Tibiotalar Impingement

Introduction

Caused by osteophyte impingement in anterior tibiotalar joint
Epidemiology
- common in athletes who play on turf or on grass including
  - rugby
  - football
  - dancers
  - soccer
Mechanism
- repetitive overuse injuries
- trauma
- degenerative sequlae

Presentation

Symptoms
- pain in anterior ankle
Physical exam
- pain with forced dorsiflexion
- limited dorsiflexion
- soft tissue swelling and effusion may be evident
- subtalar joint is pain free

Imaging

Radiographs
- recommended views
  - AP, lateral, and oblique
- findings
  - spurs seen in anterior distal tibia or dorsal aspect of the talus
  - oblique views are beneficial in revealing anteromedial talar spurs
CT
- delineates extent of bony osteophytes
MRI
- shows spurring and fluid in joint

Treatment

Nonoperative
- therapy, lifestyle modifications, NSAIDS
  - indications
    - first line of treatment
Operative
- arthroscopic excision
  - indications
    - nonoperative modalities fail

Techniques

Arthroscopic excision
- supine position with external traction device and leg over a padded bump
- use knife to only cut the skin and use hemostat to spread to avoid neurovascular injury while making portals
- ensure adequate field of view prior to burring or shaving anterior distal tibia to avoid iatrogenic dorsal NV bundle injury

Complications

Superficial peroneal nerve injury during anterolateral portal creation
Saphenous vein injury during anteromedial portal creation
Dorsal neurovascular bundle during tibiotalar spur removal

TAG

(OBQ08.198) The current body of available evidence supports the use of ankle arthroscopy for all of the following indications EXCEPT: Topic

Review Topic

1. Ankle arthrodesis
2. Debridement of diffuse degenerative ankle cartilage
3. Osteochondral lesions
4. Anterior ankle impingement
5. Loose body removal

PREFERRED RESPONSE ▶

DISCUSSION: Ankle arthroscopy has evolving indications, but the referenced study by Glazebrook et al found fair evidence-based literature to support a recommendation for the use of ankle arthroscopy for the treatment of osteochondral lesions and for ankle arthrodesis. Arthroscopy is also indicated in anterior ankle impingement as shown in the preoperative and postoperative radiographs shown in Illustration A and B. Ankle arthroscopy for ankle instability, septic arthritis, arthrofibrosis, and removal of loose bodies was supported with only limited evidence. Treatment of ankle arthritis, excluding isolated bony impingement, was not effective and therefore this indication was not recommended.

Illustrations: A

REFERENCES:

1. Glazebrook MA, Ganapathy V, Bridge MA, Stone JW, Allard JP. Evidence-based indications for ankle arthroscopy. Arthroscopy. 2009 Dec;25(12):1478-90. PMID:19962076 (Link to Abstract)

Question Authors:

Ben Taylor MD, John Badylak MD,

Please Rate Educational Value!

2.0

Average 2.0 of 29 Ratings

TAG

(OBQ05.126) A 28-year-old rugby player has had anterior ankle pain for several years. On physical exam he has painful and limited dorsiflexion of the ankle. Based on a dorsiflexed ankle radiograph shown in figure A, what is the most appropriate treatment? Topic

Review Topic

FIGURES: A

1. Arthroscopic chondral drilling
2. Arthroscopic tibial debridement
3. Modified Brostrom procedure
4. Arthroscopic os trigonum excision
5. Arthroscopic tibiotalar arthrodesis

PREFERRED RESPONSE ▶

DISCUSSION: The exam and xrays reveal tibiotalar anterior impingement without subtalar involvement. Tibiotalar impingement during dorsiflexion with concomitant mild arthritis can be treated with anterior ankle cheilectomy/debridement (arthroscopic or open). Ankle arthrodesis with cancellous screws remains the gold standard for surgical treatment of more severe ankle arthritis . Ankle arthroplasty is another option however it is technically demanding with potential complications. Illustration A shows a radiograph following arthroscopic anterior tibiotalar debridement.

Level 4 evidence from Monroe et al found a 93% rate of tibiotalar fusion using cancellous screws for fixation. Holt et al also found a 93% rate of fusion in low risk patients and 74% fusion rate overall. Similarly, Dennis et al found a 94% rate of fusion using cancellous screws for internal fixation.

Illustrations: A

REFERENCES:

1. Holt ES, Hansen ST, Mayo KA, Sangeorzan BJ. Ankle arthrodesis using internal screw fixation. Clin Orthop Relat Res. 1991 Jul;(268):21-8. PMID:2060210 (Link to Abstract)

2. Monroe MT, Beals TC, Manoli A 2nd. Clinical outcome of arthrodesis of the ankle using rigid internal fixation with cancellous screws. Foot Ankle Int. 1999 Apr;20(4):227-31. PMID:10229278 (Link to Abstract)

3. Dennis DA, Clayton ML, Wong DA, Mack RP, Susman MH. Internal fixation compression arthrodesis of the ankle. Clin Orthop Relat Res. 1990 Apr;(253):212-20. PMID:2317977 (Link to Abstract)

Question Authors:

Michael Hughes MD, Derek Moore, Patrick McCulloch MD,

Please Rate Educational Value!

3.0

Average 3.0 of 11 Ratings

Level of Evidence 4 (Case Series)

Holt ES, Hansen ST, Mayo KA, Sangeorzan BJ. Ankle arthrodesis using internal screw fixation. Clin Orthop Relat Res. 1991 Jul;(268):21-8. PMID:2060210 (Link to Abstract)
Monroe MT, Beals TC, Manoli A 2nd. Clinical outcome of arthrodesis of the ankle using rigid internal fixation with cancellous screws. Foot Ankle Int. 1999 Apr;20(4):227-31. PMID:10229278 (Link to Abstract)
Dennis DA, Clayton ML, Wong DA, Mack RP, Susman MH. Internal fixation compression arthrodesis of the ankle. Clin Orthop Relat Res. 1990 Apr;(253):212-20. PMID:2317977 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Glazebrook MA, Ganapathy V, Bridge MA, Stone JW, Allard JP. Evidence-based indications for ankle arthroscopy. Arthroscopy. 2009 Dec;25(12):1478-90. PMID:19962076 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Qbank (2 Questions)

Question Comments

Question Comments

Groups

Evidence & References Show References

Topic Comments