Posterior Ankle Impingement Research Articles

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

Posterior ankle impingement syndrome (PAIS) results from the pinching of anatomical structures in the posterior part of the ankle. 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. Data were collected prospectively in patients younger than 18years 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. Thirty-eight patients (20 females, 18 males), 51 ankles, with an average age of 12.9years 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 10.2months, there was improvement of VAS pain (7.0 to 1.1) and AOFAS ankle-hindfoot scores (65.1 to 93.5). 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.

Posterior ankle impingement-an underdiagnosed cause of ankle pain in pediatric patients.

BACKGROUNDPosterior ankle impingement syndrome (PAIS) is a cause of ankle pain due to pinching of bony or soft tissue structures in the hindfoot. The diagnosis is primarily made based on detailed history and accurate clinical examination. The delay in its diagnosis has not yet been described in the pediatric and adolescent population.AIMTo identify and characterize misdiagnosed cases of PAIS in pediatric and adolescent patients.METHODSThis descriptive prospective study at a tertiary children’s hospital included patients ≤ 18 years who underwent posterior ankle arthroscopy after presenting with chronic posterior ankle pain after being diagnosed with PAIS. Collected data included: Demographics, prior diagnoses and treatments, providers seen, time to diagnosis from presentation, and prior imaging obtained. Visual Analogue Scale (VAS) for pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted at initial presentation and follow-up.RESULTS35 patients (46 ankles) with average age of 13 years had an average 19 mo (range 0-60 mo) delay in diagnosis from initial presentation. 25 (71%) patients had previously seen multiple medical providers and were given multiple other diagnoses. All 46 (100%) ankles had tenderness to palpation over the posterior ankle joint. Radiographs were reported normal in 31/42 (72%) exams. In 32 ankles who underwent MRI, the most common findings included os trigonum (47%)/Stieda process (47%). Conservative treatment had already been attempted in all patients. Ankle impingement pathology was confirmed during arthroscopy in 46 (100%) ankles. At an average follow-up of 13.1 mo, there was an improvement of VAS (pre-op 7.0 to post-op 1.2) and AOFAS scores (pre-op 65.1 to post-op 94).CONCLUSIONThis is the first study which shows that PAIS is a clinically misdiagnosed cause of posterior ankle pain in pediatric and adolescent population; an increased awareness about this diagnosis is needed amongst providers treating young patients.

MRI of foot pain in amateur marathoners and analysis of related factors

Objective To study the MRI manifestations of foot injuries in amateur marathoners and the diagnostic value of MRI for foot injuries. Methods Forty-eight amateur marathoners were prospectively recruited from October 2018 to March 2019. Participants were grouped according to the FASS criteria. All participants underwent bilateral foot MRI examinations. The MRI features of foot in amateur marathoners with and without foot pain were analyzed.The association with gender, age, time to participate in marathon, amount of running per week, number of times to complete the whole marathon and the symptoms of foot pain was studied. Results There were 28 sides in FASS in grade 0, including 8 males and 20 females, 8 hydrocele of the first metatarsophalangeal joint, 6 edema of bone marrow, 4 edema of soft tissue, 4 hydrocele of tendon sheath, and 6 without abnormal manifestations of MRI. There were 68 sides in FASS grade 1, including 42 males and 26 females, 38 Achilles tendinitis, 14 plantar fasciitis, 12 Achilles tendon bursitis and 4 posterior ankle impingement syndrome. The incidence of foot pain in amateur marathoners was related to gender (OR=1.060, P=0.043), unrelated to age (OR=0.248, P=0.078), number of marathons completed (OR=1.006, P=0.956), time to participate in marathon (OR=1.008, P=0.944), amount of running per week (OR=0.971, P=0.407). Conclusion Among amateur marathon runners, the foot pain is mainly caused by Achilles tendon and plantar fascia, while those without foot pain are mainly characterized by joint effusion, tendon sheath effusion and bone marrow edema. Gender is the only factor affecting the incidence of foot pain in amateur marathoners. MRI examination is an effective method to determine foot injury and has important clinical application value in the diagnosis and treatment of foot injury. Key words: Athletic injuries; Foot; Magnetic resonance imaging; Marathon

