Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-2980-y
ANKLE
Combined arthroscopic management of concurrent posterior and anterior ankle pathologies Nasef Mohamed Nasef Abdelatif
Received: 11 September 2013 / Accepted: 30 March 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To determine the technical feasibility and preliminary clinical efficacy of performing simultaneous arthroscopic management in cases with combined posterior and anterior ankle pathologies utilizing previously described standard arthroscopic procedures within a single surgical sitting. Methods Nineteen consecutive patients with combined anterior and posterior ankle pathologies were included in the current study, after at least 6 months of failed conservative managements. Combined standard posterior and anterior ankle arthroscopy was performed in all patients within the same surgical session; first with the patient in the prone position, then with the patient turned onto the supine position to perform the anterior procedure. Results All patients were available for the follow-up; the median follow-up period was 33 months (range 22–61 months). No persistent neurological deficits or infections were recorded. The American Orthopedic Foot and Ankle Society Ankle and Hind foot Scale score significantly improved from 70.2 ± 15.2 points preoperatively to reach 93.0 ± 5.4 points at 1 year post-operatively (p \ 0.001). Sixteen patients (84.2 %) returned to their previous activity levels. Conclusions Combined arthroscopic management of concurrent posterior and anterior ankle pathologies within the same surgical session is initially clinically encouraging; it allows for an earlier return to activities of daily living without a significantly added morbidity. Level of evidence Case series, Level IV. N. M. N. Abdelatif (&) Department of Orthopedic Surgery, Faculty of Medicine, Bani Suef University Hospital, Bani Suef, Egypt e-mail: [email protected]; [email protected]
Keywords Ankle arthroscopy Combined anterior and posterior pathology Simultaneous management
Introduction The numerous pathological conditions that might affect the ankle joint and its immediate vicinity have typically been classified according to their anatomical location and described as being anterior, posterior, or central in the ankle joint [7–9, 11, 21, 24, 29, 33]. Generally, lesions requiring surgery can be approached arthroscopically by a two-portal anterior approach or via a two-portal posterior approach [35]. There are a few reports in literature that describe symptomatic combined anterior and posterior pathologies when occurring simultaneously within the same ankle joint and the different methods of surgical management of these concurrent conditions [2, 4, 15, 22]. When these pathologies coexist, both should be treated. The originally described management protocol involved utilization of an anterior ankle arthroscopy combined with a posterior ankle arthrotomy [15]. More recently, there have been few manuscripts that technically describe positioning manoeuvres during the proposed simultaneous management of these concurrent anterior and posterior pathologies [2, 14, 23]. There have been very few reports, however, that actually describe the application of concomitant arthroscopic measures on a case series studies of patients with simultaneous anterior and posterior ankle pathologies [3, 4, 18]. The aim of the current study was to assess the feasibility and preliminary effectiveness of performing simultaneous arthroscopic management for anterior and posterior ankle pathologies during the same surgical session, by utilizing previously described standard arthroscopic procedures.
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Materials and methods The current study and study scheme were approved by the institutional review board of our University hospital. This case series prospectively evaluated 19 patients with signs and symptoms of combined anterior and posterior ankle pathologies within the time period between April 2007 and May 2012. All patients could recall at least a single major traumatic incident to their ankle, to which they partly attributed their current status; eight patients recalled more than one single traumatic incident. The most common mechanism of injury was ankle inversion and/or plantar flexion. The primary diagnosis was based upon clinical symptoms, signs, and radiographic findings. Careful detailed history taking and staged clinical examination of the ankle were performed according to the generally accepted guidelines [25, 36]. All patients were subjected to standard weight-bearing antero-posterior and lateral radiographs, in addition to mortise views of the ankle. Stress views were performed routinely for all included patients to exclude instability of the ankle joint. In addition, magnetic resonance imaging (MRI) was performed for all the included patient population (Fig. 1). Computerized tomographic scans were performed especially when occult
