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Wolfe I, Williamson ERC, Godwin K, Schon LC, Rose DJ. Allograft Reconstruction of a Ruptured Flexor Hallucis Longus Tendon in a Professional Dancer: A Case Report. Foot Ankle Spec 2025:19386400251330103. [PMID: 40231779 DOI: 10.1177/19386400251330103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2025]
Abstract
Stenosing tenosynovitis/tendinitis of the flexor hallucis longus (FHL) tendon is a relatively common occurrence in dancers. When nonoperative management fails, surgical tenolysis/tenosynovectomy has been shown to successfully reduce pain and restore function. In this study, we present the case of a professional contemporary dancer with FHL stenosing tenosynovitis/tendinitis who underwent a z-lengthening of the FHL proximal to the intact tendon sheath which resulted in a rupture of the FHL upon return to dance. He subsequently underwent a FHL reconstruction with tendon allograft. He returned to unrestricted professional dance at 11 months postoperative, which has been maintained at 4-year clinical and MRI follow-up.Level of evidence: V.
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Affiliation(s)
- Isabel Wolfe
- From Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Emilie R C Williamson
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York
| | | | - Lew C Schon
- From Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Donald J Rose
- From Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Butler JJ, Resad S, Samsonov AP, Cole WW, Connolly P, Robin JX, Krebsbach S, Kennedy JG. Basics of Ankle Arthroscopy Part 3: Patient Positioning and Preparation for Posterior Ankle Arthroscopy. Arthrosc Tech 2024:103322. [DOI: 10.1016/j.eats.2024.103322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2025] Open
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Butler JJ, Roof M, Montgomery SR, Morgan A, Brash AI, Krebsbach S, Kennedy JG. Basics of Ankle Arthroscopy Part 4: Surface Anatomy, Portal Placement, and Diagnostic Evaluation for Posterior Ankle Arthroscopy. Arthrosc Tech 2024:103323. [DOI: 10.1016/j.eats.2024.103323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2025] Open
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Oesman I, Putra NHD, Andar AA, Mardhitiyani WA. Flexor hallucis longus impingement syndrome: A case report. Int J Surg Case Rep 2024; 121:109934. [PMID: 39024995 PMCID: PMC11295693 DOI: 10.1016/j.ijscr.2024.109934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 06/16/2024] [Accepted: 06/21/2024] [Indexed: 07/20/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Long-term friction of the FHL tendon's sheath (caused by sporting activities) can result in tendinitis, which causes pain in the foot and ankle and consequently interferes with everyday life and foot function. The FHL tendon is crucial for maintaining foot stability and can be damaged by overuse. FHL tendinitis can be also caused by inflammatory tendon sheath filled. Arthroscopy can play a role in the diagnosis and treatment of this condition. CASE PRESENTATION A 28-year-old female with left ankle pain was brought to our clinic after slipping on a train platform nine months ago. X-rays and MR imaging revealed a complete tear of the ATFL, minimal joint effusion, and a bony protrusion causing impingement. Arthroscopic surgery was performed, and the patient's pain sensation improved to 0-1 in the visual analogue scale (VAS) within three weeks. The Foot and Ankle Ability Measure (FAAM) score increased from 8 % to 100 %, and the patient was able to walk and perform daily activities normally. CLINICAL DISCUSSION The FHL tendon sheath begins at the posterior tubercles of the talus and forms a fibroosseous tunnel along the medial calcaneus, potentially leading to impingement during ankle or hallux dorsiflexion. FHL tendon impingement and tendinitis share clinical manifestations, and if conservative treatments (NSAIDs, physical therapy) fail after 6 months, arthroscopic surgery is recommended for its minimally invasive benefits. Both arthroscopic and open surgical techniques yield positive outcomes for FHL pathologies; however, they carry risks such as neurovascular complications, highlighting the necessity for surgical precision and expertise. CONCLUSION We concluded that in this case, FHL impingement was caused by the bony protrusion from Stieda process fragment. It was demonstrated that the arthroscopic surgery with loose body removal was successful and practical.
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Affiliation(s)
- Ihsan Oesman
- Foot and Ankle Division, Department of Orthopaedics and Traumatology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Nurmansyah Hata Dwi Putra
- Department of Orthopaedics and Traumatology, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Anindyo Abshar Andar
- Department of Orthopaedics and Traumatology, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.
| | - Winona Andrari Mardhitiyani
- Department of Orthopaedics and Traumatology, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Anastasio AT, Wixted CM, McGroarty NK. Osteochondral Lesions of the Talus: Etiology, Clinical Presentation, Treatment Options, and Outcomes. Foot Ankle Clin 2024; 29:193-211. [PMID: 38679433 DOI: 10.1016/j.fcl.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
This article reviews the etiology, clinical presentation, classification schemes, and treatment options for osteochondral lesions of the talus. These lesions typically occur after a traumatic injury and are best diagnosed on MRI. Asymptomatic lesions and incidentally found lesions are best treated conservatively; however, acute displaced osteochondral fragments may require surgical treatment. Lesion characteristics may dictate surgical technique. Outcomes following surgical treatment may be impacted by patient age, BMI, and lesion characteristics.
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Affiliation(s)
- Albert T Anastasio
- Department of Orthopaedics, Duke University Hospital, 200 Trent Drive, Durham, NC 27710, USA
| | - Colleen M Wixted
- Duke University School of Medicine, 8 Searle Center Drive, Durham, NC 27710, USA.
| | - Neil K McGroarty
- Department of Orthopaedics, Duke University Hospital, 200 Trent Drive, Durham, NC 27710, USA
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Mansur NSB, Femino JE, Chinnakkannu K, Fayed A, Glass N, Phisitkul P, Amendola A. Posterior Ankle Impingement: It's Not Only About the Os Trigonum. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241241326. [PMID: 38559392 PMCID: PMC10981862 DOI: 10.1177/24730114241241326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Background Os trigonum and Stieda process are common etiologies for posterior ankle impingement syndrome (PAIS), and diagnosis is typically made by radiographs, computed tomographic, or magnetic resonance imaging. However, these static tests may not detect associated soft tissue and bony pathologies. Posterior ankle and hindfoot arthroscopy (PAHA) is dynamic, providing at least ×8 magnification with full anatomical visualization. The primary aim of this study was to report the prevalence of associated conditions seen with trigonal impingement treated with PAHA. Methods In this retrospective comparative study, patients who underwent PAHA for PAIS due to trigonal impingement, from January 2011 to September 2016, were reviewed. Concomitant open posterior procedures and other indications for PAHA were excluded. Demographic data were collected with pre- and postoperative diagnosis, arthroscopic findings, type of impingement, location, associated procedures, and anatomical etiologies. Trigonal impingements were divided in os trigonal or Stieda and subgrouped as isolated, with flexor hallucis longus (FHL) disorders, with FHL plus other impingement, and with other impingement lesions. Results A total of 111 ankles were studied-74 os trigonum and 37 Stieda. Isolated trigonal disorders accounted for 15.3% of PAIS (n = 17). Cases having associated conditions had a mode of 3 additional pathologies. FHL disorders were found in 69.4%, subtalar impingement in 32.4%, posteromedial ankle synovitis in 25.2%, posterolateral ankle synovitis in 22.5%, and posterior inferior tibiofibular ligament impingement in 19.8% of cases. Associated pathologies were observed in 58.6% of cases when FHL was not considered. Significant differences were noted comparing os and Stieda (isolated: 20.3% to 5.4%, P = .040; FHL plus others: 35.1% to 59.5%, P = .015). Conclusion Trigonal bone (os trigonum or Stieda) was found to cause impingement in isolation in a small proportion of cases even when the FHL was considered part of the same disease spectrum. This should alert surgeons when considering removing trigonal impingement. Open approaches may limit the visualization and assessment of associated posterior ankle and subtalar pathoanatomy, thus possibly overlooking concomitant causes of PAIS. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- Nacime Salomao Barbachan Mansur
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Department of Orthopedics and Rehabilitation, Paulista School of Medicine, Federal University of Sao Paulo, Brazil
| | - John E. Femino
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Karthikeyan Chinnakkannu
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- BronxCare Health System, Bronx, NY, USA
| | - Aly Fayed
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Natalie Glass
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Phinit Phisitkul
- Department of Orthopaedics, Tri-State Specialists, Sioux City, IA, USA
| | - Annunziato Amendola
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Theodoulou MH, Ravine M. Posterior Ankle Impingement. Clin Podiatr Med Surg 2023; 40:413-424. [PMID: 37236679 DOI: 10.1016/j.cpm.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
This article is devoted to managing posterior ankle impingement syndrome and its management using endoscopic to arthroscopic surgical instrumentation. The authors explore the critical anatomy, pathogenesis, and clinical examination. Operative techniques, including the approach, and instrumentation used, are outlined. The postoperative protocol is discussed. Finally, a literature review is provided, which also defines known complications.
