Arthroscopy of the Foot and Ankle

Arthroscopic setup and examination

Identifying the superficial peroneal nerve

Before preparing and draping the area, the physician should localize the course of the superficial peroneal nerve because it is easier to see at this time. The nerve can often be palpated and visualized along its course anterior and inferior to the lateral malleolus by placing the foot into inversion and plantar flexing it (especially the fourth toe). Its course should be marked with a surgical pen before preparing and draping and re-marked before applying joint distraction ( Fig. 39-11 ). As stated earlier, the superficial peroneal nerve is the most commonly injured nerve during ankle arthroscopy, and every effort should be made to protect it during the surgery.

Intraoperative setup

Positioning of the patient, equipment, scrub nurse, and surgeons is critical to a successful surgery. Figure 39-16 demonstrates the authors’ preferred operating room setup.

Postoperative management

The arthroscopic portals are closed using 4-0 nylon in a vertical mattress suture pattern. Betadine or Neosporin ointment is placed over the wounds. A nonadhering petrolatum gauze dressing and 4 × 4 gauze pads are placed, and the ankle is immobilized in a well-padded splint in neutral dorsiflexion. Immobilization allows healing of the arthroscopic portals and discourages the formation of a synovial sinus. The sutures and splint are removed in 7 days. Subsequently, postoperative bracing or casting and rehabilitation depend on the pathology and treatment.

Indications and contraindications

Surgery in the rheumatoid patient is based on careful timing and evaluation of the condition of the joint as well as the patient’s overall medical condition. If the patient fails conservative therapy, ankle arthroscopy may be considered in close consultation with a rheumatologist. The indications for surgery include pain, swelling, and mechanical symptoms of locking and catching. Contraindications include local infection, vascular insufficiency, and other medical comorbidities that preclude operative intervention. If preoperative radiographs demonstrate significant joint space narrowing, synovectomy should be avoided because the results are poor with only short-term benefit.

Preoperative evaluation and planning

A careful physical examination of the ankle joint, tendons, ligaments, and soft tissue envelope is essential. A computed tomography (CT) scan or magnetic resonance imaging (MRI) can help assess articular damage, effusion, synovitis, tendinopathies, and other unsuspected abnormalities. A preoperative ankle and subtalar aspiration may be diagnostic and can rule out other inflammatory arthritides and infection. Close consultation with the patient’s rheumatologist is essential. The surgeon should carefully assess other joints and medical comorbidities.

Arthroscopic synovectomy

Results and complications

Early synovectomy has yielded better surgical results than delayed synovectomy because better results correlate with less articular cartilage involvement. Early synovectomy can slow the progression of joint degeneration; however, even in the best of circumstances, debridement and synovectomy do not prevent articular destruction. Some investigators have questioned the benefit of synovectomy. Complete synovectomy of the rheumatoid granulations is impossible. Even with a thorough debridement, 5% of the original granulations can remain.

Indications and contraindications

Arthroscopy may be indicated to confirm the diagnosis and establish treatment. Several features must be seen to establish the diagnosis, including synovitis, papillary formation, and hemosiderin deposits. The contraindications are similar to those for general ankle arthroscopy.

Preoperative evaluation and planning

The ankle and hindfoot may be warm, swollen, and tender to examination and might have limited range of motion. Aspiration of the joint can yield a dark, serosanguineous fluid. Radiographs may be helpful in making the diagnosis of tenosynovial giant cell tumor by the characteristic periarticular erosions. An MRI can show nodular masses and reveal swollen synovial tissue ( Fig. 39-17A ).

Results and complications

Arthroscopy offers several advantages over open synovectomy, including better visualization and surgical access to the ankle and hindfoot and decreased postoperative morbidity. Studies have shown successful treatment of tenosynovial giant cell tumor in the localized form, whereas the generalized form may not have lasting results, and recurrences are common.

