Anterior Ankle Impingement

Painful ankle dorsiflexion due to impingement of bone and/or soft tissue in the anterior ankle joint

Loss of ankle dorsiflexion due to anterior tibiotalar spurs

Physical examination is consistent with anterior ankle joint swelling, anterior ankle joint tenderness to palpation, and pain with forced dorsiflexion of the ankle. Passive ankle dorsiflexion may be restricted secondary to a bony block. Crepitus may be present with passive and active ankle range of motion (ROM).

Lateral weight-bearing radiographs will often demonstrate tibial and corresponding talar spur(s). Loose bodies and nondisplaced fractures of the spurs may be noted in the anterior ankle gutter ( Fig 50.1A ).

• Magnetic resonance imaging (MRI) will show anterior ankle effusion and synovitis as well as osteophytes ( Fig. 50.1B ). Hypertrophied Bassett’s ligament may be noted ( Fig 50.1C ).

• Osteochondral cysts and cartilage lesions may be noted throughout the ankle joint, indicating more severe disease and a worse long-term prognosis.

Computed tomography (CT) will show size and location of spurs that may affect portal placement, as well as subchondral cyst and sclerotic bone formation in the ankle joint and possibly in adjacent joints as well.

A positron emission tomography scan can be useful.

The superficial and deep peroneal nerves and saphenous nerve are at risk with incisions and portal placement ( Fig 50.2 ).

The dorsolateral branch of the superficial peroneal nerve is often at risk with the anterolateral portal. It can often be visualized with traction on the fourth toe ( Fig 50.3 ).

The saphenous nerve runs along the anterior aspect of the medial gutter and is at risk with the anteromedial portal.

The tibialis anterior serves as a landmark for the anteromedial incision or portal placement.

The peroneus tertius or the extensor digitorum longus (EDL) serves as a landmark for the anterolateral incision or portal placement.

The patient is positioned supine with a bump under the hip to place the foot into a neutral rotation. A sterile bump is placed under the posterior ankle for stability and to raise the leg for ease of intraoperative fluoroscopy.

A thigh tourniquet is applied prior to prepping and draping.

If arthroscopy is to be performed, a well-padded well-leg holder is utilized to keep the hip and knee flexed and provide resistance to a sterile ankle traction apparatus.

A C-arm may be positioned for lateral imaging ( Fig 50.4 ).