585525
research-article2015
FAIXXX10.1177/1071100715585525Foot & Ankle InternationalOdak et al
Article
Arthroscopic Evaluation of Impingement and Osteochondral Lesions in Chronic Lateral Ankle Instability
Foot & Ankle International® 2015, Vol. 36(9) 1045–1049 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100715585525 fai.sagepub.com
Saurabh Odak, MBBS, MRCS1, Raju Ahluwalia, MBChB, FRCS2, Deepak G. Shivarathre, MBBS, FRCS (Orth)3, Atif Mahmood, MBBS, MRCS1, Nicola Blucher, MBChB, MRCS1, Michael Hennessy, BSc, MBChB, FRCS1, and Simon Platt, MBChB, FRCS (Tr and Orth)1
Abstract Background: Anterolateral impingement associated with intra-articular synovitis, scarring, and fibrosis is a less recognized feature in patients with chronic lateral ankle instability. The aim of our study was to ascertain the incidence of intra-articular synovitis, osteochondral lesions (OCLs), impingement lesions (both intra- and extra-articular), and other associated pathologies in patients undergoing modified Broström-Gould ankle ligament reconstruction. Methods: We performed a retrospective review of all patients who underwent arthroscopically assisted modified Broström-Gould ankle ligament reconstruction for symptomatic recurrent ankle instability. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Ankle arthroscopy was performed prior to reconstruction in all patients. Data were obtained from clinical and radiological records including magnetic resonance imaging scans. Arthroscopic findings were recorded in detail intraoperatively. A total of 100 patients (53 females and 47 males) with an average age of 37 years (range, 15-65 years) were reviewed over a 10-year period. Results: Sixty-three patients (63%) had intra-articular synovitis mostly in the anterior and/or anterolateral compartment, which required arthroscopic debridement. Seventeen patients (17%) were found to have OCLs, and 12 (12%) patients had anterior bony impingement lesions. Conclusion: This study found a high incidence of anterior/anterolateral synovitis in patients with chronic lateral ankle instability. However, there was a relatively low incidence of anterior bony impingement lesions or OCLs in our series. Level of Evidence: Level IV, retrospective case series. Keywords: chronic lateral ankle instability, impingement, osteochondral lesions, Broström, ankle arthroscopy Lateral ligament injuries of the ankle are relatively common.1,8 The majority of these patients can be treated nonoperatively with early protected weightbearing, rest, and functional rehabilitation with satisfactory outcomes.14 However, 10% to 20% of these patients develop chronic instability, affecting their ability to participate in sports and recreational activities with possible early-onset ankle osteoarthritis.8,14,20 Operative reconstruction of the lateral ligament complex has been reported to provide satisfactory long-term outcomes.3,12,13,16 Along with lateral ligament complex insufficiency, several other secondary lesions like osteochondral lesions (OCLs), intra-articular synovitis, loose bodies, and impingement lesions have also been described in these patients.7,11,14,15,17 These secondary pathologies could not only account for some of the symptoms but also affect the outcomes following surgery for lateral ligament
insufficiency.17-19 Thus, an understanding of these associated pathologies is important to correlate the clinical findings, plan the treatment, and prognosticate the operative outcomes in these patients. We performed a retrospective review to assess the incidence of these secondary lesions in all patients who underwent ankle arthroscopy followed by modified Broström-Gould ankle ligament reconstruction and compare our results with those in the current literature. 1
Arrowe Park Hospital, Upton, UK Kings’s College London, London, UK 3 Royal Liverpool University Hospital, Liverpool, UK 2
Corresponding Author: Saurabh Odak, MBBS, MRCS, Arrowe Park Hospital, Arrowe Park Road, Wirral, Merseyside CH49 5PE, UK Email: [email protected]
Downloaded from fai.sagepub.com at UNIVERSITE DE MONTREAL on September 4, 2015
1046
Foot & Ankle International 36(9)
Methods
Table 1. Preoperative MRI Findings.