Indications and contraindications

Arthroscopic treatment helps establish the diagnosis and alleviate pain and mechanical symptoms. Treatment may be contraindicated in patients with extensive disease, especially in cases of large osteochondral fragments that are more amenable to open treatment.

Preoperative evaluation and planning

Patients can present with pain and symptoms of locking and giving way or with the sensation of loose bodies in the joint. Typically, there is limited range of motion as well as palpable synovium or nodules about the ankle joint. Synovial osteochondromatosis is most common in middle age. Radiographic studies can demonstrate multiple small intraarticular opacities and some calcification. The presence of intraarticular loose bodies does not establish the diagnosis of synovial chondromatosis. Loose bodies may be found in other diseases, such as degenerative joint disease, rheumatoid arthritis, neurotrophic arthritis, osteochondral fractures, osteochondritis dissecans, and tuberculosis.

Surgical treatment

In stages 1 and 2, arthroscopic surgery using joint distraction may be used to perform synovectomy and extraction of loose bodies ( Fig. 39-18 ). Debridement and loose body excision are performed in stage 3 because there is no intrasynovial activity to warrant synovectomy.

Results and complications

With open surgery, there is a 5% recurrence; Bojanic et al reported all good to excellent results in five patients with arthroscopic treatment. Recently, we have reported on results with synovial chondromatosis and found excellent outcome in patients as long as they did not have preexisting significant degenerative joint disease. An aggressive form of synovial chondromatosis has been described that tends to recur with occasional distal metastasis and should be considered a form of synovial chondrosarcoma. It is recommended to send all specimens for pathologic evaluation at the time of surgery and to follow the patients long term. Galat et al did open excision and found one of six cases (16%) to be later diagnosed with chondrosarcoma and needed below-the-knee amputation. Davis et al reported malignant transformation in 5% of cases.

Indications and contraindications

Arthroscopic synovectomy may be indicated in chronic forms of hemarthrosis. To avoid the postoperative complications and improve success, coagulation factors should be supplemented under the supervision of a hematologist.

Preoperative evaluation and planning

In the acute stage, the joint may be swollen, red, and tender. Radiographs can demonstrate an extensive loss of joint space. The guidance of a hematologist is imperative, and an infection must be excluded. The chronic stage can show obliteration of the joint space and a chronic synovitis.

Results and complications

Arthroscopic synovectomy can help to reduce the frequency and severity of future hemarthroses. In a study of arthroscopic synovectomy of the ankle, elbow, knee, and shoulder, the median arc of motion was stable or improved in the year after surgery. The median follow-up was 79 months, and joints with sufficient follow-up data showed a significant decline in median bleeding frequency. Recently, Ferkel et al reviewed the orthopedic manifestations of van Willebrand disease and described successful treatment in a young athlete ( Fig. 39-19 ).

Indications and contraindications

Acute ankle infection may be best diagnosed and treated arthroscopically. In the arthritic ankle of unknown diagnosis, arthroscopy can facilitate obtaining a biopsy and cultures as well as performing debridement. Infections involving the soft tissue envelope around the joint are best treated with open debridement.

Preoperative evaluation and planning

A careful physical examination should be performed to determine the region of involvement. Diagnostic radiographic and laboratory studies are also helpful in making the diagnosis and assessing the extent of disease. Antibiotics should be withheld until a joint culture is performed to allow the use of appropriate antibiotics.

Preoperative evaluation and planning

After a traumatic injury to the ankle joint, a generalized or localized synovitis may occur. The patient with generalized nonspecific synovitis usually complains of swelling, aching, and soreness. The history of trauma may be significant or trivial. Sometimes, no specific inciting event can be recalled.

Ankle sprains and fractures are the most common causes of nonspecific generalized synovitis. Arthroscopic debridement with lysis of the adhesions and partial synovectomy is performed in this situation and may prove to be technically challenging. The key to success is a high-flow, gravity-assisted system using a posterolateral inflow cannula. The distractor may be very helpful in these cases to improve visualization and access to the joints.

