The safety of the posterior ankle arthroscopy in management of posterior ankle impingement: A cadaveric study

BackgroundArthroscopic management of the posterior ankle impingement with the patient in supine position has the advantage of dealing with anterior ankle pathology at the same time without the need to change position of the patient. This study aims at evaluation of the safety of portal establishment and instrumentation of this technique.MethodsSixteen fresh-frozen cadaver specimens were used. The relationships of the posteromedial and posterolateral portals to the adjacent tendons and nerves and the relationship of the coaxial portal tract with the posterior ankle capsule and the flexor hallucis longus tendon were studied.ResultAngle θ₁ between the intermalleolar line and the posterior ankle coaxial portal tract averaged 1° (−10° to 22°). Angle θ₂ between the intermalleolar line and the metal rod where the neurovascular bundle started to move averaged 19° (10° to 30°). Angle θ₃ between the intermalleolar line and the metal rod where it reached the lateral border of the Achilles tendon was larger than angle θ₂ in all specimens. The angle of safety (θ_s) averaged 18° (−1° to 26°).ConclusionsInjury to the tendon, nerves or vessels is possible during establishment of the portals and resection of the os trigonum.     

Hindfoot endoscopy for the treatment of posterior ankle impingement syndrome: A safe and reproducible technique

IntroductionPosterior ankle impingement is a clinical syndrome characterized by posterior ankle pain that is mainly presented on plantar flexion. The aim of this study is to compare and evaluate the results of posterior ankle impingement treated by endoscopic hindfoot posterior portals.Materials and methodsBetween 2004 and 2009, a total of 38 endoscopic hindfoot procedures were performed to treat posterior ankle impingement. The indication for procedure was posterior ankle impingement syndrome in all cases. There were 38 patients, 17 females and 21 males. Mean age was 27.6 years (16–59 years). Mean follow-up was 27.6 months (12.5–52 months). The results were evaluated following the AOFAS score. Data statistical analysis was performed using the Student's t-test.ResultsThe main preoperative AOFAS score increased from 67.42 (range 41–91) to 97.13 (range 84–100) at follow-up. No complications were reported in any case.ConclusionHindfoot endoscopy is a reproducible and safe procedure which offers excellent outcomes in posterior ankle impingement syndrome.     

Arthroscopic treatment of anterior ankle impingement

Anterior ankle impingement is a common cause of chronic ankle pain in the athletic population. Its cause can be either soft tissue or osseous in nature. Arthroscopic debridement results in favorable and reproducible outcomes. However, in the population in which ankle instability or narrowing of the ankle joint occur, outcomes may be less favorable.     

Posterior ankle impingement syndrome: A systematic fourstage approach

Posterior ankle impingement syndrome(PAIS) is a common injury in athletes engaging in repetitive plantarflexion, particularly ballet dancers and soccer players. Despite the increase in popularity of the posterior twoportal hindfoot approach, concerns with the technique remain, including; the technical difficulty, relatively steep learning curve, and difficulty performing simultaneous anterior ankle arthroscopy. The purpose of the current literature review is to provide comprehensive knowledge about PAIS, and to describe a systematic four-stage approach of the posterior two-portal arthroscopy. The etiology, clinical presentation, diagnostic strategies are first introduced followed by options in conservative and surgical management. A detailed systematic approach to posterior hindfoot arthroscopy is then described. This technique allows for systematic review of the anatomic structures and treatment of the bony and/or soft tissue lesions in four regions of interest in the hindfoot(superolateral, superomedial, inferomedial, and inferolateral). The review then discusses biological adjuncts and postoperative rehabilitation and ends with a discussion on the most recent clinical outcomes after posterior hindfoot arthroscopy for PAIS. Although clinical evidence suggests high success rates following posterior hindfoot arthroscopy in the short- and mid-term it may be limited in the pathology that can be addressed due to the technical skills required, but the systematic four-stage approach of the posterior two-portal arthroscopy may improve upon this problem.     

Posterior ankle impingement disguised as peroneal tendon subluxation in young athletes – a case report

Posterior ankle impingement is a cause of posterior ankle pain common in those who perform frequent plantarflexion activities. Three young patients presented with posterior ankle pain which was initially attributed to peroneal tendon subluxation. However, detailed physical exam and imaging confirmed the diagnosis of posterior ankle impingement as the actual cause of pain. The peroneal tendon subluxation was not causal but an unrelated co-incidental finding. After failed prolonged conservative management (rest, immobilization and physical therapy), the patients underwent posterior ankle arthroscopic debridement for the impingement resulting in return to prior sporting activity without limitation and no recurrence of pain at 19 months follow-up. Posterior ankle impingement diagnosis could be masked by co-incidental asymptomatic peroneal tendon subluxation in pediatric patients.     

Entrapment of the flexor hallucis longus tendon following ankle arthrodesis

Impingement following arthroscopic ankle arthrodesis has not been reported in the literature previously. We present a case report of a 68-year-old male 9 months following an uncomplicated arthroscopic ankle fusion presenting with persistent posteromedial ankle pain. Flexor hallucis longus (FHL) tendon impingement resulting from a prominent os trigonum was identified. This was successfully treated utilising hindfoot endoscopy with excision of the os trigonum and FHL release.     