Patients with chronic lateral ligament complex injuries of the ankle who underwent modified Broström-Gould ankle ligament reconstruction over a period of 10 years from 2003 to 2013 were included in this retrospective study. Patients with inflammatory arthropathy, those who had undergone previous ankle surgery, or those who underwent revision procedures were excluded. All the patients were assessed by the senior authors (M.H., S.P.) preoperatively. Standard weightbearing anteroposterior, lateral, and mortise view radiographs of the ankle were taken. Magnetic resonance imaging (MRI) scans were obtained in 84 of 100 patients to rule out associated pathologies. Once diagnosed, all the patients underwent a course of functional ankle rehabilitation under the supervision of a specialist physical therapist. Operative intervention was offered to those patients when conservative measures failed to relieve the symptoms. Intraoperatively, all the patients underwent examination of the affected ankle under anesthesia, followed by ankle arthroscopy. Intra-articular pathologies such as synovitis, OCLs, and loose bodies were recorded, and additional procedures including synovial debridement, debridement of bony exostoses, and microfracture were undertaken simultaneously. This was followed by modified Broström-Gould ankle ligament reconstruction.2,9 Intra-articular synovitis was defined as inflammation of the synovial lining with scarring and fibrosis. Intra-articular impingement was defined as impingement secondary to the presence of scarring and fibrosis, whereas bony impingement was defined as impingement due to extra-articular exostoses or bony spurs. Postoperatively, all the patients underwent a regimen of physical therapy, based on the unit’s agreed protocol. A total of 100 patients (53 females, 47 males) with an average age of 37 years (range, 15-65 years) were assessed over the study period. The average duration between the onset of symptoms and operative intervention was 9 months (range, 3-18 months). The average duration of follow-up was 25 months (range, 12-48 months). Preoperative MRI was performed in 84 patients. There were 16 patients in whom a preoperative MRI scan could not be obtained. All these were taken during the initial phase of the study period. This was for 2 reasons: first, these patients had frank symptoms of instability at the time of presentation, and second, there was difficulty in acquiring a timely scan due to limited availability. In these 16 patients, although no preoperative MRI was performed, they all underwent an intraoperative examination under anesthesia with an image intensifier. Subsequently, due to the easier availability of the MRI scans, all the patients underwent preoperative scans.
Preoperative MRI Findings
Results
Two patients reported failure of lateral ligament reconstruction, requiring revision procedures. Eight patients developed postoperative pain. Of these, 1 patient was diagnosed with complex regional pain syndrome (CRPS) type I, 1
Preoperative radiographs revealed bony exostoses on the distal anterior tibial margin in 12 patients and on the dorsal
Rupture of the ATFL Sprain of the ATFL Rupture of the CFL Sprain of the CFL Presence of an OCL OCL in the medial talar dome OCL in the lateral talar dome OCL in the posteromedial talar dome OCL in the anterior tibial plafond OCL in the central tibial plafond Peroneus longus/brevis split/ degeneration/tendinosis Tibialis posterior tendinopathy Tendo Achilles tendinopathy Presence of loose bodies Osteoarthritis of the subtalar joint
No. of Patients 45 10 23 5 16 9 4 1 1 1 13 5 3 1 1
ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; MRI, magnetic resonance imaging; OCL, osteochondral lesion.
surface of the talus in 1 patient. However, the distribution and severity of the impingement lesions and intra-articular synovitis were not different in these patients when compared to the rest of the patient population. Table 1 illustrates the preoperative MRI findings (84 patients). We found that MRI scans were very sensitive in the identification of OCLs, with a sensitivity of 94%; however, the sensitivity for anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) lesions was very low (68% and 39%, respectively) (Figures 1 and 2). Table 2 illustrates intraoperative arthroscopic findings. Sixty-three patients were noted to have intra-articular synovitis (Figures 3 and 4). In 43% of patients, synovitis was localized in the anterior and/or anterolateral compartment of the tibiotalar joint. In the remaining 20%, the distribution was generalized. Seventeen (17%) patients had OCLs, which were almost equally distributed on the medial and lateral talar dome. Table 3 lists the operative interventions undertaken. As noted, all the patients underwent repair of the ATFL. Intraoperatively, the CFL was also explored, and when found to be absent or attenuated, a decision to repair the CFL was undertaken. A total of 72 patients also underwent reconstruction of the CFL along with the ATFL. Sixty-three patients underwent debridement for synovitis, and 4 patients underwent microfracture for OCLs.
