FL Gutter.com

Medial Gutter

October 23rd, 2009 |

The current state of Ankle Arthroscopy

Introduction
Burman in 1931, with area of 3 ankles with 4.Omm sheath without distraction, he found it too tight for satisfactory viewing. Ankle arthroscopy really come of age in the '90s with the development of 2.5mm arthroscope, noninvasive distraction techniques and irrigation systems.

Historical evolution
Takagi was the true father of arthroscopy. He developed an arthroscope 2.7mm. However, Watanabe matters further developed to produce an auto-focus 1.7 mm arthroscope arthroscope 28 and ankles, which describes the standard portals and normal anatomy.

Andrews wrote one of the many texts on the subject in recent years 80. Guhl developed a distracter ankle bone and wrote an excellent text.

Yates was the first to develop a noninvasive technique of distraction.

Benefits and Contraindications
ADVANTAGES
Arthroscopy allows direct inspection of articular + evaluation of the ligaments and synovial change. You can make intraoperative stress testing.

The diagnoses can be made as follows. OCD – 23.5%, Impingement – 21.3%, Chrondromalacia – 7.9%, unstable – 7.2%, DJD – 7.2%, fracture Acute – 6.5%, Arthrofibrosis – 4.8%, loose bodies, osteophytes, synovitis, bones, the anterior talofibular ligament tear, Cryptogenic pain, cyst, fracture chondral, peroneal subluxation, Torn peroneal tendon.

The following procedures can be performed. Debride side channel – 21.8%, Special / Drill OCD – 19.4% chondroplasty – 13.3%, special fibrous bands – 6.8%, loose bodies – 5.7%, Rx fracture, diagnosis, Synovectomy, osteophytes, ossicles, fusion, Stabilization CONTRAINDICATIONS – relative – DJD, edema, impairment of the vasculature.

Absolute – advanced soft tissue infections DJD.

Instrumentation
Ankle arthroscopy developed from the principles of arthroscopy of the knee and therefore initially the same instruments were applied. However, as the experience developed with smaller instruments, distraction, and fluid management systems, arthroscopy evolved.

Irrigation – gravity, gravity assist, pumps.

Athroscopes – Hopkins 2.3 mm, 2.7 mm and 1.9 mm diameter, 30 and 70 degrees.

Distraction – non-invasively.

Instrumentation – Needles, Probes, dissectors – increase in OCD lesions, bones, claws – Inclined plane pitbull loose bodies or small or large (2,7-3. Omm), forceps in Basket – straight, right and left, up and down angles (2.53.00mm), knives, curettes, Osteotomes, Power Tools, thigh / ankle holder, the objective gigas.

Diagnostic arthroscopic examination of ankle
Ankle arthroscopy is a useful diagnostic modality for evaluating the pathology and determine the correct treatment. It should not be used as a substitute for medical history, examination and research. Its main advantages are that it allows inspection in the direct examination of all intraarticular structures and dynamic evaluation. As such it is virtually 100% accuracy in diagnosing intra-articular disorders.

The ankle is the first distended with approximately 30 cc of saline. Then the anteromedial portal provides medial muscle tibialis anterior in the level of joint line, carefully avoiding the saphenous nerve. Then the anterolateral portal is made using transillumination, avoiding superficial branch of the peroneal nerve. A complete diagnostic inspection of the anterior compartment is then carried out. Then the posterolateral portal location is performed with an entry point spinal needle. Then do a full inspection of the rear compartment. Using these three portals-of-21 ankle points systemic examination can be carried out.

Soft tissue injuries of the ankle
These are difficult to diagnose without arthroscopy despite careful evaluation and research. They represent approximately 3050% of the lesions on the ankle and are diagnosed and treated by arthroscopy.

Patients with these lesions present with a combination of pain, swelling, tenderness, locking and giving way.

A review is a combination of sensation, weakness, swelling, restricted range and instability.

The investigations include XR, CT, MRI, evidence of arthritis. All this can be negative.

CLASSIFICATION
Congenital – folds bands – excise duty

Trauma – sprains, fractures, surgery ADVANCE – special generalized synovitis, localized bands excise tax, excise meniscoid lesions secondary to compression.

Injuries shock
Lateral ligament injuries are very common, with 1 ankle sprain occurs per 10,000 per day. Some 1-50% have chronic pain.

Anterolateral impingement is the most common soft tissue interactions and cause injury pain after ankle injury investment – Wolin coined the term "meniscoid injuries" to the advent of arthroscopic lateral canal in these patients.

Arthroscopic the treatment is very successful in alleviating chronic pain in 84% both subjectively and objectively.

During ankle dorsiflexion separate malleolus and syndesmosis It stands out, syndesmotic injuries are undoubtedly underestimated. Syndesmotic injuries are best diagnosed by localized tenderness and a positive compression test pressing the tibia and fibula syndesmosis halfway up the calf. syndesmotic impingement is also associated with a separate distal fascicle to the anterior talo fibular ligament. The incidence of syndesmotic injury is 3% of all ankle sprains.

Clamping can occur and was described by Hamilton, with subsequent "meniscus" pull down. Also a bun in the posterior lip of the tibia can hypertrophy when injured.