Posterior Ankle and Hindfoot Arthroscopy: Complications and Posterior Ankle Impingement Pathologies

Category:Ankle, Arthroscopy, Hindfoot, SportsIntroduction/Purpose:Posterior ankle/hindfoot arthroscopy (PAHA) is an established surgical option for treating pathologies, of posterior ankle and subtalar joints, which otherwise would require open incisions. Arthroscopic procedures are less invasive, provide magnified visualization and allow earlier rehabilitation and return to activity. Many studies have reported outcomes after PAHA, however only two studies have reported complications in larger cohorts. Although posterior ankle impingement (PAI) is a common indication for PAHA, it is a non-specific diagnosis. The aims of our study are 1) to report the complications after posterior ankle arthroscopy. 2) Delineate the structures involved in PAI into zones based on arthroscopic findings including bone impingement from the talus or tibia, soft tissue impingement from the PITFL, PTFL, inter-malleolar ligament, posterior deep deltoid ligament and synovitis.Methods:We reviewed the chart for demographic details, diagnosis, arthroscopic findings, and complications in a consecutive series of 250 PAHA in 237 patients (94 males,143 females, mean age 34.3 years) who had surgery between 2008 and 2016 and excluded those who had Haglund excision. The indications were PAI (95 ankles), subtalar arthritis/coalition/nonunion(21/12/5), flexor hallucis longus (FHL) stenosis/tenosynovitis/contracture(22/9/5), osteochondral lesions(14), and others(14)(Table 1A). There were 67 ankles with PAI and at least one other coexisting condition. For patients with PAI, we catalogued the specific anatomic etiologies of impingement.To investigate a priori factors predictive of neurological complication after PAHA, unadjusted and multivariable regression techniques were utilized. Sparse events sensitivity analysis was tested by fitting models with Firth log-likelihood approach; penalizing estimates for first-order bias correction and stability of regression coefficients. To control for clustering of outcomes across surgeons (n=3), estimates were assessed by fitting the primary log-binomial model with generalized estimating equation.Results:Complications: sensory nerves (10) (5 tibial/branches, 5 sural), portals (4) (painful/nodular (1), draining>1week (3)). Achilles pain (1) DVT (1). Nerve symptoms after 6 months (3) had; transection of the sural nerve (1), sural neurolysis (1) or tarsal tunnel release (1). (Table 1B)In unadjusted analysis, advancing age (OR: 1.04; p=0.029) and accessory portal (OR: 15.64; p<0.001) were associated with neurological complication. In multivariable regression models controlled for confounders, accessory posterolateral portal usage (OR:12.37; 95% CI: 3.11-49.27; p<0.001) was the most significant driver for neurological complication after PAHA. No significant correlation exists between neurological complications and surgical duration, surgeon, tourniquet time, BMI, FHL release.There were 162 ankles treated for PAI +/- associated conditions. PAI etiologies were grouped into: posterior, posteromedial, posterolateral, subtalar, and combined zones.Conclusion:This study supports the safety of posterior ankle/hindfoot arthroscopy for the treatment of numerous pathologies with an overall complication rate of 6.4% (16/250). There were no infections, motor nerve or vascular injuries. Complications included sensory nerve symptoms in 10 patients (4%), of which three (1.2%) did not improve and required further treatment. One patient developed DVT which required further treatment. The common pathologies of impingement were able to be grouped into zones that can correlate with physical examination (Table 1C). The ability to visualize the structures with the arthroscope provides greater magnification, detail and precision in the treatment.