Preoperative evaluation and planning

After trauma, some patients develop a localized synovitis in the medial or lateral malleolar joints. Radiograph examinations are generally negative or might show small ossicles consistent with previous trauma. MRI might show a signal change in the area of pain with or without fluid. The arthroscopic examination of localized synovitis reveals mild or localized synovitis, papillary formation, and fibrosis.

Arthroscopic synovectomy

Postoperative management

The portals should be closed postoperatively as was described for ankle arthroscopy. A drain may be placed if excessive bleeding is encountered after debridement.

A short-leg splint is applied for 5 to 7 days, after which the sutures are removed and a compression stocking is applied as well as a protective weight-bearing brace. The postoperative regimen should include early range of motion and weight bearing as tolerated, with physical therapy delayed for 2 to 3 weeks to allow the soft tissues to heal and the postoperative inflammation to resolve.

Indications and contraindications

Patients with ankle pain that has failed a period of conservative management, including immobilization, progressive weight bearing, rehabilitation, nonsteroidal medications, and injections, may be candidates for arthroscopic debridement. The pain is often vague and activity related. Complex regional pain syndrome has been a well-described entity after ankle sprains and may be a contraindication to ankle arthroscopy.

Anatomy of anterior soft tissue ankle impingement

There are some nomenclature changes for names of the ankle ligaments. In 1998, the Federative Committee on Anatomic Terminology stated that the term “inferior” should be dropped from both the anterior tibiofibular and posterior tibiofibular ligaments. In addition, the term “inferior transverse ligament” should be omitted and the ligament should be called the transverse ligament or deep component of the posterior tibiofibular ligament. The ankle pain is usually located anterolaterally but may also be anteromedially or in both areas. The borders of the lateral gutter of the ankle include the talus medially, fibula laterally, and tibia superiorly, bordered by the anterior and posterior tibiofibular (AtiFL and PtiFL) ligaments ( Figs. 39-20 and 39-21 ). The anteroinferior section of the lateral gutter is bordered by the anterior talofibular (ATFL), calcaneofibular (CFL), and anterior talocalcaneal ligaments. The posteroinferior borders are composed of the posterior talofibular (PTFL), calcaneofibular (CFL), and posterior talocalcaneal ligaments.

More recently, the anterior tibiotalar ligament has been reported as a possible contributing source of anterior soft tissue ankle impingement. Keller et al described the cadaveric anatomic and histologic features of the anterior tibiotalar ligament and postulated on its pathologic contributions to anterolateral soft tissue impingement. They found four different distinct types of ligaments. Types I and II are termed isolated ligaments and consist of a distinct band of organized fibers. Type I ligaments run over the talar neck more so than type II ligaments, which run over the lateral talar body. Types III and IV are termed widespread ligaments and are more diffuse, with no distinct thickening. Type III ligaments have parallel fibers, while type IV ligaments have crossing fibers.

Pathology

The classic sequence associated with inversion injuries of the ankle is shown in Fig. 39-22 . There are three primary sites where anterolateral soft tissue impingement of the ankle occurs ( Fig. 39-23 ). The first site is the superior portion of the AtiFL ligament. The second site is the distal portion of the AtiFL ligament, which can involve a separate fascicle known as the Bassett ligament . The third and most common site is along the anterior talofibular ligament and lateral gutter near the area of the lateral talar dome.

Figure 39-24 depicts the sequence of lateral ankle pain. Injury to the ligament initially results in synovitis and scar tissue. This in turn becomes hypertrophic and leads to impingement in the lateral gutter. Histologically, the impingement tissue is a layer of synovial membrane with subsynovial fat and collagen tissue anterior to the capsular tissues in the anterior joint space.