Inflammatory lesions
Rheumatoid arthritis, X-synovitis such PVNS and synovial chondromatosis can affect the ankle. Rheumatoid arthritis has been reported Arthroscopic has a cure. A 95% synovectomy is possible as early synovectomy is better than later.

SVP can be treated ankle arthroscopy and elsewhere. Synovial chondromatosis is rare in the ankle, but it is along standard lines arthroscopy.

Other arthritis has been described as gonarthritis, Crohn gout, chondrocalcinosis and are treated with arthroscopic synovectomy.

Infections
Bacterial and fungal infections occur and are best treated with aspiration and arthroscopic synovial biopsy followed by washing and irrigation with appropriate antimicrobial therapy.

Degenerative disease
Primary and secondary osteoarthritis can be treated arthroscopically.

Several
Arthrofibrosis post fracture or sprain can occur and is treated successfully by arthroscopic resection of fibrous bands and early physiotherapy.

ARTICULAR surface defects, loose bodies and osteophytes
OCD lesions of the talus – OLT
Osteochondral lesions of the talus, as such, were described in 1856 by Monro, but Könning coined the term "osteochondritis" when he encountered a similar condition elsewhere in the body and mind of the etiology was osteonecrosis. Kappis in 1922 first applied the term osteochondritis of the ankle joint.

Berndt and Harty in 1959 postulated a traumatic etiology and used the transchondral term fracture of the talus. O'Donoghue said the injuries were fractures and intraarticular Campbell and Ranawat was felt that the cause of ischemia in 1966. Alexander and Lichtman + Canale and Belding have subsequently supported the traumatic etiology in 1980. However, the exact etiology remains uncertain.

It is certainly a condition that tends to be diagnosed low given that the talus osteochondritis accounts for 4-10% of all osteochondritides. Affects males more frequently than women and a peak incidence in 20 to 30-years old.

The lesions are posteromedial or anterolateral. If you are posteromedial – 70% are traumatic – Are deep and usually not displaced. They are usually caused by the investment of dorsiflexion of the foot (impaction of torque) ref. Anterolateral injuries — 90% are traumatic – tend to be thinner and more commonly displaced. They are usually caused by the inversion of the foot in plantarflexion.

Clinically, patients present with a history of trauma, pain, swelling, catching, locking or giving way. A review can be found swelling and tenderness.

The diagnosis is best performed by CT or MRI. A classification based on CT findings correlated better with the original arthroscopic classification of Berndt and Harty. Zinman and colleagues found CT to be superior to the XR in the diagnosis, but MRI has also been advocated in particular by Dipaoala. Anderson has developed a classification based on MRI and CT is as good as MRI, except in the diagnosis of lesions of grade 1.

Cheng and Ferkel went on to show CT scan is the choice if the diagnosis is known, but MRI if it is not. They have also developed an arthroscopic classification.

Treatment of stage 1 and 2 of the lesions is 6-12 weeks in a cast, but arthroscopy if conservative treatment fails. Injuries stages 3 and 4 cover arthroscopy immediately.

Results of treatment are good Loomer showing with 80% good or excellent results.

The surgical approach is as follows for acute OLT. Is palpated with a hook. Chondral loose fragments only removed, but osteochondral fragments are pinned or screwed into the base of the defect is displaced or nondisplaced.

To feel the OLT chronic back with a hook, see if it is loose. Fix it if it is loose and the underlying bone is healthy, if the underlying bone is not healthy is necessary to remove the loose fragment and drill the base of the defect. Large areas can be treated by large osteochondral graft.

Buckwalter has been shown by the penetration of subchondral bone disrupts subchondral vessels, that causes bleeding, blood clot and repair fibrocartilage. The cells responsible for this comes from the bone marrow. Significant cartilage defects can be repaired by the tissue grows to drill holes to cover the exposed subchondral bone.

The results of arthroscopic treatment of OLT are so good, if not better than open surgery, ie 80% more.

Osteophytes, loose bodies and cartilage injuries in the ankle
Arthroscopic ankle surgery successful also other diseases in addition to shock and OLT. Martin and Ferkel in 1989 reported 71% good / excellent result for injuries OLT, 57% good / excellent result for loose bodies and osteophytes and 12% good / excellent results for DJD.

With the loose bodies is necessary to inspect the compartment later and is necessary that all the articular surfaces thoroughly after disposal.

Osteophytes in the ankle are a common condition known as the previous "kissing lesions" or "Footballers ankle. It O'Donoghue in 1966, which reported an incidence of 45% in soccer players American, there is an even greater incidence of 59.3% in dancers. Patients with "present Footballers ankle" pain and restricted motion capture the joint (dorsiflexion) and swelling.

Treatment aims to replicate the normal 60 degrees of tibiotalar angle. Beware to avoid neurovascular injury when surgery is performed open or closed. Arthroscopic borders of osteophytes are exposed with 3.5mm resectoscope soft tissue after bone spurs themselves are removed with burrs. For operative lateral X-ray before the implementation can be taken to ensure the resection sufficient bone has been shown that better results if patients have isolated DJD Spurs widespread, but in general excellent results are achievable.

