| Introduction | | | | diagnosis, but MRI also has been advocated |
| Burman in 1931 scoped 3 ankles using a 4.Omm | | | | particularly by Dipaoala. Anderson has developed |
| sheath without distraction, he found it too tight | | | | an MRI based classification and found CT to be as |
| for satisfactory visualisation. Ankle arthroscopy | | | | good as MRI except in diagnosing grade 1 lesions. |
| really came of age in the 90's with the | | | | Cheng and Ferkel went on to show CT to be the |
| development of 2.5mm arthroscopes, noninvasive | | | | scan of choice if the diagnosis is known but MRI if |
| distraction techniques and irrigation systems. | | | | it is not. They have also developed an |
| Historical developments | | | | arthroscopic classification. |
| Tagaki was the real father of the arthroscope. He | | | | Treatment of the stage 1& 2 lesions is 6-12 |
| developed a 2.7mm arthroscope. However | | | | weeks in a cast, but arthroscopy if conservative |
| Watanabe developed matters further producing a | | | | treatment fails. Stages 3 & 4 lesions are treated |
| self-focusing 1.7mm arthroscope and arthroscoped | | | | arthroscopically immediately. |
| 28 ankles, describing the standard portals and | | | | Results of treatment are good with Loomer |
| normal anatomy. | | | | showing 80% good or excellent results. |
| Andrews wrote one of many texts on the | | | | The surgical approach is as follows for acute OLT. |
| subject in the late 80's. Guhl developed a skeletal | | | | They are palpated with a hook. Loose chondral |
| distracter for the ankle and wrote an excellent | | | | fragments alone are excised but osteochondral |
| text. | | | | fragments are pinned or screwed into the base of |
| Yates was the first to develop a non invasive | | | | the defect whether displaced or undisplaced. |
| distraction technique. | | | | For chronic OLT again palpate with a hook, see if |
| Advantages and Contra-indications | | | | it is loose. Fix it if it is loose and the underlying |
| ADVANTAGES | | | | bone is healthy, if the underlying bone is unhealthy |
| Arthroscopy allows direct articular inspection + | | | | you need to excise the loose fragment and drill |
| assessment of ligaments and synovial change. | | | | the base of the defect. Large areas can be |
| One can perform intraoperative stress testing. | | | | treated by osteochondral graft large. |
| The following diagnoses can be made. OCD - | | | | It has been shown by Buckwalter that |
| 23.5%, Impingement - 21.3%, Chrondromalacia - | | | | penetration of subchondral bone disrupts |
| 7.9%, Instability - 7.2%, DJD - 7.2%, Acute | | | | subchondral vessels, this produces bleeding, a clot |
| Fracture - 6.5%, Arthrofibrosis - 4.8%, Loose | | | | and fibrocartilagenous repair. The cells responsible |
| Bodies, Osteophytes, Synovitis, Ossicles, Torn | | | | for this enter from the marrow. Significant |
| ATFL, Cryptogenic Pain, Cyst, Chondral Fracture, | | | | cartilage defects can be repaired by tissue which |
| Peroneal Subluxation, Torn Peroneal Tendon. | | | | grows up drill holes to cover exposed subchondral |
| The following procedures can be performed. | | | | bone. |
| Debride lateral gutter - 21.8%, Excise/Drill OCD - | | | | The results of arthroscopic treatment of OLT are |
| 19.4%, Chondroplasty - 13.3%, Excise fibrous | | | | as good if not better than open surgery i.e. 80% |
| bands - 6.8%, Loose bodies - 5.7%, Rx of | | | | plus. |
| fracture, Diagnostic, Synovectomy, Osteophytes, | | | | Osteophytes, loose bodies, and chondral lesions of |
| Ossicles, Arthrodesis, Stabilisation | | | | the ankle |
| CONTRA-INDICATIONS - Relative - DJD, | | | | Arthroscopic ankle surgery is also successful other |
| Oedema, Impaired vascularity. | | | | pathologies apart from impingement and OLT. |
| Absolute - Soft tissue infection, Advanced DJD. | | | | Martin and Ferkel in 1989 reported 71% good |
| Instrumentation | | | | excellent results for OLT lesions, 57% good |
| Ankle arthroscopy developed from the principles | | | | excellent results for loose bodies and osteophytes |
| of knee arthroscopy and hence initially the same | | | | and 12% good/excellent results for DJD. |
| instruments were applied. However as experience | | | | With loose bodies it is necessary to inspect the |
| developed with smaller instruments, distraction, | | | | posterior compartment and you need to check all |
| and fluid management systems, arthroscopy | | | | the articular surfaces carefully after their removal. |
| evolved. | | | | Osteophytes in the ankle are a common condition |
| Irrigation - Gravity, Gravity assist, Pumps. | | | | known as the "anterior kissing lesions" or |
| Athroscopes - Hopkins 2.3mm, 2.7mm and 1.9mm | | | | "Footballers Ankle". It is O'Donoghue in 1966 who |
| diameters, 30 & 70 degree. | | | | reported a 45% incidence in American Football |