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Affiliation(s)
- Michael H Theodoulou
- Podiatric Surgery, Cambridge Health Alliance, Cambridge, MA, USA; Harvard Medical School, 1439 Cambridge Street, Cambridge, MA 02139, USA.
| | - Madison Ravine
- Cambridge Health Alliance Podiatric Medicine & Surgery Residency Program, 1439 Cambridge Street, Cambridge, MA 02139, USA
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Rui Xiang T, Zhen Ning Y, Oon Thien Kevin K. Two-Year Outcomes of Posterior Ankle Arthroscopy: A Case Series. Foot Ankle Spec 2022; 15:556-562. [PMID: 33435736 DOI: 10.1177/1938640020985822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to investigate the outcomes and complications after posterior ankle arthroscopy for the treatment of posterior ankle impingement syndrome, in a local population with a single surgeon series. Two-portal posterior ankle or hindfoot arthroscopy is an alternative option to open surgery in cases of posterior ankle impingement, that showed similar results but with less morbidity and faster recovery. There has been increasing interest in minimally invasive surgical techniques. Indications include extra- and intra-articular conditions and range from bony, cartilaginous to soft tissue pathology. Posterior ankle arthroscopy has been shown to be a good option in cases that are refractory to a period of conservative therapy. Posterior ankle arthroscopy also has known complications of sural nerve damage laterally and neurovascular bundle injury medially and also a steep learning curve that has been studied in the context of os trigonum excision. There have been few or no studies on the local Singaporean population and this article seeks to describe the various indications, results, and complications in the local Singaporean population by a single surgeon.Levels of Evidence: Level IV: Case series.
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Affiliation(s)
| | - Yeo Zhen Ning
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Posterior Ankle Impingement Syndrome Clinical Features Are Not Associated With Imaging Findings in Elite Ballet Dancers and Athletes. Clin J Sport Med 2022; 32:600-607. [PMID: 36315819 DOI: 10.1097/jsm.0000000000001021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/11/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the association between clinical features and magnetic resonance imaging (MRI) findings in posterior ankle impingement syndrome (PAIS) and to compare the prevalence of imaging findings between participants with and without a clinical diagnosis of PAIS. DESIGN Case-control study. SETTING Elite ballet and sport. PARTICIPANTS Eighty-two male (54%) and female participants comprising ballet dancers (n = 43), cricket fast bowlers (n = 24), and football (soccer) players (n = 15). INDEPENDENT VARIABLES Clinical: posterior ankle pain on body chart, passive plantarflexion pain provocation test. Patient-reported outcome measures: Oslo Sports Trauma Research Center Overuse Injury Questionnaire, Foot and Ankle Ability Measure Sports subscale. MAIN OUTCOME MEASURES Imaging findings including posterior ankle bone marrow edema, os trigonum (± bone marrow edema, and increased signal at synchondrosis), Stieda process (± bone marrow edema), talocrural and subtalar joint effusion-synovitis size, flexor hallucis longus tendinopathy, and tenosynovitis identified as present or absent on 3.0-Tesla MRI. RESULTS Imaging findings were not associated with posterior ankle pain or a positive ankle plantarflexion pain provocation test. Imaging findings were not associated with patient-reported outcome measures. Imaging findings did not differ between PAIS-positive and PAIS-negative groups. Os trigonum and Stieda process were prevalent despite clinical status. CONCLUSIONS The lack of association between imaging findings and clinical features questions the role of imaging in PAIS. Clinicians should rely primarily on clinical assessment in the diagnosis and management of patients with PAIS.
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Baillie P, Mayes S, Lam J, Ferrar K, Cook J. Associations between clinical and imaging findings in posterior ankle impingement syndrome: a systematic review. Acta Radiol 2022; 63:652-657. [PMID: 33874783 DOI: 10.1177/02841851211008389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Posterior ankle impingement syndrome (PAIS) is a common and debilitating condition, commonly affecting people who participate in activities that involve repetitive ankle plantarflexion. The relationship between clinical and imaging findings in PAIS has not been established. PURPOSE To investigate the relationship between clinical and imaging features in PAIS by reviewing the literature comparing symptomatic patients to asymptomatic controls. MATERIAL AND METHODS A systematic literature search was performed to identify all English-language articles that compared imaging features in patients diagnosed with PAIS to imaging in an asymptomatic control group. RESULTS A total of 8394 articles were evaluated by title and abstract, and 156 articles were read in full text. No articles compared imaging findings to an asymptomatic control group, thus no articles met the inclusion criteria. CONCLUSION This systematic review found no published research that compared the imaging findings of people diagnosed with PAIS to asymptomatic people. Until this information is available, imaging features in people with posterior ankle impingement should be interpreted with caution.
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Affiliation(s)
- Peta Baillie
- School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, VIC, Australia
| | - Susan Mayes
- The Australian Ballet, South Melbourne, VIC, Australia
- La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia
| | - Jason Lam
- The Australian Ballet, South Melbourne, VIC, Australia
| | - Katia Ferrar
- The Australian Ballet, South Melbourne, VIC, Australia
- La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia
| | - Jill Cook
- La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia
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Mercer NP, Samsonov AP, Dankert JF, Gianakos AL, Stornebrink T, Delmonte RJ, Kerkhoffs GMJ, Kennedy JG. Improved Clinical Outcomes and Patient Satisfaction of In-Office Needle Arthroscopy for the Treatment of Posterior Ankle Impingement. Arthrosc Sports Med Rehabil 2022; 4:e629-e638. [PMID: 35494297 PMCID: PMC9042901 DOI: 10.1016/j.asmr.2021.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 12/01/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose To investigate the short-term clinical outcomes and satisfaction for the first set of patients at our institution receiving in-office needle arthroscopy (IONA) for the treatment of posterior ankle impingement syndrome (PAIS). Methods A retrospective cohort study was conducted to evaluate patients who underwent IONA for PAIS between January 2019 and January 2021. Clinical outcomes were evaluated using the Foot and Ankle Outcome Score (FAOS) and Patient-Reported Outcomes Measurement Information System Pain Interference, and Pain Intensity scores. Patient satisfaction was measured at the final follow-up visit with a 5-point Likert scale. The Wilcoxon signed-rank test was performed to compare preoperative and postoperative outcome scores. Results Ten patients (4 male and 6 female) with a mean age of 41.9 ± 15.5 years (range, 24-66 years) were included in the study. The mean follow-up time was 13.3 ± 2.9 months (range, 11-17 months). All mean preoperative FAOS scores demonstrated improvement after IONA, including FAOS symptoms (71.48 ± 10.3 to 80.3 ± 12.6), pain (69.3 ± 11.0 to 78.2 ± 13.9), activities of daily living (61.7 ± 8.8 to 77.93 ± 11.4), sports activities (55.6 ± 12.7 to 76.0 ± 13.6), and quality of life (46.6 ± 9.2 to 71.1 ± 12.1). There were 7 patients who participated in sports activities before the IONA procedure. Within this group, all patients returned to play at a median time of 4.1 weeks (range, 1-14 weeks). The median time to return to work was 3.4 ± 5.3 days. Patients reported an overall positive IONA experience with a mean rating scale of 9.5 ± 1.5 (range, 5-10). Conclusions The current study demonstrates that IONA treatment of PAIS results in significant pain reduction, a low complication rate, and excellent patient-reported outcomes. In addition, IONA for PAIS leads to high patient satisfaction with a significant willingness to undergo the same procedure again. Level of Evidence IV, therapeutic case series.
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12
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Chen JS, Kaplan DJ, Colasanti CA, Dankert JF, Kanakamedala A, Hurley ET, Mercer NP, Stone JW, Kennedy JG. Posterior Hindfoot Needle Endoscopy in the Office Setting. Arthrosc Tech 2022; 11:e273-e278. [PMID: 35256963 PMCID: PMC8897487 DOI: 10.1016/j.eats.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 10/22/2021] [Indexed: 02/03/2023] Open
Abstract
Posterior hindfoot disorders encompass a spectrum of bony, cartilaginous, and soft-tissue pathology. Traditional open surgical techniques have been increasingly replaced by less-invasive arthroscopic and endoscopic approaches. Recent innovations such as the advent of the needle arthroscope continue to push the boundary of minimally invasive interventions. This Technical Note highlights our technique for posterior hindfoot needle endoscopy for common posterior hindfoot pathologies in the wide-awake office setting, including indications, advantages, and technical pearls.
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Affiliation(s)
| | | | | | | | | | | | | | | | - John G. Kennedy
- Address correspondence to John G. Kennedy, M.D., NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E. 17th St., New York, NY 10010.
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Barchi EI, Swensen S, Dimant OE, McKay TE, Rose DJ. Flexor Hallucis Longus Tenolysis and Tenosynovectomy in Dancers. J Foot Ankle Surg 2022; 61:84-87. [PMID: 34301473 DOI: 10.1053/j.jfas.2020.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to report on a series of dancers who had undergone flexor hallucis longus (FHL) tenolysis/tenosynovectomy after having failed conservative management. Institutional human subjects committee approval was obtained prior to initiating this study. This study is a retrospective case series of 58 dancers and 63 ankles who underwent FHL tenolysis/tenosynovectomy via an open posteromedial approach by a single surgeon between 1993 and 2017. All patients were interviewed and charts reviewed. Collected variables included: preoperative and postoperative pain levels, time to return to dance, and subjective satisfaction with the procedure. Age, primary dance form, and level of dance were determined. Mean preoperative pain level decreased significantly postoperatively. Mean time to return to dance was 7.1 weeks. There was a 98% (62/63) return to dance at some level while 97% (61/63) of patients returned to dance symptom-free. There were no neurovascular or other major complications. Minor complications included stiffness at follow-up (6.3%, 4/63), superficial wound infection (3.1%, 2/63), and hypertrophic scar (4.8%, 3/63). Over 97% (61/63) of dancers considered the procedure a success and 98% (62/63) of dancers would repeat the procedure. This is one of the largest series reported of isolated FHL tenolysis/tenosynovectomy in dancers who have failed nonoperative management. Satisfactory pain relief and return to dance with a low complication rate may be expected from this surgical procedure. The results of this study can be used to help dancers and their providers make informed decisions about treatment in isolated FHL tendinitis.
