Arthroscopic Treatment for Anterior Ankle Impingement: A Systematic Review of the Current Literature Ruben Zwiers, M.Sc., Johannes I. Wiegerinck, M.D., Ph.D., Christopher D. Murawski, B.S., Ethan J. Fraser, M.D., John G. Kennedy, M.D., M.Ch., M.M.Sc., F.R.C.S.(Orth), and C. Niek van Dijk, M.D., Ph.D.
Purpose: To provide a comprehensive overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement. Methods: A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was performed. Studies that met the following inclusion criteria were reviewed: studies reporting outcomes of arthroscopic treatment for anterior ankle impingement; studies reporting on more than 20 patients; a study population with a minimum age of 18 years; and studies in the English, Dutch, German, Italian, or Spanish language. Two reviewers independently performed data extraction. Extracted data consisted of population characteristics, in addition to both primary and secondary outcome measures. The Downs and Black scale was used to assess the methodologic quality of randomized and nonrandomized studies included in this review. Results: Twenty articles were included in this systematic review. Overall, good results were found for arthroscopic treatment in patients with anterior ankle impingement. In the studies that reported patient satisfaction rates, high percentages of good to excellent satisfaction were described (74% to 100%). The percentages of patients who would undergo the same procedure again under the same circumstances were also high (94.3% to 97.5%). Complication rates were low (4.6%), particularly with respect to major complications (1.1%). The high heterogeneity of the included studies made it impossible to compare the results of the studies, including between anterolateral impingement and anteromedial impingement. Conclusions: Arthroscopic treatment for anterior ankle impingement appears to provide good outcomes with respect to patient satisfaction and low complication rates. However, on the basis of the ﬁndings of this study, no conclusion can be made in terms of the effect of the type of impingement or additional pathology on clinical outcome. Level of Evidence: Level IV, systematic review of Level II and IV studies.
See commentary on page 1597
nterior ankle impingement is a syndrome characterized by pain at the anterior aspect of the ankle joint, particularly during hyper-dorsiﬂexion.1 In addition, patients may present with swelling and
From the Academic Medical Center, University of Amsterdam (R.Z., J.I.W., C.N.v.D.), Amsterdam, The Netherlands; and Hospital for Special Surgery (C.D.M., E.J.F., J.G.K.), New York, New York, U.S.A. The authors report the following potential conﬂict of interest or source of funding: J.G.K. receives support from Arteriocyte, Ohnell Family Foundation, and Mr. and Mrs. Michael J. Levitt. Industry and philanthropic grants for research given directly to Hospital for Special Surgery. C.N.v.D. receives support from Smith & Nephew. Received September 15, 2014; accepted January 21, 2015. Address correspondence to John G. Kennedy, M.D., M.Ch., M.M.Sc., F.R.C.S.(Orth), Hospital for Special Surgery, 523 E. 72nd Street, Ste 507, New York, NY 10021, U.S.A. E-mail: [email protected]
Ó 2015 by the Arthroscopy Association of North America 0749-8063/14786/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.01.023
dorsiﬂexion may be restricted in some cases.2,3 Anterior ankle impingement is a common source of ankle pain in athletes, especially ballet dancers and soccer players,4,5 which led to the condition being described formerly as “athlete’s ankle”6 and “footballer’s ankle.”7 Presently, the term “anterior impingement” is widely used.8 On the basis of etiology and clinical presentation, differentiation between 2 separate entities is possible: osseous or bony impingement and soft-tissue impingement. A distinction can also be made clinically based on the localization of pathology and symptomatology, which includes anterolateral impingement (ALI) and anteromedial impingement (AMI) (Fig 1).9 Soft-tissue impingement is often located at the anterolateral aspect of the ankle, whereas bony impingement is predominantly located anteromedially (Fig 2).10 Therefore ALI is often referred to as “anterior soft-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 8 (August), 2015: pp 1585-1596
R. ZWIERS ET AL.
Fig 1. (A) Standard lateral radiograph shows tibial and talar osteophytes at anterolateral aspect of ankle joint. (B) Oblique anteromedial impingement view radiograph shows anteromedial osteophytes.