| Distraction - Non invasive. | | | | players, there is an even higher incidence of |
| Instrumentation - Spinal needles, Probes, | | | | 59.3% in dancers. Patients with "Footballers Ankle" |
| Dissectors - elevating OCD lesions, ossicles, | | | | present with pain catching and restricted joint |
| Graspers - flat tipped or pitbull for small or large | | | | motion (dorsiflexion) and swelling. |
| loose bodies (2.7-3.Omm), Basket forceps - | | | | Treatment aims to reproduce the normal 60 |
| straight, right and left, up and down angles | | | | degree tibiotalar angle. One must be careful to |
| (2.53.00mm), Knives, Curettes, Osteotomes, | | | | avoid neurovascular injury when performing |
| Power Instruments, Thigh/Ankle Holder, Aiming | | | | surgery open or closed. Arthroscopically the |
| jigs. | | | | borders of the osteophyte are exposed with a |
| Diagnostic Arthroscopic Examination of the Ankle | | | | 3.5mm soft tissue resector then the bony spurs |
| Ankle arthroscopy is a useful diagnostic modality | | | | themselves are removed with burrs. Per |
| to evaluate pathology and determine correct | | | | operative lateral x-ray prior to completion can be |
| treatment. It should not be used as a substitute | | | | taken to ensure sufficient bony resection, it has |
| for careful history taking, examination and | | | | been shown that one obtains better results if the |
| investigation. Its main advantages are that it | | | | patients have isolated spurs than generalised DJD |
| allows direct inspection and probing of all | | | | but overall excellent results are achievable. |
| intra-articular structures and their dynamic | | | | A classification with grades I-N was described by |
| assessment. As such it is virtually 100% accurate | | | | Scranton, (1-111 treatable arthroscopically) but |
| in diagnosing intra-articular disorders. | | | | even grade IV lesions can be addressed |
| The ankle is first distended with approximately | | | | arthroscopically. Interestingly talofibular bony |
| 30cc of saline. Then the anteromedial portal is | | | | impingement can also occur. |
| established just medial to tibialis anterior at the | | | | Chondral lesions also occur and are usually caused |
| level of the joint line carefully avoiding the | | | | by a sprain or also by an RTA with direct |
| saphenous nerve. Then the anterolateral portal is | | | | compression of the articular cartilage. The |
| established using transillumination, avoiding the | | | | pathologies range from blistering to full thickness |
| superficial branch of the lateral popliteal nerve. A | | | | flap tears. These lesions are frequently missed |
| full diagnostic inspection of the anterior | | | | because of normal XR in A/E. If such lesions are |
| compartment is then carried out. Then the | | | | suspected then ankle arthroscopy is the only sure |
| posterolateral portal is made localising the entry | | | | way to diagnose them with a full examination of |
| point with a spinal needle. Then a full inspection of | | | | anterior and posterior compartments required. |
| the posterior compartment is made. Using these | | | | Arthroscopic surgery is straight forward resecting |
| three portals a full 21 point systemic ankle | | | | chondral flaps to stable base and drill exposed |
| examination can be carried out. | | | | bone to encourage vascular invasion and |
| SOFT TISSUE LESIONS OF THE ANKLE | | | | fibrocartilage formation. |
| These are difficult to diagnose without | | | | Ankle arthroscopic debridement and lavage |
| arthroscopy despite careful assessment and | | | | parallels that of arthroscopic treatment of DJD in |
| investigation. They represent some 3050% of | | | | other joints. |
| lesions found within the ankle joint and are | | | | Lateral ligament instability |
| diagnosed and treated by arthroscopy. | | | | Lateral ligament injury of the ankle is very |
| Patients with such lesions present with a | | | | common; with one person in 10,000 sustaining the |
| combination of pain, swelling, tenderness, locking | | | | injury per day it is the commonest ligament injury |
| and giving way. | | | | seen by surgeons. Repeated lateral ligament |
| On examination one finds a combination of | | | | injuries interfere with normal daily life and with |
| tenderness, wasting, swelling, restricted range and | | | | chronic instability a minor trauma can cause a |
| instability. | | | | significant inversion injury with unpredictable |
| Investigations include XR, CT, MRI, Arthritis tests. | | | | outcome. |
| These all may be negative. | | | | Surgery to correct lateral ligament instability was |
| CLASSIFICATION | | | | described as early as 1949 by Nilsonne who |
| Congenital - Plicae / bands - excise | | | | described a peroneus brevis transfer. But it was |
| Traumatic - sprains, fractures, prior surgery - | | | | Brostrom who showed that direct repair of the |