osteochondral lesions (OCL) of the talar dome were suspected. A diagnosis of combined anterior and posterior impingement was made if patients reported ankle pain that might have followed a prior ankle injury and were found on clinical examination to have pain on forced dorsiflexion of the everted foot with or without tenderness in the notch of Harty and/or syndesmosis, and posterior pain on forced ankle plantar flexion, with or without postero-medial or postero-lateral tenderness. The physical findings were then correlated with the positive radiological data taking into consideration the fallacies and anatomical variants that could be present exclusively on the radiographs [5, 19, 20, 31] The indications for surgery were persistent ankle pain in spite of at least 6 months of conservative methods of management including oral antiinflammatory drugs, orthotics and activity modification, physiotherapy with strengthening and proprioceptive exercises, and a failure of relief of symptoms after local steroid injections. Patients were excluded if found to have had a history of inflammatory arthropathy or if diagnosed with other alternative causes of ankle pain, such as ankle fracture history, posterior tibial tendon dysfunction, Achilles tendinopathies, peroneal tendinitis or subluxations, instability of the
Fig. 1 Plain radiographs (a) and MRI (b, c, and d) of a case showing both anterior ankle compartment pathology; osteophytes and loose bodies, in addition to posterior ankle impingement; FHL tenosynovitis and symptomatic os trigonum
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ankle joint, tarsal coalitions, established arthritis, or sinus tarsi syndrome. A single surgeon performed all procedures concurrently. After standard preoperative preparation, thigh tourniquet placement, and portal markings, the arthroscopic procedure was then performed. A 4-mm, 30° angle arthroscope was used routinely. First, with the patient lying prone, the posterior pathology was addressed according to the twoportal method previously described by van Dijk et al. [34, 37]. After completion of the posterior procedure, the posterior portals were sutured and covered by sterile dressings. The patient was then turned supine on the operating table, the foot and ankle were re-prepped and sterilized, and fresh sterile draping was then applied. The anterior arthroscopy portals and anatomical landmarks were previously outlined before the start of the initial surgical procedure to facilitate the procedure. After re-positioning of the patient, the anterior procedure was performed in a similar standard fashion [32, 33]. Post-operatively, an elastic compression stocking was applied for a minimum of 1 week. Routinely, post-operative radiographs were performed for all patients (Fig. 2). Range of motion movements of the ankle joint were encouraged from the onset as soon as tolerated by the patient. Protected weight bearing was advised initially for the first 3 days. In the two cases with OCL of the talar dome, non-weight bearing on the affected limb was planned for 6 weeks post-operatively. The patients were seen 1 week after the initial procedure, and physiotherapy was prescribed for ROM, strengthening, and stability of the ankle joint.
Fig. 2 Plain post-operative radiographs of the same patient in Fig. 1 showing treatment of the anterior and posterior pathologies encountered
The primary outcome measure was the American Orthopedic Foot and Ankle Society (AOFAS) Ankle and Hind foot Scale scores [17] documented on the last followup visit. Patients’ subjective satisfaction was assessed with 3 questions: (1) Are you satisfied with the outcome of the operation on your ankle? (2) Would you perform the same operation again if you were given the choice, with your current knowledge of the procedure? and (3) Has your ankle function improved since the operation on your ankle? The patient was considered extremely satisfied if the response was ‘‘yes’’ to all questions, and moderately satisfied if the reply was ‘‘yes’’ to 2 questions. The patient was considered dissatisfied if the reply was with ‘‘yes’’ to one or none of the questions. The secondary outcome measure was the ability of the patients’ to resume their individual activity levels. Statistical analysis Data were analysed using SPSSwin statistical package version 17 (SPSS Inc., Chicago, IL). Numerical data were expressed as mean ± SD and median and range. Comparison of repeated measures of numerical variables was done using Wilcoxon signed-ranks test. A p value \0.001 was considered significant.
Results The average age of the patients was 29.4 ± 5.6 years (range 21–37 years). All but one of the included patients were males. The median duration of persistence of symptoms was 15 months (range 7–73 months). Fourteen patients (73.7 %) were actively involved in sporting activities. Table 1 shows anterior and posterior pathological lesions in the 19 patients. All patients were available for follow-up. The median followup period was 33 months (range 22–61 months). The studied group showed a significant post-operative improvement of AOFAS Ankle and Hind foot Scale scores (p \ 0.001) (Table 2). Sixteen patients (84.2 %) returned to their previous activity levels. Two patients (10.5 %) resumed a lower level of activity but were satisfied with their procedure and required no further interventions. All but one patient reported that they were either moderately (n = 3) or extremely satisfied (n = 15) with their ankle procedure. Also, all but a single patient reported they would definitely undergo the same procedure once more, if necessary. The discontented patient was a worker’s compensation case, and she complained of not being able to return to her preinjury level within the first 6 months and consequently requested a medical transfer to a less strenuous line of work.
