The course of the superficial peroneal nerve in relation to the ankle position: anatomical study with ankle arthroscopic implications

Two portals are sufficient for all-inside arthroscopic isolate anterior talofibular ligament repair

PURPOSE

All-inside arthroscopic repair of the anterior talofibular ligament (ATFL) using two or three portals is one of the most commonly performed procedures for managing chronic lateral ankle instability (CLAI). However, it remains unclear whether there are differences in functional outcomes between the use of two versus three portals.

METHODS

This retrospective comparative study included 66 patients with CLAI who underwent an all-inside arthroscopic isolated ATFL repair procedure between 2018 and 2021. Patients were divided into two groups according to the number of portals introduced. In the two-portal group (n = 31), the ATFL was repaired using two portals. In the three-portal group (n = 35), the ATFL was repaired using three portals. The American Orthopedic Foot and Ankle Society (AOFAS) scores, Karlsson Ankle Function Score (KAFS), Anterior Talar Translation (ATT), Active Joint Position Sense (AJPS), complications, as well as the time of return to sports were compared between the two groups.

RESULTS

All patients were followed up for a minimum of 2 years. Improvement in functional outcomes (AOFAS, KAFS, ATT and AJPS) was recorded at the final follow-up. No significant differences were observed between the two groups in terms of operative time, AOFAS, KAFS, ATT, AJPS, or the time of return to sports. However, no nerve complications were observed in the two-portal group.

CONCLUSION

In patients with CLAI undergoing all-inside arthroscopic isolate ATFL repair, the use of either two or three portals results in comparable and favorable functional outcomes. The two-portal procedure was also associated with no superficial peroneal nerve injuries.

LEVEL OF EVIDENCE

Level III.

Open and all-inside arthroscopic Brostrom-Gould for chronic lateral ankle instability: A comparative analysis of surgical outcomes and learning curves

OBJECTIVE

The purpose of this study was to investigate and compare the learning curve and clinical outcomes of all-inside arthroscopic and open techniques in the treatment of chronic lateral ankle instability (CLAI).

METHOD

This was a retrospective cohort analysis of 100 consecutive patients who received all-inside arthroscopic or open Brostrom-Gould surgery. These patients with CLAI were all surgically treated by the same surgeon. We applied the CUSUM analysis to assess the surgeons' learning curves, determine the cut-off point, and subsequently divide the patients into learning and proficiency groups. We recorded and compared baseline data, the preoperative and postoperative clinical function scores (AOFAS, K-P, and Tegner scores), VAS scores, time to full weight-bearing, surgery-related parameters (operation time, and postoperative hospital stays), and complications for both surgical methods during their learning and proficiency phases.

RESULT

The CUSUM analysis identified a learning curve cutoff at 12 cases for open surgery and 22 cases for arthroscopic surgery. In the open surgery group, significant differences were observed in operation time between the learning and proficiency phases (P < 0.05). However, no significant differences were found in clinical function scores and postoperative full weight-bearing time. Similar trends were seen in the arthroscopic surgery group, with significant improvements in operation timeand postoperative hospitalization time in the proficiency phase compared to the learning phase (P < 0.05). However, no significant differences were found in clinical function scores between either surgical method's learning and proficiency stages. Additionally, when comparing the two surgical approaches at the same stage, significant differences emerged in VAS scores, postoperative full weight-bearing time, operation timeand postoperative hospitalization time (P < 0.05), with the arthroscopic technique showing advantages in reduced postoperative discomfort and faster recovery times.

CONCLUSION

Although arthroscopic surgery takes longer to achieve proficiency, it offers the advantages of reduced postoperative discomfort and faster recovery times during both the learning and proficiency phases while achieving comparable clinical outcomes.

