Impingement lesions
Lateral ligament injuries are very common, with 1 ankle sprain per 10,000 occurring per day (8). Some 10-50% have some chronic pain (9,10,11).
Anterolateral impingement is the commonest soft tissue impingement lesion and cause of pain after ankle inversion injury (12). Wolin coined the term ‘the meniscoid lesion’ for the arthroscopic appearance of the lateral gutter in these patients.
Arthroscopic treatment is very successful in alleviating chronic pain (13,14,15,16) in 84% both subjectively and objectively. A recent survey by Urg’den M et al (17) in 2005 of 41 patients showed good or excellent results in 37 of the group. Also Henderson et al in 2004 showed similar results for combined anterior and posterior impingement syndrome (18).
During dorsiflexion of the ankle, the malleoli are separated and the syndesmosis is stressed. Syndesmotic injuries are undoubtably underestimated (19). Syndesmotic injuries can be diagnosed by a localised tenderness and a positive squeeze test (20, 21) - pressing the tibia and fibula together proximal to the syndesmosis half way up the calf.
However, Lui T H et al (22) showed in November 2005 that ankle arthroscopy excels stress radiographs in detecting syndesmotic injuries, even though intra-operative x-rays still play an important role in assessing fracture reduction and longitudinal orientation of the syndesmosis. Syndesmotic impingement is also associated with a separate distal fascicle to the anterior talo-fibular ligament (23). The incidence of syndesmotic injury is 3% of all ankle sprains (24).
Posterior impingement does occur and was first described by Hamilton (25) with posterior ‘meniscus’ displacing inferiorly. Also a labrum on the posterior lip of the tibia can hypertrophy when injured.
Click here for video of lateral gutter impingment
References
(8) Jackson D W, Ashley R D, Powell Jr, ‘Ankle sprains in young athletes: relation of severity and disability’ Clin Orth 1974; 101:201
(9) Smith R W, Reischl S F, ‘Treatment of ankle sprains in young athletes’ Am J Sports Med 1986; 14:465
(10) Anderson M E, ‘Reconstruction of the lateral ligaments of the ankle using the plantaris tendon’ JBJS 1985; 67A:930
(11) Freeman M A R, ‘Instability of the foot after injuries to the lateral ligament of the ankle’ JBJS 1965; 47B:669
(12) Wolin I, Glassman F, Sideman S, ‘Internal derangement of the talofibular component of the ankle’ Surg Gynecol Obstet 1950; 91:193
(13) Ferkel R D, Karzel R P, Del Pizzo W et al, ‘Arthroscopic treatment of anterolateral impingement of the ankle’ Am J Sports Med 1991; 19:440
(14) Liu S H, Raskin B S, Osti L et al, ‘Arthroscopic treatment of anterolateral ankle impingement’ Arthrosopy 1994; 10:215
(15) Martin D F, Baker C L, Curl W W et al, ‘Operative ankle arthroscopy : long term follow up’ Am J Sports Med 1989; 17:16.
(16) Meislin R J, Rose D J, Parisien S, Springer S, ‘Arthroscopic treatment of synovial impingement of the ankle’ Am J Sports Med 1993; 21:186
(17) Urg’den M, S’y’nc’ Y, Ozdemir H, Sekban H, Akyildiz F F, Aydin A T, ‘Arthroscopic treatment or anterolateral soft tissue impingement of the ankle: evaluation of factors affecting outcome’ Arthroscopy: the journal of arthroscopic and related surgery: AANA and IAA 2005; 21:3; 317-22
(18) Henderson I, La Vallette D, ‘Ankle Impingement: combined anterior and posterior impingement syndrome of the ankle’ Foot and Ankle International / Am Orthropaedic Foot and Ankle Soc 2004; 25:9; 632-8
(19) Kapandji I A, ‘The physiology of the joints’ Edinburgh: Churchill Livingstone, 1987:164
(20) Hopkinson W J, St Pierre P, Ryan J B, Wheeler J H, ‘Syndesmosis sprains of the ankle’ Foot Ankle 1990; 10:325
(21) Boytim M J, Fischer D A, Neumann L ‘Syndesmotic ankle sprains’ Am J Sports Med 1991; 19:294
(22) Lui T H, Ip K Y, Chow H T, ‘Comparison of radiographic and arthroscopic diagnoses of distal tibiofibular syndemosis disruption in acute ankle fracture’ Arthroscopy: the journal of arthroscopic and related surgery: AANA and IAA 2005; 21:11; 1370
(23) Bassett F H, Gates H S, Billys J B, et al ‘Talar impingement by the anteroinferior tibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain’ JBJS 1990; 72A:55
(24) Ferkel R D ‘Arthroscopic Surgery, The Foot and Ankle’ Lipincott Raven 1996. 132-133
(25) Hamilton W G, ‘Foot and ankle injuries in dancers’ Clin sports med 1988; 7:160
Arthrofibrosis
Arthrofibrosis post fracture or sprain can occur and is satisfactorily treated by arthroscopic resection of the fibrous bands and early physiotherapy. This was nicely demonstrated by Lui T H et al in 2006 (35)
Click here for video of arthrofibrosis.