tissue impingement,” whereby several types of pathology are described, including synovitis and meniscoid lesions, as well as thickening of the distal fascicle of the anteroinferior tibioﬁbular ligament.11-14 Conservative treatment, consisting of rest, physical therapy, ankle bracing, shoe modiﬁcation, and/or local injection, is recommended as the primary treatment strategy for symptoms of anterior ankle impingement. An intra-articular corticosteroid injection can be applied in cases in which conservative treatments are unresponsive to reduce inﬂammation. Because conservative treatment is often unsuccessful, resection of the soft tissue and/or osteophytes is often required. Historically, good results have been described for open surgical approaches.4,7,15-18 In fact, one study comparing open and arthroscopic resection of osteophytes found that patients treated arthroscopically returned to full activity sooner than those undergoing the open procedure.19 Presently, ankle arthroscopy is recommended as the gold standard for the surgical treatment of anterior ankle impingement. In this regard, several case series, including both AMI and ALI, have shown arthroscopic removal of bony and soft-tissue impediments to be effective.5,20-31 A recent systematic review on evidence-based indications for anterior ankle arthroscopy described evidence-based literature supporting the recommendation for its use in treating anterior ankle impingement.32 Simonson and Roukis33 reported ankle arthroscopy to be a safe treatment option for anterolateral soft-tissue impingement.
However, less is reported on other important outcome measures, including patient satisfaction and return to sport. This study aims to provide a comprehensive overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement.
Methods Search Strategy A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases (with a search date of August 4, 2014) was performed using the following keywords: ((ankle AND impingement) OR (ankle AND impingement AND syndrome) OR ((talar OR talus) AND compres*) OR (ankle AND osteophy*) OR ((talar OR talus OR tibiotalar) AND osteophy*) OR ((talar OR talus) AND impingement)) AND ((arthrosc*) OR (surgery OR procedures) OR (treatment)). In addition, the Cochrane database of clinical and randomized controlled trials was searched using the term “impingement.” A review of the reference lists of relevant articles was performed to identify any additional articles potentially not identiﬁed through the database search. Inclusion and Exclusion Criteria Studies that met the following inclusion criteria were reviewed: studies reporting outcomes of arthroscopic
Fig 2. (A) Soft-tissue impingement. (B) Bony impingement.
ANTERIOR ANKLE IMPINGEMENT
treatment for anterior ankle impingement; studies reporting on more than 20 patients; a study population with a minimum age of 18 years; and studies in the English, Dutch, German, Italian, or Spanish language. Each study had to report at least 2 of the following outcome measures: patient satisfaction, American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) score for pain, return to sport or return to full activity, range of motion, complications, and answering the question whether the patient would undergo the same operation under the same circumstances again. Studies reporting on a combined posterior and anterior arthroscopic approach or anterior arthroscopy combined with an additional open procedure, such as lateral ligament reconstruction, were excluded. In cases in which there were studies that reported on (partially) the same population, only the most recent data were included in our study. All studies not addressing solely anterior ankle impingement, as well as review and expert opinion articles, were also excluded. Studies were selected and independently assessed by 2 reviewers (R.Z., J.I.W.). Differences between the reviewers were discussed until agreement was achieved, and the senior authors (J.G.K., C.N.vD.) were consulted in the event of persistent disagreement. Data Extraction and Analysis Two reviewers (R.Z., J.I.W.) independently performed data extraction. Extracted data consisted of population characteristics, in addition to both primary and secondary outcome measures. Primary outcome measures were patient satisfaction and complication rates. Secondary outcome measures were clinical outcome measures, including the AOFAS AnkleHindfoot scale, VAS score, and range of motion, as well as the time to achieve return to sport or full activity after surgery. Furthermore, we extracted data on clinical outcomes expressed as excellent, good, fair, and poor outcomes, including the criteria on which these categorical outcomes were based. Good and excellent outcomes were considered successful treatment. If necessary, additional information was requested by E-mail from the authors of the studies in question. To simplify the extraction and data analysis, complications were dichotomized as “major” or “minor” complications. Quality Assessment Two reviewers (R.Z., J.I.W.) independently performed a validated quality assessment of the included studies. The Downs and Black scale was used to assess the methodologic quality of randomized and nonrandomized studies included in this review. This tool measures quality in terms of reporting, external validity, internal validity (bias and confounding), and
Fig 3. Flowchart. (CINAHL, Cumulative Index to Nursing and Allied Health Literature.)