Challenges and complications in arthroscopic ankle ligament repair: Current concepts

Arthroscopic ligament repair has gained popularity as a minimally invasive alternative for addressing ankle instability, due to its minimally invasive nature, which offers significant advantages over traditional open procedures. These benefits include smaller incisions, reduced soft tissue dissection, and the ability to concurrently manage intra-articular pathology, contributing to its popularity among surgeons and patients alike. Despite these advantages, the procedure presents a range of technical challenges and potential complications that can impact patient outcomes. Persistent instability, improper tensioning, and issues related to suture anchors are some of the primary concerns. Understanding these complexities and employing targeted strategies to mitigate them is essential for improving patient outcomes. Continued research and refinement of surgical techniques will play a key role in enhancing the safety and efficacy of this procedure.

Clinical outcomes of all-inside arthroscopic lateral ankle ligament reconstruction for chronic lateral ankle instability: A prospective series with minimum 12 month outcomes

BACKGROUND

Chronic lateral ankle instability (CAI) is a common condition that can be effectively treated with lateral ankle ligament reconstruction to restore ankle stability and function. The aim was to assess the functional outcomes of arthroscopic lateral ligament reconstruction using the Manchester-Oxford Foot Questionnaire (MOXFQ), Visual Analog Score (VAS) and Euroqol-5D-5L (EQ-5D) patient-reported outcome measures (PROMs).

METHODS

This prospective series included 36 consecutive patients who underwent isolated arthroscopic lateral ligament reconstruction for CAI between November 2020 and November 2022 with minimum 12-month follow up. All patients completed the MOXFQ, VAS, and EQ5D PROMs preoperatively, and a minimum of 12 months postoperatively. The MOXFQ is a foot and ankle-specific PROM that assesses foot and ankle function, the VAS measures pain and the EQ5D evaluates general health-related quality of life.

RESULTS

Patients were followed up for 12-25 months. In all patients, there was significant improvement in all postoperative PROMs (p < 0.05). The MOXFQ index decreased from 59.1 ± 19.2-13.5 ± 18.1 (p < 0.01), EQ-5D index increased from 0.607 ± 0.224-0.854 ± 0.175 (p < 0.01) and VAS pain decreased from 36.6 ± 22.3-13.6 ± 18.4 (p < 0.01).A total of 6 patients(16.3 %) were lost to follow up and mean follow-up time was 1.63 ± 0.54 years.

CONCLUSION

Arthroscopic lateral ankle ligament reconstruction is an effective treatment for chronic ankle instability, with significant improvements in clinical and health-related quality of life outcomes.

LEVEL OF EVIDENCE

IV.

Results of Anatomical Arthroscopic Repair of Anterior Talofibular Ligament in Chronic Lateral Ankle Instability Patients

BACKGROUND

To assess the clinical and functional outcomes of all-inside arthroscopic anatomical repair of anterior talofibular ligament (ATFL) for management of chronic lateral ankle instability (CLAI) in a considerable number of patients during medium-term follow-up.

METHODS

A retrospective analytic study was performed on 100 patients with CLAI who presented between August 2015 and July 2020 (average age: 32.9 years; range: 16-54 years). All-inside arthroscopic ATFL direct repair was performed in all patients through 2 portals only with fixation using 2 knotless anchors. Associated intraarticular lesions were treated in the same procedure. Outcomes were assessed with pre- and postoperative visual analog scale (VAS), the ankle-hindfoot score of the American Orthopaedic Foot & Ankle Society (AOFAS), and the Karlsson Ankle Functional Score (KAFS).

RESULTS

All patients were followed for 24-48 months. At the final follow-up, ankle pain had improved significantly. Both the ankle anterior drawer test and the ankle varus stress tests were negative. There was no loss of ankle range of motion compared with preoperative measures, and all patients returned to normal gait. The mean VAS score decreased to 0.39 ± 0.63, the AOFAS score increased to 95.17 ± 4.7, and the KAFS score increased to 95 ± 4.07. All the follow-up indexes significantly improved compared to those before surgery.