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Knee Surg Sports Traumatol Arthrosc Table 1 The anterior and posterior pathological ankle lesions in the studied group Number
Percentage
Anterior ankle pathology
Discussion
Bony impingement ? AL imping Bony impingement
2
10.5
13
68.4
Bony impingement and synovial chondromatosis
1
5.3
OCL PM talus
1
5.3
Anterolateral impingement
1
5.3
Anterolateral impingement and OCL
1
5.3
4
21.1
4
21.1
11
57.9
Posterior ankle pathology FHL tenosynovitis Os trigonum Os trigonum ? FHL tenosynovitis
AL anterolateral, OCL osteochondral lesion, PM postero-medial
Table 2 Duration and outcome of surgery in the studied group Mean ± SD
Median (range)
Duration of surgery Anterior procedure (min.)
33.9 ± 8.4
35 (20–50)
Posterior procedure (min.)
55.8 ± 11.7
55 (40–80)
Position changing (min.) Total (min.)
14.7 ± 3.5 102.9 ± 17.0
15 (10–20) 105 (70–140)
Time to weight bearing on the affected ankle (days)
11.6 ± 11.8
7 (4–45)
Time to return to full activity (weeks)
7.4 ± 1.9
7 (5–12)
AOFAS ankle and hind foot scale scores Preoperative
70.2 ± 15.2
74 (30–81)
Post-operative
93.0 ± 5.4
93 (85–100)
Ankle movement Plantar flexion Preoperative
30°–9°
30° (10°–40°)
Post-operative
44°–6°
45° (25°–50°)
Preoperative
12°–3°
15° (5°–15°)
Post-operative
18°–3°
20° (10°–20°)
Preoperative
42°–11°
45° (15°–55°)
Post-operative
63°–8°
65° (35°–70°)
Dorsiflexion
Range of motion
There were no documented cases of neurovascular complications in both the anterior and posterior ankle compartments. There was one case of mild paresthesia on the dorsum of the lateral aspect of the foot and ankle that resolved spontaneously within 5 weeks. A single patient had a superficial skin infection, which was treated with
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antibiotic therapy, proper dressings, and wound care and resolved within 3 weeks.
The current case series demonstrates satisfactory results when performing concurrent standard ankle arthroscopy for management of cases with combined posterior and anterior ankle pathology within the same surgical session without adding marked morbidity. The possibility of the occurrence of both anterior and posterior ankle pathologies within the same ankle joint should be in the mind of clinicians when examining patients with chronic ankle pain. Hamilton [13] was first accredited to have described posterior ankle impingement occurring after anterior impingement, in dancers with associated ankle rotatory instability. Following which, there have been reports where the anterior procedure was performed arthroscopically while the posterior pathology was performed through an open arthrotomy [15]. Theoretically, changing the patient’s set-up from the prone to the supine position or vice versa would prolong the operative time and would carry the potential risk of contamination of the arthroscopic instruments and consequently increase the overall risk of infection [18]. It was such possible hazards that lead several articles to be focused mainly on the technical tips of performing such combined arthroscopic manoeuvres without the need for re-positioning of the patient [1, 2, 14, 18, 23]. There have been a few published reports on posterior ankle arthroscopy in which the authors found it necessary to perform an anterior arthroscopy for additional anterior ankle pathology [6, 12, 27, 38]. It is, however, unclear in all of these studies whether the diagnosis and management of both conditions were prepared for and managed simultaneously. To the best of our knowledge, there have been no case series reporting the use of standard posterior and anterior ankle arthroscopic measures to treat concurrent posterior and anterior ankle pathologies within the same surgical session as is described in the current study. However, recently, Scholten and Van Dijk presented a case report, describing standard arthroscopic management of a single patient with similar combined ankle pathology [30]. Anterior and posterior ankle pathologies have been well established in literature and have usually been considered as different entities with different methods of causation and different treatment modalities. Standard ankle arthroscopy portals have likewise been well described in literature [29, 33]. The efficacy of the arthroscopic procedures to treat ankle pathologies individually has also been well documented in the literature [10, 16, 28, 29, 33, 37]. The current study was found to have similar success with regard to the significant improvement of the AOFAS Ankle and Hind
Knee Surg Sports Traumatol Arthrosc
foot Scale scores from 70.2 ± 15.2 to 93.0 ± 5.4 points (p \ 0.001). These results favour comparably with each of the anterior arthroscopic procedures and the posterior arthroscopic procedures individually, even though they have both been performed concurrently within the same surgical session. The time taken to re-position the patient (14.7 ± 3.5 min) was found to be acceptable and did not ultimately interfere with the maximal application time of a single lower limb tourniquet. The rate of infection was also not affected by the need to re-position the patient during the procedure; we found only one case of mild superficial infection of the anterolateral portal, a complication rate that favoured well with other studies [10, 26, 39]. The limitations of the current study are obvious and several. As is with all preliminary case series reports, these limitations include primarily; the small number of patients included, in addition to the diversity of the anterior and posterior ankle pathologies treated. Because of these limitations, it might be difficult to make definitive conclusive statements regarding the efficiency of this combined surgical technique. Further investigation is clearly necessary to provide more accurate information in this regard. Long-term follow-up studies with proper patient pathology selection and the comparison to open management and individualized staged arthroscopic procedures may prove to be of value.