power, with a maximum score of 32 points.34 Adapted from Jäkel and von Hauenschild,35 Downs and Black scores of greater than 24 points were considered good; 8 to 24 points, moderate; and less than 8 points, poor. The Downs and Black checklist has been developed to assess the methodologic quality of both randomized and nonrandomized studies. Disagreement was resolved after discussion among the reviewers and in consultation with the senior authors.
Results Search Results After the search results of the different databases were combined and duplicate publications were removed, 950 articles remained for review. Thereafter 826 articles were excluded based on the title or abstract; because of the study design or the size or mean age of the study
R. ZWIERS ET AL.
Table 1. Characteristics of Included Studies Study (Level of Evidence) Akseki et al.36 (IV) Arnold37 (IV) Baums et al.38* (IV)
ST B Branca et al.23 (IV) Brennan et al.24 (IV) Cavallo et al.39* (IV) B ST Di Palma et al.40 (IV) Ferkel et al.41 (IV) Hassan42 (II) Jerosch et al.25 (IV) Koczy et al.43* (IV) Liu et al.14 (IV) Mardani-Kivi et al.44 (IV) Murawski and Kennedy9 (IV) Ogilvie-Harris et al.45* (IV) AL Ant Rasmussen and Hjorth30 (IV) Rouvillain et al.46 (IV) Ürgüden et al.47 (IV) van Dijk et al.3z (II) AL AM Tol et al.5z (II) Total or weighted mean
Year 1999 2011 2006 d d 1997 2012 2013 d d 1999 1991 2007 1994 2009 1994 2013 2010 1993 d d 2002 2014 2005 1997 d d 2001
N 21 32 26 12 14 58 41 280 203 77 67y 31 23 35y 22 55 23 35 26 17 11 105 24 41 62 32 30 57 972
Sex (M/F), n 7/14 d 16/10 7/5 9/5 37/21 26/15 174/106 121/82 53/24 45/19y 17/14 18/5 24/19y 33/22 8/15 d d d d 61/44 3/21 25/16 42/20 d d 38/19 536/361
Time to Surgery, mo 24 (4-60) d 20 (11-32) 20.7 (13-29) 19.4 (11-32) d 21 (4-48) d d d d 24 (3-120) 13 (5-60) 15.8 12.2 60 (24-96) d d d d d d 12 (6-60) 21 (5-60) 23.4 (5-132) d d d d 22.5
Follow-up Time, mo 34 (24-48) 49 31 (25-48) 32.8 (25-48) 34.2 (25-45) 21.5 (8-62) 13 39.1 17.3 d d 23.5 (8-60) 33.5 (24-66) 25 (12-38) 32.2 19.4 3 and 12 31.2 (12-54) 3 and 6 d d d d 24 (21-26) 22 (12-92) 83.7 (21-152) 12 and 24 d d 78 (60-96) 35.3
Age at Surgery, yr 31 (11-68) 38 (16-65) 27 (19-32) 25.2 (19-31) 28.1 (19-32) 28.5 (19-47) 31 (16-62) 35.4 12.3 35.3 13.6 31.2 14.2 24.5 (17-42) 34 (16-74) 27.2 (15-53) 25 8.3 (14-43) 34 (17-55) 34 (20-67) 38.13 6.85 d d d d 35 (16-62) 35 (21-54) 33.2 (15-63) 31 (16-52) d d 36 (21-59)x 32.7
NOTE. Data are presented as mean (range), mean SD, or mean SD (range) unless otherwise indicated. e, not reported; AL, anterolateral impingement; AM, anteromedial impingement; Ant, anterior impingement; B, bony impingement; F, female; M, male; ST, soft-tissue impingement. *Additional information was requested from authors. y Incorrect number of patients or sex distribution reported in study. z Studies on same population. x At follow-up.