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Affiliation(s)
- Elizabeth I Barchi
- Clinical Assistant Professor, Department of Orthopedics, NYU Langone Health, New York, NY.
| | - Stephanie Swensen
- Fellow, Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Oscar E Dimant
- Resident, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ
| | - Tracy Espiritu McKay
- Clinical Assistant Professor, Department of Physical Medicine and Rehabilitation, NYU Langone Health, New York, NY
| | - Donald J Rose
- Clinical Associate Professor, Department of Orthopedics, NYU Langone Health, New York, NY
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D'Hooghe P, Waldén M, Hägglund M, Bengtsson H, Ekstrand J. Anterior ankle impingment syndrome is less frequent, but associated with a longer absence and higher re-injury rate compared to posterior syndrome: a prospective cohort study of 6754 male professional soccer players. Knee Surg Sports Traumatol Arthrosc 2022; 30:4262-4269. [PMID: 35689100 PMCID: PMC9668948 DOI: 10.1007/s00167-022-07004-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 05/10/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To study the epidemiology and return to play characteristics of anterior and posterior ankle impingement syndromes (AAIS and PAIS) over 18 consecutive seasons in male professional soccer players. METHODS Between the 2001-2002 and 2018-2019 seasons, 120 European soccer teams were followed prospectively for various seasons. Time loss injuries and player exposures were recorded individually in 6754 unique players. Injury incidence and burden were reported as the number of injuries and days absence per 1000 h with 95% confidence intervals (CIs). Injury severity was reported as median absence in days with the interquartile range (IQR). RESULTS Out of 25,462 reported injuries, 93 (0.4%) were diagnosed as AAIS (38%) or PAIS (62%) in 77 players. AAIS and PAIS were similar regarding injury characteristics except for a greater proportion of AAIS having a gradual onset (69% vs.47%; P = 0.03) and being re-injuries (31% vs. 9%; P = 0.01). Impingement syndromes resulted in an overall incidence of 0.03 injuries (95% CI 0.02-0.03) per 1000 h and an injury burden of 0.4 absence days per 1000 h. PAIS incidence was significantly higher than that for AAIS [0.02 (95% CI 0.002-0.03) vs. 0.01 (95% CI 0.005-0.01) injuries per 1000 h (RR = 1.7). The absence was significantly longer in AAIS than in PAIS [10 (22) vs. 6 (11) days; P = 0.023]. Impingement syndromes that presented with a gradual onset had longer absences in comparison to impingement with an acute onset [8 (22) vs. 5 (11) days; P = 0.014]. Match play was associated with a higher incidence and greater injury burden than training: 0.08 vs. 0.02 injuries per 1000 h (RR 4.7), respectively, and 0.9 vs. 0.3 days absence per 1000 h (RR 2.5). CONCLUSION Ankle injuries are frequent in men's professional soccer and ankle impingement is increasingly recognized as a common source of pain, limited range of motion, and potential time loss. In our study, ankle impingement was the cause of time loss in less than 0.5% of all injuries. PAIS was more frequently reported than AAIS, but AAIS was associated with more absence days and a higher re-injury rate than PAIS. The findings in this study can assist the physician in best practice management on ankle impingment syndromes in professional football. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Pieter D'Hooghe
- Aspetar Orthopaedic and Sports Medicine Hospital, Sports City Street, Inside Aspire Zone, Al Buwairda St., PO Box 29222, Doha, Qatar.
- Football Research Group, Linköping, Sweden.
| | - Markus Waldén
- Football Research Group, Linköping, Sweden
- Unit of Community Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Martin Hägglund
- Football Research Group, Linköping, Sweden
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Håkan Bengtsson
- Football Research Group, Linköping, Sweden
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jan Ekstrand
- Football Research Group, Linköping, Sweden
- Unit of Community Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Five-year follow-up of endoscopic resection of symptomatic os trigonum: a prospective interventional cohort study of a possible cause of ankle and big toe pain. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Ankle impingement presents with painful and limited range of motion with dorsiflexion or plantar flexion, originating from pathological contact between bone and/or soft-tissue structures. Diagnosis is made primarily through clinical examination with adjunct radiographs and magnetic resonance imaging, with care taken to rule out a plethora of similarly presenting pathologies. Arthroscopic surgical approaches bring satisfactory short, mid, and long-term outcomes, with the current body of evidence dominated by Level-IV studies. Minimally invasive techniques offer improvements in time to return to play and complication rates relative to open approaches. Recent advances in the arthroscopic management of ankle impingement include long-term outcome studies, novel prognostic classification systems, and strategies for concomitant lesion management.
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Chronic Fracture of the Posteromedial Tubercle of the Talus Masquerading as Os Trigonum Syndrome. Case Rep Orthop 2021; 2021:6637081. [PMID: 34258093 PMCID: PMC8261161 DOI: 10.1155/2021/6637081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 06/08/2021] [Indexed: 11/18/2022] Open
Abstract
Posterior ankle impingement syndrome (PAIS) can be caused by osseous pathology from the posterior aspect of the talus. The commonest cause is an os trigonum, an accessory ossicle arising from the lateral tubercle of the posterior talus. We have observed cases where the osseous impingement is due to a chronic fracture nonunion of the medial tubercle of the posterior talus with unique symptoms, differentiating this clinical syndrome from the more common os trigonum syndrome. These can be readily overlooked on imaging and confused with an often coexisting os trigonum. Awareness of these lesions is paramount to ensure appropriate management and safe surgery. We describe a series of patients presenting to the senior author with this clinical syndrome, discuss its unique clinical and radiological features, and describe our surgical technique.
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Thompson JM, Langan TM, Hyer CF. Posterior Ankle Scope Approach to Symptomatic Os Trigonum Removal. Foot Ankle Spec 2021; 14:266-270. [PMID: 33435740 DOI: 10.1177/1938640020984304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Os trigonum can become symptomatic following acute or chronic repetitive compression of the posterior ankle. Following conservative treatment failure, removal is often warranted. Current surgical options include traditional open resection and endoscopic removal. The purpose of this article is to review a population of patients who underwent endoscopic excision of symptomatic accessory os trigonum through a posterior approach and evaluate the outcomes of the procedure. METHODS From May 2009 to September 2018, all patients who underwent excision of a symptomatic os trigonum were reviewed. Outcomes of interest were major and minor complications and time to return to full weight-bearing activities. Postoperative protocol included 5 to 7 days non-weight-bearing and 1 to 2 weeks of protected weight-bearing followed by full release to weight-bearing activities. RESULTS Twelve patients who met the inclusion criteria were studied. Mean follow-up was 10.2 (±7.4) months with no major complications and 1 minor wound complication. Average advancement to protected weight-bearing was 7.1 days. Average return to full weight-bearing activities without restriction was 24.4 days. CONCLUSION The current study describes the technique and results to minimally invasive os trigonum removal with favorable postoperative outcomes. Results demonstrated minimal complications and postoperative pain, also quick return to weight-bearing and full activity. LEVEL OF EVIDENCE Therapeutic, Level IV: Case series.
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Affiliation(s)
| | | | - Christopher F Hyer
- Grant Medical Center, Columbus, Ohio
- Orthopedic Foot and Ankle Center, Worthington, Ohio
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Causes of delayed diagnosis of posterior ankle impingement in the pediatric and adolescent population. Foot (Edinb) 2021; 47:101799. [PMID: 33957524 DOI: 10.1016/j.foot.2021.101799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 03/24/2021] [Accepted: 04/03/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to identify and characterize various causes of delay in the diagnosis of posterior ankle impingement syndrome (PAIS) in pediatric patients. METHODS IRB approved prospective study of patients under 18 years who underwent arthroscopic surgery for the diagnosis of posterior ankle impingement after failed conservative treatment at a tertiary children's hospital. Radiographic findings were compared with an age-matched control group. Descriptive and inferential statistics were employed. RESULTS 47 patients (61 ankles), mean age 13 years, had an average 14 months delay in diagnosis of PAIS from the initial presentation. 33 (70%) patients had seen multiple medical providers and given other diagnoses. 9 (19%) patients participated in ballet or soccer, and 16 (34%) patients had unrelated associated foot and ankle diagnoses. 25 (41%) of 61 ankles did not have pain on forced plantar flexion; all 61(100%) ankles had tenderness to palpation over the posterior ankle joint line. Radiographs were reported to be normal in 37/52 (71%) ankles, while MRI report did not mention the diagnosis in 20/41 (49%) studies. There was a significant difference in the MRI findings in the patient population when compared to the control group. Indication for surgery was failed conservative treatment. All 61 ankles had posterior ankle impingement pathology confirmed visually during arthroscopy. At average 15 months follow-up, there was significant improvement pre- to post-operatively (p<0.001) for both pain VAS (6.9-0.9) and AOFAS ankle-hindfoot scores (65-94). CONCLUSION Multiple clinical and imaging factors can lead to delayed diagnosis of posterior ankle impingement. An increased awareness about the features of PAIS is needed amongst medical providers involved in treating young patients.
