Michael Hughes MD
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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?
Ankle arthropscopy with synovial debridement
Open Brostrom ligament repair with Gould modification
Chrisman-Snook tendon transfer
Syndesmosis reduction and screw fixation
Ankle arthroscopy with loose body removal
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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.
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.
Ferkel RD, Tyorkin M, Applegate GR, Heinen GT.
Foot Ankle Int. 2010 Aug;31(8):655-61. PMID: 20727312 (Link to Abstract)
Ferkel, FAI 2010
Ferkel RD, Karzel RP, Del Pizzo W, Friedman MJ, Fischer SP.
Am J Sports Med. 1991 Sep-Oct;19(5):440-6. PMID: 1962707 (Link to Abstract)
Ferkel, AJSM 1991
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The current body of available evidence supports the use of ankle arthroscopy for all of the following indications EXCEPT:
Debridement of diffuse degenerative ankle cartilage
Anterior ankle impingement
Loose body removal
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.
Glazebrook MA, Ganapathy V, Bridge MA, Stone JW, Allard JP.
Arthroscopy. 2009 Dec;25(12):1478-90. PMID: 19962076 (Link to Abstract)
Glazebrook, ASCOPY 2009
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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 operative treatment?
Arthroscopic chondral drilling
Arthroscopic tibial debridement
Modified Brostrom procedure
Arthroscopic os trigonum excision
Arthroscopic tibiotalar arthrodesis
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.
Talusan et al in their review article note that conservative management including physical therapy, strengthening exercises, activity modification, bracing, and anti-inflammatory medication should be initial treatment. The group also notes that most patients despite an arthroscopic debridement still require an open approach.
Holt ES, Hansen ST, Mayo KA, Sangeorzan BJ.
Clin Orthop Relat Res. 1991 Jul;(268):21-8. PMID: 2060210 (Link to Abstract)
Holt, CORR 1991
Monroe MT, Beals TC, Manoli A 2nd.
Foot Ankle Int. 1999 Apr;20(4):227-31. PMID: 10229278 (Link to Abstract)
Monroe, FAI 1999
Dennis DA, Clayton ML, Wong DA, Mack RP, Susman MH.
Clin Orthop Relat Res. 1990 Apr;(253):212-20. PMID: 2317977 (Link to Abstract)
Dennis, CORR 1990
Talusan PG, Toy J, Perez JL, Milewski MD, Reach JS Jr.
J Am Acad Orthop Surg. 2014 May;22(5):333-9. PMID: 24788449 (Link to Abstract)
Talusan, JAAOS 2014
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