Preoperative examination and planning

The diagnosis of soft tissue impingement can be made with a thorough physical examination and can be further confirmed with diagnostic studies. Careful palpation and stress testing of the ankle can assist in making the diagnosis ( Fig. 39-25 ). Attention should focus on the distal syndesmotic region, the area of the ATFL, CFL, and the anterior gutter. It is important to evaluate for subtalar pain as well because this presents in a similar manner and may coexist. Molloy et al reported a sensitivity of 94.8% and specificity of 88% on special physical examination testing for synovial impingement.

Radiographs can reveal calcifications or heterotopic bone in the interosseous space, indicating a previous injury to the distal tibiofibular syndesmosis. Ossicles along the tip of the fibula and the lateral talar dome are consistent with anterior talofibular ligament injuries. Stress view radiographs and ultrasonography have also been described in the literature for these conditions.

MRI has yielded a diagnostic accuracy of 78.8% and a sensitivity and specificity of 83.3% and 78.6%, respectively ( Fig. 39-26 ). Sagittal T1 and short tau inversion recovery (STIR) images help discern a collection of fluid (edema) or soft tissue that has caused the displacement of subcutaneous fat normally found immediately adjacent to the fibula anteriorly. Kinematic MRI has also been described to show impingement.

Indications and contraindications

As with anterolateral soft tissue impingement, the patient with medial ankle pain that has failed conservative management may be a candidate for ankle arthroscopy.

Preoperative examination and planning

Injury to the deltoid ligament or capsule can result in scarring and hyalinization or hypertrophy of the synovium. This can in turn lead to medial sided symptoms. Egol and Parisien have described a “medial meniscoid” lesion similar to that described in anterolateral impingement.

It is important to perform a careful physical examination to document medial ankle tenderness. Diagnostic studies can assist in making the diagnosis. Radiographs can reveal deep deltoid ligament avulsions, and stress radiographs can demonstrate medial joint space widening if there is associated ankle instability. An MRI can demonstrate inflammatory changes of scar tissue in the medial gutter or anteromedial joint.

Indications and contraindications

Patients with chronic pain in the posterior ankle joint, usually worsened with plantar flexion, may be candidates for surgery. A trial of conservative management is advised.

Anatomy of posterior ankle impingement

The posterior capsuloligamentous structures of the ankle have recently been classified in a review of 222 ankle arthroscopies. The posterolateral gutter structures include the posterior talofibular ligament, posterior tibiofibular ligament (PtiFL), transverse tibiofibular ligament (TTL), posterior intermalleolar ligament (tibial slip), FHL tendon, and a synovial nodule in the tibiofibular recess ( Fig. 39-27 ). The structures of the posteromedial gutter of the ankle include the FHL tendon and deep portion of the deltoid ligament.

The configuration of the PtiFL and TTL remain controversial in the literature. Ferkel et al have classified these ligaments into four subtypes ( Fig. 39-28 ). Sarrafian describes the PtiFL as composed of a superficial and deep ligament. The deep ligament is also known as the TTL. Types II and III occurred most often at 33% and 35%, respectively, whereas types I and IV had an incidence of 26% and 9%, respectively. A normal variant bifid or three-limbed TTL has also been described, although it remains a rare finding and is most commonly found in type II and III configurations. In a review of 102 ankles, there were two tears of the TTL and one avulsion of the ligament from the posterior articular surface.

A posterior intermalleolar ligament (tibial slip) was noted in approximately 10% to 15% of ankles. This thin band lies in the floor of the posterior cul-de-sac and extends from the superior border of the posterior talofibular ligament laterally and courses medially and cephalad, eventually blending with the fibers of the TTL ( Fig. 39-29 ). Another posterior structure noted in 30% of ankles was a vertical band of tissue of varying thickness overlying the inferior aspect of the TTL.

Sarrafian found that the HL tendon and its sheath are in communication with the posterior capsule in 13% of ankles. Anatomic variation in capsule thickness or synovial proliferation can obstruct visualization of the flexor hallucis tendon in 60% of arthroscopies. In 20%, only a faint recess or shadow was evident, whereas in 11.8%, the recess was easily identified. Only 9.8% of patients had a discrete tendon ( Fig. 39-30 ).

