Eur J Orthop Surg Traumatol DOI 10.1007/s00590-013-1357-0
ORIGINAL ARTICLE
Distraction-free ankle arthroscopy for anterolateral impingement Jean Louis Rouvillain • Wael Daoud • Adrian Donica • Emmanuel Garron • Andre´ Pierre Uzel
Received: 6 October 2013 / Accepted: 30 October 2013 Ó Springer-Verlag France 2013
Abstract The origin of chronic pain after external ankle sprain is better known with arthroscopy’s contribution. Chronic hypertrophic synovitis of the anterolateral ankle region is seemingly the cause, resulting in ‘‘anterolateral ankle impingement.’’ But is partial synovectomy with fibrosis resection under arthroscopy always possible without any distraction? Are results affected? This retrospective study concerned only patients with soft tissue ankle impingement. All cases with bone and joint diseases were excluded. The final sample of 24 patients had a mean age of 35 years (21–54 years) and presented anterolateral mechanical pain associated with oedema following external ankle sprain. Medical and rehabilitative treatment was undertaken for more than 6 months before arthroscopy. Average time between trauma and arthroscopy was 21 months (5–60 months). Clinical examination revealed no ankle instability or laxity. Debridement with joint lavage was systematically performed under arthroscopy without any distraction. Average patient follow-up was 22 months (12–92 months). All patients had a good Kitaoka score, with 22 patients registering excellent results. There were no septic complications or algodystrophy. Two transient hypoesthesias were observed in the dorsal surface and lateral border of the foot with full postoperative recovery at 6 months. Distraction was never used and
J. L. Rouvillain (&) W. Daoud A. Donica E. Garron Department of Orthopaedic Surgery and Traumatology 2C, Pierre Zobda-Quitman University Hospital, BP 632, 97200 Fort-de-France, Martinique, French West Indies e-mail: [email protected] A. P. Uzel Department of Orthopaedic Surgery and Traumatology, Guadeloupe University Hospital, 97110 Les Abymes, Guadeloupe, French West Indies
simple dorsiflexion was sufficient to perform arthroscopic debridement. In this study, anterolateral ankle impingement diagnosis was primarily clinical. Arthroscopic treatment yielded significant benefits on pain, oedema and resumption of sport activities. Arthroscopic treatment of anterolateral ankle impingements is thus possible with simple dorsiflexion and no distraction, resulting in a possible decrease in complication rates. Level of evidence Retrospective cohort study, Level IV. Keywords Ankle Arthroscopy Lateral sprain Chronic lateral ankle pain Anterolateral impingement
Introduction Advances in medical imaging and the development of arthroscopy have enabled a better understanding of the origin of chronic pain by anterolateral impingement after external sprain. Their frequency, as well as their impact, had been underestimated for a long time. Between 10 and 50 % of patients have residual pain after an ankle sprain. These pains may be due to bone lesions, an osteochondral fracture, an avulsion fracture of the talus, tendon injuries and abnormal ligament healing [1]. Incomplete healing of the anterior talo-fibular ligament is thought to cause chronic hypertrophic synovitis of the anterolateral ankle region responsible for painful symptomatology without instability or laxity, called ‘‘anterolateral impingement.’’ The latter is a common etiology of post-traumatic residual ankle pain [2–8]. Arthroscopy allows the conduct of partial synovectomy associated with total fibrosis resection. Like the Leeuw and Van Dijk teams [8, 9], we thought that such an arthroscopic act could be
123
Eur J Orthop Surg Traumatol
achieved without any distraction system, thus reducing postoperative complications.