CONCLUSION

At minimum 24-month follow-up, the all-inside arthroscopic ATFL repair used to treat CLAI was found to restore ankle stability and yield good clinical outcomes with a relatively low complication rate.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Comparison of arthroscopic and open Brostrom-Gould surgery for chronic ankle instability: a systematic review and meta-analysis

BACKGROUND

Approximately 20% of acute ankle sprains progress to chronic lateral ankle instability (CLAI) requiring surgical intervention. There has been growing interest among surgeons regarding whether arthroscopic techniques can replace open Brostrom-Gould surgery in treating CLAI. The purpose of this study was to pool the results of multiple studies comparing the treatment effects of these two fixation approaches.

METHODS

Our study involved thorough searches across multiple electronic databases, including PubMed, Cochrane, Embase, and Web of Science, to identify all relevant publications on CLAI that were repaired using the arthroscopic or open Broström-Gould technique. Through a comprehensive meta-analysis, we evaluated several outcomes, including post-operative function, radiological measurements, complications, and time efficiency.

RESULT

A total of 686 patients from 11 studies were included in the analysis. Among them, 351 patients underwent open repair, and 335 underwent arthroscopic Brostrom-Gould surgery. The present study revealed that arthroscopic and open Brostrom-Gould techniques demonstrated no significant differences in talar tilt, talar anterior translation, complication rate, and time to return to previous level of activity. Furthermore, no significant differences were observed in AOFAS, K-P, VAS, and Tegner scores at the 2-year follow-up. However, significant differences were noted between the two surgical approaches in terms of early weight-bearing (WMD = - 1.33 weeks, 95% CI = [- 1.91, - 0.76], P = 0.17, I2 = 40%), as well as AOFAS scores (WMD = 1.00, 95% CI = [0.05, 1.95], P = 0.73, I2 = 0%), K-P scores (WMD = 1.57, 95% CI = [0.49, 2.64], P = 0.15, I2 = 47%), and VAS scores (WMD = - 0.15, 95% CI = [- 0.60, 0.29], P < 0.08, I2 = 61%) within the first postoperative year.

CONCLUSIONS

Our findings support that arthroscopic repair yields comparable outcomes to open surgery. Consequently, we advocate for adopting arthroscopic repair as a preferred alternative to the conventional open Broström-Gould procedure for treating chronic lateral ankle instability.

The Superficial Peroneal Nerve Is at Risk during the "All Inside" Arthroscopic Broström Procedure: A Cadaveric Study

Background: The arthroscopic Broström procedure is a promising treatment for chronic ankle instability. However, little is known regarding the location of the intermediate superficial peroneal nerve at the level of the inferior extensor retinaculum; knowledge about this location is important for procedural safety. The purpose of this cadaveric study was to clarify the anatomical relationship between the intermediate superficial peroneal nerve and the sural nerve at the level of the inferior extensor retinaculum. Methods: Eleven dissections of cadaveric lower extremities were performed. The origin of the experimental three-dimensional axis was defined as the location of the anterolateral portal during ankle arthroscopy. The distances from the standard anterolateral portal to the inferior extensor retinaculum, sural nerve, and intermediate superficial peroneal nerve were measured using an electronic digital caliper. The location of inferior extensor retinaculum, the tract of sural nerve, and intermediate superficial peroneal nerve were checked using average and standard deviations. For the statistical analyses, data are presented as average ± standard deviation, and then they are reported as means and standard deviations. Fisher's exact test was used to identify statistically significant differences. Results: At the level of the inferior extensor retinaculum, the mean distances from the anterolateral portal to the proximal and distal intermediate superficial peroneal nerve were 15.9 ± 4.1 (range, 11.3-23.0) mm and 30.1 ± 5.5 (range, 20.8-37.9) mm, respectively. The mean distances from the anterolateral portal to the proximal and distal sural nerve were 47.6 ± 5.7 (range, 37.4-57.2) mm and 47.2 ± 4.1 (range, 41.0-51.8) mm), respectively. Conclusions: During the arthroscopic Broström procedure, the intermediate superficial peroneal nerve may be damaged by the anterolateral portal; the proximal and distal parts of the intermediate superficial peroneal nerve were located within 15.9 and 30.1 mm, respectively, at the level of the inferior extensor retinaculum in cadavers. These areas should be considered danger zones during the arthroscopic Broström procedure.