The Prevalence and Clinical Significance of FHL Tears in Athletes with Posterior Ankle Impingement Surgery

Category:Ankle, Hindfoot, SportsIntroduction/Purpose:Posterior ankle pain in the athlete is common and thought to be caused by Flexor Hallucis Longus (FHL) tendon tear/tendinopathy or Os trigonum syndrome. The association of flexor hallucis longus (FHL) pathology in conjunction with PAIS has not been described. The purpose of this study is to report the prevalence of FHL tears in athletes who undergo surgical treatment for PAIS. We also report the outcome of 36 athletes treated with FHL repair with PAIS surgery and compare them to 122 athletes undergoing PAIS surgery without FHL tears. The utility of advanced imaging, standardized outcome scores at standard post-operative time intervals, return to sport (RTS) and time to RTS were all evaluated in the 158 athletes.Methods:Our clinical database was searched for appropriate surgical codes, and patients from 1996 through March 2016 were retrospectively collected. Inclusion criteria included surgical treatment of PAIS, age between ten and 50, and participation in recreational or competitive athletics. Exclusion criteria included other injuries that could affect return to sport or recovery process. 158 patients met these criteria, (36 dancers, 122 non-dancers). Pre-operative imaging, operative records, dorsiflexion range of motion at six weeks and one year postoperatively, and time to return to sport are reported. AAOS Foot & Ankle, and Lower Limb Core Module (FALLC) scores were obtained (six weeks, three months, and one year post-operatively). Questionnaire data and functionality scores were compared between the two groups using two-sample Student t-tests. Categorical data outcomes were compared using chi-square tests or Fisher’s exact tests.Results:74/158 patients had magnetic resonance imaging (MRI) pre-operatively. 5/14 patients with an FHL tear had positive MRI suggesting an FHL tear, 9/14 patients with FHL tear had negative MRI (sensitivity of 0.26). FHL tears occurred in 36/158 (23%) of athletes with PAIS, 16/36 (44.4%) of dancers and 20/122 (16.4%) non-dancers. RTS did not differ between athletes with and without FHL tears, but time until RTS increased-average of 13.5 days (67.5 versus 81) with FHL repairs. Dancers with FHL tears reported increased foot pain and lower foot and ankle function at 3 months relative to those without tears. Scores were similar at one year.Conclusion:FHL tears in athletes undergoing surgical treatment for PAIS is 23% and in dancers can be as high as 44%. Pre- operative MRI has a poor sensitivity for FHL tears in this population. Concomitant FHL tear with repair during PAIS surgery does not decrease the rate of RTS or long term overall outcome. Overall, dancers have a higher rate of FHL tear at time of PAIS than non-dancers. FHL results in only a mild delay in RTS time. This is the first study to note FHL tear rate in association with PAI surgery.

Exorotated radiographic views have additional diagnostic value in detecting an osseous impediment in patients with posterior ankle impingement

ObjectivesA standard lateral radiograph is the first step in the diagnostic workup in patients with posterior ankle pain. Because of overprojection by other structures at suboptimal radiographic projection angle, often an os trigonum is not discovered or erroneously be mistaken for a hypertrophic posterior talar process. The aim of this study was to identify the projection angles at which a radiograph is optimal for detecting bony impediments in patients suffering from posterior ankle impingement.MethodsUsing ankle CT scans of patients with posterior ankle impingement, digitally reconstructed radiographs (DRRs) simulating 13 different radiographic projection angles were generated. The ankle CT scans served as a reference for the detection of an os trigonum and hypertrophic posterior talar process. Members of the Ankleplatform Study Group were invited to assess the DRRs, for presence or absence of an os trigonum or hypertrophic posterior talar process. Diagnostic accuracy and interobserver reliability were estimated for each projection angle. In addition, the diagnostic accuracy of the standard lateral view in combination with the rotated views was calculated.ResultsHigh sensitivity for detecting an os trigonum was found for +15° (90.3%), +20° (81.7%) and +25° (89.7%) degrees of exorotation. Specificity in this range of projection angles was between 89.6% and 97.8%. Regarding the presence of a hypertrophic posterior talar process, increased sensitivity was found for +15° (65.7%), +20° (61.0%), +25° (60.7%), +30° (56.3%) and +35° (54.5%). Specificity ranged from 78.0% to 94.7%. The combination of the standard lateral view in combination with exorotated views showed higher sensitivity. For detecting an os trigonum, a negative predictive value of 94.6% (+15°), 94.1% (+20°) and 96.1% (+25°) was found.ConclusionThis study underlines the additional diagnostic value of exorotated views instead of, or in addition to the standard lateral view in detecting an osseous impediment. We recommend to use the 25° exorotated view in combination with the routine standard lateral ankle view in the workup of patients with posterior ankle pain.Level of evidenceLevel III