Conclusion Simultaneous arthroscopic management of concurrent anterior and posterior pathologies of the ankle joint is a minimally invasive technique. It allows for management of the various pathologies that might be encountered within a single surgical sitting; obviating the need for staged arthroscopic procedures or for the less familiar, more complex positioning manoeuvres.
References 1. Acevedo JI, Busch MT, Ganey TM, Hutton WC, Ogden JA (2000) Coaxial portals for posterior ankle arthroscopy: an anatomic study, with clinical correlation on 29 patients. Arthroscopy 16(8):836–842 2. Allegra F, Maffulli N, Cerza F, Delianni E (2009) Posteromedial approach procedure in the supine position for one-step anterior and posterior ankle arthroscopy. Sports Med Arthrosc 17(3):185–189 3. Allegra F, Maffulli N (2010) Double postero-medial portals for posterior ankle arthroscopy in supine position. Clin Orthop Relat Res 468(4):996–1001 4. Bojanic I, Bergovec M, Smoljanovic T (2009) Combined anterior and posterior arthroscopic portals for loose body removal and synovectomy for synovial chondromatosis. Foot Ankle Int 30(11):1120–1123
5. Bureau NJ, Cardinal E, Hobden R, Aubin B (2000) Posterior ankle impingement syndrome; MR imaging findings in seven patients. Radiology 215(2):497–503 6. Corte-Real NM, Moreira RM, Guerra-Pinto F (2012) Arthroscopic treatment of tenosynovitis of the flexor hallucis longus tendon. Foot Ankle Int 33(12):1108–1112 7. Coughlin MJ, Mann RA (1993) Tarsal tunnel syndrome. In: Mann RA, Coughlin MJ (eds) Surgery of the foot and ankle, 6th edn. Mosby, St. Louis, pp 554–558 8. Cutsuries AM, Saltrick KR, Wagner J, Catanzariti AR (1994) Arthroscopic arthroplasty of the ankle joint. Clin Podiatr Med Surg 11(3):449–467 9. de Leeuw PA, Golano P, van Dijk CN (2008) A 3-portal endoscopic groove deepening technique for recurrent peroneal tendon dislocation. Tech Foot Ankle Surg 7(4):250–256 10. Deng DF, Hamilton GA, Lee M, Rush S, Ford LA, Patel S (2012) Complications associated with foot and ankle arthroscopy. J Foot Ankle Surg 51(3):281–284 11. Gougoulias NE, Agathangelidis FG, Parsons SW (2007) Arthroscopic ankle arthrodesis. Foot Ankle Int 28(6):695–706 12. Guo QW, Hu YL, Jiao C, Ao YF, Tian DX (2010) Open versus endoscopic excision of a symptomatic os trigonum: a comparative study of 41 cases. Arthroscopy 26(3):384–390 13. Hamilton WG (1993) Foot and ankle injuries in dancers. In: Mann RA, Coughlin MJ (eds) Surgery of the foot and ankle, 6th edn. Mosby, St. Louis, pp 1241–1276 14. Hampton CB, Shawen SB, Keeling JJ (2010) Positioning technique for combined anterior, lateral, and posterior ankle and hind foot procedures: technical tip. Foot Ankle Int 31(4):348–350 15. Henderson I, La Valette D (2004) Ankle impingement: combined anterior and posterior impingement syndrome of the ankle. Foot Ankle Int 25(9):632–638 16. Jacobson K, Ng A, Haffner KE (2011) Arthroscopic treatment of anterior ankle impingement. Clin Podiatr Med Surg 28(3):491–510 17. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M (1994) Clinical rating systems for the ankle-hindfoot, midfoot hallux and lesser toes. Foot Ankle Int 15(7):349–353 18. Kim HK, Jeon JY, Dong Q, Kim HN, Park YW (2013) Ankle arthroscopy in a hanging position combined with hindfoot endoscopy for the treatment of concurrent anterior and posterior impingement syndrome of the ankle. J Foot Ankle Surg 52(6):704–709 19. Lawson JP (1985) Symptomatic radiographic variants in the extremities. Radiology 157(3):625–631 20. Liu SH, Nuccion SL, Finerman G (1997) Diagnosis of anterolateral ankle impingement: comparison between magnetic resonance imaging and clinical examination. Am J Sports Med 25(3):390–394 21. Lombardi CM, Silhanek AD, Connolly FG (1999) Modified arthroscopic excision of the symptomatic os trigonum and release of the flexor hallucis longus tendon: operative technique and case study. J Foot Ankle Surg 38(5):347–351 22. Lui TH, Chan WK, Chan KB (2006) The arthroscopic management of frozen ankle. Arthroscopy 22(3):283–286 23. Lui TH (2008) Ankle arthroscopy with patient in prone position. Arch Orthop Trauma Surg 128(11):1283–1285 24. McGahan PJ, Pinney SJ (2010) Current concept review: osteochondral lesions of the talus. Foot Ankle Int 31(1):90–101 25. Mizel MS, Hecht PJ, Marymont JV, Temple HT (2004) Evaluation and treatment of chronic ankle pain. J Bone Joint Surg Am 86:622–632 26. Nickisch F, Barg A, Saltzman CL, Beals TC, Bonasia DE, Phisitkul P, Femino JE, Amendola A (2012) Postoperative complications of posterior ankle and hindfoot arthroscopy. J Bone Joint Surg Am 94(5):439–446