A synovial nodule is a normal finding of the tibiofibular synovial recess, located at the posterior margin of the distal fibula just anterior and superior to the PtiFL. The lesions ranged in size, apparently correlated to the amount of inflammation in the nodule. The majority of patients, 49%, had small discrete nodules without a significant inflammatory response, although a small subset of almost 12% had a seemingly large, noninflamed nodule. Twenty percent of ankles had small, inflamed nodules, whereas almost 20% had a large nodule with significant vascular injection.

Preoperative evaluation and planning

Posterolateral soft tissue impingement may be an isolated entity; however, it is often found concomitantly with anterolateral soft tissue impingement of the ankle. In addition, generalized posterolateral soft tissue impingement can also occur with fibrosis, capsulitis, and synovial swelling. Although often normal, radiographs can reveal posterior osteophytes or loose bodies. An MRI study can show hypertrophy or tears of the posterior ligaments and might demonstrate synovitis.

Both localized and generalized posterolateral soft tissue impingement may be missed during ankle arthroscopy if visualization from the posterolateral portal is not performed. Furthermore, it is routinely difficult to see synovial disease in the posterolateral aspect of the ankle without the use of a distraction device.

Soft tissue posterior impingement can also be caused by hypertrophy or tears of the posterior tibiofibular ligament, transverse tibiofibular ligament, or posterior intermalleolar ligament (tibial slip) on the posterior ankle joint ( Fig. 39-31 ). The transverse tibiofibular ligament can be hypertrophied or become torn and pathologic in certain instances. Ferkel et al have reported 25 tears of the TTL tears, with an incidence of 1.56% in more than 1600 ankle arthroscopies ( Fig. 39-32 ).

The posterior intermalleolar ligament (tibial slip) can also become hypertrophied and be a cause of posterior soft tissue impingement. The posterior intermalleolar ligament (tibial slip) runs between the posterior tibiofibular ligament and the transverse ligament (see Fig. 39-29 ). This ligament can develop fibrosis after trauma to the ankle, with subsequent pain and swelling. It can also be associated with injuries to the transverse ligament.

Hamilton (cited in Guhl) has described a tibial labrum on the posterior lip of the tibia. This can become pathologic, just like the superior labrum in the shoulder. The authors think that this disease is actually a tear of the transverse ligament or the posterior intermalleolar ligament (tibial slip). Hamilton has also described the “meniscus of the ankle” in the posterior ankle joint of ballet dancers. Tears in this region could displace into the joint, causing symptoms, and probably represent tears of the posterior structures.

Indications and contraindications

Surgery is indicated for patients with chronic pain after a “high ankle sprain” that fails conservative treatment. Those with syndesmotic instability are best treated with surgical stabilization.

Anatomy and pathology of syndesmotic impingement

The tibiofibular articulation is stabilized by the syndesmosis, which is composed of: the anterior tibiofibular ligament (AtiFL) and its fascicle; the posterior tibiofibular ligament (PtiFL), including its distal and deep component, the transverse ligament; and the interosseous ligament, and membrane.

There are three primary sites of syndesmotic impingement. These include the AtiFL, the tibiofibular joint, and the PtiFL ( Fig. 39-33 ).

Preoperative evaluation and planning

Injuries to the syndesmosis are among the most serious ligamentous injuries that occur in the ankle. Unfortunately, the incidence of these injuries has been underestimated in the past, particularly after an inversion injury. During an acute ankle sprain, if the talus inverts and the tibia rotates, stress is placed across the syndesmosis, and a tear of the syndesmosis may occur.