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Hirtler L, Rath C, Kügler P, Reissig L, Willegger M. Maximum Ankle Plantarflexion and Dorsiflexion Allow for Optimal Arthroscopic Access to the Talar Dome: An Anatomic 3-Dimensional Radiography Study. Arthroscopy 2021; 37:1245-1257. [PMID: 33359819 DOI: 10.1016/j.arthro.2020.12.207] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE (1) to improve the comprehension of the topographical position of the talar dome beneath the inferior articular surface of the tibia and, (2) to illustrate the changes of possible access to the articular surface of the talar dome during arthroscopic treatment of talar osteochondral defects in an anatomical model. METHODS Twenty matched pairs (n = 40) of anatomical ankle specimen were used. All specimens were mounted in a standardized fashion, 3-dimensional radiography was performed in 4 defined positions (maximum dorsiflexion, neutral position, noninvasive distraction, and maximum plantarflexion). All radiographs were analyzed and statistically compared. RESULTS Anterior accessibility was highest in maximum plantarflexion (medial: 49.20 ± 9.86%, lateral: 48.19 ± 8.85%), followed by non-invasive distraction (medial: 33.60 ± 7.96%, lateral: 31.98 ± 8.30%). Neutral position (medial: 19.34 ± 6.90%, lateral: 17.54 ± 6.63%) and dorsiflexion (medial: 15.36 ± 5.03%, lateral: 13.88 ± 4.33%) were not able to significantly increase accessibility. Posterior accessibility was greatest in maximum dorsiflexion (medial: 56.69 ± 9.65%, lateral: 46.82 ± 8.36%), followed by neutral position of the ankle joint (medial: 40.95 ± 8.28%, lateral: 31.06 ± 6.92%). Noninvasive distraction (medial: 31.41 ± 8.18%, lateral: 22.99 ± 7.63%) was still significantly better than plantarflexion (medial: 14.54 ± 5.10%, lateral: 13.89 ± 3.14%) and slightly increased accessibility to the talar dome. Medially, a central area of 5.89 ± 9.76% was accessible by maximum plantarflexion and maximum dorsiflexion from anterior and posterior, respectively, laterally a central blind spot of 4.99 ± 8.61% was detected. CONCLUSIONS From an anatomical point of view, maximum joint positions of the ankle (i.e., plantarflexion and dorsiflexion) allow for better access to the talar dome in anterior and posterior ankle arthroscopy. Noninvasive distraction may increase accessibility in anterior approaches, but has no benefit from posterior. CLINICAL RELEVANCE This study provides insight into the morphology of the ankle joint in a standardized laboratory setup and illustrates the influence of different surgically relevant ankle joint positions. The presented data allow for better preoperative planning for the arthroscopic treatment of talar osteochondral defects.
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Affiliation(s)
- Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria.
| | - Claus Rath
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Paul Kügler
- Department of Plastic, Aesthetic and Reconstructive Surgery, Klagenfurt Clinic, Klagenfurt, Austria
| | - Lukas Reissig
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Madeleine Willegger
- Division of Orthopedics, Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Vienna, Austria
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21
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Abstract
This article offers an overview of os trigonum syndrome, complications, operative techniques, and the authors' preferred protocol. Os trigonum is an ossicle like many other ossicles in the foot and ankle. Individuals who require repetitive plantarflexion of the ankle for activity may develop symptoms of an enlarged os trigonum. Usually, symptoms will be isolated to the posteriolateral aspect of the ankle. Because of the normal anatomic route of the flexor hallucis longus tendon, its range of motion may also elicit pain to the posterolateral ankle. Conservative, as well as surgical including both endoscopic and open excision, has been described.
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Affiliation(s)
- Jeffrey E McAlister
- Phoenix Foot and Ankle Institute, 7301 East 2nd Street, Suite 206, Scottsdale, AZ 85251, USA.
| | - Usman Urooj
- Department of Surgery-Podiatry, Carl T. Hayden Medical Center, 650 East Indian School Road, Phoenix, AZ 85012, USA
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22
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Batista JP, Duarte Pereira HM, van Dijk CN, Del Vecchio JJ. Posterior arthroscopic treatment of ankle osteochondral lesions: technical note. J ISAKOS 2020. [DOI: 10.1136/jisakos-2019-000375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Kushare I, Ditzler MG, Jadhav SP. Delayed diagnosis of posterior ankle impingement in pediatric and adolescent patients: does radiology play a role? Pediatr Radiol 2020; 50:216-223. [PMID: 31707447 DOI: 10.1007/s00247-019-04547-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/29/2019] [Accepted: 09/24/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Posterior ankle impingement syndrome (PAIS) results from the pinching of anatomical structures in the posterior part of the ankle. OBJECTIVE To identify the possible role of imaging in the delayed diagnosis of PAIS and identify key findings on imaging to suggest PAIS in pediatric and adolescent patients. MATERIALS AND METHODS Data were collected prospectively in patients younger than 18 years of age who underwent arthroscopy after being diagnosed with PAIS. Imaging was reviewed retrospectively by two radiologists, compared with findings in literature and an age-matched control group, and correlated with arthroscopic findings. Pre- and postsurgical Visual Analogue Scale (VAS) pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted. RESULTS Thirty-eight patients (20 females, 18 males), 51 ankles, with an average age of 12.9 years had an average 18-month delay in diagnosis. Twenty-seven of the 38 (73%) patients had previously seen multiple medical providers and were given multiple misdiagnoses. Radiographs were reported normal in 34/47 (72%) ankles. Thirty patients had magnetic resonance imaging (MRI) and findings included the presence of an os trigonum/Stieda process (94%) with associated osseous edema (69%), flexor hallucis longus (FHL) tenosynovitis (16%), and edema in Kager's fat pad (63%). Although individual findings were noted, the impression in the MRI reports in 16/32 (50%) did not mention PAIS as the likely diagnosis. There was a significant difference in the MRI findings of ankle impingement in the patient population when compared to the control group. Surgery was indicated after conservative treatment failed. All 51 ankles had a PAIS diagnosis confirmed during arthroscopy. At an average follow-up of 10.2 months, there was improvement of VAS pain (7.0 to 1.1) and AOFAS ankle-hindfoot scores (65.1 to 93.5). CONCLUSION PAIS as a diagnosis is commonly delayed clinically in young patients with radiologic misinterpretation being a contributing factor. Increased awareness about this condition is needed among radiologists and physicians treating young athletes.
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Affiliation(s)
- Indranil Kushare
- Department of Orthopedics, Texas Children's Hospital, Houston, TX, USA
| | - Matthew G Ditzler
- E. B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA
| | - Siddharth P Jadhav
- E. B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.
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24
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Kushare I, Kastan K, Allahabadi S. Posterior ankle impingement–an underdiagnosed cause of ankle pain in pediatric patients. World J Orthop 2019; 10:364-370. [PMID: 31750084 PMCID: PMC6854055 DOI: 10.5312/wjo.v10.i10.364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 08/08/2019] [Accepted: 09/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Posterior ankle impingement syndrome (PAIS) is a cause of ankle pain due to pinching of bony or soft tissue structures in the hindfoot. The diagnosis is primarily made based on detailed history and accurate clinical examination. The delay in its diagnosis has not yet been described in the pediatric and adolescent population.
AIM To identify and characterize misdiagnosed cases of PAIS in pediatric and adolescent patients.
METHODS This descriptive prospective study at a tertiary children’s hospital included patients ≤ 18 years who underwent posterior ankle arthroscopy after presenting with chronic posterior ankle pain after being diagnosed with PAIS. Collected data included: Demographics, prior diagnoses and treatments, providers seen, time to diagnosis from presentation, and prior imaging obtained. Visual Analogue Scale (VAS) for pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted at initial presentation and follow-up.
RESULTS 35 patients (46 ankles) with average age of 13 years had an average 19 mo (range 0-60 mo) delay in diagnosis from initial presentation. 25 (71%) patients had previously seen multiple medical providers and were given multiple other diagnoses. All 46 (100%) ankles had tenderness to palpation over the posterior ankle joint. Radiographs were reported normal in 31/42 (72%) exams. In 32 ankles who underwent MRI, the most common findings included os trigonum (47%)/Stieda process (47%). Conservative treatment had already been attempted in all patients. Ankle impingement pathology was confirmed during arthroscopy in 46 (100%) ankles. At an average follow-up of 13.1 mo, there was an improvement of VAS (pre-op 7.0 to post-op 1.2) and AOFAS scores (pre-op 65.1 to post-op 94).
CONCLUSION This is the first study which shows that PAIS is a clinically misdiagnosed cause of posterior ankle pain in pediatric and adolescent population; an increased awareness about this diagnosis is needed amongst providers treating young patients.
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Affiliation(s)
- Indranil Kushare
- Department of Orthopaedics, Texas Children’s hospital, The Woodlands, TX 77384, United States
| | - Kristen Kastan
- Department of Orthopaedics, Texas Children’s hospital, The Woodlands, TX 77384, United States
| | - Sachin Allahabadi
- Department of Orthopaedics, University of California, San Francisco, CA 94143, United States
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Kalbouneh HM, Alajoulin O, Alsalem M, Mansour Y, Shawaqfeh J, Altarawneh T, Alhusni D, Al-Muhtaseb MH. Incidence of symptomatic os trigonum among nonathletic patients with ankle sprain. Surg Radiol Anat 2019; 41:1433-1439. [DOI: 10.1007/s00276-019-02354-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/25/2019] [Indexed: 01/29/2023]
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Hirtler L, Schellander K, Schuh R. Accessibility to Talar Dome in Neutral Position, Dorsiflexion, or Noninvasive Distraction in Posterior Ankle Arthroscopy. Foot Ankle Int 2019; 40:978-986. [PMID: 31081369 PMCID: PMC6669825 DOI: 10.1177/1071100719847134] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Osteochondral lesions of the talus are frequent pathologies of the ankle joint. Especially through arthroscopy, the treatment is kept as minimally invasive as possible. However, there are some drawbacks as to the reachability because of the high congruency of the ankle joint. Here, either noninvasive distraction or maximal dorsiflexion may be an option for better access to the lesion. The purpose of this study was to evaluate maximal dorsiflexion compared to neutral position or noninvasive distraction of the ankle joint in the arthroscopic reachability of the talar dome. The hypothesis of this study was that maximal dorsiflexion would allow for greater accessibility of the talar dome compared to neutral position or noninvasive distraction of the joint. METHODS Twenty matched pairs (n=40) of anatomical ankle specimens were used. The effects of neutral position, maximal dorsiflexion, and noninvasive distraction of the ankle joint on arthroscopic accessibility of the ankle joint were tested. After disarticulation of the talus, reach was measured and compared between the 3 positions. RESULTS In neutral position, 13.7±1.2 mm of the talar dome was reached laterally and 14.0±1.0 mm medially. In maximal dorsiflexion, the distance was 19.0±1.1mm laterally and 19.8±1.4 mm medially, and in noninvasive distraction it was 16.1±1.5 mm laterally and 15.7±1.0 mm medially. The statistical comparison showed a significantly better reach in dorsiflexion laterally (P = .003) and medially (P = .026). CONCLUSION Accessibility of the talar dome in maximal dorsiflexion was superior to that in neutral position or noninvasive distraction. CLINICAL RELEVANCE Results of this study may allow for better planning in arthroscopic treatment of osteochondral lesions of the talus.