A ranking in scoring was described by Scranton, (1-111 treatable arthroscopy), but grade IV lesions can be addressed arthroscopically. It is interesting talofibular bone shock may also occur.

Chondral lesions also occur and are usually caused by a sprain or also by an RTA with direct compression of the articular cartilage. Pathologies range from blistering to tears full thickness flap. These lesions are often frustrated XR because of normal in A / E. If these lesions are suspected ankle arthroscopy is the only sure way to diagnose a full examination of the anterior and posterior compartments required. Arthroscopic surgery is fairly straightforward to resect chondral flaps stable and exposed bone drilling to encourage the formation and vascular invasion of fibrocartilage.

Arthroscopic ankle debridement and parallels of arthroscopic lavage treatment of ODL in other joints.

Lateral ligament instability
Lateral ligament injury of the ankle is very common, with one person in 10,000 maintenance per day injury is injury common ligament seen by surgeons. Repeated lateral ligament injuries interfere with normal daily life with chronic instability and a minor trauma can cause injury by significant investment with unpredictable results.

Surgery to correct the lateral ligament instability was described in 1949 by Nilsonne he described brevis transfer. But it was Broström indicating that the direct lateral ligament repair was possible, even years after the acute injury and Hamilton reported 93% good or excellent results with a modified Broström procedure. With lateral ligament tears is the anterior talo fibular ligament not first break calcaneal fibular ligament is rare. A repair and reconstruction has to reproduce the ideal ATFL in its anatomical position and this is what a Hamilton Broström or procedure does.

The diagnosis of lateral ligament instability is simple, there is a history of instability of the ligaments side are tender and moving the ankle shows overinvestment and excessive anterior drawer test, that is when the foot and talus above are translocated in stiffness and the momentum of previous recorded and compared with the normal side.

Radiographic views lateral forces can make the application to establish forces investment. But the results of tests that instability may be questionable if the ligament is intact and calcaneofibular these patients still have instability.

There Arthroscopic anterolateral bowing of the capsule that looks and feels thinner than normal. It is common to see healing and side-channel syndesmosis associated with loose bodies or ossicles and the dome or lateral plafond chondral changes.

The treatment is either open or closed after Broström repair three weeks in a cast boot below standard physiotherapy. Arthroscopic results are as good as open.

Ankle Arthrodesis
An ankle arthrodesis on success allows a patient to return to work and some sports with a march to normal. The fusion rates have been reported of any series and the order of 80% and infection occur in 5-25%. Morgan, in 1985, reported a 96% fusion rate with 90% good / very good results. He held the contour of the dome of the talus, the ankle held in neutral and using cross screw fixation.

Two years previously described Schneider first arthroscopic ankle arthrodesis. But it was Morgan who published the first report in 1987. Myerson techniques compared open and closed arthrodesis reported ankle with a faster fusion time of 8.7 arthroscopy vs. 14.5 weeks in theory, due to lack of disruption of the soft tissues and therefore both a better supply of blood to surface melting. The faster rate of fusion was supported by Ogilvie-Harris, who reported a 89% rate Arthroscopic fusion with 88% cast for third place operating months!

The advantages of an arthroscopic arthrodesis reduced morbidity, hospital stay shortest, the fastest rate of fusion, better cosmetic results and lower complication rates. Against these are long learning curve for surgeons in the operating room is a lengthier procedure requires expensive equipment and arthroscopic. Also you can not correct large varus, or rotational deformities.

The contra-indications for an arthroscopic arthrodesis are> 15 degrees deformity, previously failed fusion, the presence of infection, RSD and a Charcot joint. Mann showed that the best position is the ankle fusion in neutral, to avoid> 10 degrees plantar flexion and with the OS-Chalcis by 5 degrees valgus. Also The "Mann" The results in the best position in the march. However, what makes you lose 70% of its total range of motion with an ankle fusion and hypermobility tarsal is increased by 85%.

The arthroscopic technique is created with standard arthroscopic both invasive or noninvasive distraction. Remove all cartilage articular initially from the dome of the talus and then planfond bleeding sewers to expose the underlying bone, and finally the front of osteophytes needs expulsion, as this would otherwise oppose the reduction of the talus. The merger is fixed with cannulated screws crossed. Positioning of the screws is arthroscopy assisted and the length of the screws can be assisted image intensifier.

The patients then spend 3 weeks non-weight bearing for 4-6 weeks followed by partial load. The screws can be removed later if they are causing pain. A range of 3-12 months has been reported with the standard open fusion to occur, this compares unfavorably with the arthroscopic technique. Mann, a multicenter study has recently demonstrated 91% fusion and 84% good / very good results. This type of merger jumps 96% if you know the poor techniques are avoided, for example, lasers, external compression type Charley.

This article was written specifically Chiropody Review and to thank Mr Simon Moyes for the time and trouble you took.

PODIATRY REVIEW, December 1998

About the Author

Mr Simon Moyes MB FRCS FRCSOrth is a Consultant Orthopaedic Surgeon at the Wellington & Devonshire Hospitals, London and webmaster of www.simonmoyes.com which is the source of this article.