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Knee Surg Sports Traumatol Arthrosc 27. Ogut T, Ayhan E, Irgit K, Sarikaya AI (2011) Endoscopic treatment of posterior ankle pain. Knee Surg Sports Traumatol Arthrosc 19(8):1355–1361 28. Robinson DE, Winson IG, Harries WJ, Kelly AJ (2003) Arthroscopic treatment of osteochondral lesions of the talus. J Bone Joint Surg Br 85(7):989–993 29. Scholten PE, Seirevelt IN, van Dijk CN (2008) Hindfoot endoscopy for posterior ankle impingement. J Bone Joint Surg Am 90(12):2665–2672 30. Scholten PE, van Dijk CN (2012) Case report: combined posterior and anterior ankle arthroscopy. Case Rep Orthop 2012:693124. doi:10.1155/2012/693124 31. Schweitzer ME, van Leersum M, Ehrlich SS, Wapner K (1994) Fluid in normal and abnormal ankle joints: amount and distribution as seen on MR images. Am J Roentgenol 162(1):111–114 32. Tol JL, van Dijk CN (2006) Anterior ankle impingement. Foot Ankle Clin 11(2):297–310
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33. Tol JL, Verheyen CP, van Dijk CN (2001) Arthroscopic treatment of anterior impingement in the ankle. J Bone Joint Surg Br 83(1):9–13 34. van Dijk CN, Scholten PE, Krips R (2000) A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthroscopy 16(8):871–876 35. van Dijk CN, van Bergen CJ (2008) Advancements in ankle arthroscopy. J Am Acad Orthop Surg 16(11):635–646 36. van Dijk CN (2006) Anterior and posterior ankle impingement. Foot Ankle Clin 11(3):663–683 37. van Dijk CN (2006) Hindfoot endoscopy. Foot Ankle Clin 11(2):391–414 38. Willits K, Sonneveld H, Amendola A, Giffin JR, Griffin S, Fowler PJ (2008) Outcome of posterior ankle arthroscopy for hindfoot impingement. Arthroscopy 24(2):196–202 39. Zengerink M, van Dijk CN (2012) Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 20(8):1420–1431
ANKLE
Combined arthroscopic management of concurrent posterior and anterior ankle pathologies Nasef Mohamed Nasef Abdelatif
Received: 11 September 2013 / Accepted: 30 March 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To determine the technical feasibility and preliminary clinical efficacy of performing simultaneous arthroscopic management in cases with combined posterior and anterior ankle pathologies utilizing previously described standard arthroscopic procedures within a single surgical sitting. Methods Nineteen consecutive patients with combined anterior and posterior ankle pathologies were included in the current study, after at least 6 months of failed conservative managements. Combined standard posterior and anterior ankle arthroscopy was performed in all patients within the same surgical session; first with the patient in the prone position, then with the patient turned onto the supine position to perform the anterior procedure. Results All patients were available for the follow-up; the median follow-up period was 33 months (range 22–61 months). No persistent neurological deficits or infections were recorded. The American Orthopedic Foot and Ankle Society Ankle and Hind foot Scale score significantly improved from 70.2 ± 15.2 points preoperatively to reach 93.0 ± 5.4 points at 1 year post-operatively (p \ 0.001). Sixteen patients (84.2 %) returned to their previous activity levels. Conclusions Combined arthroscopic management of concurrent posterior and anterior ankle pathologies within the same surgical session is initially clinically encouraging; it allows for an earlier return to activities of daily living without a significantly added morbidity. Level of evidence Case series, Level IV. N. M. N. Abdelatif (&) Department of Orthopedic Surgery, Faculty of Medicine, Bani Suef University Hospital, Bani Suef, Egypt e-mail: [email protected]; [email protected]
Keywords Ankle arthroscopy Combined anterior and posterior pathology Simultaneous management
Introduction The numerous pathological conditions that might affect the ankle joint and its immediate vicinity have typically been classified according to their anatomical location and described as being anterior, posterior, or central in the ankle joint [7–9, 11, 21, 24, 29, 33]. Generally, lesions requiring surgery can be approached arthroscopically by a two-portal anterior approach or via a two-portal posterior approach [35]. There are a few reports in literature that describe symptomatic combined anterior and posterior pathologies when occurring simultaneously within the same ankle joint and the different methods of surgical management of these concurrent conditions [2, 4, 15, 22]. When these pathologies coexist, both should be treated. The originally described management protocol involved utilization of an anterior ankle arthroscopy combined with a posterior ankle arthrotomy [15]. More recently, there have been few manuscripts that technically describe positioning manoeuvres during the proposed simultaneous management of these concurrent anterior and posterior pathologies [2, 14, 23]. There have been very few reports, however, that actually describe the application of concomitant arthroscopic measures on a case series studies of patients with simultaneous anterior and posterior ankle pathologies [3, 4, 18]. The aim of the current study was to assess the feasibility and preliminary effectiveness of performing simultaneous arthroscopic management for anterior and posterior ankle pathologies during the same surgical session, by utilizing previously described standard arthroscopic procedures.