Complications
Downloaded from fai.sagepub.com at UNIVERSITE DE MONTREAL on September 4, 2015
1047
Odak et al Table 2. Intraoperative Arthroscopic Findings. Intraoperative Arthroscopic Findings
No. of Patients
OCL OCL in the medial talar dome OCL in the lateral talar dome OCL in the posteromedial talar dome OCL in the anterior tibial plafond OCL in the central tibial plafond Intra-articular synovitis Loose bodies
17 9 8 0 1 1 63 1
OCL, osteochondral lesion.
Figure 1. Axial proton density image showing absence of the anterior talofibular ligament (arrow).
Figure 3. Arthroscopic intra-articular fibrosis and synovitis.
ankle pain. Of the 5 patients with ankle pain, 2 were reported to have both intra-articular synovitis and chondral lesions and 3 patients to have only synovitis affecting the anterolateral compartment based on the arthroscopic findings. All these 5 patients were treated conservatively with intra-articular steroid injections and analgesia. Two patients subsequently developed ankle osteoarthritis. Of these, 1 patient underwent arthroscopic ankle fusion 4 years after the primary repair; the other patient was treated conservatively.
Discussion Figure 2. Coronal proton density image showing absence of the calcaneofibular ligament (arrow).
patient presented with pain along the distribution of the sural nerve, and 1 patient presented along the distribution of the saphenous nerve. The other 5 patients complained of
Several methods have been described for operative reconstruction of lateral ligament insufficiency.2,4-6,12 Although the majority of patients achieve satisfactory outcomes both in the short and long term, about 13% to 35% of patients complain of persistent postoperative pain.1,16 The presence of secondary intra-articular pathologies, particularly OCLs, has been implicated to be the most important predictor in poor long-term outcomes in these patients.11 The incidence
Downloaded from fai.sagepub.com at UNIVERSITE DE MONTREAL on September 4, 2015
1048
Foot & Ankle International 36(9)
Figure 4. Another arthroscopic image of florid intra-articular synovitis and fibrosis. Table 3. Various Operative Interventions Undertaken. Operative Intervention Repair of the ATFL Repair of the CFL Arthroscopic debridement Arthroscopic excision of bony exostoses Microfracture Peroneus groove deepening Repair of the peroneal retinaculum Tubularization of peroneal tendons
No. of Patients 100 72 63 12 4 1 1 2
ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament.
of these secondary intra-articular lesions has been reported to be as high as 95% in some studies.17 Although the majority of the authors have previously reported on the incidence of OCLs, the incidence of other intra-articular pathologies including synovitis, scarring, and loose bodies has been variable.7,17 These intra-articular pathologies could also potentially affect the final outcomes. Nery et al16 reported no difference in the long-term outcome in patients with chondral lesions treated with microfracture when compared with patients without any chondral lesions. However, patients with soft tissue impingement had poorer outcomes.16 In one of the largest series published on the subject, Hinterman et al10 reported the incidence of intra-articular synovitis to be 32% and chondral lesions to be 55%. In our series, we noted a high incidence of intra-articular synovitis (63%). In 43% of patients, synovitis was localized in the anterior and/or anterolateral compartment of the tibiotalar joint. All these patients underwent arthroscopic debridement. In our series, the incidence of OCLs was relatively low (17%), and these were almost equally distributed
in the medial and lateral talar dome. Twenty-three percent (23%) of patients with OCLs (4/17) required microfracture. The incidence of anterior bony spurs causing bony impingement was also reported to be low (12%). We observed that all the patients who complained of persistent postoperative pain (n = 5) had intra-articular synovitis, whereas only 2 patients had any chondral lesions. The majority of our patients achieved satisfactory results following lateral ligament reconstruction. We noticed a high incidence of intra-articular synovitis in our patient population. This could be due to altered mechanics of a laterally deficient ankle. We believe that the restoration of lateral ankle stability could prevent the further progression of intra-articular impingement and synovitis; however, it is difficult to believe that it could spontaneously resolve. Several authors have also reported poor outcomes despite the restoration of lateral ankle stability in patients with preceding intra-articular lesions including OCLs and synovitis.16,17 Based on the findings of our study, one could argue to perform ankle arthroscopy prior to modified Broström-Gould ankle ligament reconstruction to address these secondary pathologies. The limitations of our study are that we did not report any objective outcome measures, which could have further strengthened our conclusions, and the average follow-up duration was relatively short.