A careful examination includes assessment of the soft tissues, neurovascular status, and palpation over the syndesmosis and the interosseous membrane more proximally. The squeeze and external rotation tests are helpful in discerning syndesmotic injuries. Radiographs include anteroposterior (AP), mortise, and lateral views to discern ankle instability. Stress views under general anesthesia with fluoroscopy will verify an unstable ankle. Further studies may include MRI and weight-bearing CT scans.

After injury, synovitis and scarring can occur in the area of the AtiFL and corresponding joint. With increased activity, soft tissue impingement can develop around the area of the ligament and the undersurface of the joint. At surgery, a reddened synovium is often seen surrounding the AtiFL and extruding into the distal tibiofibular joint. Sometimes, the synovitis can extend to the posterior recess ( Fig. 39-34 ).

Several studies have reported impingement from a separate fascicle of the AtiFL. Bassett et al performed an anatomic study and found the fascicle to be present in 10 of 11 cadavers, a finding supported by Nikolopoulos et al in 22 of 24 cadaver specimens. The ligament is oriented distal and parallel to the AtiFL and separated by a fibrofatty septum. Bassett et al suggested that with a tear of the anterior talofibular ligament, the patient can develop increased laxity, and the talar dome can extrude anteriorly in dorsiflexion and cause soft tissue impingement. The authors think that the accessory fascicle rarely becomes symptomatic except after trauma.

A triad of pathologic findings were identified by Ogilvie-Harris in patients with chronic symptoms consistent with syndesmosis disruption: disruption of the PtiFL, interosseous ligament, and a posterolateral tibial plafond chondral fracture.

Surgical technique

The technique is as follows.

• 1.

  Patient equipment, instrumentation, positioning, and anesthesia were described previously for ankle arthroscopy.

• 2.

  For syndesmotic impingement, before preparing and draping, intraoperative stress radiographs are taken while the patient is under anesthesia. Talar tilt and tibiotalar clear space widening are assessed. In case of tibiotalar instability, reduction and internal fixation is recommended and is performed after the arthroscopic syndesmotic evaluation and debridement.

• 3.

  A noninvasive ankle strap is used to for joint distraction; however, the anterolateral compartment of the ankle can become occluded with over-distraction, making visualization difficult. Visualization is best when the ankle is dorsiflexed with the distraction relaxed. In dorsiflexion, the anterior capsule becomes relaxed and the lateral malleolus lateralizes, rotates internally, and is pulled superiorly. Furthermore, the interosseous membrane, the anterior tibiofibular ligament, and the anterior talofibular ligament become more horizontal.

• 4.

  The anteromedial, anterolateral, and posterolateral portals are placed as described for ankle arthroscopy.

• 5.

  A 30-degree 2.7-mm arthroscope is used initially, and the ankle is visualized through all portals to perform the 21-point examination.

• 6.

  A 70-degree 2.7-mm arthroscope is routinely used to visualize the lateral and medial gutters. This arthroscope permits the surgeon to see over the talar dome from both the anterior and posterior portals. In severely tight ankles, a 30-degree, 1.9-mm arthroscope is recommended.

• 7.

  A posterolateral high-inflow cannula is placed to maintain fluid pressure and to remove shavings during the debridement.

• 8.

  A 2.9-mm full-radius shaver, baskets, and graspers are necessary for the debridement.

• 9.

  Debridement includes the removal of the inflamed synovium, thickened adhesive bands, inflamed capsular bands and ligamentous tissue, osteophytes, and loose bodies. Debridement is performed to expose the underlying cartilage, which often reveals chondromalacia of the fibula and talus.

• 10.

  For anterolateral soft tissue impingement, the inflamed tissue may extend superiorly into the syndesmosis region. Care must be taken to not excise any of the functional remnants of the anterior talofibular ligament ( Figs. 39-35 and 39-36 ). The lateral gutter can be approached with a 30- or 70-degree arthroscope in the anteromedial portal and the working instrument in the anterolateral portal. In addition, small ossicles or larger symptomatic nonunions may be present, and loose bodies may be hidden in the soft tissues at the tip of the fibula.