Patients and methods Patient inclusion The patient sample was composed solely of soft tissue impingement cases after ankle sprain diagnosed from 2004 to 2010. All ankle arthroscopies, showing anterior tibial and/or talar osteophytes after radiography, or osteochondral lesions after arthrography or magnetic resonance imaging (MRI), were excluded from the study. In all, 24 patients presenting anterolateral mechanical pains, associated with painful anterolateral ankle thickening, were included in the study and were examined retrospectively. The patient sample comprised 21 women and 3 men aged between 21 and 54 years (mean age: 35 years). Five of the patients also presented an associated anteromedial pain. A lateral ankle sprain was considered severe in 14 cases and of moderate severity in 10 cases. In 9 cases, such a sprain was the resultant of a sports injury which can be detailed as follows: handball practice (4), dance practice (4) and football practice (1). Initial sprain treatment was immobilization with a standard Air-CastÒ brace for 17 patients, application of strapping for 3 patients and a fiberglass cast boot for 4 patients. Time lapse between trauma and arthroscopic treatment went from 5 to 60 months, with a mean time of 21 months. Ankle mobility was quite normal in 20 cases. A limited dorsiflexion was observed in 4 cases. The criteria described by Liu et al. [10] were investigated in all patients: all six criteria were positive in 7 patients, and 5 out of 6 criteria were positive for the rest. The Molloy test [11] was also performed on all participants and gave a positive result in everyone. All patients received medical treatment before arthroscopy: nonsteroidal anti-inflammatory drugs (NSAIDs) and proprioceptive ankle rehabilitation. Three patients had had an infiltration, performed elsewhere before the first consultation. No infiltration was made in our service, the resulting effect was not constant [12]. Only seven patients experienced improvement following medical treatment, but this improvement was deemed insufficient for a resumption of occupational and sports activities. No patient had ankle instability. No ankle laxity was found clinically.
with tibial or talar osteophytes. If clinical laxity was suspected, stress X-rays were performed (11 cases). These comparative X-rays were performed manually. When patients were seen in consultation, 15 of them had already benefited from CT arthrography while 5 patients had undergone an MRI and 4 had done a MR arthrography. Only 2 patients had had a scintigraphy. CT arthrography and MRI allowed the exclusion of patients presenting talar osteochondral lesions. CT arthrography showed an irregular thickening associated with a fibrous filling of the anterolateral gutter, ‘‘signs’’ interpreted as synovial hypertrophy. MRI and MR arthrography showed an external synovitis (hyper-signal) associated with an external synovial hypertrophy in all nine cases. For the two patients who underwent scintigraphies, results showed an external increased activity. Installation, surgical approach and technique All patients were operated by two surgeons (JLR and WD) in a supine position with a pillow placed under the ipsilateral buttock to correct external rotation. No distraction system (external fixator/traction strap) was used. For all patients, the surgical procedures were anterointernal with an optical approach and anterolateral with an instrumental approach. Procedures were inversed when necessary (Fig. 1). Debridement was performed with a 4-mm-diameter arthroscope at an angle of 30° and a 4-mm motorized endoscopic synovial resector and a VIPER (a high-frequency electrocautery device equipped with a wide electrode and a suction system). In all cases, a fibro-synovial proliferation, obstructing the anterolateral joint space, was found (Fig. 2). Resection of this arthro-fibrosis and/or synovitis was easily performed in all patients. There was no need for any form of traction.
Radiological assessment All patients underwent preoperative conventional anteroposterior and lateral X-rays in order to exclude patients
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Fig. 1 Anteromedial and anterolateral surgical approaches
Eur J Orthop Surg Traumatol
Fig. 2 Intra-articular fibrosis in the anterolateral gutter
The ankle was simply placed in dorsiflexion, as well described by the Leeuw and Van Dijk teams [8, 9]. This resection allowed the localization of underlying ligaments: The anterior and inferior tibiofibular ligament was normal in 11 patients and cicatricial in 6 patients. The Bassett ligament was not found in 7 patients. The anterior fascicle of the lateral collateral ligament was found in 20 patients. The latter had a cicatricial aspect in 16 patients, was relaxed in 4 patients and normal in the remaining ones. No tibiotalar chondropathy was found. It should be noted that all cases presenting chondral lesions had already been eliminated from the study sample. Postoperative care was generally simple. As such, no postoperative immobilization was performed. Every patient was allowed walking with full weightbearing on the first postoperative day (D-1). Discharge was consecutively carried out on the same day. A rehabilitative program was also started on D-1 which preferably consisted in massage and drainage associated with a passive and active mobilization of the ankle.
Results All patients were called back for a follow-up between 12 and 92 months after discharge (mean time lapse of 22 months). The registered American Orthopaedic Foot and Ankle Scores (AOFAS) were comprised between 81 and 100 (mean score 93/100). According to the Kitaoka score [1], 22 patients had a score higher than 90 and were classified as excellent results. Two patients presented a score between 80 and 90 and were classified as good results. Twenty patients no longer felt any pain. Four patients (17 % of study sample) kept occasional moderate pain, compared to a generally described proportion of 20–29 % in scientific literature [13].
