The Current State of Ankle Arthroscopy
Burman in 1931 scoped 3 ankles using a 4.Omm sheath without
distraction, he found it too tight for satisfactory visualisation.
Ankle arthroscopy really came of age in the 90's with the development
of 2.5mm arthroscopes, noninvasive distraction techniques and
Tagaki was the real father of the arthroscope. He developed a 2.7mm
arthroscope. However Watanabe developed matters further producing a
self-focusing 1.7mm arthroscope and arthroscoped 28 ankles, describing
the standard portals and normal anatomy.
Andrews wrote one of many texts on the subject in the late 80's. Guhl
developed a skeletal distracter for the ankle and wrote an excellent
Yates was the first to develop a non invasive distraction technique.
Advantages and Contra-indications
Arthroscopy allows direct articular inspection + assessment of
ligaments and synovial change. One can perform intraoperative stress
The following diagnoses can be made. OCD - 23.5%, Impingement - 21.3%,
Chrondromalacia - 7.9%, Instability - 7.2%, DJD - 7.2%, Acute Fracture
- 6.5%, Arthrofibrosis - 4.8%, Loose Bodies, Osteophytes, Synovitis,
Ossicles, Torn ATFL, Cryptogenic Pain, Cyst, Chondral Fracture,
Peroneal Subluxation, Torn Peroneal Tendon.
The following procedures can be performed. Debride lateral gutter -
21.8%, Excise/Drill OCD - 19.4%, Chondroplasty - 13.3%, Excise fibrous
bands - 6.8%, Loose bodies - 5.7%, Rx of fracture, Diagnostic,
Synovectomy, Osteophytes, Ossicles, Arthrodesis, Stabilisation
CONTRA-INDICATIONS - Relative - DJD, Oedema, Impaired vascularity.
Absolute - Soft tissue infection, Advanced DJD.
Ankle arthroscopy developed from the principles of knee arthroscopy and
hence initially the same instruments were applied. However as
experience developed with smaller instruments, distraction, and fluid
management systems, arthroscopy evolved.
Irrigation - Gravity, Gravity assist, Pumps.
Athroscopes - Hopkins 2.3mm, 2.7mm and 1.9mm diameters, 30 & 70
Distraction - Non invasive.
Instrumentation - Spinal needles, Probes, Dissectors - elevating OCD
lesions, ossicles, Graspers - flat tipped or pitbull for small or large
loose bodies (2.7-3.Omm), Basket forceps - straight, right and left, up
and down angles (2.53.00mm), Knives, Curettes, Osteotomes, Power
Instruments, Thigh/Ankle Holder, Aiming jigs.
Diagnostic Arthroscopic Examination of the Ankle
Ankle arthroscopy is a useful diagnostic modality to evaluate pathology
and determine correct treatment. It should not be used as a substitute
for careful history taking, examination and investigation. Its main
advantages are that it allows direct inspection and probing of all
intra-articular structures and their dynamic assessment. As such it is
virtually 100% accurate in diagnosing intra-articular disorders.
The ankle is first distended with approximately 30cc of saline. Then
the anteromedial portal is established just medial to tibialis anterior
at the level of the joint line carefully avoiding the saphenous nerve.
Then the anterolateral portal is established using transillumination,
avoiding the superficial branch of the lateral popliteal nerve. A full
diagnostic inspection of the anterior compartment is then carried out.
Then the posterolateral portal is made localising the entry point with
a spinal needle. Then a full inspection of the posterior compartment is
made. Using these three portals a full 21 point systemic ankle
examination can be carried out.
SOFT TISSUE LESIONS OF THE ANKLE
These are difficult to diagnose without arthroscopy despite careful
assessment and investigation. They represent some 3050% of lesions
found within the ankle joint and are diagnosed and treated by
Patients with such lesions present with a combination of pain,
swelling, tenderness, locking and giving way.
On examination one finds a combination of tenderness, wasting,
swelling, restricted range and instability.