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Affiliation(s)
- Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria,Lena Hirtler, MA, MD, PhD, Medical University of Vienna, Center for Anatomy and Cell Biology, Division of Anatomy, Währinger Straße 13, Vienna, 1090, Austria.
| | - Katarina Schellander
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Reinhard Schuh
- Department of Pediatric Orthopedics and Foot Surgery, Orthopedic Hospital Vienna–Speising, Vienna, Austria
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Wang C, Kang MW, Kim HN. Arthroscopic Treatment of Osteochondral Lesions of the Talus in a Suspended Position With the Patient in a Prone Position. Foot Ankle Int 2019; 40:811-817. [PMID: 30957543 DOI: 10.1177/1071100719839697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the clinical results and the safety of arthroscopic microfracture with the ankle suspended on a shoulder-holding traction frame for simultaneous anterior and posterior ankle arthroscopy in the prone position. METHODS Between May 2010 and January 2016, 31 patients with posterior osteochondral lesions of the talus (OLTs) were treated with arthroscopic microfracture in a suspended position with the patient prone. Ankle distraction was achieved by suspending the affected ankle on a shoulder-holding traction frame. The 100 mm visual analog scale (VAS) and the Foot Function Index (FFI) were checked preoperatively and at final follow-up. Postoperative complications related to the suspended position were analyzed. Lower leg intramuscular compartment pressure was checked after the surgery to determine if there was any risk of compartment syndrome. RESULTS The mean 100-mm VAS score, and FFI improved from 62.8 ±11.3 and 48.5 ± 12.1, respectively, preoperatively to 15.8 ± 10.4 and 16.4 ± 9.2, respectively, at final follow-up (P = .025, and P = .005, respectively). The mean anterior, lateral, superficial posterior, and deep posterior compartment pressures were 7.3 ± 1.5, 8.1 ± 1.1, 5.6 ± 1.9, and 9.2 ± 2.4 mmHg, respectively. No compartment syndrome occurred. CONCLUSION Arthroscopic treatment of OLT in a prone position with the ankle suspended on a shoulder-holding traction frame allowed the use of simultaneous anterior and posterior portals for viewing and instrumentation without major operative complications, such as compartment syndrome. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Chenyu Wang
- 1 Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Min Wook Kang
- 1 Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyong Nyun Kim
- 1 Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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Zhou Y, Chen Z, Jiang C, Song B. Arthroscopic Lengthening of the Flexor Hallucis Longus Tendon to Correct Hallux Flexion Deformity. J Foot Ankle Surg 2019; 58:766-770. [PMID: 30962106 DOI: 10.1053/j.jfas.2018.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Indexed: 02/03/2023]
Abstract
Contracture of the flexor hallucis longus (FHL) tendon is one of the most common factors leading to hallux flexion deformity. Few cases treated by arthroscopic technology have been reported. In this article, we perform a new method to lengthen the FHL tendon under an arthroscope. We present a case of 1 patient treated with this technique and followed for 2 years. The appearance of his halluces remarkably improved at the follow-up visits, and movement was refined simultaneously. From the satisfactory effect of this operation, lengthening the FHL tendon under arthroscope is an effective method to correct flexion deformity of the hallux with minimal incisions. This technique also provides an innovative application of minimally invasive surgeries to treat clinically infrequent diseases.
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Affiliation(s)
- Yunfeng Zhou
- Orthopaedist, Orthopedic Department, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zhong Chen
- Orthopaedist, Orthopedic Department, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Chuan Jiang
- Orthopaedist, Orthopedic Department, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Bin Song
- Associate Professor, Orthopedic Department, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.
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29
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D’Hooghe P, Alkhelaifi K, Almusa E, Tabben M, Wilson MG, Kaux JF. Chronic lateral ankle instability increases the likelihood for surgery in athletes with os trigonum syndrome. Knee Surg Sports Traumatol Arthrosc 2019; 27:2813-2817. [PMID: 30276436 PMCID: PMC6706354 DOI: 10.1007/s00167-018-5183-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 09/26/2018] [Indexed: 12/31/2022]
Abstract
PURPOSE The etiology and incidence of os trigonum syndrome in professional athletes is highly variable. There is a paucity of data to ascertain why some athletes evolve towards surgery whilst others remain asymptomatic. We hypothesized that a lateral ligament ankle injury would increase the likelihood for surgery in those athletes with os trigonum syndrome. METHODS Eighty professional athletes with clinical and radiological signs of os trigonum syndrome were identified to ascertain the incidence of injury to the lateral ligamentous ankle complex (acute and chronic) by magnetic resonance imaging (MRI). This cohort was subdivided into 2 groups; a surgical (n = 40) and a non-surgical (n = 40) cohort. Surgical division was decided if (1) the clinical hyper-plantar flexion test was positive, (2) a positive diagnostic ultrasound-guided injection and (3) no improvement was observed after 6 weeks of conservative rehabilitation. RESULTS From the surgical cohort, 37 players (94.1%) had a chronic lateral ankle ligament injury on MRI, whilst 3 players (5.9%) had an acute lateral ankle ligament injury. Binary logistic linear modelling revealed that having a chronic lateral ligament injury increases the likelihood of os trigonum syndrome surgery by ten times compared to those with an acute lateral ligament injury. CONCLUSION Professional athletes with chronic lateral ligament ankle injury have an approximate ten times greater risk for os trigonum syndrome surgery compared to athletes with acute lateral ligament ankle injury. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- P. D’Hooghe
- Aspetar Qatar Orthopaedic and Sports Medicine Hospital Doha, Near Khalifa Stadium, Doha, Qatar
| | - K. Alkhelaifi
- Aspetar Qatar Orthopaedic and Sports Medicine Hospital Doha, Near Khalifa Stadium, Doha, Qatar
| | - E. Almusa
- Aspetar Qatar Orthopaedic and Sports Medicine Hospital Doha, Near Khalifa Stadium, Doha, Qatar
| | - M. Tabben
- Aspetar Qatar Orthopaedic and Sports Medicine Hospital Doha, Near Khalifa Stadium, Doha, Qatar
| | - M. G. Wilson
- Aspetar Qatar Orthopaedic and Sports Medicine Hospital Doha, Near Khalifa Stadium, Doha, Qatar
| | - J. F. Kaux
- Aspetar Qatar Orthopaedic and Sports Medicine Hospital Doha, Near Khalifa Stadium, Doha, Qatar
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30
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Heyer JH, Dai AZ, Rose DJ. Excision of Os Trigonum in Dancers via an Open Posteromedial Approach. JBJS Essent Surg Tech 2018; 8:e31. [PMID: 30775136 DOI: 10.2106/jbjs.st.18.00015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
An os trigonum is a potential source of posterior ankle pain in dancers, often associated with flexor hallucis longus (FHL) pathology. Surgical excision is indicated on failure of nonoperative management. Options for surgical excision include open excision (via a posterolateral or posteromedial approach), subtalar arthroscopy, and posterior endoscopy. Os trigonum excision via an open posteromedial approach with concomitant FHL tenolysis/tenosynovectomy is a safe and effective method for the operative treatment of a symptomatic os trigonum that allows for identification and treatment of associated FHL pathology. The major steps in the procedure, which are demonstrated in this video article, are: (1) preoperative planning with appropriate imaging; (2) patient is positioned in a supine position with the operative extremity in figure-of-4 position; (3) a 3-cm, slightly curvilinear longitudinal incision is made midway between the posterior aspect of the medial malleolus and the anterior aspect of the Achilles tendon, over the palpated FHL tendon, and the flexor retinaculum is exposed and incised; the neurovascular bundle is retracted anteriorly, exposing the FHL tendon and sheath; (4) FHL tenolysis/tenosynovectomy is performed; (5) the FHL is retracted anteriorly and a capsulotomy is performed over the os trigonum and the os trigonum is excised; (6) the capsule is repaired and closure is performed; and (7) dressings and a CAM (controlled ankle motion) walking boot are applied. The patient begins physical therapy at 2 weeks postoperatively and may return to dance at 4 to 6 weeks postoperatively as tolerated. In our series of 40 cases, 95% of patients who desired to return to dance were able to return to their pre-injury level of dance. There were no major neurovascular complications.