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

To investigate the mid-to-long-term efficacy of patients with chronic ankle instability combined with posterior impingement syndrome after 3-9 years of follow-up, and to analyze the influencing factors. From February 2010 to December 2015, 46 patients underwent concurrent lateral ankle ligament repair with posterior ankle arthroscopic surgery at the Institute of Sports Medicine, Peking University Third Hospital. The patient was first placed in a prone position and underwent arthroscopic debridement for the posterior impingement. After finishing the posterior arthroscopy, the surgeon and assistants first translated the patient to the affected side, then turned to the healthy side, and changed the position to the supine position. During the turning over, another assistant held the arthroscope and the instrument to ensure that it was sterile and could be used without replacement. The anterior ankle arthroscopy was operated if necessary and the lateral ankle ligament repair was anatomic repaired with anchors. The 42 patients were followed up, including 26 males and 16 females. The average age was (28.9±10.0) years. The patient's clinical symptoms, joint stability, mobility and motor function were compared by questionnaire and physical examination. The preoperative and postoperative visual analogue scale (VAS) scores, American Orthopaedic Foot and Ankle Society (AOFAS) scores, Tegner scores were compared, and the clinical scores and the patient age, gender, height and weight were compared. The correlations between body mass index (BMI), preoperative duration, surgery duration, and cartilage injury were analyzed. The mean follow-up time was (71.8±22.8) months. The postoperative VAS scores (1.0 vs. 5.0, P<0.001), AOFAS scores (92 vs. 80, P<0.001), and Tegner scores (6.5 vs. 2, P<0.001) were significantly superior to the preoperative levels. The excellent and good rate was 97.6%. The postoperative VAS score (t=2.719, P=0.10), AOFAS score (t=-2.853, P=0.10), Tegner score (t=-3.443, P=0.001) and time to return exercise (t=2.814, P=0.008) were negatively correlated with the patient age, and the postoperative VAS score was negatively correlated with cartilage injury (Z=-2.195, P=0.028). The mid-to-long-term clinical outcomes of the chronic ankle ligament instability combined with the posterior impingement were good. The age of the patients was negatively correlated with the clinical outcome. The combined cartilage injury could aggravate the postoperative pain.

Posterior ankle impingement syndrome in athletes

Objective: This study sought to evaluate the results of 10 athletes diagnosed with posterior ankle impingement syndrome (PAIS) treated with arthroscopy between 2016 and 2017 by the Sports Traumatology Center of our University. Methods: Patients were evaluated with regard to the presence of associated lesions, the etiology of PAIS, and treatment outcomes using a visual analog scale (VAS) and the American Foot and Ankle Society (AOFAS) scores. All cases were treated using an arthroscopic approach to the posterior ankle. Results: Six patients presented with ankle instability and were treated with Brostrom-Gould ligament repair as an adjuvant procedure. One patient had sinus tarsi syndrome, and this space was debrided. Injury of the peroneus brevis tendon was identified in two cases, and Achilles tendinopathy was identified in one individual. Only three patients did not receive adjuvant treatment. During surgery, five cases of trigonal processes, three cases of Stieda process, one case of hallux saltans, and one case of accessory ossicle of the fibula were identified as the causes of the impingement. The mean VAS score was 1.28 (0.6-2.5), and the mean AOFAS score was 88.6 (72-100). No complications were reported. Conclusion: Arthroscopic resection of the cause of the impingement, alone or in combination with the treatment of secondary conditions, was used to effectively treat pain and reestablish function. Level of Evidence IV; Therapeutic Studies; Case series.

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.

