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Introduction
  • Most often caused by osteophyte impingement in anterior tibiotalar joint
  • can also be caused by excessive anterolateral soft tissues  or posterior soft tissue or osseous abnormalities
  • Epidemiology
    • common in athletes who play on turf or on grass including
      • rugby
      • football
      • dancers
      • soccer
  • Mechanism
    • repetitive overuse injuries
    • trauma
    • degenerative sequelae
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 injury during tibiotalar spur removal
 

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Questions (3)

(OBQ12.194) A 34-year-old active duty military officer has lateral right ankle pain with running during physical training that is worsening over the past 6 months. He recalls sustaining an ankle sprain 3 years ago that resolved with physical therapy. On examination the skin is intact and the talar drawer test is normal. He has pain anterolaterally with end-arc passive dorsiflexion and no pain posteriorly with passive plantarflexion. He has no tenderness on palpation at the distal fibula, anterior talofibular ligament, calcaneofibular ligament. An axial MR arthrogram of the ankle is shown in Figure A. What is the next most appropriate step in management following recalcitrant pain despite conservative management? Review Topic

QID:4554
FIGURES:
1

Ankle arthropscopy with synovial debridement

56%

(1067/1912)

2

Open Brostrom ligament repair with Gould modification

17%

(328/1912)

3

Chrisman-Snook tendon transfer

4%

(86/1912)

4

Syndesmosis reduction and screw fixation

8%

(154/1912)

5

Ankle arthroscopy with loose body removal

14%

(267/1912)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The patient has a clinical presentation consistent with anterolateral ankle soft tissue impingement. Ankle arthroscopy with synovial debridement is indicated in cases recalcitrant to conservative management.

Ferkel et al. present a Level 4 study evaluating 24 patients who had an arthroscopic diagnosis of anterolateral soft tissue impingement. They then reviewed the MR images of the patients and found a 78.9% accuracy in diagnosing anterolateral soft tissue impingement.

Ferkel et al. also conducted a Level 4 study of 31 patients that underwent a partial synovectomy with debridement of scar tissue from the lateral gutter. They found that most patients had a good to excellent result at 2 year follow-up.

Figure A demonstrates anterolateral soft tissue as shown by the arrow. Illustration A demonstrates a normal ankle MR arthrogram with fluid anterior to the fibula. Illustration B is an arthroscopic images show synovitis and scarring in the anterolateral gutter (*) of the ankle. T = talus. Illustration C is a drawing depicting the common region for anterolateral ankle soft tissue impingement between the ATFL and anterior inferior tibiofibular ligaments.

Incorrect Answers:
Answer 2: A Brostrom repair and Gould modification is an anatomic shortening and reinsertion of the ATFL and CFL reinforced with the inferior extensor retinaculum and distal fibular periosteum
Answer 3: Chrisman-Snook procedure is a nonanatomic reconstruction using a split peroneus brevis tendon to reinforce the anterior talofibular and calcaneofibular ligaments.
Answer 4: Syndesmosis reduction and screw fixation is indicated in syndesmosis diastasis.
Answer 5: There is no loose body evident in this patient's presentation.

ILLUSTRATIONS:

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Question COMMENTS (3)

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

QID:584
1

Ankle arthrodesis

27%

(353/1328)

2

Debridement of diffuse degenerative ankle cartilage

70%

(936/1328)

3

Osteochondral lesions

1%

(7/1328)

4

Anterior ankle impingement

2%

(28/1328)

5

Loose body removal

0%

(3/1328)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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.

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(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? Review Topic

QID:1012
FIGURES:
1

Arthroscopic chondral drilling

1%

(20/1700)

2

Arthroscopic tibial debridement

92%

(1559/1700)

3

Modified Brostrom procedure

1%

(23/1700)

4

Arthroscopic os trigonum excision

5%

(90/1700)

5

Arthroscopic tibiotalar arthrodesis

0%

(4/1700)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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.

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EVIDENCE & REFERENCES (11)
Topic COMMENTS (6)