Anterior Ankle Arthroscopy: Advantage of a Preoperative Ultrasound Mapping to Prevent Neurovascular Complications

PURPOSE

The aim of this study is to verify the usefulness of ultrasound-assisted mapping of the vascular and neurological structures in the anterior compartment of the ankle just before an anterior arthroscopic procedure to reduce these kinds of complications.

METHODS

Various complications can be present in anterior arthroscopy of the ankle. The structures most prone to iatrogenic damage are vessels and nerves. They are macroscopically visible and palpable in a little more than 50% of cases, but arterial ramifications are not visible because they are located deeper.

RESULTS

The authors have investigated how to reduce potential iatrogenic damage to the complex and variable neuro-vascular network of the anterior aspect of the ankle. They have completed the classic routine marking of the bony and tendinous structures with an ultrasound mapping of the neurovascular structures.

CONCLUSIONS

The authors concluded that ultrasound-assisted mapping is a non-invasive, fast, and safe procedure that can help to reduce potential iatrogenic damage when performing anterior arthroscopic surgery.

Does Demineralized Bone Matrix Affect the Nonunion Rate in Arthroscopic Ankle Arthrodesis?

Demineralized bone matrix (DBM) has been shown to have positive effects on union rates in many orthopedic subspecialties; however, minimal evidence exists about bone graft substitutes in foot and ankle surgery. The purpose of this study is to compare nonunion rates in arthroscopic ankle arthrodesis in patients receiving DBM with those without. We hypothesized DBM to be associated with a decreased risk of nonunion. This retrospective review includes 516 consecutive ankle arthrodesis cases from March 2002 to May 2016. Of these, 58 ankles (56 patients) that underwent primary arthroscopic ankle arthrodesis met the inclusion criteria, and 31 of these ankles received DBM, while 27 did not. Nonunion was assessed by clinical examination and routine postoperative radiographs. If nonunion was suspected, a computed tomography (CT) scan was performed. The primary outcome measure was nonunion rate. Secondary outcome measures included wound complications, return to operating room (OR), and rate of postoperative deep vein thrombosis (DVT) or pulmonary embolism (PE). From the study cases, 58 were available for final follow-up. The average age was 55.9 years (±17.4), and mean follow-up was 43.0 months (range 6.3–119.4). There was no difference in nonunion rate in patients who received DBM (4/31, 12.9%) versus those who did not (4/27, 14.8%) (p = 0.83). Similarly, when comparing the two groups, there were no statistically significant differences in superficial wound complications (6.5% vs. 3.7%, p = 1.0) or rate of return to OR (29% or 0.037/person-years vs. 37% or 0.099/person-years; p = 0.20). No major complications including deep wound infections, DVTs, or PEs occurred. This is the largest study to directly compare nonunion rates and complications for patients receiving DBM versus those who did not in primary arthroscopic ankle arthrodesis. No significant association was found between DBM usage and risk of nonunion, wound complications, return to OR, or postoperative DVT or PE development.

Visualization of the distal tibial plafond articular surface using four established approaches and the efficacy of instrumented distraction: a cadaveric study

Purpose

Direct visualization is a very effective method in accomplishing adequate articular surface reconstruction in fracture repair. This study investigates distal tibial plafond articular surface visibility using the anteromedial, anterolateral, posteromedial, and posterolateral approaches, the effect of instrumented distraction on visibility, and which zones of the articular surface are visible for each approach.

Methods

The anteromedial, anterolateral, posteromedial, and posterolateral approaches to the distal tibial plafond were performed on 16 cadaveric ankle specimens. The articular surface visualization for each approach was marked using an electrocautery device with manual and instrumented distraction. Articular surface visualization was photographically documented. Digital axial segmentation and quantitative analysis of the visualized distal tibial plafond articular surface were performed.