Endoscopic treatment for posterior ankle impingement: high patient satisfaction and low recurrence rate at long-term follow-up

ObjectivesGood short-term outcomes have been described for endoscopic treatment of posterior ankle impingement. However, long-term outcome is unknown. The aim of this study is to determine the long-term patient satisfaction after endoscopic treatment and evaluate the recurrence rate of posterior ankle impingement. In addition, the aim of this study is to identify factors associated with favourable long-term outcome.MethodsA consecutive series of patients treated endoscopically for posterior ankle impingement between 2000 and 2011 in the Academic Medical Centre in Amsterdam were retrospectively reviewed. Primary outcome was patient satisfaction. Secondary outcome measures were function, pain, recurrence rate and Foot Ankle Outcome Scores. In addition, factors associated with long-term outcome were identified.ResultsTwo-hundred and three patients with 5–15 years of follow-up were included. Median satisfaction score was 8/10 and for 9/10 for function . Patients had no pain at follow-up. Outcome was similar for different types of impingement and type or level of sport participation. Symptoms recurred in 5% of the patients. In a multivariable analysis, additional flexor hallucis longus (FHL) tendinopathy was associated with lower satisfaction and a higher recurrence rate.ConclusionLong-term outcome of endoscopic treatment for posterior ankle impingement demonstrated good results, with high patient satisfaction, good functional outcome scores and a low rate of recurrence for all types of posterior ankle impingement. Type and level of sports did not influence outcome. Only the presence of FHL tendinopathy was associated with lower satisfaction and a higher recurrence rate.Level of evidenceLevel IV.

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

Category: Arthroscopy Introduction/Purpose: We introduce a novel method of combining the standard anteromedial and anterolateral approaches and dual posterolateral approaches in the arthroscopic treatment of posterior and anterior ankle impingement syndrome and compare the postoperative outcomes with conventional anteromedial/anterolateral and posteromedial/posterolateral Methods: From January 2015 to January 2017, we treated 28 patients with posterior and anterior ankle impingement syndrome by arthroscopy. The patients were divided into the conventional group (n = 13) and the modified group (n = 15) according to the surgical approaches used in the operation. Preoperative and postoperative American Orthopaedic Foot &amp; Ankle Society (AOFAS) score, visual analog scale (VAS) score, range of ankle motion, and operation time were recorded. The average follow-up was 16 months (range 6-24 months). Results: Posterior and anterior ankle impingement syndrome was confirmed arthroscopically in all patients. After the operation, the range of ankle motion in all patients was restored. There was no significant difference in postoperative AOFAS score, VAS score, dorsiflexion, and plantarflexion between the conventional group and the modified group. Moreover, the operation time was significantly reduced in the modified group compared with the conventional group. There was no recurrence of osteophyte and no complications such as infection, neurovascular injury, or delayed healing of surgical incision in the modified group. Conclusion: Dual posterolateral approaches combined with standard anteromedial and anterolateral approaches was a novel method for arthroscopic treatment of posterior and anterior ankle impingement syndrome. It proved to be safe and effective, and significantly reduced the operation time. Reposition, repeated prep and drape, and limb distraction were avoided.

