Diagnostic Ankle Arthroscopy Research Articles

Effect of Arthroscopically Confirmed Syndesmotic Widening on Outcome Following Isolated Broström Operation for Chronic Lateral Ankle Instability.

Tibiofibular syndesmosis (TFS) widening sometimes is not evident on radiography but can be found under arthroscopy in chronic lateral ankle instability (CLAI). This study aimed to evaluate the effect of TFS widening severity on clinical outcomes and return to activities after isolated Broström operation in CLAI patients and to propose an indication for its surgical intervention. A total of 118 CLAI patients undergoing diagnostic ankle arthroscopy and open Broström-Gould operation were included. Based on the middle width of TFS measured under arthroscopy, patients were divided into the TFS-2 group (≤2 mm, n = 44), the TFS-3 group (2-4 mm, n = 42), and the TFS-4 group (≥4 mm, n = 32). The time to return to recreational sport and work, Tegner activity score, and proportion of returning to preinjury sports at the final follow-up were evaluated and compared. Other subjective evaluations included the American Orthopaedic Foot & Ankle Society score, visual analog scale, and Karlsson-Peterson score. Among the 3 groups, the TFS-4 group demonstrated the longest mean time to return to work and recreational sports, with the lowest proportion returning to preinjury sports. The TFS-4 group showed a significantly higher rate of sprain recurrence (12.5%) than the other 2 groups (P =.021). All the other subjective scores significantly improved after the operation without differences among the 3 groups. Concomitant severe syndesmotic widening adversely affects the return to activities after Broström operation in CLAI cases. The CLAI patients with a middle TFS width ≥4 mm were associated with delayed return to work and sports, a lower proportion of returning to preinjury sports, and more sprain recurrence, which might require further surgical intervention for syndesmosis in addition to Broström surgery. Level III, retrospective cohort study.

Chronic Ankle Instability - Mechanical vs. Functional.

Chronic ankle instability arises from three interacting contributing factors: mechanical ankle instability, functional ankle instability, and perceived ankle instability. To decide on the most appropriate individual recommendation for therapeutic options, it is necessary to assess which of the two main aetiologies - functional vs. mechanical - is dominant in causing the perceived impairment. It is essential to perform a thorough analysis and diagnosis, even though quantifying mechanical ankle instability is still a challenge in the clinical approach to this common pathology. When diagnosing mechanical instability, the most established procedure is physical examination, although this unfortunately does not allow the deficit to be quantified. Additional options include stress-ultrasound, 3D stress-MRI (3SAM), ankle arthrometry, marker-based 3D motion analysis, and diagnostic ankle arthroscopy. Of these the latter is considered the gold standard, even though it is an invasive procedure, it may not be performed for diagnostic reasons only, and it also does not allow the mechanical instability to be quantified. For diagnosing functional instability there are non-instrumented tests such as the Star Excursion Balance Test or Y-Balance Test, posturography/stabilometry, and gait and running analysis, possibly combined with EMG acquisition and isokinetic strength testing.To date, the standard of care is conservative management of ankle instability, and the therapy should include sensorimotor training, strength training of the periarticular muscles, balance training, and gait and running exercises on different surfaces. However, it is increasingly clear that a certain degree of mechanical instability cannot be compensated for by functional training. Thus, it is the goal of differential diagnostics to identify those patients and guide them to mechanical therapy, including ankle bracing, taping, and surgical ligament reconstruction.

Arthroscopic findings and treatment of maisonneuve fracture complex

BackgroundThe Maisonneuve fracture complex (MFC) is a well-known lower leg injury. However, the optimal treatment is still not clear and there is limited data on concomitant injuries of cartilage. Therefore, the aim of our study was to report the incidence of incidental cartilage injuries and their management in arthroscopic treatment of MFC.Patients and methodsBetween February 2018 and February 2021 all patients presenting with MFC in our department were treated with diagnostic ankle arthroscopy and percutaneous syndesmotic screw or suture-endobutton fixation. In case of instable cartilage, it was debrided and according to the International Consensus Meeting on Cartilage Repair of the Ankle, in grade IV lesions < 10 mm or < 100 mm2 area the subchondral bone was microfractured.ResultsEighteen patients, 16 male and two female, with a mean age of 48.1 years, were included. In all cases, instability of the distal tibiofibular articulation was confirmed arthroscopically. Injuries of the cartilage were found in 56% of the cases and in 31% of the patients surgical intervention was required. In three talar and one tibial lesion additional arthroscopic bone marrow stimulation with microfracture of the subchondral bone was performed.ConclusionsAnkle arthroscopy is a helpful method to guide fibular reduction and to detect and address associated cartilage injuries. Due to the high rate of chondral lesions, addressing these arthroscopically may contribute to better postoperative results.Level of evidenceIV

Assessment of Basic Ankle Arthroscopy Skills in Orthopedic Trainees.