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Affiliation(s)
- Jessica H Heyer
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, DC
| | - Amos Z Dai
- Department of Orthopaedic Surgery, Stony Brook University Hospital, Stony Brook, New York
| | - Donald J Rose
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
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31
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Abstract
Ankle arthroscopy is a diagnostic and therapeutic surgical procedure which was first attempted on cadavers by Dr Burman in 1931 and first successfully described in patients by Dr Takagi in 1939. Two general approaches to ankle arthroscopy currently exist: (1) anterior ankle arthroscopy and (2) posterior ankle arthroscopy. The indications for ankle arthroscopy have expanded as increased experience has been obtained treating various pathologic entities and as the surgical results have been reported in the literature. There has been significant progress in ankle arthroscopic surgery over the past decades, notably allowing surgical procedures to be performed with fewer complications and with quicker return to work and play. We anticipate that expanding indications for arthroscopic ankle surgical procedures combined with further development of biomedical devices to enhance these procedures will result in improved patient outcomes in the future.
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Tonogai I, Hayashi F, Tsuruo Y, Sairyo K. Anatomic Study of Anterior and Posterior Ankle Portal Sites for Ankle Arthroscopy in Plantarflexion and Dorsiflexion: A Cadaveric Study in the Japanese Population. J Foot Ankle Surg 2018; 57:537-542. [PMID: 29548631 DOI: 10.1053/j.jfas.2017.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Indexed: 02/03/2023]
Abstract
Arthroscopy is an important and minimally invasive diagnostic and therapeutic tool. However, the risk of injury to the neurovascular structures around the portals exists during arthroscopy of the ankle. In the present study, we measured the distance between each portal and the adjacent neurovascular structures with the foot in plantarflexion and dorsiflexion in the Japanese population. Standard anterolateral (AL), anteromedial, posterolateral (PL), and posteromedial portal positions were identified in 6 fresh adult cadaveric feet. The skin was dissected from the underlying tissue to visualize the adjacent neurovascular structures as noninvasively as possible. The superficial peroneal nerve was the structure closest to an anterior (i.e., AL) portal (3.2 ± 4.2 and 8.3 ± 3.9 mm in plantarflexion and 5.2 ± 4.3 and 10.8 ± 4.1 mm in dorsiflexion), followed by the saphenous nerve and great saphenous vein (SpV). The distance from the superficial peroneal nerve to the AL portal and from the saphenous nerve and great SpV to the anteromedial portal increased significantly with dorsiflexion and decreased significantly with plantarflexion. The sural nerve was the structure closest to the posterior (i.e., PL) portal (10.4 ± 4.8 mm in plantarflexion and 8.5 ± 3.9 mm in dorsiflexion), followed by the lesser SpV. The distance from the sural nerve, saphenous nerve, and lesser SpV to the PL portal and from flexor hallucis longus, posterior tibial artery, and tibial nerve to the posteromedial portal increased significantly in plantarflexion and decreased significantly in dorsiflexion. These findings could help to prevent damage to the neurovascular structures during ankle arthroscopy.
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Affiliation(s)
- Ichiro Tonogai
- Assistant Professor, Department of Orthopedics, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
| | - Fumio Hayashi
- Senior Resident, Department of Orthopedics, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
| | - Yoshihiro Tsuruo
- Professor & Chairman, Department of Anatomy and Cell Biology, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
| | - Koichi Sairyo
- Professor & Chairman, Department of Orthopedics, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan.
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Hirtler L, Schuh R. Accessibility of the Talar Dome-Anatomic Comparison of Plantarflexion Versus Noninvasive Distraction in Arthroscopy. Arthroscopy 2018; 34:573-580. [PMID: 29079263 DOI: 10.1016/j.arthro.2017.07.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/28/2017] [Accepted: 07/28/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the difference in accessibility of the talar dome during ankle arthroscopy between noninvasive distraction and maximum plantar flexion without distraction. METHODS For this study, 20 matched pairs (n = 40) of anatomic ankle specimens were used. Two groups (distraction or maximum plantar flexion) were defined. Through the use of chondral picks, the accessibility of each technique was tested arthroscopically. Afterward, the ankle joint was dissected and the reach achieved was measured and compared between the 2 groups. RESULTS Through noninvasive distraction, 13.1 ± 4.4 mm of the talar dome was reached laterally and 16.7 ± 3.7 mm medially. Through plantar flexion, 18.1 ± 3.4 mm of the talar dome was reached laterally and 18.1 ± 3.4 mm medially. Statistical comparison revealed a significantly better reach in plantar flexion on the lateral side of the talar dome (P = .007). There was no significant difference medially. CONCLUSIONS Plantar flexion significantly improves reachability of the dome on the lateral side and it is equal to noninvasive distraction medially. Results of this study may allow for better access to the lesion of the talus. CLINICAL RELEVANCE Results of this study allow for a better planning of interventions in OCD of the talus.
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Affiliation(s)
- Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria.
| | - Reinhard Schuh
- Department of Pediatric Orthopedics and Foot Surgery, Orthopedic Hospital Vienna-Speising, Vienna, Austria
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Pereira H, Vuurberg G, Stone J, Lui TH. Ankle tendoscopy: state of the art. J ISAKOS 2017. [DOI: 10.1136/jisakos-2017-000139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Van Dijk CN, Vuurberg G, Batista J, d’Hooghe P. Posterior ankle arthroscopy: current state of the art. J ISAKOS 2017. [DOI: 10.1136/jisakos-2016-000082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kumar J, Singh MS, Tandon S. Endoscopic management of posterior ankle impingement syndrome-A case report. J Clin Orthop Trauma 2017; 8:S21-S25. [PMID: 28878534 PMCID: PMC5574854 DOI: 10.1016/j.jcot.2017.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/26/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022] Open
Abstract
Posterior ankle impingement syndrome (PAIS) is a clinical condition characterized by pain in the posterior aspect of ankle on performing activities requiring extreme plantar flexion. The impinging lesion could be bony and/or soft tissue. The operative treatment aims at removing the impinging lesion either by open or endoscopic surgery. The later has been shown to have benefits of early return to sports, better cosmesis, less wound complications. We report a case of a 19 year old footballer with PAIS secondary to Os Trigonum. The patient complained of pain on performing running and on kicking football. Conservative treatment in form of NSAIDS, rest, physiotherapy modality use could not ensure pain free return to sports.The patient was managed using endoscopic excision of the Os Trigonum followed by aggressive rehabilitation. The patient returned to competitive football at the end of 14 weeks after surgery. There were no wound complications. AAFOS score had changed from 73 to 100 and NPS scale showed pain score reduce from 7/10 to 1/10. We concluded that endoscopic management of PAIS to remove the impinging lesion is a minimally invasive technique that ensures early return to sports, good cosmesis, less risk of wound complications and good patient satisfaction.
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Affiliation(s)
- Jayant Kumar
- Department of Arthroscopy and Sports Medicine, Indian Spinal Injuries Center, New Delhi, India,Corresponding author at: SFS Flat 101/3, A block, Saket, New Delhi, India.
| | - Maninder S. Singh
- Department of Arthroscopy and Sports Medicine, Indian Spinal Injuries Center, New Delhi, India
| | - Suparna Tandon
- Department of Rehabilitation, Indian Spinal Injuries Center, New Delhi, India
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Abstract
The two-portal hindfoot arthroscopy is an effective procedure enabling direct visualisation of posterior ankle pathology with low invasiveness. An important stage of the hindfoot endoscopy is localisation of the flexor hallucis longus (FHL) tendon to protect the neurovascular bundle which is located just medial to it. Posterior ankle impingement syndrome and FHL tenosynovitis are common causes of posterior ankle pain and frequently occur together. Posteriorly localised talar osteochondral lesions, Achilles tendon disorders, osteoarthritis, talar bone cysts and talar fractures are among the other pathologies that can be treated with hindfoot arthroscopy. Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160055. Originally published online at www.efortopenreviews.org
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Affiliation(s)
- Tahir Ögüt
- Cerrahpasa Medical School, Departmant of Orthopaedics and Traumatology, University of Istanbul, Turkey
| | - N Selcuk Yontar
- Cerrahpasa Medical School, Departmant of Orthopaedics and Traumatology, University of Istanbul, Turkey
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Khan N, Sahota N, Shepel ML, Obaid H. Posterior ankle labral changes at MRI: A preliminary study. J Med Imaging Radiat Oncol 2017; 61:622-629. [PMID: 28419756 DOI: 10.1111/1754-9485.12609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/24/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The transverse ligament in the ankle joint has been described as a labrum-like structure in a previous cadaveric study. The purpose of this study is to assess the spectrum of abnormal changes related to this structure on imaging/MRI, and correlate these findings with other ankle joint findings and patient symptoms. METHOD A retrospective observational review of 172 ankle MRI scans was carried out independently by two fellowship trained musculoskeletal Radiologists. Correlation between abnormal labral changes, other ankle joint findings and patient symptomatology was performed. RESULTS Abnormal labral changes were seen in 26% of the MRI scans (n = 44/172) and included signal change, contour abnormality with heterogeneous signal change, linear fluid filled clefts, multidirectional fluid filled clefts, and a macerated labrum. There was a statistically significant association between abnormal labral changes and the presence of Stieda process/os trigonum (P = 0.001), talocrural joint osteoarthritis (P = 0.0003), paralabral cysts (P = 0.0001), imaging features of posterior impingement (P = 0.01), and both medial (P = 0.005) and lateral (P = 0.01) ankle ligament injuries. However, there was no statistically significant association between abnormal labral changes and patient symptoms. CONCLUSION The posterior ankle labrum can develop a spectrum of abnormal MRI appearances in patients with other ankle joint abnormalities. Although this study showed no correlation between patients' symptoms and posterior ankle labral changes, larger studies are needed to examine the biomechanical alterations that may arise from these labral changes.
