Arthroscopy: The Journal of Arthroscopic and Related Surgery 8(4):537-540 Published by Raven Press, Ltd. 0 1992 Arthroscopy Association of North America
Operative Arthroscopy
of the Ankle
G. Cerulli, A. Caraffa, V. Buompadre,
and G. Bensi
Summary: The long-term results of 30 operative arthroscopies of the ankle performed from 1983 to 1989 are the basis of this study. The most frequent lesions are synovitis and osteochondral defects of the talus. The treatment consists of lavage, synovial debridement, osteochondral debridement, and the removal of loose bodies. Of the 30 cases, 86.7% obtained excellent or good results and 88% of the athletes returned to their sport. Key Words: Ankle synovitis.
of the patients were posttraumatic. The diagnoses were: synovitis in 16 cases, osteochondral defects in 8 cases, loose bodies and/or osteophytes in 8 cases, osteoarthritis in 6 cases, and a “painful” ankle in the last 7 cases.
Although Burrman (1) experimented with arthroscopy of the ankle in 1931, only recently has it become an accepted procedure (2-6). Although reports (1-6) adequately described ankle arthroscopy in terms of technique and anatomy, few articles describing the results of operative procedures and long-term follow-up have been presented (5,7,8,9). Since 1983, we have done more than 100 diagnostic and operative ankle arthroscopies in acute intraarticular lesions, specifically in chronic cases. To evaluate the extent of the lesion and any other intraarticular problems in acute cases such as sprains, we did ankle arthroscopy only in high-level athletes. We also used ankle arthroscopy in chronic cases if pain, swelling, and stiffness continue with more than 6 months of conservative treatment or if a radiographic abnormality exists. We excluded from this study those patients who underwent concomitant diagnostic arthroscopy or open procedures.
SURGICAL TECHNIQUE Arthroscopy was performed with patients under general anesthesia with a tourniquet. A 4-mm 30” scope was used. The anteromedial and anterolateral portals were used routinely. Care must be taken to avoid the tibialis anterior tendon, saphenous vein, and dorsal cutaneous branch of the superficial peroneal nerve. The following lesions were identified: hypertrophic synovitis in 28 cases, loose bodies and/or osteophytes in 6 cases, osteoarthritis in 6 cases, anterolateral laxity in 5 cases, and osteochondral defects in 9 cases (Figs. l-4). The osteochondral defects of the talus were all posttraumatic (6 lateral and 3 medial). According to Berndt and Harty’s classifications, five of these defects were stage 2, 3 were stage 3, and one was Stage 4. In 13.3% of the cases, the arthroscopic and clinical diagnoses were different. The treatment, using manual and motorized instruments, included various methods: lavage in 45 cases, synovial debridement in 28 cases (Fig. 5); osteochondral defects, debridement, curettage and/ or chondroplasty in 9 cases; removal of loose bodies in 7 cases (Fig. 6); and abrasion in 4 cases. For postoperative care, we used a compressive
MATERIALS AND METHODS From June 1983 to January 1988,45 patients were treated (29 male and 16 female). Twenty-eight were athletes. The average age was 27 years (range: 16 46 years). In all cases there were chronic lesions; 26 From the Department of Orthopaedics and Traumatology, University of Perugia, Italy. Addresscorrespondenceand reprint requests to GiulianoCerulli, AssociateProfessor, Departmentof Orthopaedicsand Traumatology, University of Perugia, Perugia, Italy. 537
538
G. CERULLI ET AL.
FIG. 1. Lateral osteochondral defect of the talus. FIG. 2. Medical osteochondral defect of the talus.
dressing and ice packs for the first 6-8 days. As soon as possible, the patients were started on active range of motion exercises. Between 2 and 4 weeks (varying according to the patients’ pathology and recovery rate), the patients began weightbearing. They returned to their sport after 2 months. Complications were found in only three cases (6.7%). In two cases there was a subcutaneous edema, and in another patient a plantar fascitis appeared but completely healed within a short time.
RESULTS The follow-up examinations were performed between 24 months and 6-S years (an average of 3 years). The criteria for evaluating results were subjective (pain, swelling) and functional/objective (stiffness, limp, reduction of activity, giving way). The results were classified as either excellent, good, or poor. Overall, 86% of the cases obtained excellent or good results. In 30 cases (66.6%), the results were excellent and in 9 cases (20%) the results were
Arthroscopy,
Vol. 8, No. 4, 1992
good. These patients experienced subjectively mild pain and/or swelling with exercise, functionally mild stiffness, and/or occasional giving way. There was a reduction of activity in only three cases. Fourteen percent of the cases had poor outcomes. All cases with poor results had osteoarthritis and in two of these patients further surgery was necessary. If we consider the cases with an isolated pathology, the results are as follows: synovitis (12 cases: 80% excellent, 20% good); osteochondral defects (6 cases: 80% excellent, 20% good); loose bodies (6 cases: 100% excellent); and osteoarthritis (6 cases: 100% poor). In all posttraumatic cases, we found hypertrophic synovitis, especially anteriorly and laterally. In three cases we found a “meniscoid” lesion. Of the patients who had osteochondral defects, four cases were stage 2, the other two were stage 3. Their treatment involved the debridement of the fragment and curettage or chondroplasty of the bony bed. We did not find any correlation between lesion stage and results. Twenty-seven of the 28 athletes (%.4%) returned to their sport after an average of 3 months.