Learning Curve in the Posterior Endoscopy of the Ankle

Category: Arthroscopy Introduction/Purpose: The Posterior Ankle Impingement Syndrome (PAIS) can be treated by the endoscopic technique with posterior portals and patient in prone position. There is discussion whether this would be the best method, given the possible difficulty in learning and applying this technique, risks of complications and prolonged time of surgery. We conducted this retrospective study to assess the time spent to perform the posterior endoscopy along the learning curve and the relationship of the duration of the procedure to the presence of complications. Methods: We evaluated 39 patients undergoing endoscopic treatment through posterior ankle portals technique and prone position, operated by a single surgeon between 2005 and 2014. We divided the patients into four groups of ten subjects according to the chronological sequence of the surgeries. We used the Jonckheere-Terpstra test to compare the surgery time between the four analyzed groups. We used the Mann-Whitney test to compare operative time and the occurrence of complications, and the relationship between surgical procedure time and presence of intraoperative fibrosis. We used the Wilcoxon signed-rank test to compare preoperative and postoperative AOFAS Ankle-Hindfoot Score. For all statistical analysis, p-values &lt;0.05 were considered to be significant. Results: We found a significant decreasing of the surgery duration over time (p=0.0273) (Figure). Figure: Representing surgery time (in minutes) to groups of patients (Groups 1 to 4, being Group 1 patients 1-10, Group 2 patients 11-20, Group 3 patients 21- 30 and Group 4 patients 31-39).There were three complications not related to the duration of the surgery (p=0.6909). The presence of extensive fibrosis had an impact on the operative time (p=0.0387). The AOFAS Score evolved from 64.0±16.9 preoperatively to 93.7±8.9 postoperatively (p&lt;0.0001). Conclusion: The time of the procedure decreased as the surgeon’s experience increased, and our complications showed no relationship with the surgery time.

Hindfoot Endoscopy: Correlation of the Preoperative Indications with the Perioperative Endoscopic Findings

Background: The aim of this study was to review the disorders treated with hindfoot endoscopy and investigate the detected ratio and type of combined pathologies. The second aim was to evaluate the preoperative and peroperative findings before and at the time of hindfoot endoscopy.Patients and Methods: 81 hindfoot endoscopies of the 77 patients performed between 2010-2015 were reviewed. Demographic informations, preoperative physical and radiological findings and operative data of all patients were noted. Preoperative physical examination for hindfoot was performed in a standart fashion for all patients. Weight-bearing anteroposterior and lateral radiographs were taken for all patients. Magnetic resonance imaging(MRI) was performed to all patients except obvious prescence of bony impingement. The hindfoot endoscopy was performed to all patients at prone position under either spinal or general anesthesia with standart posteromedial and posterolateral portals described as Van Dijk et al.Results: In this case series; the most detected preoperative indications were flexor hallucis longus tendinopathy(27.1%), symptomatic os trigonum(22.2%) as a cause of posterior ankle impingement and insertional achilles tendinopathy(20.9%). The most detected endoscopic findings were flexor hallucis longus tendinopathy(33.3%), symptomatic os trigonum(19.3%), and retrocalcaneal bursitis(16.2%).16 patients(19.7%) had preoperatively detected combined pathologies. In 32 patients(39.5%), a new indication was added to preoperative indication. Conclusion: Posterior ankle impingement and peri-achilles pathologies are the most seen indications for this technique. It is important that we all must aware of perioperatively detected new indications and rare conditions.

Results of Treatment of Posterior Ankle Impingement Syndrome and Flexor Hallucis Longus Tendinopathy in Dancers: A Systematic Review.

Dancing on pointe and relevé requires extreme plantar flexion of the talo-crural joint. Hence, these positions may lead to posterior ankle impingement syndrome (PAIS). PAIS often coincides with flexor hallucis longus tendinopathy (FHL tendinopathy, or "dancers' tendinitis"). Both injuries can appear in isolation as well. The goal of this review is to evaluate the results and the available levels of evidence of conservative and operative treatment (both open and endoscopic) of PAIS and FHL tendinopathy in dancers. It also offers an insight into the history of dance medical publications on this subject. In October 2016, a systematic search of PubMed, Embase, Cochrane, CINAHL, Web of Science, and (in French) ScienceDirect databases was undertaken. Five hundred and seventy-six publications were found, of which a total of 27 reported the results of operative treatment in 376 ankles (344 open, 32 endoscopic) in 324 dancers. The outcome was good to excellent in most cases (89%). The mean period of return to dance for all surgeries combined (PAIS and FHL tendinopathy, open and endo) was 11 weeks (range: 4 to 36 weeks), and for isolated FHL tendinopathy 16 weeks (range: 8 to 36 weeks). Only six publications reported the results of conservative treatment in 33 ankles (13 PAIS, 20 FHL tendinopathy) of 28 dancers, which does not allow for any evidence-based recommendations. Most studies failed to include dance-specific baseline characteristics, like dance style and level of participation. We concluded that only retrospective studies with levels of evidence four and five show that operative treatment for PAIS and FHL tendinopathy is successful with few complications. Since isolated PAIS, PAIS combined with FHL tendinopathy, and isolated FHL injuries appear to be different pathological entities, more research taking into account demography, dance type, and level of participation is needed to find out in which cases early operative management should be considered or avoided. The same applies to defining the place of endoscopic surgery in dancers and being able better to predict which pathology is likely to produce worse outcomes or delay the return to dance. Future research should have a prospective design, including dance-specific outcome scores both preand post-treatment. Furthermore, preferably a prospective randomized controlled design should be used to compare different conservative and operative treatment options.