There is increasing emphasis on assessing resident competency, but little has been published on how to best evaluate trainee competency for ankle arthroscopy. The purpose of this study was to validate an objective model for assessing basic ankle arthroscopy knowledge and operative skills on a cadaveric ankle. The Diagnostic Ankle Arthroscopy Skills Scoring System was adapted from previously validated assessment tools for knee arthroscopy. The scoring system included (1) an oral questionnaire (0-23 points), (2) an operative task-specific checklist (0-19 points), and (3) a global operative skills rating (12-60 points). Thirty-three trainees consisting of orthopedic residents and medical students performed a diagnostic ankle arthroscopy on a cadaveric ankle and were assessed by a single observer, while a subset were tested by 2 evaluators to determine interobserver reliability. There was strong correlation between educational level and scores on the global operative skills rating scale (r = 0.967, P < .0001), task-specific checklist (r = 0.815, P < .815), and oral questionnaire (r = 0.896, P < .0001). The global operative skills scores significantly improved with training level, and the largest difference was between medical students and senior residents. The most notable year-to-year increases in skill were between postgraduate year (PGY) 1 and 2 (P < .01) and between PGY2 and PGY3 (P < .05). Oral questionnaire and task-specific checklists were significantly lower for medical students than PGY1 residents (P < .001). There was also significant improvement in the oral questionnaire between senior and junior residents (P < .05). There was a moderate correlation between number of self-reported ankle arthroscopy cases and scores on the global operative skills score (r = 0.7019, P < .0001). Interobserver reliability was high for the global operative skills scores (interclass correlation coefficient = 0.89). The study revealed a valid measure to objectively assess trainees' ankle arthroscopy clinical knowledge and operative skills in a bioskills laboratory. This tool should enable residency programs to evaluate competency and track individual trainee progress over time.

Evaluating a Diagnostic Ankle Arthroscopy Scoring System to Assess Competency in Orthopaedic Trainees

Category:ArthroscopyIntroduction/Purpose:While there has been an increasing emphasis on assessing resident competency, little has been published on how to best evaluate competency for ankle arthroscopy. The purpose of this study was to design and validate an objective model for assessing basic ankle arthroscopy knowledge and surgical skills on a cadaveric ankle.Methods:The Basic Ankle Arthroscopy Skills Scoring System was adapted from previously validated assessment tools for knee arthroscopy. The scoring system includes (1) an oral questionnaire (0-23 points), (2) a surgical task-specific checklist (0-19 points), and (3) a global surgical skills rating (12-60 points). Ten medical students and twenty-three residents participated. All participants performed a diagnostic ankle arthroscopy on a cadaveric ankle and were assessed by a single observer. Six participants were tested by two evaluators to determine inter-observer reliability.Results:There was strong correlation between educational level and scores on the global surgical skills rating scale (r=0.967, p<0.0001), task-specific checklist (r=0.815, p<0.815), and oral questionnaire (r=0.896, p<0.0001). The global surgical skills scores were significantly different over multiple trainee levels but most notably between post graduate year (PGY) 1 and 2 (p<0.01) and between PGY 2 and 3 (p<0.05) [Figure 1a]. Oral questionnaire and task-specific checklists were significantly lower for medical students than PGY1 residents (p<0.001) [Figure 1b-c]. There was significant improvement in the oral questionnaire between senior and junior residents (p<0.05). There was a moderate correlation between number of ankle arthroscopy cases and scores on the global surgical skills score (r=0.7019, p<0.0001). Inter-observer reliability was high for the global surgical skills scores (ICC=0.89).Conclusion:The Basic Ankle Arthroscopy Skills Scoring System is a valid measure to objectively assess trainees’ ankle arthroscopy clinical knowledge and surgical skills in a bioskills laboratory. This tool will allow residency programs to evaluate competency and track individual progress over time.