OPERATIVE
ARTHROSCOPY
FIG. 3. Central osteochondral FIG. 4. Loose body.
CONCLUSIONS Our experience confirmed that ankle arthroscopy is useful in selected patients who have not responded to prolonged conservative treatment. The results were very good in 86.7% of the cases. All of them had singular or associative synovitis, osteochondral defects, and/or loose bodies. All patients
FIG. 5. Synovial debridement.
539
OF ANKLE
defect of the talus.
with osteoarthritis had poor results, which corroborates other reports and literature. Only three patients had complications, and 88% of the athletes returned to their sport on the same level. On the basis of our experience, both technique and postoperative care are critical. The technique must be meticulous. There remain several technical
FIG. 6. Removal of the loose body.
Arthroscopy,
Voi. 8, No. 4. 1992
G. CERULLI ET AL. problems with joint distention and instrumentation. With careful attention to the progress and timing of postoperative treatment, the patient can return quickly to athletic activity after ankle arthroscopy. REFERENCES 1. Bunman MS. Arthroscopy or the direct visualization of the joint. J Bone Surg 1931;13:6YY. 2. Drez D, Guhl J, Gollehon DR. Ankle arthroscopy technique and indications. Clin Sports Med 1982;1:35.
Arthroscopy, Vol. 8, No. 4, 1992
3. Andrews JR, Previte WJ, Carson WG. Arthroscopy of the ankle: technique and indications. Foot Ankle lY85;6:29. 4. Ghul JF. New techniques for arthroscopic surgery of the ankle: preliminary report. Orthopaedics 1986;2:261. 5. Parisien JS. Arthroscopic treatment of osteochondral lesions of the talus. Am J Sports Med 1986;14:11-7. 6. Cerulli G, Ca&a A, Bensi G. Artroscopia di caviglia. Minerva Ortopedica 198&7:535-Y. 7. Carson WG, Andrews JR. Arthroscopy of the ankle. Clin Sports Med 1987;6:503-12. 8. Parisien JS, Vangsness T. Operative arthroscopy of the ankle: three years experience. Clin Orthop 1985;199:46. 9. Martin FD, Curl WW, Baker CL. Arthroscopic treatment of chronic synovitis of the ankle. Arthroscopy 1989;2: 1lw.
Operative Arthroscopy
of the Ankle
G. Cerulli, A. Caraffa, V. Buompadre,
and G. Bensi
Summary: The long-term results of 30 operative arthroscopies of the ankle performed from 1983 to 1989 are the basis of this study. The most frequent lesions are synovitis and osteochondral defects of the talus. The treatment consists of lavage, synovial debridement, osteochondral debridement, and the removal of loose bodies. Of the 30 cases, 86.7% obtained excellent or good results and 88% of the athletes returned to their sport. Key Words: Ankle synovitis.
of the patients were posttraumatic. The diagnoses were: synovitis in 16 cases, osteochondral defects in 8 cases, loose bodies and/or osteophytes in 8 cases, osteoarthritis in 6 cases, and a “painful” ankle in the last 7 cases.
Although Burrman (1) experimented with arthroscopy of the ankle in 1931, only recently has it become an accepted procedure (2-6). Although reports (1-6) adequately described ankle arthroscopy in terms of technique and anatomy, few articles describing the results of operative procedures and long-term follow-up have been presented (5,7,8,9). Since 1983, we have done more than 100 diagnostic and operative ankle arthroscopies in acute intraarticular lesions, specifically in chronic cases. To evaluate the extent of the lesion and any other intraarticular problems in acute cases such as sprains, we did ankle arthroscopy only in high-level athletes. We also used ankle arthroscopy in chronic cases if pain, swelling, and stiffness continue with more than 6 months of conservative treatment or if a radiographic abnormality exists. We excluded from this study those patients who underwent concomitant diagnostic arthroscopy or open procedures.
SURGICAL TECHNIQUE Arthroscopy was performed with patients under general anesthesia with a tourniquet. A 4-mm 30” scope was used. The anteromedial and anterolateral portals were used routinely. Care must be taken to avoid the tibialis anterior tendon, saphenous vein, and dorsal cutaneous branch of the superficial peroneal nerve. The following lesions were identified: hypertrophic synovitis in 28 cases, loose bodies and/or osteophytes in 6 cases, osteoarthritis in 6 cases, anterolateral laxity in 5 cases, and osteochondral defects in 9 cases (Figs. l-4). The osteochondral defects of the talus were all posttraumatic (6 lateral and 3 medial). According to Berndt and Harty’s classifications, five of these defects were stage 2, 3 were stage 3, and one was Stage 4. In 13.3% of the cases, the arthroscopic and clinical diagnoses were different. The treatment, using manual and motorized instruments, included various methods: lavage in 45 cases, synovial debridement in 28 cases (Fig. 5); osteochondral defects, debridement, curettage and/ or chondroplasty in 9 cases; removal of loose bodies in 7 cases (Fig. 6); and abrasion in 4 cases. For postoperative care, we used a compressive
MATERIALS AND METHODS From June 1983 to January 1988,45 patients were treated (29 male and 16 female). Twenty-eight were athletes. The average age was 27 years (range: 16 46 years). In all cases there were chronic lesions; 26 From the Department of Orthopaedics and Traumatology, University of Perugia, Italy. Addresscorrespondenceand reprint requests to GiulianoCerulli, AssociateProfessor, Departmentof Orthopaedicsand Traumatology, University of Perugia, Perugia, Italy. 537