Mobility was quite painless and normal for 22 patients (20° dorsiflexion, 40° plantar flexion). Two patients, however, kept a painful limited dorsiflexion at 15°. All patients, practicing sports, managed to return to their respective sports practice. Time lapse till sports resumption was between 35 and 70 days (mean time: 45 days). Ten out of 11 patients returned to their previous level of physical activity. There was no reported infection in the patient group. Other studies generally cite an infection rate comprised between 0 and 40 % [12–14]. Similarly, no case of algodystrophy was observed in the study participants. Two patients presented a hypoesthesia on the dorsal surface of the foot with a full postoperative recovery at 6 months. Overall, 22 patients reported to be ‘‘very satisfied’’ with the surgical outcome while two declared to be simply ‘‘satisfied.’’
Discussion Clinical examination performed on all study participants showed an anterolateral pain associated with painful anterolateral ankle thickening, in everyone. The drawer test was carried out in all patients who were also tested for the presence of lateral laxity. The sign of Molloy [11] was positive in all patients. This test, with a specificity of 88 % and a sensitivity of 94.8 %, was described by Molloy et al. in 2002. The test is positive if dorsiflexing the ankle, while maintaining an anterolateral pressure aggravates pain level. The criteria, as described by Liu et al. [10], were investigated in all patients: all six criteria were positive in 7 patients while the remaining 17 patients had five positive criteria out of six. For Liu and his team [10], diagnosis is confirmed if 5 out of the following six criteria are found: lateral pre-malleolar ankle pain during palpation, lateral pre-malleolar swelling, pain reproduced during clinical examination by forcing the foot in dorsiflexion and eversion, lateral pre-malleolar pain during monopodal squatting, pain during physical activity and absence of tibiotalar laxity. The presence of five of these six elements ensures a diagnosis with a sensitivity of 94 % and a specificity of 75 %. For Liu and his colleagues, a single tear of the talofibular ligament or synovial tissue, without jeopardy to the dynamic stability of the ankle, is enough to generate a chronic tissue inflammation and an interposition syndrome. During this study, clinical examination seemed sufficient to make the diagnosis of anterolateral ankle impingement without resorting to an infiltration test which does not guarantee a consistent result [12]. Standard systematic radiographic examination allowed to rule out osteophyte lesions, for which arthroscopic
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resection gives good results for pain management but more limited ones for mobility, as reported by Bauer et al. [15]. In case of clinical suspicion, stress X-ray helped eliminate the existence of any ankle laxity, despite the high frequency of false positives and false negatives as reported by Robinson et al. [16]. CT arthrography, performed in 15 patients from the study sample, showed good sensitivity for the diagnosis of abnormalities of the anterolateral gutter of the ankle and the presence of irregular thickening associated with fibrous filling of the anterolateral gutter. For Robinson and his team [16], CT arthrography has a 100 % sensitivity and specificity for abnormality detection in the external gutter. The technique also allows the observation of frequently associated chondral lesions (21 % of cases for Meislin et al. [6] and 54 % for Bassett et al. [17]). The presence of these lesions usually worsens arthroscopy results. This was not the case in the present study as patients with such lesions were excluded. MRI and MR arthrography, performed in 9 patients, revealed synovitis or anterolateral synovial hypertrophy in all of them. The existence of synovial hypertrophy or fibrosis, visible on MRI results, in the sector of the anterior fascicle of the lateral collateral ligament, confirms anterolateral impingement. For most authors, anterolateral ankle impingement diagnosis by MRI remains difficult, and there is consensus on the inadequacy of using MRI for such a diagnosis [10, 18–20]. In contrast, for others, MR arthrography remains the best technique to analyze anterolateral impingement [16, 21]. Horizontal cuts are then the most interesting cross sections to assess the importance of synovial hypertrophy while simultaneously studying ligaments and tendons. A low rate of complications was also noted in this study. Two transient hypoesthesias of the dorsal foot surface were observed while no algodystrophic complication was described. No distraction was used in our study, which seems to be the major difference with results reported in other patient series. Indeed, distraction seems to be a factor favoring neurological and algodystrophic complications [22–26]. The teams of Parisien and Vangsness [27], Martin [28], Ogilvie-Harris [29, 30], Valentine [31] and Amendola [3] all related more than 10 % of neurological and algodystrophic complications after use of distraction. Accordingly, our team therefore paid special attention to compliance toward technique and anatomical landmarks during surgical procedures and excluded any use of distraction. Technically, resection of the anterolateral fibrous synovial tissue is quite possible without any distraction of the ankle. Placing the tibiotalus in dorsiflexion accounts for good visualization and makes the anterior neurovascular structures of the ankle more distant [8, 9].