  
  

• 11.

  For medial soft tissue impingement, a 30- or 70-degree arthroscope can be placed in the anterolateral portal to view the medial gutter, with instrumentation in the anteromedial portal. The surgeon must be careful to preserve the deep deltoid ligament. For posterior impingement, the torn posterior ligaments can be visualized from the anterior portals as well as the posterior portal using 30- and 70-degree arthroscopes (see Fig. 39-32 ). The torn PtiFL, TTL, or posterior intermalleolar ligament (tibial slip) is debrided to its more normal appearing structure, with the shaver in the posterolateral portal. Visualization is best through the anteromedial portal through the notch of Harty. Alternatively, a suction basket may be used from the anterolateral portal.

• 12.

  For syndesmotic impingement, previous anatomic studies have shown that approximately 20% of the ATiFL syndesmotic ligament is intraarticular. Debridement of the ATiFL ligament and tibiofibular joint is performed using a full-radius 2.9-mm shaver or 2.5-mm suction basket. In addition, if a separate fascicle is seen, it should be removed. On rare occasions, the authors have excised this intraarticular portion of the ligament without any untoward effects to the patient at long-term follow-up ( Fig. 39-37 ).

  

Postoperative care

Postoperatively, patients are placed in a non–weight-bearing short-leg splint for 5 to 7 days. The stitches are removed, and the splint is discarded at 1 week, at which time a compression stocking and supportive brace are applied. Physical therapy is started at 2 to 3 weeks after surgery, and sports activities are permitted to begin 6 weeks postoperatively.

Results and complications

Since the 1980s, Ferkel has operated on numerous patients with pain in the anterolateral gutter of the ankle after an inversion stress injury. Initially, the results were analyzed in 30 patients with longer follow-up. The average patient age was 34 years, and average follow-up was 34 months. All patients had tenderness over the anterolateral corner of the talar dome and the lateral gutter. All patients had a history of a previous sprain, with an average interval of 24 months from injury to surgery. In every case, the patients had failed a complete course of conservative management, including nonsteroidal antiinflammatories (100%), physical therapy (100%), bracing (75%), casting (50%), and steroid injection (62%). Radiograph findings were normal in 50% of the patients; others had mild spurs, calcification, and joint space narrowing. Stress radiograph films of all patients showed no evidence of chronic ligamentous instability. MRI revealed synovial thickening consistent with soft tissue impingement in the anterolateral gutter.

At the time of surgery, all patients had synovitis and fibrosis of the anterolateral gutter, and some patients showed chondromalacia of the talus and fibula. In some patients, a thick band of tissue could be identified and excised, which probably corresponded to the meniscoid lesion Wolin described. Postoperative assessment found 84% of the patients rated good to excellent. Since then, numerous patients have been treated, with similar findings and results. Other authors have also found similar results with arthroscopic treatment of anterolateral soft tissue impingement.

Liu and Mirzayan initially reported a case of chronic posteromedial impingement after a lateral ankle injury that resulted in soft tissue impingement between the medial talus and tibial plafond. Medial impingement is believed to be predominately associated with lateral ankle instability, with secondary pathologic contact of medial structures. Since then, several authors have reported on small series of patients, showing promising results in most patients. An additional detailed review of evaluation and treatment of posterior ankle impingement is presented in the prone arthroscopy section.

Ogilvie-Harris and others have shown a significant improvement with arthroscopically treated syndesmotic injuries. Operative intervention requires a careful assessment of the soft tissue envelope, especially in grade III sprains with the potential for compartment syndrome. The surgeon is advised to assess the preoperative neurovascular status and be cognizant of complex regional pain syndromes occasionally associated with high-energy ankle sprains. Ankle stiffness, hardware loosening or breakage, loss of reduction, fibular stress fracture, and arthrosis are all possible complications.