Investigations include XR, CT, MRI, Arthritis tests. These all may be
Congenital - Plicae / bands - excise
Traumatic - sprains, fractures, prior surgery - excise generalised
synovitis, excise localised bands, excise meniscoid lesions secondary
Lateral ligament injuries are very common, with 1 ankle sprain per
10,000 occurring per day. Some 1-50% have some chronic pain.
Anterolateral impingement is the commonest
soft tissue impingement lesion and cause of pain after ankle inversion
injury - Wolin coined the term "the meniscoid lesions" for the
arthroscopic appearance of the lateral gutter in these patients.
Arthroscopic treatment is very successful in alleviating chronic pain
in 84% both subjectively and objectively.
During dorsiflexion of the ankle the malleoli are separated and the
syndesmosis is stressed, syndesmotic injuries are undoubtedly
underestimated. Syndesmotic injuries are best diagnosed by a localised
tenderness and a positive squeeze test pressing the tibia and fibula
together proximal to the syndesmosis half way up the calf. Syndesmotic
impingement is also associated with a separate distal
fascicle to the anterior talo-fibula ligament. The incidence of
syndesmotic injury is 3% of all ankle sprains.
Posterior impingement can occur and was first
described by Hamilton with posterior "meniscus" displacing inferiorly.
Also a labrum on the posterior lip of the tibia can hypertrophy when
Rheumatoid arthritis, X-tal synovitis, PVNS and Synovial Chondromatosis
can all affect the ankle. Rheumatoid arthritis has been reported to
have an arthroscopic cure. A 95% synovectomy is possible, and early
synovectomy is better than later.
PVNS can be treated arthroscopically in the ankle as elsewhere.
Synovial Chondromatosis is rare in the ankle, but is treated along
standard arthroscopic lines.
Other arthritides have been described such as gonarthritis, Crohn's
gout, chondrocalcinosis and are treated with arthroscopic synovectomy.
Bacterial and fungal infections occur and are best treated with
arthroscopic aspiration and synovial biopsy followed by washout and
irrigation then appropriate antibiotic therapy.
Primary and secondary osteoarthritis can be treated arthroscopically.
Arthrofibrosis post fracture or sprain can occur and is satisfactorily
treated by arthroscopic resection of the fibrous bands and early
ARTICULAR SURFACE DEFECTS, LOOSE BODIES AND OSTEOPHYTES
OCD Lesions of the talus - OLT
Osteochondral lesions of the talus as such were first described in 1856
by Monro but Konning coined the term "osteochondritis" when he found
similar pathology elsewhere in the body and thought the aetiology was
osteonecrosis. Kappis in 1922 first applied the term osteochondritis to
the ankle joint.
Berndt and Harty in 1959 postulated a traumatic aetiology and used the
term transchondral fracture of the talus. O'Donoghue said the lesions
were intra-articular fractures and Campbell and Ranawat felt the cause
was ischaemia in 1966. Alexander and Lichtman + Canale and Belding have
subsequently lent support to the traumatic aetiology in 1980. However
the exact aetiology remains uncertain.
It is certainly a condition which tends to be under diagnosed bearing
in mind that talar osteochondritis accounts for 4-10% of all
osteochondritides. It affects males more commonly than females and a
peak incidence at 20-30-years of age.
The lesions are either posteromedial or anterolateral. If they are
posteromedial - 70% are traumatic - are deep and not usually displaced.
They are usually caused by inversion of the dorsiflexed foot (torsional
impaction) ref. Of the anterolateral lesions - 90% are traumatic - are
usually thinner and are more commonly displaced. They are typically
caused by inversion of the plantar flexed foot.
Clinically patients present with a history of trauma, pain, swelling,
catching, givingway or locking. On examination one may find swelling
The diagnosis is best made by CT or MRI. A classification based on CT
correlates better with the arthroscopic findings than the original
classification of Berndt and Harty. Zinman and his colleagues found CT
to be superior to XR's in diagnosis, but MRI also has been advocated
particularly by Dipaoala. Anderson has developed an MRI based
classification and found CT to be as good as MRI except in diagnosing
grade 1 lesions.