538
G. CERULLI ET AL.
FIG. 1. Lateral osteochondral defect of the talus. FIG. 2. Medical osteochondral defect of the talus.
dressing and ice packs for the first 6-8 days. As soon as possible, the patients were started on active range of motion exercises. Between 2 and 4 weeks (varying according to the patients’ pathology and recovery rate), the patients began weightbearing. They returned to their sport after 2 months. Complications were found in only three cases (6.7%). In two cases there was a subcutaneous edema, and in another patient a plantar fascitis appeared but completely healed within a short time.
RESULTS The follow-up examinations were performed between 24 months and 6-S years (an average of 3 years). The criteria for evaluating results were subjective (pain, swelling) and functional/objective (stiffness, limp, reduction of activity, giving way). The results were classified as either excellent, good, or poor. Overall, 86% of the cases obtained excellent or good results. In 30 cases (66.6%), the results were excellent and in 9 cases (20%) the results were
Arthroscopy,
Vol. 8, No. 4, 1992
good. These patients experienced subjectively mild pain and/or swelling with exercise, functionally mild stiffness, and/or occasional giving way. There was a reduction of activity in only three cases. Fourteen percent of the cases had poor outcomes. All cases with poor results had osteoarthritis and in two of these patients further surgery was necessary. If we consider the cases with an isolated pathology, the results are as follows: synovitis (12 cases: 80% excellent, 20% good); osteochondral defects (6 cases: 80% excellent, 20% good); loose bodies (6 cases: 100% excellent); and osteoarthritis (6 cases: 100% poor). In all posttraumatic cases, we found hypertrophic synovitis, especially anteriorly and laterally. In three cases we found a “meniscoid” lesion. Of the patients who had osteochondral defects, four cases were stage 2, the other two were stage 3. Their treatment involved the debridement of the fragment and curettage or chondroplasty of the bony bed. We did not find any correlation between lesion stage and results. Twenty-seven of the 28 athletes (%.4%) returned to their sport after an average of 3 months.
OPERATIVE
ARTHROSCOPY
FIG. 3. Central osteochondral FIG. 4. Loose body.
CONCLUSIONS Our experience confirmed that ankle arthroscopy is useful in selected patients who have not responded to prolonged conservative treatment. The results were very good in 86.7% of the cases. All of them had singular or associative synovitis, osteochondral defects, and/or loose bodies. All patients
FIG. 5. Synovial debridement.
539
OF ANKLE
defect of the talus.
with osteoarthritis had poor results, which corroborates other reports and literature. Only three patients had complications, and 88% of the athletes returned to their sport on the same level. On the basis of our experience, both technique and postoperative care are critical. The technique must be meticulous. There remain several technical
FIG. 6. Removal of the loose body.
Arthroscopy,
Voi. 8, No. 4. 1992
G. CERULLI ET AL. problems with joint distention and instrumentation. With careful attention to the progress and timing of postoperative treatment, the patient can return quickly to athletic activity after ankle arthroscopy. REFERENCES 1. Bunman MS. Arthroscopy or the direct visualization of the joint. J Bone Surg 1931;13:6YY. 2. Drez D, Guhl J, Gollehon DR. Ankle arthroscopy technique and indications. Clin Sports Med 1982;1:35.
Arthroscopy, Vol. 8, No. 4, 1992
3. Andrews JR, Previte WJ, Carson WG. Arthroscopy of the ankle: technique and indications. Foot Ankle lY85;6:29. 4. Ghul JF. New techniques for arthroscopic surgery of the ankle: preliminary report. Orthopaedics 1986;2:261. 5. Parisien JS. Arthroscopic treatment of osteochondral lesions of the talus. Am J Sports Med 1986;14:11-7. 6. Cerulli G, Ca&a A, Bensi G. Artroscopia di caviglia. Minerva Ortopedica 198&7:535-Y. 7. Carson WG, Andrews JR. Arthroscopy of the ankle. Clin Sports Med 1987;6:503-12. 8. Parisien JS, Vangsness T. Operative arthroscopy of the ankle: three years experience. Clin Orthop 1985;199:46. 9. Martin FD, Curl WW, Baker CL. Arthroscopic treatment of chronic synovitis of the ankle. Arthroscopy 1989;2: 1lw.