| excise generalised synovitis, excise localised bands, | | | | lateral ligament was possible even years after |
| excise meniscoid lesions secondary to | | | | acute injury and Hamilton reported 93% good or |
| impingement. | | | | excellent results with a modified Brostrom |
| Impingement lesions | | | | procedure. With lateral ligament tears it is the |
| Lateral ligament injuries are very common, with 1 | | | | anterior talo-fibular ligament fails first, calcaneo |
| ankle sprain per 10,000 occurring per day. Some | | | | fibular ligament rupture is rare. A repair |
| 1-50% have some chronic pain. | | | | reconstruction ideally needs to reproduce the |
| Anterolateral impingement is the commonest soft | | | | ATFL in its anatomic position and this is what a |
| tissue impingement lesion and cause of pain after | | | | Brostrom or Hamilton procedure does. |
| ankle inversion injury - Wolin coined the term "the | | | | The diagnosis of lateral ligament instability is |
| meniscoid lesions" for the arthroscopic appearance | | | | straight forward, there is a history of instability |
| of the lateral gutter in these patients. | | | | the lateral ligaments are tender and moving the |
| Arthroscopic treatment is very successful in | | | | ankle demonstrates excessive inversion and an |
| alleviating chronic pain in 84% both subjectively | | | | exaggerated anterior draw test, this is when the |
| and objectively. | | | | foot and talus are translocated anteriorly in the |
| During dorsiflexion of the ankle the malleoli are | | | | mortis and the amount of anterior movement |
| separated and the syndesmosis is stressed, | | | | recorded and compared with the normal side. |
| syndesmotic injuries are undoubtedly | | | | Radiographic lateral stress views can be |
| underestimated. Syndesmotic injuries are best | | | | performed applying set forces of inversion. But |
| diagnosed by a localised tenderness and a positive | | | | results of such instability testing can be |
| squeeze test pressing the tibia and fibula together | | | | questionable if the calcaneofibular ligament is intact |
| proximal to the syndesmosis half way up the calf. | | | | and these patients still have instability. |
| Syndesmotic impingement is also associated with | | | | Arthroscopically there is ballooning of the |
| a separate distal fascicle to the anterior talo-fibula | | | | anterolateral capsule which appears and feels |
| ligament. The incidence of syndesmotic injury is | | | | thinner than normal. One frequently sees scarring |
| 3% of all ankle sprains. | | | | of the lateral gutter and syndesmosis with |
| Posterior impingement can occur and was first | | | | associated loose bodies or ossicles and lateral |
| described by Hamilton with posterior "meniscus" | | | | dome or plafond chondral changes. |
| displacing inferiorly. Also a labrum on the posterior | | | | Treatment is either an open or closed modified |
| lip of the tibia can hypertrophy when injured. | | | | Brostrom repair with three weeks in a |
| Inflammatory Lesions | | | | below-knee cast then standard physiotherapy. |
| Rheumatoid arthritis, X-tal synovitis, PVNS and | | | | Arthroscopic results are as good as open. |
| Synovial Chondromatosis can all affect the ankle. | | | | Ankle arthrodesis |
| Rheumatoid arthritis has been reported to have | | | | An ankle arthrodesis if successful allows a patient |
| an arthroscopic cure. A 95% synovectomy is | | | | to return to work and some sports with a |
| possible, and early synovectomy is better than | | | | virtually normal gait. Fusion rates have been |
| later. | | | | reported from any series as in the order of 80% |
| PVNS can be treated arthroscopically in the ankle | | | | and infection occurring in 5-25%. Morgan in 1985 |
| as elsewhere. Synovial Chondromatosis is rare in | | | | reported a 96% fusion rate with 90% good |
| the ankle, but is treated along standard | | | | excellent results. He maintained the contour of the |
| arthroscopic lines. | | | | talar dome, kept the ankle in neutral and used |
| Other arthritides have been described such as | | | | cross-screw internal fixation. |
| gonarthritis, Crohn's gout, chondrocalcinosis and | | | | Two years earlier Schneider first described |
| are treated with arthroscopic synovectomy. | | | | arthroscopic ankle arthrodesis. But it was Morgan |
| Infections | | | | who published the first report in 1987. Myerson |
| Bacterial and fungal infections occur and are best | | | | compared open and closed techniques of ankle |
| treated with arthroscopic aspiration and synovial | | | | arthrodesis with a reported quicker fusion time |
| biopsy followed by washout and irrigation then | | | | arthroscopically of 8.7 versus 14.5 weeks |
| appropriate antibiotic therapy. | | | | theoretically because of the lack of disruption of |