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Affiliation(s)
- Nasir Khan
- Department of Medical Imaging, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Navdeep Sahota
- Department of Medical Imaging, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Michael L Shepel
- Department of Medical Imaging, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Haron Obaid
- Department of Medical Imaging, Royal University Hospital, Saskatoon, Saskatchewan, Canada.,Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada
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Abstract
BACKGROUND An os trigonum is a potential source of posterior ankle pain in dancers, often associated with flexor hallucis longus (FHL) pathology. Options for operative excision include open excision, subtalar arthroscopy, and posterior endoscopy. The purpose of this paper was to present a series of dancers who underwent excision of a symptomatic os trigonum via an open posteromedial approach. METHODS This study is a retrospective case series of 40 ankles in 38 dancers who underwent os trigonum excision via an open posteromedial approach with FHL tenolysis between 2000 and 2013. All patients were interviewed and charts retrospectively analyzed. Collected variables included pre- and postoperative pain level, time to return to dance, and subjective satisfaction. The average age was 19.2 years; ballet was the primary dance form in 36 (95%) of patient-cases. Eight (20%) of the patient-cases were professional dancers, and 30 (75%) were students or preprofessional dancers. RESULTS Average preoperative pain level was 7.7/10, which decreased to 0.6/10 postoperatively. Seventeen (42.5%) experienced concurrent preoperation-associated FHL symptomatology, all of whom experienced relief postoperatively. The average time to return to dance was 7.9 weeks, and time to pain-free dance was 17.7 weeks. Of the 37 patient-cases desiring to return to dance, 35 (94.6%) returned to their preoperative level of dance. There were no neurovascular or other major complications. Four (10%) had minor wound complications that resolved, and 38 cases (95%) considered the procedure a success. CONCLUSION Open posteromedial excision of an os trigonum in dancers provided satisfactory pain relief, return to dance, and complication rates compared to other approaches, and allowed for identifying and treating any associated FHL pathology. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Jessica H Heyer
- 1 Orthopaedic Surgery Department, George Washington University Hospital, Washington, DC, USA
| | - Donald J Rose
- 2 Department of Orthopaedic Surgery, Harkness Center for Dance Injuries, New York University Hospital for Joint Diseases, New York, NY, USA
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Abstract
Arthroscopic subtalar arthrodesis is gaining in popularity based on evidence of bone fusion in over 90% of cases, with a shorter time to healing, a simpler postoperative course, and fewer complication compared to open surgery. Two arthroscopic techniques have been reported: one with the patient in lateral decubitus and lateral portals and the other with the patient prone and posterior portals. The objective of this technical note is to describe these two techniques, with emphasis on the specific characteristics of each.
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Yasui Y, Hannon CP, Hurley E, Kennedy JG. Posterior ankle impingement syndrome: A systematic four-stage approach. World J Orthop 2016; 7:657-663. [PMID: 27795947 PMCID: PMC5065672 DOI: 10.5312/wjo.v7.i10.657] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/15/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
Posterior ankle impingement syndrome (PAIS) is a common injury in athletes engaging in repetitive plantarflexion, particularly ballet dancers and soccer players. Despite the increase in popularity of the posterior two-portal hindfoot approach, concerns with the technique remain, including; the technical difficulty, relatively steep learning curve, and difficulty performing simultaneous anterior ankle arthroscopy. The purpose of the current literature review is to provide comprehensive knowledge about PAIS, and to describe a systematic four-stage approach of the posterior two-portal arthroscopy. The etiology, clinical presentation, diagnostic strategies are first introduced followed by options in conservative and surgical management. A detailed systematic approach to posterior hindfoot arthroscopy is then described. This technique allows for systematic review of the anatomic structures and treatment of the bony and/or soft tissue lesions in four regions of interest in the hindfoot (superolateral, superomedial, inferomedial, and inferolateral). The review then discusses biological adjuncts and postoperative rehabilitation and ends with a discussion on the most recent clinical outcomes after posterior hindfoot arthroscopy for PAIS. Although clinical evidence suggests high success rates following posterior hindfoot arthroscopy in the short- and mid-term it may be limited in the pathology that can be addressed due to the technical skills required, but the systematic four-stage approach of the posterior two-portal arthroscopy may improve upon this problem.
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Abstract
Posterior ankle pain can occur for many reasons. If it is produced by forced plantarflexion of the foot, it is often a result of impingement from an enlarged posterior talar process or an os trigonum. This condition may present in an acute or chronic state. Management is initially nonoperative, but surgical treatments are available. This condition is often seen in athletes, so procedures that limit surgical trauma and allow early return to activity are ideal. An arthroscopic approach for this disorder produces good outcomes with limited complications. Understanding the indications, local anatomy, and surgical technique, allows good, reproducible outcomes.
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Lui TH, Chan LK. Posterior ankle and hindfoot endoscopy: A cadaveric study. Foot Ankle Surg 2016; 22:186-190. [PMID: 27502228 DOI: 10.1016/j.fas.2015.07.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 02/22/2015] [Accepted: 07/25/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND The list of indications of posterior ankle endoscopy is expanding and includes various soft tissue and bony pathologies of the posterior ankle. Some of the indications, e.g. release of frozen ankle, debridement of posteromedial soft tissue impingement of the ankle and debridement or fixation of the posteromedial osteochondral lesion of the talus, require approach to the posterior ankle medial to the flexor hallucis longus tendon. The purpose of this study was to assess the risk of injury to the posterior tibial neurovascular bundle during posterior ankle endoscopy. METHODS Fourteen fresh frozen foot and ankle specimens were used. A metal rod was inserted into the posteromedial, posterolateral and modified posteromedial portals and touched the medial border of the posterolateral talar tubercle and the posteromedial corner of the ankle mortise in turn. The neurovascular bundle and FHL tendon were examined for any kink. RESULTS The neurovascular bundle was kinked in all specimens (100%) with the rod at the posteromedial corner of the ankle mortise through the posteromedial portal and was kinked in 11 specimens (79%) with the rod through the modified posteromedial portal. The neurovascular bundle was kinked in 1 specimen (7%) with the rod through the posterolateral portal. CONCLUSIONS The neurovascular bundle was at risk during instrumentation of the posteromedial ankle through the posteromedial portal but was safe through the posterolateral portal.
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Affiliation(s)
- T H Lui
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China.
| | - L K Chan
- Institute of Medical and Health Sciences Education and Department of Anatomy, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong SAR, China.
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Barg A, Saltzman CL, Beals TC, Bachus KN, Blankenhorn BD, Nickisch F. Arthroscopic Talar Dome Access Using a Standard Versus Wire-Based Traction Method for Ankle Joint Distraction. Arthroscopy 2016; 32:1367-74. [PMID: 27050022 DOI: 10.1016/j.arthro.2016.01.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 11/20/2015] [Accepted: 01/13/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the accessibility of the talar dome through anterior and posterior portals for ankle arthroscopy with the standard noninvasive distraction versus wire-based longitudinal distraction using a tensioned wire placed transversely through the calcaneal tuberosity. METHODS Seven matched pairs of thigh-to-foot specimens underwent ankle arthroscopy with 1 of 2 methods of distraction: a standard noninvasive strapping technique or a calcaneal tuberosity wire-based technique. The order of the arthroscopic approach and use of a distraction method was randomly determined. The areas accessed from both 2-portal anterior and 2-portal posterior approaches were determined by using a molded translucent grid. RESULTS The mean talar surface accessible by anterior ankle arthroscopy was comparable with noninvasive versus calcaneal wire distraction with 57.8% ± 17.2% (range, 32.9% to 75.7%) versus 61.5% ± 15.2% (range, 38.5% to 79.1%) of the talar dome, respectively (P = .590). The use of calcaneal wire distraction significantly improved posterior talar dome accessibility compared with noninvasive distraction, with 56.4% ± 20.0% (range, 14.4% to 78.0%) versus 39.8% ± 14.9% (range, 20.0% to 57.6%) of the talar dome, respectively (P = .031). CONCLUSIONS Under the conditions studied, our cadaveric model showed equivalent talar dome access with 2-portal anterior arthroscopy of calcaneal wire-based distraction versus noninvasive strap distraction, but improved access for 2-portal posterior arthroscopy with calcaneal wire-based distraction versus noninvasive strap distraction. CLINICAL RELEVANCE The posterior 40% of the talar dome is difficult to access via anterior ankle arthroscopy. Posterior calcaneal tuberosity wire-based longitudinal distraction improved arthroscopic access to the centro-posterior talar dome with a posterior arthroscopic approach.
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Affiliation(s)
- Alexej Barg
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A.; Orthopaedic Research Laboratory, Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A
| | - Charles L Saltzman
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A..
| | - Timothy C Beals
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A
| | - Kent N Bachus
- Orthopaedic Research Laboratory, Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A
| | - Brad D Blankenhorn
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Florian Nickisch
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A..