Conclusion We conclude that the incidence of OCLs in our series was significantly lower (17%) than that previously published in the literature (up to 55% in some studies). However, in our series, there was a high incidence of intra-articular soft tissue impingement lesions and synovitis (63%). Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Ajis A, Younger AS, Maffulli N. Anatomic repair for chronic lateral ankle instability. Foot Ankle Clin. 2006;11(3): 539-545. 2. Broström L. Sprained ankles VI: surgical treatment of “chronic” ligament ruptures. Acta Chir Scand. 1966;132: 551-565. 3. Buerer Y, Winkler M, Burn A, Chopra S, Crevoisier X. Evaluation of a modified Brostrom-Gould procedure for treatment of chronic lateral ankle instability: a retrospective study
Downloaded from fai.sagepub.com at UNIVERSITE DE MONTREAL on September 4, 2015
1049
Odak et al with critical analysis of outcome scoring. Foot Ankle Surg. 2013;19(1):36-41. 4. Chrisman OD, Snook GA. Reconstruction of lateral ligament tears of the ankle: an experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Joint Surg. 1969;51-A:904-912. 5. Colville MR, Grondel RJ. Anatomic reconstruction of the lateral ankle ligaments using a split peroneus brevis tendon graft. Am J Sports Med. 1995;23:210-213. 6. Evans DL. Recurrent instability of the ankle: a method of surgical treatment. Proc R Soc Med. 1953;46:343-344. 7. Ferkel RD, Chams RN. Chronic lateral instability: arthroscopic findings and long-term results. Foot Ankle Int. 2007;28(1):24-31. 8. Garrick JG. The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. Am J Sports Med. 1977;5(6):241-242. 9. Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle. 1980;1(2):84-89. 10. Hintermann B, Boss A, Schafer D. Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med. 2002;30(3):402-409. 11. Hua Y, Chen S, Li Y, Chen J, Li H. Combination of modified Brostrom procedure with ankle arthroscopy for chronic ankle instability accompanied by intra-articular symptoms. Arthroscopy. 2010;26(4):524-528. 12. Karlsson J, Bergsten T, Lansinger O, Peterson L. Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg. 1988;70-A:581-588.
13. Karlsson J, Lansinger O. Lateral instability of the ankle joint. Clin Orthop Relat Res. 1992;276:253-261. 14. Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. 2007;2:CD000380. 15. Komenda GA, Ferkel RD. Arthroscopic findings associated with the unstable ankle. Foot Ankle Int. 1999;20(11): 708-713. 16. Nery C, Raduan F, Del Buono A, Asaumi ID, Cohen M, Maffulli N. Arthroscopic-assisted Brostrom-Gould for chronic ankle instability: a long-term follow-up. Am J Sports Med. 2011;39(11):2381-2388. 17. Okuda R, Kinoshita M, Morikawa J, Yasuda T, Abe M. Arthroscopic findings in chronic lateral ankle instability: do focal chondral lesions influence the results of ligament reconstruction? Am J Sports Med. 2005;33(1):35-42. 18. Sugimoto K, Takakura Y, Okahashi K, Samoto N, Kawata K, Iwai M. Chondral injuries of the ankle with recurrent lateral instability: an arthroscopic study. J Bone Joint Surg Am. 2009;91(1):99-106. 19. Taga I, Shino K, Inoue M, Nakata K, Maeda A. Articular cartilage lesions in ankles with lateral ligament injury: an arthroscopic study. Am J Sports Med. 1993;21(1):120-126. 20. Wikstrom EA, Hubbard-Turner T, McKeon PO. Under standing and treating lateral ankle sprains and their consequences: a constraints-based approach. Sports Med. 2013;46(3):385-393.