| Degenerative disease | | | | the soft tissues and therefore a better blood |
| Primary and secondary osteoarthritis can be | | | | supply to the fusing surfaces. The faster fusion |
| treated arthroscopically. | | | | rate was backed up by Ogilvie-Harris who |
| Miscellaneous | | | | reported an 89% fusion rate arthroscopically with |
| Arthrofibrosis post fracture or sprain can occur | | | | 88% fused by the third post operative month! |
| and is satisfactorily treated by arthroscopic | | | | The advantages of an arthroscopic arthrodesis |
| resection of the fibrous bands and early | | | | are reduced morbidity, shorter Hospital stay, |
| physiotherapy. | | | | faster fusion rate, better cosmesis and lower |
| ARTICULAR SURFACE DEFECTS, LOOSE | | | | complication rates. Against these are long learning |
| BODIES AND OSTEOPHYTES | | | | curve for the surgeon and theatre staff, it is a |
| OCD Lesions of the talus - OLT | | | | longer procedure and requires expensive |
| Osteochondral lesions of the talus as such were | | | | arthroscopic equipment. Also it cannot correct |
| first described in 1856 by Monro but Konning | | | | large varus, or rotational deformities. |
| coined the term "osteochondritis" when he found | | | | The contra-indications for an arthroscopic |
| similar pathology elsewhere in the body and | | | | arthrodesis are >15 Degrees deformity, a |
| thought the aetiology was osteonecrosis. Kappis in | | | | previously failed arthrodesis, the presence of |
| 1922 first applied the term osteochondritis to the | | | | infection, RSD and a charcot joint. Mann showed |
| ankle joint. | | | | that the best fusion position is with the ankle in |
| Berndt and Harty in 1959 postulated a traumatic | | | | neutral, avoiding >10 Degrees plantar-flexion and |
| aetiology and used the term transchondral | | | | with the os-calcis in 5 degrees valgus. Also the |
| fracture of the talus. O'Donoghue said the lesions | | | | "Mann" position results in the best gait. You do |
| were intra-articular fractures and Campbell and | | | | however lose 70% of your total motion arc with |
| Ranawat felt the cause was ischaemia in 1966. | | | | an ankle fusion and tarsal hypermobility is |
| Alexander and Lichtman + Canale and Belding | | | | increased 85%. |
| have subsequently lent support to the traumatic | | | | The arthroscopic technique is to have the |
| aetiology in 1980. However the exact aetiology | | | | standard arthroscopic set up with either invasive |
| remains uncertain. | | | | or non-invasive distraction. Remove all articular |
| It is certainly a condition which tends to be under | | | | cartilage initially from the talar dome and planfond |
| diagnosed bearing in mind that talar | | | | then the gutters to expose bleeding underlying |
| osteochondritis accounts for 4-10% of all | | | | bone and finally the anterior osteophyte needs |
| osteochondritides. It affects males more | | | | removal as this would otherwise resist talar |
| commonly than females and a peak incidence at | | | | reduction. The fusion is secured with crossed |
| 20-30-years of age. | | | | cannulated screws. Screw positioning is |
| The lesions are either posteromedial or | | | | arthroscopically assisted and the length of the |
| anterolateral. If they are posteromedial - 70% are | | | | screws can be image intensifier assisted. |
| traumatic - are deep and not usually displaced. | | | | The patients then spend 3 weeks non weight |
| They are usually caused by inversion of the | | | | bearing followed by 4-6 weeks partial weight |
| dorsiflexed foot (torsional impaction) ref. Of the | | | | bearing. The screws can be removed later if they |
| anterolateral lesions - 90% are traumatic - are | | | | are causing pain. A range of 3-12 months has |
| usually thinner and are more commonly displaced. | | | | been reported for standard open fusion to occur, |
| They are typically caused by inversion of the | | | | this compares unfavourably with the arthroscopic |
| plantar flexed foot. | | | | technique. Mann from a multi-centre trial recently |
| Clinically patients present with a history of trauma, | | | | demonstrated a 91% fusion and 84% good |
| pain, swelling, catching, givingway or locking. On | | | | excellent results. This fusion rate leaps to 96% if |
| examination one may find swelling and tenderness. | | | | known poor techniques are avoided, e.g. laser, |
| The diagnosis is best made by CT or MRI. A | | | | external charley type compression. |
| classification based on CT correlates better with | | | | This article was specifically written for Chiropody |
| the arthroscopic findings than the original | | | | Review and we thank Mr Simon Moyes for the |
| classification of Berndt and Harty. Zinman and his | | | | time and trouble he took. |
| colleagues found CT to be superior to XR's in | | | | |