123
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Materials and methods The current study and study scheme were approved by the institutional review board of our University hospital. This case series prospectively evaluated 19 patients with signs and symptoms of combined anterior and posterior ankle pathologies within the time period between April 2007 and May 2012. All patients could recall at least a single major traumatic incident to their ankle, to which they partly attributed their current status; eight patients recalled more than one single traumatic incident. The most common mechanism of injury was ankle inversion and/or plantar flexion. The primary diagnosis was based upon clinical symptoms, signs, and radiographic findings. Careful detailed history taking and staged clinical examination of the ankle were performed according to the generally accepted guidelines [25, 36]. All patients were subjected to standard weight-bearing antero-posterior and lateral radiographs, in addition to mortise views of the ankle. Stress views were performed routinely for all included patients to exclude instability of the ankle joint. In addition, magnetic resonance imaging (MRI) was performed for all the included patient population (Fig. 1). Computerized tomographic scans were performed especially when occult
osteochondral lesions (OCL) of the talar dome were suspected. A diagnosis of combined anterior and posterior impingement was made if patients reported ankle pain that might have followed a prior ankle injury and were found on clinical examination to have pain on forced dorsiflexion of the everted foot with or without tenderness in the notch of Harty and/or syndesmosis, and posterior pain on forced ankle plantar flexion, with or without postero-medial or postero-lateral tenderness. The physical findings were then correlated with the positive radiological data taking into consideration the fallacies and anatomical variants that could be present exclusively on the radiographs [5, 19, 20, 31] The indications for surgery were persistent ankle pain in spite of at least 6 months of conservative methods of management including oral antiinflammatory drugs, orthotics and activity modification, physiotherapy with strengthening and proprioceptive exercises, and a failure of relief of symptoms after local steroid injections. Patients were excluded if found to have had a history of inflammatory arthropathy or if diagnosed with other alternative causes of ankle pain, such as ankle fracture history, posterior tibial tendon dysfunction, Achilles tendinopathies, peroneal tendinitis or subluxations, instability of the
Fig. 1 Plain radiographs (a) and MRI (b, c, and d) of a case showing both anterior ankle compartment pathology; osteophytes and loose bodies, in addition to posterior ankle impingement; FHL tenosynovitis and symptomatic os trigonum
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ankle joint, tarsal coalitions, established arthritis, or sinus tarsi syndrome. A single surgeon performed all procedures concurrently. After standard preoperative preparation, thigh tourniquet placement, and portal markings, the arthroscopic procedure was then performed. A 4-mm, 30° angle arthroscope was used routinely. First, with the patient lying prone, the posterior pathology was addressed according to the twoportal method previously described by van Dijk et al. [34, 37]. After completion of the posterior procedure, the posterior portals were sutured and covered by sterile dressings. The patient was then turned supine on the operating table, the foot and ankle were re-prepped and sterilized, and fresh sterile draping was then applied. The anterior arthroscopy portals and anatomical landmarks were previously outlined before the start of the initial surgical procedure to facilitate the procedure. After re-positioning of the patient, the anterior procedure was performed in a similar standard fashion [32, 33]. Post-operatively, an elastic compression stocking was applied for a minimum of 1 week. Routinely, post-operative radiographs were performed for all patients (Fig. 2). Range of motion movements of the ankle joint were encouraged from the onset as soon as tolerated by the patient. Protected weight bearing was advised initially for the first 3 days. In the two cases with OCL of the talar dome, non-weight bearing on the affected limb was planned for 6 weeks post-operatively. The patients were seen 1 week after the initial procedure, and physiotherapy was prescribed for ROM, strengthening, and stability of the ankle joint.