Posterior Ankle Impingement Syndrome and M. Flexor Hallucis Longus Tendinopathy in Dancers Results of Open Surgery.

Posterior ankle impingement syndrome (PAIS), the result of posterolateral soft tissue or bony impingement of the ankle, and tendinopathy of the flexor hallucis longus (FHL tendinopathy) in the ankle are common in dancers. If conservative treatment of these conditions fails to produce adequate results, surgical intervention might be necessary. However, outcomes of treatment by open surgery for these diagnoses have been described only in small series of dancers. For this study, data were extracted from clinical files and operative reports of an orthopaedic surgery clinic specialized in dance medicine. Prior to October 2016, 148 patients (82.1% female, median age 19 years) underwent 190 open procedures, 57 (30%) for FHL, 83 (43.7%) for PAIS, and 50 (26.3%) for a combination thereof. In 90.8% of cases, patients reported a "better" or "much better" postoperative outcome. There were only minor, transient complications that neither required re-intervention nor influenced outcome. Patients were followed up for a median of 157 days (interquartile range: 91-245 days). Those operated on by a lateral approach were discharged from follow-up earlier (lateral 113 days vs. 190 for medial approach, p = 0.005), but there was no difference in outcome at discharge. It is concluded that the open surgical treatment of PAIS and FHL tendinopathy in dancers has a high success rate and can be considered a successful standard operative procedure. More detailed information is needed about dance-specific outcomes and the early postoperative course of rehabilitation.

Operative Treatment of Posterior Ankle Impingement Syndrome and Flexor Hallucis Longus Tendinopathy in Dancers Open Versus Endoscopic Approach.

Posterior ankle impingement syndrome (PAIS) is a painful, usually limited plantar flexion of the ankle joint due to soft tissue impingement or a bony impediment often coinciding with tendinopathy of the flexor hallucis longus (FHL) behind the medial malleolus. In persistent complaints, the bony impediment is removed, the tunnel of the FHL tendon is released, or a combination of both procedures has traditionally been performed by open surgery. In 2000, an endoscopic surgical technique for PAIS and FHL tendinopathy was introduced. To date there is no evidence of the superiority of one surgical technique over the other in dancers; both the open and the endoscopic approach provide up to 90% good and excellent long-term results. We compared the first 20 consecutive open procedures with the first 19 consecutive endoscopic procedures in dancers, all operated by the same orthopaedic surgeon. The postoperative outcomes were reviewed by studying the patient files, clinical evaluation, American Orthopaedic Foot and Ankle Society (AOFAS) scoring, and we administered a dance-specific questionnaire. The results in the open group were: nine excellent, nine good, one moderate, and one poor (90% excellent and good). In the endoscopic group: nine excellent, six good, three moderate, one poor (79% excellent and good). Both groups returned to dance (barre) at a median of 8 weeks (IQR: 2). The direct postoperative morbidity in the endoscopic group was less favorable and was mainly related to hematomas and an inflammatory response or deep scar tissue formation. There were no major complications requiring re-intervention. Although the two small groups of patients and the retrospective character of our descriptive study do not allow firm conclusions or statistical analysis of subgroups, the results of this study indicate that the open approach seems to be better than the endoscopic approach in the surgical treatment of PAIS and FHL tendinopathy in dancers.