population; or because they did not report on the outcome of anterior arthroscopy. One study was added after review of the reference lists, resulting in a total of 65 full-text articles for the full-text review. On the basis of full-text evaluation, 45 articles were excluded. The remaining 20 articles were included in this systematic review3,5,9,14,23-25,30,36-47 (Fig 3). Population Characteristics One of the 20 studies reported on the long-term follow-up of another study; therefore only 19 unique study populations were included. The number of patients in these studies totaled 905, with a mean age of 32.7 years and a male-female ratio of 536:361. The mean follow-up time was 35.3 months, and the mean time until surgery was 22.5 months (Table 1). Ten studies reported on “anterolateral impingement,” four studies reported on “anterior impingement,” and one study reported the results of the treatment of “anteromedial impingement.” The 4 remaining studies reported on “anterolateral and anterior impingement”
or “anterolateral and anteromedial impingement” (Table 2). Two studies drew distinction between bony and softtissue or ﬁbrous impingement. Two studies reported a mean follow-up time of less than 1 year,43,44 whereas 2 other studies reported a mean follow-up of more than 5 years.5,47 A complete overview of the study characteristics is provided in Tables 1 and 2. Five studies made use of a classiﬁcation for anterior impingement. Five studies used the Scranton and McDermott scale,19 of which 2 studies excluded stage IV. An osteoarthritis scale3 was used by 2 studies of the same patient population (Table 3). Ten studies excluded patients with signs of osteoarthritis, whereas 10 others either did not exclude or did not report exclusion criteria. Chondral damage was reported in 9 studies, and 6 studies excluded patients with osteochondral defects or related pathology. Five studies excluded patients with ankle instability. Table 3 shows the distribution of arthroscopic ﬁndings in the different populations.
Table 2. Exclusion Criteria Localization AL Ant AL/Ant
Invasive Distraction No No No
Surgeons 1 d d
Diagnosis Phys exam, Xap, Xlat, MRI Phys exam, Xap, Xlat, MRI Phys exam, Xap, Xlat, MRI
Branca et al.23 Brennan et al.24
Phys exam, Xlat MRI
Cavallo et al.39 Di Palma et al.40 Ferkel et al.41 Hassan42
AM/AL/W/T AL AL AL
d Yes No No
1 d d 1
Phys exam, Xap, Xlat, MRI Phys exam, Xap, Xlat, CTartro, MRI Phys exam, Xap, Xlat, MRI Phys exam, Xap, Xlat, Xobl, MRI
Ant AL AL AL
No NR No d
d d 4 d
Phys exam, Xap, Xlat, Xstress, bone scan, MRI Phys exam, Xap, Xlat, MRI Phys exam, Xlat, Phys exam, Xlat, Xap, MRI
Murawski and Kennedy9 Ogilvie-Harris et al.45* Rasmussen and Hjorth30 Rouvillain et al.46
AM AL/Ant Ant AL
No No No No
1 d d 2
Phys exam, Xlat, X AMI, MRI, injection Phys exam, Xlat, Xap, Xstress, MRI Phys exam Phys exam, Xlat, Xstress, CTartro, MRI, bone scan
Ürgüden et al.47 van Dijk et al.3y
Phys exam, Xlat, MRI Phys exam, Xap, Xlat
Jerosch et al.25 Koczy et al.43* Liu et al.14 Mardani-Kivi et al.44
Tol et al.5y
Exclusion Criteria NR Sc IV Signiﬁcant instability, severe osteoarthritic changes NR Degenerative changes, osteochondral defects, intra-articular loose bodies, infection, inﬂammatory arthritis NR Serious chronic lateral instability Associated fracture,