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The proportion of good clinical results on pain management and sports resumption, described in scientific literature after arthroscopic debridement of anterolateral ankle impingements, tends to be more variable (77–100 %) [5, 7, 8, 11, 30]. In the present study, excellent and good clinical results rated 83 %. Improved mobility observed in this series (92 %) is also comparable to the results described by other medical teams [11, 13]. However, 17 % of included patients still maintain moderate residual pains with a Visual Analogue Scale (VAS) score of 4/10. The presence of these residual pains usually varies between 20 and 29 % in other series [13]. Several prospective studies will be necessary in order to assess the benefit of combining a postoperative medical treatment with an intensive rehabilitative program that could improve clinical outcomes in the short, medium and especially long term.
Conclusion Anterolateral impingement is caused by tissue interposition It can consist in localized or diffuse synovial reactions, presence of intra-articular fibrous bands, hypertrophic talofibular or tibial-fibular ligament scars or traumatic sequelae of avulsion or partial ligament ruptures. These lesions can either be isolated or associated. Their only similarity is their localization in the talo-fibular gutter or at the level of the tibiofibular angle. Their post-traumatic origin and clinical expression are dominated by mechanical pain and localized painful anterolateral ankle thickening. Arthroscopic treatment of anterolateral ankle impingement gives significant therapeutic benefits on pain management and rapid resumption of daily physical and sports activities. Technically, distraction is not required which reduces the frequency of complications. Acknowledgments The authors thank Dr Rishika Banydeen for help with English translation. Conflict of interest All authors declare that they have no conflict of interest relevant to the subject of this article.
References 1. Kitaoka HB, Lee MD, Morrey BF (1997) Repair and delayed reconstruction for lateral ankle instability: twenty year follow-up study. J Orthop Trauma 11:530–535 2. Seeber PW, Staschiak VJ (2002) Diagnosis and treatment of ankle pain with the use of arthroscopy. Clin Podiatr Med Surg 19:509–517 3. Amendola A, Webser-Bogaerts S (1996) Ankle arthroscopy: outcome in 79 consecutive patients. Arthroscopy 12(5):565–573 4. Ferkel RD, Karzel RP, Del Pizzo W, Friedmann MJ, Fischer SP (1991) Arthroscopic treatment of antero-lateral impingement of the ankle. Am J Sports Med 19:440–446
Eur J Orthop Surg Traumatol 5. Martin DF, Baker CL, Curl WW, Andrews JR, Robie DB (1989) Operative ankle arthroscopy long-term follow up. Am J Sports Med 17:16–23 6. Meislin RJ, Rose DJ, Parisien JS, Springer S (1993) Arthroscopic treatment of synovial impingement of the ankle. Am J Sports Med 21:186–189 7. Wb Stetson, Rd Ferkel (1996) Ankle arthroscopy: indications and results. J Am Acad Orthop Surg 4:24–34 8. Leeuw PA, Dijk CN (2009) Fixed distraction is not necessary for anterior ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 17:1399–1400 9. de Leeuw PA, Golano´ P, Clavero JA, van Dijk CN (2010) Anterior ankle arthroscopy, distraction or dorsiflexion? Knee Surg Sports Traumatol Arthrosc 18(5):594–600 10. Liu H, Niccion S, Finerman G (1997) Diagnosis of antero-lateral impingement. Am J Sport Med 25:389–393 11. Molloy S, Solan MC, Bendall SP (2003) Synovial impingement in the ankle a new physical sign. J Bone Joint Surg Br 85(3):330–333 12. Tol JL, Van Dijk CN (2006) Anterior ankle impingement. Foot Ankle Clin 11(2):297–310 13. Rasmussen S, Hjorth Jensen C (2002) Arthroscopic treatment of impingement of the ankle reduces pain and enhances function. Scand J Med Sci Sports 12:69–72 14. D’Angelo GL, Ogilve-Harris DJ (1988) Septic arthritis following arthroscopy with cost/benefit analysis of antibiotic prophylaxis. Arthroscopy 4:10–14 15. Bauer T, Breda R, Hardy P (2010) Anterior ankle bony impingement with joint motion loss: the arthroscopic resection option. Orthop Traumatol Surg Res 96(4):462–468 16. Robinson P, White LM (2002) Soft tissue and osseous impingement syndromes of the ankle; role of imaging in diagnosis and management. Radiographics 22(6):1457–1469 [discussion: 1470-1] 17. Basset FH, Gates HS, Billys JB, Morris HB, Nikolaou PK (1990) Talar impingement by the antero-inferior tibio-fibular ligament. J Bone Joint Surg Am 72(1):55–59