Downloaded from fai.sagepub.com at UNIVERSITE DE MONTREAL on September 4, 2015
research-article2015
FAIXXX10.1177/1071100715585525Foot & Ankle InternationalOdak et al
Article
Arthroscopic Evaluation of Impingement and Osteochondral Lesions in Chronic Lateral Ankle Instability
Foot & Ankle International® 2015, Vol. 36(9) 1045–1049 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100715585525 fai.sagepub.com
Saurabh Odak, MBBS, MRCS1, Raju Ahluwalia, MBChB, FRCS2, Deepak G. Shivarathre, MBBS, FRCS (Orth)3, Atif Mahmood, MBBS, MRCS1, Nicola Blucher, MBChB, MRCS1, Michael Hennessy, BSc, MBChB, FRCS1, and Simon Platt, MBChB, FRCS (Tr and Orth)1
Abstract Background: Anterolateral impingement associated with intra-articular synovitis, scarring, and fibrosis is a less recognized feature in patients with chronic lateral ankle instability. The aim of our study was to ascertain the incidence of intra-articular synovitis, osteochondral lesions (OCLs), impingement lesions (both intra- and extra-articular), and other associated pathologies in patients undergoing modified Broström-Gould ankle ligament reconstruction. Methods: We performed a retrospective review of all patients who underwent arthroscopically assisted modified Broström-Gould ankle ligament reconstruction for symptomatic recurrent ankle instability. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Ankle arthroscopy was performed prior to reconstruction in all patients. Data were obtained from clinical and radiological records including magnetic resonance imaging scans. Arthroscopic findings were recorded in detail intraoperatively. A total of 100 patients (53 females and 47 males) with an average age of 37 years (range, 15-65 years) were reviewed over a 10-year period. Results: Sixty-three patients (63%) had intra-articular synovitis mostly in the anterior and/or anterolateral compartment, which required arthroscopic debridement. Seventeen patients (17%) were found to have OCLs, and 12 (12%) patients had anterior bony impingement lesions. Conclusion: This study found a high incidence of anterior/anterolateral synovitis in patients with chronic lateral ankle instability. However, there was a relatively low incidence of anterior bony impingement lesions or OCLs in our series. Level of Evidence: Level IV, retrospective case series. Keywords: chronic lateral ankle instability, impingement, osteochondral lesions, Broström, ankle arthroscopy Lateral ligament injuries of the ankle are relatively common.1,8 The majority of these patients can be treated nonoperatively with early protected weightbearing, rest, and functional rehabilitation with satisfactory outcomes.14 However, 10% to 20% of these patients develop chronic instability, affecting their ability to participate in sports and recreational activities with possible early-onset ankle osteoarthritis.8,14,20 Operative reconstruction of the lateral ligament complex has been reported to provide satisfactory long-term outcomes.3,12,13,16 Along with lateral ligament complex insufficiency, several other secondary lesions like osteochondral lesions (OCLs), intra-articular synovitis, loose bodies, and impingement lesions have also been described in these patients.7,11,14,15,17 These secondary pathologies could not only account for some of the symptoms but also affect the outcomes following surgery for lateral ligament
insufficiency.17-19 Thus, an understanding of these associated pathologies is important to correlate the clinical findings, plan the treatment, and prognosticate the operative outcomes in these patients. We performed a retrospective review to assess the incidence of these secondary lesions in all patients who underwent ankle arthroscopy followed by modified Broström-Gould ankle ligament reconstruction and compare our results with those in the current literature. 1
Arrowe Park Hospital, Upton, UK Kings’s College London, London, UK 3 Royal Liverpool University Hospital, Liverpool, UK 2
Corresponding Author: Saurabh Odak, MBBS, MRCS, Arrowe Park Hospital, Arrowe Park Road, Wirral, Merseyside CH49 5PE, UK Email: [email protected]
Downloaded from fai.sagepub.com at UNIVERSITE DE MONTREAL on September 4, 2015
1046
Foot & Ankle International 36(9)
Methods
Table 1. Preoperative MRI Findings.