Signs and symptoms

Loose bodies in the ankle joint can cause symptoms of catching and locking, with resultant pain, swelling, and limitation of range of motion. Symptoms may be intermittent because a loose body can become fixed in the synovial lining, therefore being asymptomatic until it is loosened and enters the ankle joint. The physical examination is generally unrevealing. Often, it is difficult to detect a specific area of tenderness. Rarely is a loose body palpable. It is important to rule out extraarticular pathology, which may mimic a loose body in the ankle joint.

Diagnostic evaluation

Patients being evaluated for loose bodies and osteophytes should have weight-bearing AP, lateral, and mortise views of the ankle. Sometimes the lateral x-ray should be done in maximum dorsiflexion to detect bony impingement. The subtalar joint should also be carefully evaluated.

Scranton and McDermott, in 1992, proposed a radiographic classification system for anterior ankle osteophytes, based on the size of the anterior tibial osteophyte, the association with a talar osteophyte, and the presence of generalized degenerative changes in the ankle joint ( Table 39-5 ). In 1997, van Dijk et al developed a classification of osteoarthritis changes of the ankle joint that is commonly used to describe x-ray changes of degenerative joint disease on patients’ x-rays ( Table 39-6 ).

Although plain radiographs generally reveal the presence of an osseous loose body, chondral loose bodies are not visible on plain radiograph examination ( Fig. 39-39 ). The CT arthrogram can effectively reveal the presence of chondral loose bodies, particularly in the presence of synovial chondromatosis.

MRI appears to be the study of choice for revealing chondral lesions not otherwise visible on plain radiographs. Gadolinium used with the MRI helps to detect cartilage injury and chondral loose bodies. Therefore, a combination of diagnostic tests, including radiographs and CT or MRI scans should be used to effectively diagnose the presence and origin of the loose bodies preoperatively. Weight-bearing CT scans can be particularly helpful in evaluating loose bodies, osteophytes, osteochondral lesions, and numerous other conditions of the foot and ankle. Preoperative imaging should also be carefully studied to identify the source of the loose body (e.g., OLT). It is critically important to determine the general location of the loose body, whether it is intraarticular, intracapsular, or extraarticular, as part of the preoperative planning. This will aide in intraoperative localization of the lesion.

Osteophyte resection

Preoperative radiographic assessment determines the amount and location of osteophyte resection. The goal of anterior osteophyte excision should be to restore the normal 60-degree angle between the distal tibia and talar neck. Positioning, equipment, instrumentation, distraction, and anesthesia were discussed previously for ankle arthroscopy. Ankle distraction can limit visualization of the anterior joint, particularly the superior and inferior confines of the osteophyte. Distraction should be decreased if this occurs.

It is not imperative to completely resect both the talar and tibial osteophytes. As the talar lesion is typically more medial while the tibial osteophyte is more lateral, it is not always necessary to fully resect both lesions because they may not impinge. In addition, many of the talar osteophytes may be extraarticular. With that in mind, the authors recommend only safely resecting enough talar osteophyte to avoid any impingement and enough tibial osteophyte to restore the 60-degree angle.

Results and complications

Martin et al have suggested that patients with isolated osteophytes are more amenable to arthroscopic debridement than those with more diffuse disease. There have been several reports of good outcomes after arthroscopic resection for anterior osteophyte impingement, although outcomes have been correlated with the degree of arthritic joint changes. Patients undergoing arthroscopic excision recover faster compared with open excision. van Dijk et al studied 62 patients with ankle arthroscopy and found 90% of the patients had good and excellent results if they did not have joint space narrowing on their x-rays, while only 50% had good and excellent results if they had joint space narrowing. They felt that the stage of osteoarthritis was a better prognostic indicator to determine outcome than the size and location of spurs. Arthroscopic osteophyte excision may prove to be a challenging procedure, especially in cases of large anterior and posterior osteophytes. It is imperative that the surgeon has a thorough understanding of the ankle anatomy and that the location of the osteophyte is determined preoperatively.