18. Farooki S, Yao L, Seeger L (1998) Anterolateral impingement of the ankle: effectiveness of MR imaging. Radiology 207:357–360 19. Da Rubin, Nw Tischkoff, La Britton, Sf Lonti, Jd Towers (1997) Antero-lateral soft-tissue impingement in the ankle: diagnosis using MR imaging. AJR Am J Roentgenol 169(3):829–835 20. Umans H (2002) Ankle impingement syndrome. Semin Musculoskelet Radiol 6:133–139 21. Robinson P, White LM, Salonnen DC, Daniels TR, OgilvieHarris D (2001) Anterolateral ankle impingement: MR arthrographic assessment of the anterolateral recess. Radiology 221(1):186–190 22. Albert J, Reiman P, Njus G, Kay DB, Theken R (1992) Ligament strain and ankle joint opening during ankle distraction. Arthroscopy 8:469–473 23. Dowdy PA, Watson BV, Amendola A, Brown JD (1996) Non invasive ankle distraction: relationship between force, magnitude of distraction and nerve conduction abnormalities. Arthroscopy 12(1):64–69 24. Feiwell LA, Frey C (1994) Anatomic study of arthroscopic debridement of the ankle. Foot Ankle Int 15(11):614–621 25. Ferkel RD, Heath DD, Guhl JF (1996) Neurological complications of ankle arthroscopy. Arthroscopy 12(2):200–208 26. Guhl JF (1988) New concepts (distraction) in ankle arthroscopy. Arthroscopy 4(3):160–167 27. Parisien JS, Vangsness T (1985) Operative arthroscopy of the ankle. Clin Orthop Relat Res 199:46–53 28. Martin DF, Curl WW, Baker CL (1989) Arthroscopic treatment of chronic synovitis of the ankle. Arthroscopy 5:110–114 29. Ogilvie-Harris D (2001) Anterolateral ankle impingement: MR arthrographic assessment of the anterolateral recess. Radiology 221:186–190 30. Ogilvie-Harris DJ, Gilbart MK, Chorney K (1997) Chronic pain following ankle sprains in athletes: the role of arthroscopic surgery. Arthroscopy 13:564–574 31. Valentin A, Winge S, Stark A, Eriksson E (1994) Late follow-up results of operative ankle arthroscopy in patients under local anaesthesia. Knee Surg Sports Traumatol Arthros 2:250–254
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ORIGINAL ARTICLE
Distraction-free ankle arthroscopy for anterolateral impingement Jean Louis Rouvillain • Wael Daoud • Adrian Donica • Emmanuel Garron • Andre´ Pierre Uzel
Received: 6 October 2013 / Accepted: 30 October 2013 Ó Springer-Verlag France 2013
Abstract The origin of chronic pain after external ankle sprain is better known with arthroscopy’s contribution. Chronic hypertrophic synovitis of the anterolateral ankle region is seemingly the cause, resulting in ‘‘anterolateral ankle impingement.’’ But is partial synovectomy with fibrosis resection under arthroscopy always possible without any distraction? Are results affected? This retrospective study concerned only patients with soft tissue ankle impingement. All cases with bone and joint diseases were excluded. The final sample of 24 patients had a mean age of 35 years (21–54 years) and presented anterolateral mechanical pain associated with oedema following external ankle sprain. Medical and rehabilitative treatment was undertaken for more than 6 months before arthroscopy. Average time between trauma and arthroscopy was 21 months (5–60 months). Clinical examination revealed no ankle instability or laxity. Debridement with joint lavage was systematically performed under arthroscopy without any distraction. Average patient follow-up was 22 months (12–92 months). All patients had a good Kitaoka score, with 22 patients registering excellent results. There were no septic complications or algodystrophy. Two transient hypoesthesias were observed in the dorsal surface and lateral border of the foot with full postoperative recovery at 6 months. Distraction was never used and
