and treatment of the lesions within the ankle joint, producing a satisfactory surgical outcome.

LEVEL OF EVIDENCE

Level IV, therapeutic study, case series (no control group).

Arthroscopic treatment of osteochondral lesions of the talus with correlation of outcome scoring systems

PURPOSE

The goal of this study was to perform a retrospective review of arthroscopically treated osteochondral lesions of the talus (OCLTs) to determine their outcome and to analyze the correlation of 3 subjective outcome scoring systems for the ankle.

METHODS

Between 1985 and 1999, 37 arthroscopic debridement or subchondral drilling procedures were performed on 33 ankles to treat OCLTs. The charts of these patients were reviewed for general demographic, preoperative, surgical, and postoperative information. Patients were sent a questionnaire that included 3 subjective outcome scoring systems: the Martin Score questionnaire; the Berndt and Harty scale; and the Single Assessment Numeric Evaluation (SANE) question. Twenty-eight people responded to the questionnaire. Twenty-four patients reported a history of trauma. There were 17 lesions on the medial aspect of the talus, 10 laterally, and 1 centrally. The lesions were classified according to their arthroscopic appearance. There were 7 stage I, 2 stage II, 10 stage III, and 9 stage IV lesions. After all data were analyzed, the Pearson product-moment correlation coefficient (r) and correlation of determination (r2) were performed among the 3 outcome scales.

RESULTS

The mean follow-up time was 66 months (range, 6-169 months). Outcome results varied according to the scoring system. Using the Berndt and Harty scale, 13 (46%) patients had good, 13 (46%) fair, and 2 (8%) poor results. According to the Martin Score, 1 patient (4%) had excellent, 10 (35%) good, 9 (32%) fair, and 8 (29%) had poor results. According to the SANE score, 5 patients (18%) had excellent, 8 (29%) good, 9 (32%) fair, and 6 (21%) had poor results. Seventeen patients reported some form of pain at follow-up examination. Analysis of variables, including age at operation, stage of the lesion, length of follow-up, and previous surgery revealed no statistical significance. All 3 scales showed positive correlations. Based on these outcome data, the Berndt and Harty scale showed good correlation with both the SANE and the Martin outcome systems (r =.81 and r =.69, respectively). The Martin Score showed moderate correlation with the SANE outcome system (r =.57).

CONCLUSIONS

The outcome results for our patient population were not as successful as has been previously reported. Our analysis showed positive correlation among the 3 subjective outcome systems. However, it remains difficult to compare these data with previous results secondary to the variety of outcome measures employed by previous reports in the literature.

Overload syndromes of the peritalar region

INTRODUCTION

The purpose of this study was to identify the diagnostic possibilities of the different diagnostic techniques in the evaluation of the pathological conditions affecting the peritalar region.

MATERIALS AND METHODS

Between September 1995 and December 1996, 58 patients, with a painful syndrome at peritalar level were submitted to MRI, which was performed using a 'dedicated system' consisting of 0.2 and 0.5 T equipment. Spin-Echo T1-weighted and Gradient-Echo T2-weighted sequences were used on sagittal, coronal and axial planes, with slice thickness of 3-5 mm. Conventional radiography was previously performed in all patients, while 18 of them underwent CT. Surgery or arthroscopy was performed in 22 cases. 36 patients underwent clinical follow-up associated with conventional radiography in six cases, MRI in 11 and to both of them in six patients.

RESULTS

After arthroscopy and surgery, an involvement of the tibio-talar joint was found (one pathogenic synovial plica, three meniscoid syndrome and 12 anterior impingement) in 16 patients. Concerning the subtalar joint, surgical examination revealed a cellulo-adipostis of the sinus tarsi in two patients, while in three cases osteochondral damage of the subtalar joint was identified. In the last patient, degenerative changes of the posterior tibial tendon associated with osteochondral pathology of the talo-navicular joint were found. MRI findings agreed with the surgical and arthroscopic ones in all patients except for the synovial plica; in this case, the MRI was negative. Follow-up performed on 36 patients revealed 12 tibio-talar joint, 17 subtalar joint and 7 talo-navicular joint pathological conditions.

DISCUSSION

Concerning the tibio-talar joint, MRI findings were confirmed by arthroscopy in all cases of anterior impingement. Magnetic resonance (MR), due to its capability in detecting osteochondral damage and identifying osteophyte sites, results in the best imaging method for evaluating this condition. Meniscoid syndrome is easily detected by MRI only in the presence of sufficient scar tissue, while conventional radiography reveals the calcific stage. In sinus tarsi syndrome, the ligamentous damage associated with sero-hemorrhagic effusion at fatty tissue level may lead to a 'chopping' effect on the nerve endings: this condition is well demonstrated by MRI. In all cases of osteochondral alterations affecting both the subtalar and talo-navicular joint, it has been possible to obtain correct diagnosis with MRI, which also depicted well the tenosynovitis of the posterior tibial tendon. In cases of stress fracture of the navicular bone, both CT and MRI demonstrated the lesions well, even when, in the early phases, conventional radiography produced a negative result. In conclusion, MRI may be considered the choice method in the study of different pathological alterations affecting the peritalar region, also providing detailed information useful for a therapeutic approach.

Arthroscopic treatment of soft-tissue impingement of the ankle in athletes

Sixty ankle arthroscopies were performed on patients with chronic soft-tissue impingement of the ankle after an ankle sprain between January 1989 and January 1994. Preoperative examination findings featured tenderness localized to the anterolateral aspect of the ankle, no instability, and, with the exception of 2 patients, normal radiographs. A preoperative bone scan was performed on 34 patients and was positive in each case but was not specific. Arthroscopy was performed an average of 23 months after injury. Results were determined by using a new ankle rating score. Hypertrophic synovium, synovitis, or fibrous adhesions were arthroscopically visualized and resected in all cases. The average follow-up was 27 months (range, 6 to 64 months). Thirty-one patients underwent complete evaluation and 29 were evaluated over the telephone. There were 51 excellent, 7 good, 1 fair, and 1 poor results. The diagnosis of chronic soft-tissue impingement of the ankle can be made from an appropriate history, thorough physical examination, and plain radiographs. Ankle arthroscopy with resection of impinging hypertrophic synovium or fibrous bands occurring after an ankle sprain was effective in alleviating pain in athletes.

Ankle arthroscopy: follow-up study of 33 ankles--effect of physical therapy and obesity

A retrospective analysis was conducted of 32 patients (33 ankles) who had undergone surgical ankle arthroscopy for chronic ankle pain that was recalcitrant to conservative treatment. All patients were examined clinically and completed a written questionnaire. Intraoperative ankle arthroscopy showed hypertrophic synovitis, adhesive bands, chondral bands with synovitis, osteophytes, and abnormalities in the talar dome. Results of treatment after an average follow-up time of 1.4 years (range: 0.33 to 12.5 years) showed ankle scores of 15 excellent, 11 good, 5 fair, and 2 poor. Obesity was significantly related to the outcomes of arthroscopy procedures. Obese patients were more likely to be rated as fair or poor, while nonobese patients were significantly more likely to be rated excellent or good. Those patients who received physical therapy postoperatively for one or more months had significantly better ankle ratings than those who did not elect to have physical therapy.