Findings of Routine Diagnostic Ankle Arthroscopy for Management of AO 44-C Fibular Fractures

Category: Ankle, Arthroscopy, Trauma Introduction/Purpose: High fibula fractures, including Maisonneuve and Weber type C fractures are commonly associated with syndesmotic injuries resulting in subluxation and dislocation of the ankle. These injuries to the joint are rarely evaluated or addressed during operative fixation, which generally consists of open reduction internal fixation of the fibula with or without fixation of the syndesmosis. Chondral lesions and loose bodies in ankle fractures may predict a poor result and can be addressed using arthroscopy to avoid exacerbating articular damage. The purpose of this study is to identify the frequency and severity of articular pathology in Weber C and Maisonneuve fibula fractures. Methods: A single surgeon case series of operatively managed ankle fractures with arthroscopic assessment from 2011-2015 was retrospectively reviewed. Inclusion criteria were patients with AO 44-C ankle fractures who were aged &gt;17 and underwent arthroscopic assessment of the ankle joint prior to open reduction and internal fixation. Patients were excluded from the series if they presented &lt;2 weeks from the time of injury, had a pilon variant, or had incomplete medical records available. Demographic information on the patients including age, sex, and BMI were collected. Information on mechanism of injury was recorded. Operative reports were reviewed and the presence of chondral injury and loose bodies was recorded. Descriptive statistics were performed on the collected data. Results: 18 patients (12 male, 6 female) with a mean age of 38.3 years (range 17-61; SD 13.9) were included in the case series. The average BMI 29.6 (SD 6.92). Five of the included fractures were Maisonneuve fractures while the remaining 13 were Weber C ankle fractures. The mechanism of injury of the fracture was low energy in 12, high energy in 1, and unknown in 5. On arthroscopic examination, 12 (66.7%) of the fractures were associated with full thickness articular cartilage injury requiring formal chondroplasty, 16 (88.9%) were associated with a minimum of partial articular damage, and only 2 (11.1%) had no articular damage identified on arthroscopy. Additionally, 12 (66.7%) had loose bodies that were removed during ankle arthroscopy. Conclusion: This study adds to a growing collection of literature concerning chondral injuries during ankle fractures. The data from this study suggest that AO 44-C fibular fractures are associated with a high rate of intraarticular pathology that can be effectively identified and managed during arthroscopy. Prospective studies are required to determine if there are therapeutic benefits to routine ankle arthroscopy in AO 44-C ankle fractures.

Arthroscopic Correlates of Subtle Syndesmotic Injury.

Arthroscopic criteria for identifying syndesmotic disruption have been variable and subjective. We aimed to quantify syndesmotic disruption arthroscopically using a standardized measurement device. Ten cadaveric lower extremity specimens were tested in intact state and after serial sectioning of the syndesmotic structures (anterior inferior tibiofibular ligament [AiTFL], interosseous ligament [IOL], posterior inferior tibiofibular ligament [PiTFL], deltoid). Diagnostic ankle arthroscopy was performed after each sectioning. Manual external rotational stress was applied across the tibiofibular joint. Custom-manufactured spherical balls of increasing diameter mounted on the end of an arthroscopic probe were inserted into the tibiofibular space to determine the degree of diastasis of the tibiofibular joint under each condition. A ball 3 mm in diameter reliably indicated a high likelihood of combined disruption of the AiTFL and IOL. Disruption of the AiTFL alone could not be reliably distinguished from the intact state. Use of a spherical probe placed into the tibiofibular space during manual external rotation of the ankle provided an objective measure of syndesmotic instability. Passage of a 2.5-mm probe indicated some disruption of the syndesmosis, but the test had poor negative predictive value. Passage of a 3.0-mm spherical probe indicated very high likelihood of disruption of both the AiTFL and the IOL. The findings challenge the previously used but unsupported standard of a 2-mm diastasis of the tibiofibular articulation for diagnosis of subtle syndesmotic instability.