Fig. 2 Plain post-operative radiographs of the same patient in Fig. 1 showing treatment of the anterior and posterior pathologies encountered
The primary outcome measure was the American Orthopedic Foot and Ankle Society (AOFAS) Ankle and Hind foot Scale scores [17] documented on the last followup visit. Patients’ subjective satisfaction was assessed with 3 questions: (1) Are you satisfied with the outcome of the operation on your ankle? (2) Would you perform the same operation again if you were given the choice, with your current knowledge of the procedure? and (3) Has your ankle function improved since the operation on your ankle? The patient was considered extremely satisfied if the response was ‘‘yes’’ to all questions, and moderately satisfied if the reply was ‘‘yes’’ to 2 questions. The patient was considered dissatisfied if the reply was with ‘‘yes’’ to one or none of the questions. The secondary outcome measure was the ability of the patients’ to resume their individual activity levels. Statistical analysis Data were analysed using SPSSwin statistical package version 17 (SPSS Inc., Chicago, IL). Numerical data were expressed as mean ± SD and median and range. Comparison of repeated measures of numerical variables was done using Wilcoxon signed-ranks test. A p value \0.001 was considered significant.
Results The average age of the patients was 29.4 ± 5.6 years (range 21–37 years). All but one of the included patients were males. The median duration of persistence of symptoms was 15 months (range 7–73 months). Fourteen patients (73.7 %) were actively involved in sporting activities. Table 1 shows anterior and posterior pathological lesions in the 19 patients. All patients were available for follow-up. The median followup period was 33 months (range 22–61 months). The studied group showed a significant post-operative improvement of AOFAS Ankle and Hind foot Scale scores (p \ 0.001) (Table 2). Sixteen patients (84.2 %) returned to their previous activity levels. Two patients (10.5 %) resumed a lower level of activity but were satisfied with their procedure and required no further interventions. All but one patient reported that they were either moderately (n = 3) or extremely satisfied (n = 15) with their ankle procedure. Also, all but a single patient reported they would definitely undergo the same procedure once more, if necessary. The discontented patient was a worker’s compensation case, and she complained of not being able to return to her preinjury level within the first 6 months and consequently requested a medical transfer to a less strenuous line of work.
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Knee Surg Sports Traumatol Arthrosc Table 1 The anterior and posterior pathological ankle lesions in the studied group Number
Percentage
Anterior ankle pathology
Discussion
Bony impingement ? AL imping Bony impingement
2
10.5
13
68.4
Bony impingement and synovial chondromatosis
1
5.3
OCL PM talus
1
5.3
Anterolateral impingement
1
5.3
Anterolateral impingement and OCL
1
5.3
4
21.1
4
21.1
11
57.9
Posterior ankle pathology FHL tenosynovitis Os trigonum Os trigonum ? FHL tenosynovitis
AL anterolateral, OCL osteochondral lesion, PM postero-medial
Table 2 Duration and outcome of surgery in the studied group Mean ± SD
Median (range)
Duration of surgery Anterior procedure (min.)
33.9 ± 8.4
35 (20–50)
Posterior procedure (min.)
55.8 ± 11.7
55 (40–80)
Position changing (min.) Total (min.)