The peroneocalcaneus internus tendon: case report of a rare cause of posterior ankle impingement treated by arthroscopy

The peroneocalcaneus internus tendon: case report of a rare cause of posterior ankle impingement treated by arthroscopy

Prevalence of Os Trigonum on CT Imaging

The os trigonum is known as one of the main causes of posterior ankle impingement. In the literature, a wide variation of occurrence has been reported. All foot and/or ankle computed tomography (CT) scans made between January 2012 and December 2013 were reviewed. CT images were assessed, blinded for patient characteristics, for the presence of an os trigonum, size of the os trigonum, and type of os trigonum. In addition, the shape of the lateral tubercle of the posterior talar process was assessed. A total of 628 patients (1256 ankles) were included. In 32.5% of the patients of the cohort, an os trigonum was present. In 14.3% of these patients, it was present bilaterally. In a subgroup of patients without posterior ankle impingement the prevalence was 30.3%. Of the nonaffected ankles, an os trigonum was present in 23.7%. Patients with posterior ankle impingement were more likely to have an os trigonum (adjusted odds ratio [OR], 1.86). Afro-Caribbean/Surinamese/Central African origin was associated with a lower rate of occurrence of os trigonum (adjusted OR 0.43). In the ankles without an os trigonum, an enlarged lateral tubercle of the posterior talar process was found in 34.9% and 36.5% of the ankles. This study showed that os trigonum is a common accessory bone. With a prevalence of 30.3% in a population of patients with CT imaging of both ankles and 23.7% of the nonaffected ankles, the os trigonum is more common than previously reported. Patients with posterior ankle impingement complaints had a higher prevalence of an os trigonum. In one-third of the patients without an os trigonum, there was an enlarged lateral tubercle of the posterior talar process. Level III, retrospective comparative study.

Deep Vein Thrombosis in Combined Ankle Arthroscopy for the Anterior and Posterior Ankle Impingement Syndrome

Introduction: The ankle arthroscopy complication rates from 7.6% to 13.6% and deep vein thrombosis (DVT) is considered as a serious complication. The risk of DVT for patients with isolated foot and ankle conditions, even with plaster cast immobilization, and the possible benefits of mechanical and chemical prophylaxis are poorly studied. Nevertheless, some studies mentioned the risk factors such as injury severity, immobilization, obesity, nonweight-bearing, hindfoot surgery, and tourniquet time. Case Presentation: A 27-year-old male patient, smoker, and casual athlete with complaint of left recurrent painful ankle presented an anterior ankle impingement type B and a posterior impingement syndrome. In the immediate postoperative period, the patient developed a DVT as a complication of a combined ankle arthroscopy (anterior and posterior). Conclusions: It seems that the use of prolonged tourniquet in addition to repositioning the patient may increase the risk of complications such as VTE (venous thromboembolism) and the combination was not included in any published protocol. The current study recommended the use of the Calder antithrombotic recommendations associated with the Caprini risk assessment model in order to cover a greater at-risk population.

Endoscopic All-inside Repair of the Flexor Hallucis Longus Tendon in Posterior Ankle Impingement Patients

Longitudinal flexor hallucis longus (FHL) tendon tears are sometimes complicated by posterior ankle impingement syndrome (PAIS), especially in ballet dancers. In recent years, PAIS has been treated endoscopically, but it is difficult to suture FHL tendon tears endoscopically. In this report, we describe how to suture the FHL tendon endoscopically with the Meniscal Viper Repair system (Arthrex, Naples, FL). Without our endoscopic technique, when a patient is found to have a longitudinal tear of the FHL under endoscopy, we must choose to either neglect the tear or convert to an open repair. Open tendon suture techniques have reportedly had relatively good results but require a longer skin incision than endoscopic surgery for PAIS. Compared with the open repair, the advantages of our technique include earlier recovery, less pain, a lower rate of soft tissue complications, and improved healing through better preservation of the blood supply. This technique is an attractive and useful option because it is an easy and safe method for longitudinal FHL tendon tears.