Cheng and Ferkel went on to show CT to be the scan of choice if the
diagnosis is known but MRI if it is not. They have also developed an
Treatment of the stage 1& 2 lesions is 6-12 weeks in a cast,
but arthroscopy if conservative treatment fails. Stages 3 & 4
lesions are treated arthroscopically immediately.
Results of treatment are good with Loomer showing 80% good or excellent
The surgical approach is as follows for acute OLT. They are palpated
with a hook. Loose chondral fragments alone are excised but
osteochondral fragments are pinned or screwed into the base of the
defect whether displaced or undisplaced.
For chronic OLT again palpate with a hook, see if it is loose. Fix it
if it is loose and the underlying bone is healthy, if the underlying
bone is unhealthy you need to excise the loose fragment and drill the
base of the defect. Large areas can be treated by osteochondral graft
It has been shown by Buckwalter that penetration of subchondral bone
disrupts subchondral vessels, this produces bleeding, a clot and
fibrocartilagenous repair. The cells responsible for this enter from
the marrow. Significant cartilage defects can be repaired by tissue
which grows up drill holes to cover exposed subchondral bone.
The results of arthroscopic treatment of OLT are as good if not better
than open surgery i.e. 80% plus.
Osteophytes, loose bodies, and chondral lesions of the
Arthroscopic ankle surgery is also successful other pathologies apart
from impingement and OLT. Martin and Ferkel in 1989 reported 71%
good/excellent results for OLT lesions, 57% good/excellent results for
loose bodies and osteophytes and 12% good/excellent results for DJD.
With loose bodies it is necessary to inspect the posterior compartment
and you need to check all the articular surfaces carefully after their
Osteophytes in the ankle are a common condition known as the "anterior
kissing lesions" or "Footballers Ankle". It is O'Donoghue in 1966 who
reported a 45% incidence in American Football players, there is an even
higher incidence of 59.3% in dancers. Patients with "Footballers Ankle"
present with pain catching and restricted joint motion (dorsiflexion)
Treatment aims to reproduce the normal 60 degree tibiotalar angle. One
must be careful to avoid neurovascular injury when performing surgery
open or closed. Arthroscopically the borders of the osteophyte are
exposed with a 3.5mm soft tissue resector then the bony spurs
themselves are removed with burrs. Per operative lateral x-ray prior to
completion can be taken to ensure sufficient bony resection, it has
been shown that one obtains better results if the patients have
isolated spurs than generalised DJD but overall excellent results are
A classification with grades I-N was described by Scranton, (1-111
treatable arthroscopically) but even grade IV lesions can be addressed
arthroscopically. Interestingly talofibular bony impingement can also
Chondral lesions also occur and are usually caused by a sprain or also
by an RTA with direct compression of the articular cartilage. The
pathologies range from blistering to full thickness flap tears. These
lesions are frequently missed because of normal XR in A/E. If such
lesions are suspected then ankle arthroscopy is the only sure way to
diagnose them with a full examination of anterior and posterior
compartments required. Arthroscopic surgery is straight forward
resecting chondral flaps to stable base and drill exposed bone to
encourage vascular invasion and fibrocartilage formation.
Ankle arthroscopic debridement and lavage parallels that of
arthroscopic treatment of DJD in other joints.
Lateral ligament instability
Lateral ligament injury of the ankle is very common; with one person in
10,000 sustaining the injury per day it is the commonest ligament
injury seen by surgeons. Repeated lateral ligament injuries interfere
with normal daily life and with chronic instability a minor trauma can
cause a significant inversion injury with unpredictable outcome.
Surgery to correct lateral ligament instability was described as early
as 1949 by Nilsonne who described a peroneus brevis transfer. But it
was Brostrom who showed that direct repair of the lateral ligament was
possible even years after acute injury and Hamilton reported 93% good
or excellent results with a modified Brostrom procedure. With lateral
ligament tears it is the anterior talo-fibular ligament fails first,
calcaneo fibular ligament rupture is rare. A repair/reconstruction
ideally needs to reproduce the ATFL in its anatomic position and this
is what a Brostrom or Hamilton procedure does.