14.7 ± 3.5 102.9 ± 17.0
15 (10–20) 105 (70–140)
Time to weight bearing on the affected ankle (days)
11.6 ± 11.8
7 (4–45)
Time to return to full activity (weeks)
7.4 ± 1.9
7 (5–12)
AOFAS ankle and hind foot scale scores Preoperative
70.2 ± 15.2
74 (30–81)
Post-operative
93.0 ± 5.4
93 (85–100)
Ankle movement Plantar flexion Preoperative
30°–9°
30° (10°–40°)
Post-operative
44°–6°
45° (25°–50°)
Preoperative
12°–3°
15° (5°–15°)
Post-operative
18°–3°
20° (10°–20°)
Preoperative
42°–11°
45° (15°–55°)
Post-operative
63°–8°
65° (35°–70°)
Dorsiflexion
Range of motion
There were no documented cases of neurovascular complications in both the anterior and posterior ankle compartments. There was one case of mild paresthesia on the dorsum of the lateral aspect of the foot and ankle that resolved spontaneously within 5 weeks. A single patient had a superficial skin infection, which was treated with
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antibiotic therapy, proper dressings, and wound care and resolved within 3 weeks.
The current case series demonstrates satisfactory results when performing concurrent standard ankle arthroscopy for management of cases with combined posterior and anterior ankle pathology within the same surgical session without adding marked morbidity. The possibility of the occurrence of both anterior and posterior ankle pathologies within the same ankle joint should be in the mind of clinicians when examining patients with chronic ankle pain. Hamilton [13] was first accredited to have described posterior ankle impingement occurring after anterior impingement, in dancers with associated ankle rotatory instability. Following which, there have been reports where the anterior procedure was performed arthroscopically while the posterior pathology was performed through an open arthrotomy [15]. Theoretically, changing the patient’s set-up from the prone to the supine position or vice versa would prolong the operative time and would carry the potential risk of contamination of the arthroscopic instruments and consequently increase the overall risk of infection [18]. It was such possible hazards that lead several articles to be focused mainly on the technical tips of performing such combined arthroscopic manoeuvres without the need for re-positioning of the patient [1, 2, 14, 18, 23]. There have been a few published reports on posterior ankle arthroscopy in which the authors found it necessary to perform an anterior arthroscopy for additional anterior ankle pathology [6, 12, 27, 38]. It is, however, unclear in all of these studies whether the diagnosis and management of both conditions were prepared for and managed simultaneously. To the best of our knowledge, there have been no case series reporting the use of standard posterior and anterior ankle arthroscopic measures to treat concurrent posterior and anterior ankle pathologies within the same surgical session as is described in the current study. However, recently, Scholten and Van Dijk presented a case report, describing standard arthroscopic management of a single patient with similar combined ankle pathology [30]. Anterior and posterior ankle pathologies have been well established in literature and have usually been considered as different entities with different methods of causation and different treatment modalities. Standard ankle arthroscopy portals have likewise been well described in literature [29, 33]. The efficacy of the arthroscopic procedures to treat ankle pathologies individually has also been well documented in the literature [10, 16, 28, 29, 33, 37]. The current study was found to have similar success with regard to the significant improvement of the AOFAS Ankle and Hind
Knee Surg Sports Traumatol Arthrosc
foot Scale scores from 70.2 ± 15.2 to 93.0 ± 5.4 points (p \ 0.001). These results favour comparably with each of the anterior arthroscopic procedures and the posterior arthroscopic procedures individually, even though they have both been performed concurrently within the same surgical session. The time taken to re-position the patient (14.7 ± 3.5 min) was found to be acceptable and did not ultimately interfere with the maximal application time of a single lower limb tourniquet. The rate of infection was also not affected by the need to re-position the patient during the procedure; we found only one case of mild superficial infection of the anterolateral portal, a complication rate that favoured well with other studies [10, 26, 39]. The limitations of the current study are obvious and several. As is with all preliminary case series reports, these limitations include primarily; the small number of patients included, in addition to the diversity of the anterior and posterior ankle pathologies treated. Because of these limitations, it might be difficult to make definitive conclusive statements regarding the efficiency of this combined surgical technique. Further investigation is clearly necessary to provide more accurate information in this regard. Long-term follow-up studies with proper patient pathology selection and the comparison to open management and individualized staged arthroscopic procedures may prove to be of value.
Conclusion Simultaneous arthroscopic management of concurrent anterior and posterior pathologies of the ankle joint is a minimally invasive technique. It allows for management of the various pathologies that might be encountered within a single surgical sitting; obviating the need for staged arthroscopic procedures or for the less familiar, more complex positioning manoeuvres.
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