Anatomical Lateral and Medial Ligament Reconstruction in Rotational Chronic Ankle Instability

Category: Sports. Introduction/Purpose: Rotational (combined lateral and medial) chronic ankle instability (CAI) can present with pain and tenderness at the ankle joint, and can be associated with feeling of giving way, repetitive sprains, and life quality limitation. In case of surgery, anatomical reconstruction of the ligaments and treatment of comorbidities are essential for a solid outcome. Methods: A retrospective chart review of 81 rotational CAI patients (average age: 35.3 years, age range: 16-64; right sided: 41(50.6%); left sided: 40(49.4%)) was performed. The average latest follow-up visit was 10.8 months (range: 3-47 months). The patients underwent in our center a standardized surgical treatment protocol. Following diagnostic ankle arthroscopy, a combined lateral and medial anatomical ligament reconstruction was performed. Hindfoot realignment procedures and treatment of associated pathologies (such as talar osteochondral lesions) were carried out at the same time. Postoperatively, all patients were mobilised with partial weight bearing (15 kg) for six weeks in an Aircast walker ® (DJO, LLC, USA). Adequate postoperative analgesia and physiotherapy were initiated. Results: Combined lateral and medial ligament reconstruction without additional surgeries was performed in 20 cases (24.7%). In the other cases, to address associated pathologies, additional surgeries were performed, such as: lateral calcaneal lengthening osteotomy (LCLO) in 42 cases (51.9%), medial sliding calcaneal osteotomy (MSCO) in 3 Cases (3.7%), osteochondral lesion reconstruction in 20 cases (24.7%), peroneal tendon pathology treatment in 3 cases (3.7%), cavovarus foot correction in 1 case (1.2%), supramalleolar osteotomy in 1 case (1.2%), and calcaneonavicular coalition excision in 1 case (1.2%). The outcome variables will be presented at the conference. Conclusion: Anatomical lateral and medial ligament reconstruction of rotational CAI is a safe surgical treatment and leads to a favourable outcome. Beside the ligament reconstruction, associated comorbidities, as malalignment, osteochondral lesions, and others, have to be addressed at the same surgery to achieve physiological biomechanics and a complete pain relieve.

Venous Thromboembolism Following Ankle Arthroscopy

Background: The number of ankle arthroscopies being performed is increasing for both diagnosis and treatment of intra-articular pathology. Venous thromboembolism is an uncommon complication following ankle arthroscopy, but can have devastating outcomes. Publication of procedure-specific studies evaluating rates of post-operative thromboembolism is lacking, and current guidelines reflect this. Aim: To evaluate the incidence of thromboembolism in a consecutive series of patients undergoing diagnostic ankle arthroscopy, with intervention requiring immobilisation in a non-weight bearing cast post-operatively. Method: An analysis of consecutive patients undergoing diagnostic ankle arthroscopy with either ligament reconstruction or supramalleolar osteotomy by a single surgeon over a 12 month period. A retrospective review of the incidence of any complications was undertaken, with a particular focus on venous thromboembolism. Results: 104 patients underwent ankle arthroscopy during the 12 month period. All patients completed routine follow-up at 6 weeks, 3 months and 6 months. The overall complication rate was 3.8%. The incidence of venous thromboembolism in our series was 0.96%. Conclusion: Our incidence of venous thromboembolism with standard use of low molecular weight heparin in all patients is lower than previously published. Larger trials will aid in identifying whether chemoprophylaxis is required in all those undergoing ankle arthroscopy with post-operative immobilisation, or just patients with additional risk factors.

Navigierte retrograde Anbohrung bei Osteochondrosis dissecans (OCD) des Talus

Subchondral decompression and revascularization in Osteochondrosis dissecans (OCD) of the talus with cartilage preservation. Symptomatic talar OCD stage I and II, i.e., cartilage intact or almost intact. Talar OCD stage III and IV, i.e., cartilage not intact. Diagnostic ankle arthroscopy. Insertion of dynamic reference base (DRB) in the talar neck through a stab incision. After 3D image acquisition and planning of the drilling, navigated drilling with a 5mm drill. Insertion of a 1mm titanium wire into the canal and 3D image acquisition for evaluation of the canal. Autologous cancellous bone transplantation into the canal. Arthroscopic evaluation. For 6weeks, 15kg partial weight bearing without immobilization. After 6weeks full weight bearing. A total of 52patients with symptomatic talar OCD stage I and II were included in a clinical follow-up study. Time needed for preparation, including the placement of the DRB, scanning time, and preparation of the trajectories was 7min 32s (4-30min). In 50cases (96%), the drilling was judged with 3D imaging to be correct. In the remaining 2cases (4%), the drilling ended in the caudal portion of the lesion. A perforation of the cartilage was not registered arthroscopically. Follow-up after 12months (range 6-36months) was possible in 48patients (92%). Three patients (6%) had been converted to bone cartilage transplantation (OATS) due to recurrent symptoms. These patients were excluded from follow-up. The follow-up scores were Visual Analogue Scale Foot and Ankle (mean 93points [range 86-100points]) and the SF 36 (standardized to 100 point maximum, 90points [range 79-100points]).