Anterior tibiotalar impingement associated with chronic ankle instability

The authors describe the surgical treatment of 13 cases of chronic ankle instability and concomitant anterior bony impingement of the ankle in professional and recreational athletes. All patients had symptoms and signs of lateral instability and a painful block to dorsiflexion. Two patients presented with recurrence of impingement after a previous debridement alone without an ankle stabilization. The anterior osteophytes were debrided arthroscopically and a Brostrom-Gould open stabilization was performed. After a mean follow-up period of 12 months (range 4-23 months), all 13 patients had mechanically and functionally stable ankles. The mean improvement in range of dorsiflexion was 12.4 degrees and all but one had improvement with respect to a subjective and functional outcome assessment. There have been no recurrences of impingement to date. These results suggest that ankle stabilization performed in conjunction with debridement of osteophytes may reduce the recurrence of exostoses as well as improving the outcome.     

踝关节镜前后联合入路治疗踝关节撞击综合征

目的 :分析踝关节镜前后联合入路对踝关节撞击综合症患者镜下行清理的临床疗效及术中注意事项。方法:回顾性分析自2011年4月至2015年4月采用踝关节镜治疗并获得完整随访的17例踝关节撞击综合症患者,其中男12例,女5例;手术时年龄22~47岁,平均32.4岁。结合患者临床症状和影像学评估予踝关节镜清理,并去除引起症状的撞击部位,术后常规予非甾体消炎药和关节内注射透明质酸钠治疗。采用AOFAS(美国足踝外科协会)后足-踝评分,Ogilvie-Harris踝关节评分对术前情况及术后末次随访情况进行评分。结果:17例手术中情况:关节镜下显示前外踝撞击征8例,前内踝撞击征2例,前踝撞击征2例,后踝撞击征2例,3例为同时合并前后踝撞击。术中清除增生的骨赘,引起撞击的下胫腓前韧带远侧束,距腓前韧带,滑膜组织和疤痕组织。4例同时合并关节软骨损伤,软骨损伤面积约1 mm×3 mm至1.5 mm×4 mm大小。术中同时采用直径1.2 mm的克氏针行钻孔微骨折处理。17例术后随访时间8~24个月,平均14.3个月。AOFAS评分由手术前的62.30±5.20增加至术后的87.60±5.40。Ogilvie-Harris踝关节评分由手术前的6.70±0.98增加至术后的12.80±1.21。术后患者均无神经血管损伤,无伤口感染,愈合不良等并发症。患者有不同程度的踝关节肿胀,于术后4~8周逐步消失。结论:对踝关节撞击综合症患者,前后联合入路可以有效清除引起踝关节撞击的骨性撞击和软组织撞击,结合术后非甾体消炎药和关节内注射透明质酸钠治疗,可以有效缓解踝痛症状,达到较好的治疗效果。     

A direct lateral approach for diagnosis and treatment of subtalar and posterior ankle pathology

The direct lateral approach to the subtalar joint through the IFT portal provides safe and speedy access to reach the posterior aspect of the subtalar joint and the ankle joint. This viewing portal allows for excellent visualization that extend from the posteromedial corner to the lateral joint space and anterolateral corner of the subtalar joint. Two working portals comprising of the posterolateral and sinus tarsi portals are safely made to enable visualization from the IFT portal. These portals are also useful to observe the CFL and interosseous talocalcaneal ligament.     

踝前撞击综合征的病因分析及治疗对策

[目的]探讨踝前撞击综合征的病因、预防措施及治疗对策。[方法]2000年6月～2004年12月对18例无骨折脱位的急性创伤性踝关节积血,20例踝关节前侧及前内、前外疼痛伴背屈疼痛及背屈功能障碍者的关节镜检查及治疗效果进行随访分析总结。[结果]全部随访,时间6—52个月,平均28个月,无骨折脱位的急性创伤性踝关节积血组：优17例,良1例,可0例,差0例;踝前撞击综合征组：优12例,良6例,可2例,差0例。[结论]踝关节创伤及退变是踝前撞击综合征的两大原因,无骨折脱位的急性创伤性踝关节积血的早期关节镜检查及治疗是预防踝前撞击综合征的积极最佳方法;关节镜下踝关节清理术是踝前撞击综合征最佳的微创治疗对策。     

Posterior ankle arthroscopy for posterior ankle synovitis with an enlarged posterior talar process caused by a cat bite or scratch: A case report

IntroductionLegs are sometimes infected and swollen by cat bite or scratch. However, there is no report of synovitis with an enlarged talar posterior process in the posterior ankle caused by a cat bite or scratch which was treated by removal of the enlarged process and synovectomy with release of the flexor hallucis longus tendon via posterior ankle arthroscopy.Presentation of caseThe patient was a 58-year-old woman who had started keeping a cat 7 months earlier. She subsequently sustained cat bite and scratch wounds to her lower legs, which gradually became increasingly swollen. On presentation, there was left lower leg swelling, particularly on the posterior aspect of the ankle. Imaging revealed bone marrow edema in the enlarged posterior talar process and inflammation of the adjacent soft tissue. We excised the enlarged posterior talar process, performed synovectomy, and released the flexor hallucis longus tendon using a posterior arthroscopic technique via standard posterolateral and posteromedial portals. Microbial culture was negative.DiscussionThe patient returned to daily activities approximately 3 weeks after arthroscopic debridement. There was no recurrence at the 1-year follow-up visit. To our knowledge.ConclusionWe report a rare case of posterior ankle synovitis with an enlarged posterior talar process caused by a cat bite or scratch which was treated successfully by posterior ankle arthroscopic debridement.