J. L. Rouvillain (&) W. Daoud A. Donica E. Garron Department of Orthopaedic Surgery and Traumatology 2C, Pierre Zobda-Quitman University Hospital, BP 632, 97200 Fort-de-France, Martinique, French West Indies e-mail: [email protected] A. P. Uzel Department of Orthopaedic Surgery and Traumatology, Guadeloupe University Hospital, 97110 Les Abymes, Guadeloupe, French West Indies
simple dorsiflexion was sufficient to perform arthroscopic debridement. In this study, anterolateral ankle impingement diagnosis was primarily clinical. Arthroscopic treatment yielded significant benefits on pain, oedema and resumption of sport activities. Arthroscopic treatment of anterolateral ankle impingements is thus possible with simple dorsiflexion and no distraction, resulting in a possible decrease in complication rates. Level of evidence Retrospective cohort study, Level IV. Keywords Ankle Arthroscopy Lateral sprain Chronic lateral ankle pain Anterolateral impingement
Introduction Advances in medical imaging and the development of arthroscopy have enabled a better understanding of the origin of chronic pain by anterolateral impingement after external sprain. Their frequency, as well as their impact, had been underestimated for a long time. Between 10 and 50 % of patients have residual pain after an ankle sprain. These pains may be due to bone lesions, an osteochondral fracture, an avulsion fracture of the talus, tendon injuries and abnormal ligament healing [1]. Incomplete healing of the anterior talo-fibular ligament is thought to cause chronic hypertrophic synovitis of the anterolateral ankle region responsible for painful symptomatology without instability or laxity, called ‘‘anterolateral impingement.’’ The latter is a common etiology of post-traumatic residual ankle pain [2–8]. Arthroscopy allows the conduct of partial synovectomy associated with total fibrosis resection. Like the Leeuw and Van Dijk teams [8, 9], we thought that such an arthroscopic act could be
123
Eur J Orthop Surg Traumatol
achieved without any distraction system, thus reducing postoperative complications.
Patients and methods Patient inclusion The patient sample was composed solely of soft tissue impingement cases after ankle sprain diagnosed from 2004 to 2010. All ankle arthroscopies, showing anterior tibial and/or talar osteophytes after radiography, or osteochondral lesions after arthrography or magnetic resonance imaging (MRI), were excluded from the study. In all, 24 patients presenting anterolateral mechanical pains, associated with painful anterolateral ankle thickening, were included in the study and were examined retrospectively. The patient sample comprised 21 women and 3 men aged between 21 and 54 years (mean age: 35 years). Five of the patients also presented an associated anteromedial pain. A lateral ankle sprain was considered severe in 14 cases and of moderate severity in 10 cases. In 9 cases, such a sprain was the resultant of a sports injury which can be detailed as follows: handball practice (4), dance practice (4) and football practice (1). Initial sprain treatment was immobilization with a standard Air-CastÒ brace for 17 patients, application of strapping for 3 patients and a fiberglass cast boot for 4 patients. Time lapse between trauma and arthroscopic treatment went from 5 to 60 months, with a mean time of 21 months. Ankle mobility was quite normal in 20 cases. A limited dorsiflexion was observed in 4 cases. The criteria described by Liu et al. [10] were investigated in all patients: all six criteria were positive in 7 patients, and 5 out of 6 criteria were positive for the rest. The Molloy test [11] was also performed on all participants and gave a positive result in everyone. All patients received medical treatment before arthroscopy: nonsteroidal anti-inflammatory drugs (NSAIDs) and proprioceptive ankle rehabilitation. Three patients had had an infiltration, performed elsewhere before the first consultation. No infiltration was made in our service, the resulting effect was not constant [12]. Only seven patients experienced improvement following medical treatment, but this improvement was deemed insufficient for a resumption of occupational and sports activities. No patient had ankle instability. No ankle laxity was found clinically.