Reference
(35) Lui T H, Chan W K, Chan K B, ‘The arthroscopic management management of frozen ankle’ Arthroscopy: the journal of arthroscopic & related surgery: official publication of the AANA and IAA 2006; 22:3; 283-6
Inflammatory lesions
Rheumatoid arthritis, X-tal synovitis, PVNS and synovial chondromatosis
can all affect the ankle.
Rheumatoid arthritis has been reported to have an arthroscopic cure (26). A 95% synovectomy is possible (27), and early synovectomy is better than late (28).
PVNS can be treated arthroscopically in the ankle as elsewhere (29).
Synovial chondromatosis is rare in the ankle, but is treated along standard arthroscopic lines (30).
Other arthritides such as gonarthritis, Crohn’s, gout, chondrocalcinosis are treated with arthroscopic synovectomy (31).
An article in 2004 in the Journal of Paediatric Orthopaedics (32) of 39 ankles shows successful results with arthroscopic synovectomy for haemophilic arthropathy.
Click here for video of synovial disease
References
(26) Schoenholz G J, ‘Athroscopic surgery of the shoulder elbow and ankle’ Springfield, IL:Charles C Thomas 1987:59
(27) Aschan W, Moberg E, ‘A long term study of the effect of early synovectomy in rheumatoid arthritis’ Bull Hosp Jt Dis Orthop Inst 1984; 44:106.
(28) Goldie I F, ‘Synovectomy in rheumatoid arthritis: The theoretical aspects and a 14 year follow up in the knee’ Reconstr Surg Traumatol 1981; 18:2
(29) Granowitz S P, D’Antonia J, Mankin H J, ‘The pathogenesis and long term results of PVNS’ Clin Orth 1976; 114:335 Beltran J, Notto AM, Mosure J C, ‘Ankle surface coil MR imaging at 1.5tl’ Radiology 1986; 161:203
(30) Holm C L, ‘Primary synovial chondromatosis of the ankle’ JBJS 1976; 58A:878.
(31) Chen Y, ‘Arthroscopy of the ankle joint’; ‘Arthroscopy of small joints’ New York: Ikaku-shoin, 1985
(32) Dunn Amy L, Busch M T, Wyly J B, Sullivan K M, Abshire T C, ‘Arthroscopic synovectomy for hemophilic joint disease in pediatric population’ Journal of Pediatric Orthopedics 2004; 24:4; 414-26
Infections
Bacterial and fungal infections occur and are best treated with arthroscopic aspiration and synovial biopsy followed by washout and irrigation, then appropriate antibiotic therapy (33).
Stutz G et al (34) published a series of 78 infected joints, being able to cure 91% of them with arthroscopy and IV antibiotics alone.
References
(33) Ferkel R D ‘Arthroscopic Surgery, The Foot and Ankle’ Lipincott Raven 1996. 140-141
(34) Stutz G, Kuster M S, Kleinst’ck F, G’chter A, ‘Arthroscopic management of septic arthritis: stages of infection and results’ Knee Surgery Sports Traumatology Arthrocsopy: official journal of the ESSKA 2000; 8:5; 270-4