Patients with chronic lateral ligament complex injuries of the ankle who underwent modified Broström-Gould ankle ligament reconstruction over a period of 10 years from 2003 to 2013 were included in this retrospective study. Patients with inflammatory arthropathy, those who had undergone previous ankle surgery, or those who underwent revision procedures were excluded. All the patients were assessed by the senior authors (M.H., S.P.) preoperatively. Standard weightbearing anteroposterior, lateral, and mortise view radiographs of the ankle were taken. Magnetic resonance imaging (MRI) scans were obtained in 84 of 100 patients to rule out associated pathologies. Once diagnosed, all the patients underwent a course of functional ankle rehabilitation under the supervision of a specialist physical therapist. Operative intervention was offered to those patients when conservative measures failed to relieve the symptoms. Intraoperatively, all the patients underwent examination of the affected ankle under anesthesia, followed by ankle arthroscopy. Intra-articular pathologies such as synovitis, OCLs, and loose bodies were recorded, and additional procedures including synovial debridement, debridement of bony exostoses, and microfracture were undertaken simultaneously. This was followed by modified Broström-Gould ankle ligament reconstruction.2,9 Intra-articular synovitis was defined as inflammation of the synovial lining with scarring and fibrosis. Intra-articular impingement was defined as impingement secondary to the presence of scarring and fibrosis, whereas bony impingement was defined as impingement due to extra-articular exostoses or bony spurs. Postoperatively, all the patients underwent a regimen of physical therapy, based on the unit’s agreed protocol. A total of 100 patients (53 females, 47 males) with an average age of 37 years (range, 15-65 years) were assessed over the study period. The average duration between the onset of symptoms and operative intervention was 9 months (range, 3-18 months). The average duration of follow-up was 25 months (range, 12-48 months). Preoperative MRI was performed in 84 patients. There were 16 patients in whom a preoperative MRI scan could not be obtained. All these were taken during the initial phase of the study period. This was for 2 reasons: first, these patients had frank symptoms of instability at the time of presentation, and second, there was difficulty in acquiring a timely scan due to limited availability. In these 16 patients, although no preoperative MRI was performed, they all underwent an intraoperative examination under anesthesia with an image intensifier. Subsequently, due to the easier availability of the MRI scans, all the patients underwent preoperative scans.
Preoperative MRI Findings
Results
Two patients reported failure of lateral ligament reconstruction, requiring revision procedures. Eight patients developed postoperative pain. Of these, 1 patient was diagnosed with complex regional pain syndrome (CRPS) type I, 1
Preoperative radiographs revealed bony exostoses on the distal anterior tibial margin in 12 patients and on the dorsal
Rupture of the ATFL Sprain of the ATFL Rupture of the CFL Sprain of the CFL Presence of an OCL OCL in the medial talar dome OCL in the lateral talar dome OCL in the posteromedial talar dome OCL in the anterior tibial plafond OCL in the central tibial plafond Peroneus longus/brevis split/ degeneration/tendinosis Tibialis posterior tendinopathy Tendo Achilles tendinopathy Presence of loose bodies Osteoarthritis of the subtalar joint
No. of Patients 45 10 23 5 16 9 4 1 1 1 13 5 3 1 1
ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; MRI, magnetic resonance imaging; OCL, osteochondral lesion.
surface of the talus in 1 patient. However, the distribution and severity of the impingement lesions and intra-articular synovitis were not different in these patients when compared to the rest of the patient population. Table 1 illustrates the preoperative MRI findings (84 patients). We found that MRI scans were very sensitive in the identification of OCLs, with a sensitivity of 94%; however, the sensitivity for anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) lesions was very low (68% and 39%, respectively) (Figures 1 and 2). Table 2 illustrates intraoperative arthroscopic findings. Sixty-three patients were noted to have intra-articular synovitis (Figures 3 and 4). In 43% of patients, synovitis was localized in the anterior and/or anterolateral compartment of the tibiotalar joint. In the remaining 20%, the distribution was generalized. Seventeen (17%) patients had OCLs, which were almost equally distributed on the medial and lateral talar dome. Table 3 lists the operative interventions undertaken. As noted, all the patients underwent repair of the ATFL. Intraoperatively, the CFL was also explored, and when found to be absent or attenuated, a decision to repair the CFL was undertaken. A total of 72 patients also underwent reconstruction of the CFL along with the ATFL. Sixty-three patients underwent debridement for synovitis, and 4 patients underwent microfracture for OCLs.