The diagnosis of lateral ligament instability is straight forward,
there is a history of instability the lateral ligaments are tender and
moving the ankle demonstrates excessive inversion and an exaggerated
anterior draw test, this is when the foot and talus are translocated
anteriorly in the mortis and the amount of anterior movement recorded
and compared with the normal side.
Radiographic lateral stress views can be performed applying set forces
of inversion. But results of such instability testing can be
questionable if the calcaneofibular ligament is intact and these
patients still have instability.
Arthroscopically there is ballooning of the anterolateral capsule which
appears and feels thinner than normal. One frequently sees scarring of
the lateral gutter and syndesmosis with associated loose bodies or
ossicles and lateral dome or plafond chondral changes.
Treatment is either an open or closed modified Brostrom repair with
three weeks in a below-knee cast then standard physiotherapy.
Arthroscopic results are as good as open.
An ankle arthrodesis if successful allows a patient to return to work
and some sports with a virtually normal gait. Fusion rates have been
reported from any series as in the order of 80% and infection occurring
in 5-25%. Morgan in 1985 reported a 96% fusion rate with 90%
good/excellent results. He maintained the contour of the talar dome,
kept the ankle in neutral and used cross-screw internal fixation.
Two years earlier Schneider first described arthroscopic ankle
arthrodesis. But it was Morgan who published the first report in 1987.
Myerson compared open and closed techniques of ankle arthrodesis with a
reported quicker fusion time arthroscopically of 8.7 versus 14.5 weeks
theoretically because of the lack of disruption of the soft tissues and
therefore a better blood supply to the fusing surfaces. The faster
fusion rate was backed up by Ogilvie-Harris who reported an 89% fusion
rate arthroscopically with 88% fused by the third post operative month!
The advantages of an arthroscopic arthrodesis are reduced morbidity,
shorter Hospital stay, faster fusion rate, better cosmesis and lower
complication rates. Against these are long learning curve for the
surgeon and theatre staff, it is a longer procedure and requires
expensive arthroscopic equipment. Also it cannot correct large varus,
or rotational deformities.
The contra-indications for an arthroscopic arthrodesis are >15
Degrees deformity, a previously failed arthrodesis, the presence of
infection, RSD and a charcot joint. Mann showed that the best fusion
position is with the ankle in neutral, avoiding >10 Degrees
plantar-flexion and with the os-calcis in 5 degrees valgus. Also the
"Mann" position results in the best gait. You do however lose 70% of
your total motion arc with an ankle fusion and tarsal hypermobility is
The arthroscopic technique is to have the standard arthroscopic set up
with either invasive or non-invasive distraction. Remove all articular
cartilage initially from the talar dome and planfond then the gutters
to expose bleeding underlying bone and finally the anterior osteophyte
needs removal as this would otherwise resist talar reduction. The
fusion is secured with crossed cannulated screws. Screw positioning is
arthroscopically assisted and the length of the screws can be image
The patients then spend 3 weeks non weight bearing followed by 4-6
weeks partial weight bearing. The screws can be removed later if they
are causing pain. A range of 3-12 months has been reported for standard
open fusion to occur, this compares unfavourably with the arthroscopic
technique. Mann from a multi-centre trial recently demonstrated a 91%
fusion and 84% good/excellent results. This fusion rate leaps to 96% if
known poor techniques are avoided, e.g. laser, external charley type
This article was specifically written for Chiropody Review and we thank
Mr Simon Moyes for the time and trouble he took.
CHIROPODY REVIEW,DECEMBER 1998
Article Source: http://www.articlesbase.com/medicine-articles/
About the Author
Mr Simon Moyes MB FRCS FRCSOrth is a Consultant
Orthopaedic Surgeon at the Wellington & Devonshire Hospitals,
London and webmaster of www.simonmoyes.com which is the
source of this article.