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Balcı Hİ, Polat G, Dikmen G, Atalar A, Kapıcıoğlu M, Aşık M. Safety of posterior ankle arthroscopy portals in different ankle positions: a cadaveric study. Knee Surg Sports Traumatol Arthrosc 2016; 24:2119-23. [PMID: 25502830 DOI: 10.1007/s00167-014-3475-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 12/04/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate anatomic relation of standard and coaxial ankle arthroscopy portals with neurovascular structures during different degrees of ankle motion. METHODS Twenty posterior ankles of ten fresh cadavers were assessed. Posteromedial, posterolateral and coaxial (transmalleolar) portals were created using 4-mm Steinmann pins in accordance with the defined technique in neutral position. The ankles were then dissected, and the distance from the portals to the peroneal tendons, short saphenous vein and sural nerve was measured laterally and that from the tibial nerve, flexor hallucis longus tendon and posterior tibial artery was measured medially. Changes in the distance between these structures were noted in neutral positions, 15° of dorsiflexion and 30° plantar flexion. RESULTS In the neutral position, the mean distance of the conventional posterolateral portal to the sural nerve was 6 mm (SD 2.9, range 2.7-14.5). The mean distance of the posterolateral coaxial portal to the peroneal tendon was 1.6 mm (SD 0.55, range 1.1-2.9). The mean distance of the posteromedial portal to the FHL was 2.11 mm (SD 1.1, range 0-4.7). The mean distance of the posteromedial coaxial portal to the posterior tibial artery was 6 mm (SD 1.4, range 3.9-9.5). Although not statistically significant, the distance between the portal and neurovascular structures increased in dorsiflexion for the portals placed posteriorly to the neurovascular structures and increased in plantar flexion for the portals placed anterior to the neurovascular structures. CONCLUSIONS In comparison with the portals made in the neutral position, the distance between neurovascular structures and portals changes with portal placement in plantar flexion and dorsiflexion. In clinical practice, therefore, it might be safer to place the posteromedial-posterolateral portals in dorsiflexion and posterolateral-posteromedial coaxial portals in plantar flexion. The tibial nerve is closer to the posteromedial coaxial in dorsiflexion and could be in danger if making this portal with the foot in this position.
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Affiliation(s)
- Halil İbrahim Balcı
- Department of Orthopaedics and Traumatology, Istanbul Medical Faculty, Istanbul University, Millet Caddesi Çapa, Fatih, 34690, Istanbul, Turkey
| | - Gökhan Polat
- Department of Orthopaedics and Traumatology, Istanbul Medical Faculty, Istanbul University, Millet Caddesi Çapa, Fatih, 34690, Istanbul, Turkey.
| | - Göksel Dikmen
- Department of Orthopedics and Traumatology, Acıbadem Maslak Hospital, 34398, Istanbul, Turkey
| | - Atacan Atalar
- Department of Orthopaedics and Traumatology, Istanbul Medical Faculty, Istanbul University, Millet Caddesi Çapa, Fatih, 34690, Istanbul, Turkey
| | - Mehmet Kapıcıoğlu
- Department of Orthopaedics and Traumatology, Mardin Kızıltepe State Hospital, Mardin, Turkey
| | - Mehmet Aşık
- Department of Orthopaedics and Traumatology, Istanbul Medical Faculty, Istanbul University, Millet Caddesi Çapa, Fatih, 34690, Istanbul, Turkey
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Liebensteiner MC, Braito M, Giesinger JM, Fuchs A, Putzer D, Schuh R, Haid C, Kaufmann G. Driving ability after right-sided ankle arthroscopy--A prospective Study. Injury 2016; 47:762-5. [PMID: 26679091 DOI: 10.1016/j.injury.2015.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/17/2015] [Accepted: 11/10/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Due to the current lack of evidence the aim of this study was to investigate the driving ability after right-sided ankle arthroscopy. MATERIALS AND METHODS Nineteen patients underwent right-sided ankle arthroscopy. Brake response time (BRT) was assessed preoperatively, 2 days, 2 weeks, 6 weeks, and 12 weeks postoperative. We also determined patients' clinical outcome (AOFAS and AOS questionnaires) and their driving frequency. RESULTS BRT was 606ms preoperatively and changed to 821ms 2 days postoperative (p<0.001). The further postoperative BRT course was 606ms (2 weeks), 596ms (6 weeks) and 603ms (12 weeks) (p=n.s.). In addition, a significant influence of the AOS and AOFAS scores on BRT was found, namely poorer clinical outcome also leads to a prolonged BRT (p<0.01 for both). BRT was significantly prolonged in patients with little driving frequency (p=0.001). Furthermore, the 'time-by-driving interaction' was significant (p=0.018), which means the BRT-peak on the second day was much lower in low-frequency drivers. CONCLUSIONS From the findings made in the current study we conclude that a driving abstinence of two weeks is necessary following right-sided ankle arthroscopy. Greater driving frequency and good clinical outcome seem to be associated with better driving ability. However, for the time being no exceptions should be made from the above-mentioned recommendation on driving abstinence.
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Affiliation(s)
- Michael C Liebensteiner
- Department of Orthopaedic Surgery, Innsbruck Medical University, Anichstraße 35, Innsbruck, Austria.
| | - Matthias Braito
- Department of Orthopaedic Surgery, Innsbruck Medical University, Anichstraße 35, Innsbruck, Austria.
| | - Johannes M Giesinger
- Department of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, Netherlands.
| | - Andreas Fuchs
- Department of Orthopedics and Trauma Surgery, University Medical Center Freiburg, Hugstetter Straße 55, Freiburg, Germany.
| | - David Putzer
- Department of Experimental Orthopaedics, Innsbruck Medical University, Innrain 36, Innsbruck, Austria.
| | - Reinhard Schuh
- Department of Orthopedics, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Christian Haid
- Department of Experimental Orthopaedics, Innsbruck Medical University, Innrain 36, Innsbruck, Austria.
| | - Gerhard Kaufmann
- Department of Orthopaedic Surgery, Innsbruck Medical University, Anichstraße 35, Innsbruck, Austria.
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Walls RJ, Ross KA, Fraser EJ, Hodgkins CW, Smyth NA, Egan CJ, Calder J, Kennedy JG. Football injuries of the ankle: A review of injury mechanisms, diagnosis and management. World J Orthop 2016; 7:8-19. [PMID: 26807351 PMCID: PMC4716575 DOI: 10.5312/wjo.v7.i1.8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 06/06/2015] [Accepted: 09/18/2015] [Indexed: 02/06/2023] Open
Abstract
Football is the most popular sport worldwide and is associated with a high injury rate, most of which are the result of trauma from player contact. Ankle injuries are among the most commonly diagnosed injuries in the game. The result is reduced physical activity and endurance levels, lost game time, and considerable medical cost. Sports medicine professionals must employ the correct diagnostic tools and effective treatments and rehabilitation protocols to minimize the impact of these injuries on the player. This review examines the diagnosis, treatment, and postoperative rehabilitation for common football injuries of the ankle based on the clinical evidence provided in the current literature.
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Funasaki H, Hayashi H, Sakamoto K, Tsuruga R, Marumo K. Arthroscopic Release of Flexor Hallucis Longus Tendon Sheath in Female Ballet Dancers: Dynamic Pathology, Surgical Technique, and Return to Dancing Performance. Arthrosc Tech 2015; 4:e769-74. [PMID: 27284509 PMCID: PMC4886817 DOI: 10.1016/j.eats.2015.07.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 07/29/2015] [Indexed: 02/03/2023] Open
Abstract
Stenosing tenosynovitis of the flexor hallucis longus (FHL) tendon is known as a major overuse lesion in female dancers. We describe arthroscopic surgical techniques in relation to the dynamic pathology of the disease. Crepitus and pain on moving the great toe with the ankle in plantar flexion on preoperative examination confirm the diagnosis of FHL stenosing tenosynovitis even if the os trigonum is not evident. The ankle is approached through standard posterolateral and posteromedial portals. A 4.0-mm-diameter 30° arthroscope is used. Soft tissues around the talus are cleared with a motorized shaver and a radiofrequency device. The posterior aspects of the talus, os trigonum, and FHL tendon surrounded by the tendon sheath are visualized. The dynamic pathology of the FHL tendon is well observed on passive motion of the great toe. The prominent bone fragment of the talus is removed and the tendon sheath is cut with a retrograde knife and a motorized shaver from the superior border down to the entrance of the fibro-osseous tunnel. Arthroscopic release of the FHL tendon sheath is a useful and easy method to directly approach the dynamic pathology of FHL tenosynovitis in female ballet dancers.
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Affiliation(s)
- Hiroki Funasaki
- Address correspondence to Hiroki Funasaki, M.D., Department of Sports and Wellness Clinic, Jikei University School of Medicine, 3-25-8 Nishishinbashi Minato-ku, Tokyo 105-8461, Japan.
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Arthroscopic Excision of a Symptomatic Os Trigonum. Arthroscopy 2015; 31:2082-8. [PMID: 26076662 DOI: 10.1016/j.arthro.2015.04.086] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 03/23/2015] [Accepted: 04/10/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the clinical outcomes of arthroscopic excision for a symptomatic os trigonum initially viewing through the posteromedial ankle portal with the motorized instrument in the posterolateral portal. METHODS A retrospective review of a consecutive series of patients with symptomatic os trigonum failing nonoperative management and treated with arthroscopic excision was performed. Demographic data, clinical data, American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scores, and Single Assessment Numeric Evaluation scores were obtained. Any complications and the time required to return to sports or full activities were recorded. RESULTS Twenty-four patients with an arthroscopic excision of a symptomatic os trigonum were included. There were 13 male and 11 female patients. The average age was 36.7 ± 17 years. Twenty-one isolated os trigonum excisions and 3 excisions combined with other procedures were studied. At a mean follow-up of 26 months (range, 24 to 31 months), average preoperative AOFAS scores significantly improved from 55.3 to 92.3 postoperatively (P < .0001). The preoperative AOFAS function component improved from 17.1 to 33.8 (P < .0001). The mean postoperative Single Assessment Numeric Evaluation score was 90. Patients reported full activity at an average of 1.5 months with no limitations at an average of 7.8 months after surgery. The only complication was a posterior tibial nerve calcaneal branch neurapraxia. CONCLUSIONS Arthroscopic excision in the prone position without traction of a symptomatic os trigonum viewing initially through the posteromedial portal with a high-speed burr in the posterolateral portal resulted in significantly improved AOFAS scores with a single transient neurapraxia in 24 patients. Patients returned to their normal daily activities without limitations at an average of 1.5 months. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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