Ankle Arthroscopy

Ankle arthroscopy is indicated for numerous sports-related injuries and conditions. It provides a rapid and reliable means of directly visualizing and treating all ankle intra-articular structures and can be a valuable adjunct in the treatment of ankle fractures. Advances in the areas of instrumentation and diagnostic imaging, namely magnetic resonance imaging, have expanded the role for ankle athroscopy. Ankle arthroscopy is relatively simple but can be significantly more challenging than routine knee or shoulder work. It is of critical importance to have the proper equipment and to consider certain aspects of patient positioning to optimize surgical success. Sports medicine specialists and general orthopedic surgeons, as well as foot and ankle specialists, should feel comfortable performing diagnostic ankle arthroscopy. A straightforward technique for routine ankle arthroscopy is presented. Operative results from the United States Naval Academy will be discussed.

Anterior Tibial Artery Pseudoaneurysm after Ankle Arthroscopy

Arthroscopy of the ankle has dramatically expanded its role in diagnostic and therapeutic value afforded to the patient; however, it is not without complications. Although the majority of the complications described are neurological in origin, vascular injuries can occur. A case of a patient with normal coagulation parameters who underwent a purely diagnostic ankle arthroscopy and later developed a pseudoaneurysm of her distal anterior tibial artery is described. The pseudoaneurysm was resected without complications and early postoperative recovery has been uneventful.

Anterior tibial artery pseudoaneurysm after ankle arthroscopy

Arthroscopy of the ankle has dramatically expanded its role in diagnostic and therapeutic value afforded to the patient; however, it is not without complications. Although the majority of the complications described are neurological in origin, vascular injuries can occur. A case of a patient with normal coagulation parameters who underwent a purely diagnostic ankle arthroscopy and later developed a pseudoaneurysm of her distal anterior tibial artery is described. The pseudoaneurysm was resected without complications and early postoperative recovery has been uneventful.

ARTHROSCOPY FOR PROBLEMS AFTER ANKLE FRACTURE

From 1990 to 1994 we undertook arthroscopy of the ankle on 34 consecutive patients with residual complaints following fracture. Two groups were compared prospectively. Group I comprised 18 patients with complaints which could be attributed clinically to anterior bony or soft-tissue impingement. In group II the complaints of the 16 patients were more diffuse and despite extensive investigation the definitive diagnosis was not clear before arthroscopy. At the time of the fracture, some osteophytes were already present in 41% of the patients. These were related to previous supination trauma and participation in soccer. Arthroscopic treatment consisted of removal of the anteriorly located osteophytes and/or scar tissue. After two years, group I showed a significantly better score for patient satisfaction (p = 0.02). There were good or excellent results in group I in 76% and group II in 43%. Patients with residual complaints after an ankle fracture and clinical signs of anterior impingement may benefit from arthroscopic surgery. The place for diagnostic ankle arthroscopy is limited.

A Disposable Fiberoptic Arthroscope: A Cadaver Study

Nine fresh cadaver ankle joints underwent arthroscopy to determine effectiveness of a small diameter, disposable, fiberoptic arthroscope. A sequential examination of the joint was performed through routine anteromedial and anterolateral portals. The anterior aspect of the joint with all anatomical structures was well visualized via the two anterior portals. The posterior aspect of the joint was also well visualized via anterior portals without distraction due to the flexibility of the scope and its small diameter. The quality of the visualization of the posterior joint from the anterior portals alone was comparable to that from the posterior approach. The results of this study indicate that diagnostic arthroscopy of the ankle joint with this disposable 1.6-mm arthroscope is comparable to the standard 2.7-mm to 5-mm arthroscopes. The size, flexibility, and 30 degrees viewing angle of this scope allow excellent and thorough joint visualization by routine anterior portals and minimize the need for joint distractors and posterior portals during routine diagnostic ankle arthroscopy.