Complications
Downloaded from fai.sagepub.com at UNIVERSITE DE MONTREAL on September 4, 2015
1047
Odak et al Table 2. Intraoperative Arthroscopic Findings. Intraoperative Arthroscopic Findings
No. of Patients
OCL OCL in the medial talar dome OCL in the lateral talar dome OCL in the posteromedial talar dome OCL in the anterior tibial plafond OCL in the central tibial plafond Intra-articular synovitis Loose bodies
17 9 8 0 1 1 63 1
OCL, osteochondral lesion.
Figure 1. Axial proton density image showing absence of the anterior talofibular ligament (arrow).
Figure 3. Arthroscopic intra-articular fibrosis and synovitis.
ankle pain. Of the 5 patients with ankle pain, 2 were reported to have both intra-articular synovitis and chondral lesions and 3 patients to have only synovitis affecting the anterolateral compartment based on the arthroscopic findings. All these 5 patients were treated conservatively with intra-articular steroid injections and analgesia. Two patients subsequently developed ankle osteoarthritis. Of these, 1 patient underwent arthroscopic ankle fusion 4 years after the primary repair; the other patient was treated conservatively.
Discussion Figure 2. Coronal proton density image showing absence of the calcaneofibular ligament (arrow).
patient presented with pain along the distribution of the sural nerve, and 1 patient presented along the distribution of the saphenous nerve. The other 5 patients complained of
Several methods have been described for operative reconstruction of lateral ligament insufficiency.2,4-6,12 Although the majority of patients achieve satisfactory outcomes both in the short and long term, about 13% to 35% of patients complain of persistent postoperative pain.1,16 The presence of secondary intra-articular pathologies, particularly OCLs, has been implicated to be the most important predictor in poor long-term outcomes in these patients.11 The incidence
Downloaded from fai.sagepub.com at UNIVERSITE DE MONTREAL on September 4, 2015
1048
Foot & Ankle International 36(9)
Figure 4. Another arthroscopic image of florid intra-articular synovitis and fibrosis. Table 3. Various Operative Interventions Undertaken. Operative Intervention Repair of the ATFL Repair of the CFL Arthroscopic debridement Arthroscopic excision of bony exostoses Microfracture Peroneus groove deepening Repair of the peroneal retinaculum Tubularization of peroneal tendons
No. of Patients 100 72 63 12 4 1 1 2
ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament.
of these secondary intra-articular lesions has been reported to be as high as 95% in some studies.17 Although the majority of the authors have previously reported on the incidence of OCLs, the incidence of other intra-articular pathologies including synovitis, scarring, and loose bodies has been variable.7,17 These intra-articular pathologies could also potentially affect the final outcomes. Nery et al16 reported no difference in the long-term outcome in patients with chondral lesions treated with microfracture when compared with patients without any chondral lesions. However, patients with soft tissue impingement had poorer outcomes.16 In one of the largest series published on the subject, Hinterman et al10 reported the incidence of intra-articular synovitis to be 32% and chondral lesions to be 55%. In our series, we noted a high incidence of intra-articular synovitis (63%). In 43% of patients, synovitis was localized in the anterior and/or anterolateral compartment of the tibiotalar joint. All these patients underwent arthroscopic debridement. In our series, the incidence of OCLs was relatively low (17%), and these were almost equally distributed
in the medial and lateral talar dome. Twenty-three percent (23%) of patients with OCLs (4/17) required microfracture. The incidence of anterior bony spurs causing bony impingement was also reported to be low (12%). We observed that all the patients who complained of persistent postoperative pain (n = 5) had intra-articular synovitis, whereas only 2 patients had any chondral lesions. The majority of our patients achieved satisfactory results following lateral ligament reconstruction. We noticed a high incidence of intra-articular synovitis in our patient population. This could be due to altered mechanics of a laterally deficient ankle. We believe that the restoration of lateral ankle stability could prevent the further progression of intra-articular impingement and synovitis; however, it is difficult to believe that it could spontaneously resolve. Several authors have also reported poor outcomes despite the restoration of lateral ankle stability in patients with preceding intra-articular lesions including OCLs and synovitis.16,17 Based on the findings of our study, one could argue to perform ankle arthroscopy prior to modified Broström-Gould ankle ligament reconstruction to address these secondary pathologies. The limitations of our study are that we did not report any objective outcome measures, which could have further strengthened our conclusions, and the average follow-up duration was relatively short.