with tibial or talar osteophytes. If clinical laxity was suspected, stress X-rays were performed (11 cases). These comparative X-rays were performed manually. When patients were seen in consultation, 15 of them had already benefited from CT arthrography while 5 patients had undergone an MRI and 4 had done a MR arthrography. Only 2 patients had had a scintigraphy. CT arthrography and MRI allowed the exclusion of patients presenting talar osteochondral lesions. CT arthrography showed an irregular thickening associated with a fibrous filling of the anterolateral gutter, ‘‘signs’’ interpreted as synovial hypertrophy. MRI and MR arthrography showed an external synovitis (hyper-signal) associated with an external synovial hypertrophy in all nine cases. For the two patients who underwent scintigraphies, results showed an external increased activity. Installation, surgical approach and technique All patients were operated by two surgeons (JLR and WD) in a supine position with a pillow placed under the ipsilateral buttock to correct external rotation. No distraction system (external fixator/traction strap) was used. For all patients, the surgical procedures were anterointernal with an optical approach and anterolateral with an instrumental approach. Procedures were inversed when necessary (Fig. 1). Debridement was performed with a 4-mm-diameter arthroscope at an angle of 30° and a 4-mm motorized endoscopic synovial resector and a VIPER (a high-frequency electrocautery device equipped with a wide electrode and a suction system). In all cases, a fibro-synovial proliferation, obstructing the anterolateral joint space, was found (Fig. 2). Resection of this arthro-fibrosis and/or synovitis was easily performed in all patients. There was no need for any form of traction.
Radiological assessment All patients underwent preoperative conventional anteroposterior and lateral X-rays in order to exclude patients
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Fig. 1 Anteromedial and anterolateral surgical approaches
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Fig. 2 Intra-articular fibrosis in the anterolateral gutter
The ankle was simply placed in dorsiflexion, as well described by the Leeuw and Van Dijk teams [8, 9]. This resection allowed the localization of underlying ligaments: The anterior and inferior tibiofibular ligament was normal in 11 patients and cicatricial in 6 patients. The Bassett ligament was not found in 7 patients. The anterior fascicle of the lateral collateral ligament was found in 20 patients. The latter had a cicatricial aspect in 16 patients, was relaxed in 4 patients and normal in the remaining ones. No tibiotalar chondropathy was found. It should be noted that all cases presenting chondral lesions had already been eliminated from the study sample. Postoperative care was generally simple. As such, no postoperative immobilization was performed. Every patient was allowed walking with full weightbearing on the first postoperative day (D-1). Discharge was consecutively carried out on the same day. A rehabilitative program was also started on D-1 which preferably consisted in massage and drainage associated with a passive and active mobilization of the ankle.
Results All patients were called back for a follow-up between 12 and 92 months after discharge (mean time lapse of 22 months). The registered American Orthopaedic Foot and Ankle Scores (AOFAS) were comprised between 81 and 100 (mean score 93/100). According to the Kitaoka score [1], 22 patients had a score higher than 90 and were classified as excellent results. Two patients presented a score between 80 and 90 and were classified as good results. Twenty patients no longer felt any pain. Four patients (17 % of study sample) kept occasional moderate pain, compared to a generally described proportion of 20–29 % in scientific literature [13].
Mobility was quite painless and normal for 22 patients (20° dorsiflexion, 40° plantar flexion). Two patients, however, kept a painful limited dorsiflexion at 15°. All patients, practicing sports, managed to return to their respective sports practice. Time lapse till sports resumption was between 35 and 70 days (mean time: 45 days). Ten out of 11 patients returned to their previous level of physical activity. There was no reported infection in the patient group. Other studies generally cite an infection rate comprised between 0 and 40 % [12–14]. Similarly, no case of algodystrophy was observed in the study participants. Two patients presented a hypoesthesia on the dorsal surface of the foot with a full postoperative recovery at 6 months. Overall, 22 patients reported to be ‘‘very satisfied’’ with the surgical outcome while two declared to be simply ‘‘satisfied.’’