Conclusion We conclude that the incidence of OCLs in our series was significantly lower (17%) than that previously published in the literature (up to 55% in some studies). However, in our series, there was a high incidence of intra-articular soft tissue impingement lesions and synovitis (63%). Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Ajis A, Younger AS, Maffulli N. Anatomic repair for chronic lateral ankle instability. Foot Ankle Clin. 2006;11(3): 539-545. 2. Broström L. Sprained ankles VI: surgical treatment of “chronic” ligament ruptures. Acta Chir Scand. 1966;132: 551-565. 3. Buerer Y, Winkler M, Burn A, Chopra S, Crevoisier X. Evaluation of a modified Brostrom-Gould procedure for treatment of chronic lateral ankle instability: a retrospective study
Downloaded from fai.sagepub.com at UNIVERSITE DE MONTREAL on September 4, 2015
1049
Odak et al with critical analysis of outcome scoring. Foot Ankle Surg. 2013;19(1):36-41. 4. Chrisman OD, Snook GA. Reconstruction of lateral ligament tears of the ankle: an experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Joint Surg. 1969;51-A:904-912. 5. Colville MR, Grondel RJ. Anatomic reconstruction of the lateral ankle ligaments using a split peroneus brevis tendon graft. Am J Sports Med. 1995;23:210-213. 6. Evans DL. Recurrent instability of the ankle: a method of surgical treatment. Proc R Soc Med. 1953;46:343-344. 7. Ferkel RD, Chams RN. Chronic lateral instability: arthroscopic findings and long-term results. Foot Ankle Int. 2007;28(1):24-31. 8. Garrick JG. The frequency of injury, mechanism of injury, and epidemiology of ankle sprains. Am J Sports Med. 1977;5(6):241-242. 9. Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle. 1980;1(2):84-89. 10. Hintermann B, Boss A, Schafer D. Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med. 2002;30(3):402-409. 11. Hua Y, Chen S, Li Y, Chen J, Li H. Combination of modified Brostrom procedure with ankle arthroscopy for chronic ankle instability accompanied by intra-articular symptoms. Arthroscopy. 2010;26(4):524-528. 12. Karlsson J, Bergsten T, Lansinger O, Peterson L. Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg. 1988;70-A:581-588.
13. Karlsson J, Lansinger O. Lateral instability of the ankle joint. Clin Orthop Relat Res. 1992;276:253-261. 14. Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. 2007;2:CD000380. 15. Komenda GA, Ferkel RD. Arthroscopic findings associated with the unstable ankle. Foot Ankle Int. 1999;20(11): 708-713. 16. Nery C, Raduan F, Del Buono A, Asaumi ID, Cohen M, Maffulli N. Arthroscopic-assisted Brostrom-Gould for chronic ankle instability: a long-term follow-up. Am J Sports Med. 2011;39(11):2381-2388. 17. Okuda R, Kinoshita M, Morikawa J, Yasuda T, Abe M. Arthroscopic findings in chronic lateral ankle instability: do focal chondral lesions influence the results of ligament reconstruction? Am J Sports Med. 2005;33(1):35-42. 18. Sugimoto K, Takakura Y, Okahashi K, Samoto N, Kawata K, Iwai M. Chondral injuries of the ankle with recurrent lateral instability: an arthroscopic study. J Bone Joint Surg Am. 2009;91(1):99-106. 19. Taga I, Shino K, Inoue M, Nakata K, Maeda A. Articular cartilage lesions in ankles with lateral ligament injury: an arthroscopic study. Am J Sports Med. 1993;21(1):120-126. 20. Wikstrom EA, Hubbard-Turner T, McKeon PO. Under standing and treating lateral ankle sprains and their consequences: a constraints-based approach. Sports Med. 2013;46(3):385-393.
Downloaded from fai.sagepub.com at UNIVERSITE DE MONTREAL on September 4, 2015