Discussion Clinical examination performed on all study participants showed an anterolateral pain associated with painful anterolateral ankle thickening, in everyone. The drawer test was carried out in all patients who were also tested for the presence of lateral laxity. The sign of Molloy [11] was positive in all patients. This test, with a specificity of 88 % and a sensitivity of 94.8 %, was described by Molloy et al. in 2002. The test is positive if dorsiflexing the ankle, while maintaining an anterolateral pressure aggravates pain level. The criteria, as described by Liu et al. [10], were investigated in all patients: all six criteria were positive in 7 patients while the remaining 17 patients had five positive criteria out of six. For Liu and his team [10], diagnosis is confirmed if 5 out of the following six criteria are found: lateral pre-malleolar ankle pain during palpation, lateral pre-malleolar swelling, pain reproduced during clinical examination by forcing the foot in dorsiflexion and eversion, lateral pre-malleolar pain during monopodal squatting, pain during physical activity and absence of tibiotalar laxity. The presence of five of these six elements ensures a diagnosis with a sensitivity of 94 % and a specificity of 75 %. For Liu and his colleagues, a single tear of the talofibular ligament or synovial tissue, without jeopardy to the dynamic stability of the ankle, is enough to generate a chronic tissue inflammation and an interposition syndrome. During this study, clinical examination seemed sufficient to make the diagnosis of anterolateral ankle impingement without resorting to an infiltration test which does not guarantee a consistent result [12]. Standard systematic radiographic examination allowed to rule out osteophyte lesions, for which arthroscopic
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resection gives good results for pain management but more limited ones for mobility, as reported by Bauer et al. [15]. In case of clinical suspicion, stress X-ray helped eliminate the existence of any ankle laxity, despite the high frequency of false positives and false negatives as reported by Robinson et al. [16]. CT arthrography, performed in 15 patients from the study sample, showed good sensitivity for the diagnosis of abnormalities of the anterolateral gutter of the ankle and the presence of irregular thickening associated with fibrous filling of the anterolateral gutter. For Robinson and his team [16], CT arthrography has a 100 % sensitivity and specificity for abnormality detection in the external gutter. The technique also allows the observation of frequently associated chondral lesions (21 % of cases for Meislin et al. [6] and 54 % for Bassett et al. [17]). The presence of these lesions usually worsens arthroscopy results. This was not the case in the present study as patients with such lesions were excluded. MRI and MR arthrography, performed in 9 patients, revealed synovitis or anterolateral synovial hypertrophy in all of them. The existence of synovial hypertrophy or fibrosis, visible on MRI results, in the sector of the anterior fascicle of the lateral collateral ligament, confirms anterolateral impingement. For most authors, anterolateral ankle impingement diagnosis by MRI remains difficult, and there is consensus on the inadequacy of using MRI for such a diagnosis [10, 18–20]. In contrast, for others, MR arthrography remains the best technique to analyze anterolateral impingement [16, 21]. Horizontal cuts are then the most interesting cross sections to assess the importance of synovial hypertrophy while simultaneously studying ligaments and tendons. A low rate of complications was also noted in this study. Two transient hypoesthesias of the dorsal foot surface were observed while no algodystrophic complication was described. No distraction was used in our study, which seems to be the major difference with results reported in other patient series. Indeed, distraction seems to be a factor favoring neurological and algodystrophic complications [22–26]. The teams of Parisien and Vangsness [27], Martin [28], Ogilvie-Harris [29, 30], Valentine [31] and Amendola [3] all related more than 10 % of neurological and algodystrophic complications after use of distraction. Accordingly, our team therefore paid special attention to compliance toward technique and anatomical landmarks during surgical procedures and excluded any use of distraction. Technically, resection of the anterolateral fibrous synovial tissue is quite possible without any distraction of the ankle. Placing the tibiotalus in dorsiflexion accounts for good visualization and makes the anterior neurovascular structures of the ankle more distant [8, 9].
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The proportion of good clinical results on pain management and sports resumption, described in scientific literature after arthroscopic debridement of anterolateral ankle impingements, tends to be more variable (77–100 %) [5, 7, 8, 11, 30]. In the present study, excellent and good clinical results rated 83 %. Improved mobility observed in this series (92 %) is also comparable to the results described by other medical teams [11, 13]. However, 17 % of included patients still maintain moderate residual pains with a Visual Analogue Scale (VAS) score of 4/10. The presence of these residual pains usually varies between 20 and 29 % in other series [13]. Several prospective studies will be necessary in order to assess the benefit of combining a postoperative medical treatment with an intensive rehabilitative program that could improve clinical outcomes in the short, medium and especially long term.
Conclusion Anterolateral impingement is caused by tissue interposition It can consist in localized or diffuse synovial reactions, presence of intra-articular fibrous bands, hypertrophic talofibular or tibial-fibular ligament scars or traumatic sequelae of avulsion or partial ligament ruptures. These lesions can either be isolated or associated. Their only similarity is their localization in the talo-fibular gutter or at the level of the tibiofibular angle. Their post-traumatic origin and clinical expression are dominated by mechanical pain and localized painful anterolateral ankle thickening. Arthroscopic treatment of anterolateral ankle impingement gives significant therapeutic benefits on pain management and rapid resumption of daily physical and sports activities. Technically, distraction is not required which reduces the frequency of complications. Acknowledgments The authors thank Dr Rishika Banydeen for help with English translation. Conflict of interest All authors declare that they have no conflict of interest relevant to the subject of this article.
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