Results

With manual distraction, distal tibial plafond articular surface visualization, expressed in percent of overall articular surface, was limited to 9% (SD ± 9) for the anteromedial, 24% (SD ± 18) for the anterolateral, 26% (SD ± 10) for the posteromedial, and 30% (SD ± 18) for the posterolateral approaches. Using instrumented distraction significantly improved articular surface visualization in all instances (p < 0.001). The anteromedial approach visible articular surface increased to 63% (SD ± 13), the anterolateral to 72% (SD ± 22), the posteromedial to 62% (SD ± 11), and the posterolateral to 50% (± 17).

Conclusion

This study demonstrates the efficacy of instrumented distraction when attempting surgical visualization of the distal tibial plafond articular surface. Knowledge of approach specific articular surface visibility may assist the surgeon in choosing the appropriate approach(es) based on case-specific distal tibial plafond fracture patterns.

Level of evidence

IV, cadaver study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01927-w.

Anatomy of the superficial peroneal nerve: Can we predict nerve location and minimize iatrogenic lesion?

OBJECTIVE OF THE STUDY

Knowledge of anatomical variations of the superficial peroneal nerve (SPN) may minimize iatrogenic insults. The aim of the investigation was to perform an anatomical description of the SPN.

MATERIALS AND METHODS

Twenty-three embalmed cadaver lower limbs were dissected.

RESULTS

The SPN emerged from the crural fascia about 6.3±7.7mm anteromedial to the anterior border of the fibula and 26.8±12.6mm anteromedial and 113.6±43.9mm superior to the tip of the lateral malleolus. The median point of bifurcation into two terminal branches was 13.0mm anteromedial to the anterior border of the fibula and 34.9±14.7mm anteromedial and 81.0±69.0mm superior to the tip of the lateral malleolus. The SPN was found between 5.76% and 7.70% of the individual's height proximal to the tip of the lateral malleolus, with an unpredictable branching pattern over the intermalleolar line.

CONCLUSION

A lateral ankle approach over the posterolateral surface of the fibula (posterior to the tip of the lateral malleolus) minimizes the risk of iatrogenic nerve lesion.

Comparison of Arthroscopic Surgery Versus Open Surgical Repair of the Anterior Talofibular Ligament: A Retrospective Study of 80 Patients from a Single Center

Background

This retrospective study from a single center aimed to compare the safety and clinical outcomes of arthroscopic surgery vs open surgical repair of the anterior talofibular ligament (ATFL).

Material/Methods

We randomly divided 80 patients with ATFL injury divided into 2 groups: an open surgery group and an arthroscopic group. The operation time, intraoperative bleeding volume, and the postoperative recovery time of all patients were analyzed. The anterior displacement and talus tilt angle, the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS), the Jersey Shore Science Fair (JSSF) ankle-hindfoot scale score, and the Karlsson Ankle Functional Score (KAFS) were compared at 6 months, 1 year, and 2 years after surgery. We collected data on the incidence of postoperative complications during follow-up. All significant results were supported with a P value.

Results

The operation time, intraoperative bleeding volume, and postoperative recovery time in the arthroscopic group were better than in the open group (P<0.05). The AOFAS, JSSF, and KAFS in the arthroscopic group were better than in the open group at 6 months after the operation (P<0.05). The AOFAS, JSSF, and KAFS scale scores were not significantly different between the 2 groups at 1 year and 2 years after the operation (P<0.05).

Conclusions

The findings from this retrospective study showed that the use of arthroscopic surgical repair of the ATFL is a safe minimally invasive technique with reduced blood loss and surgical duration and good clinical outcomes.

Role of Arthroscopy in Various Ankle Disorders

INTRODUCTION

Ankle arthroscopy has come a long way since it was thought, it is not feasible because of tight joint and anatomical characteristics of ankle joint. The same anatomical features like capsular attachment and safe accessory portals are used to access the whole joint even with a rigid arthroscope. Ankle distraction method was routinely used to access the anterior ankle. However, nowadays, anterior arthroscopy is done in dorsiflexion as this increases the anterior ankle joint volume, and thereby easy access to various anatomical structures. On the other hand, intermittent traction is used to access the posterior ankle. Initially used as a diagnostic tool, ankle arthroscopy is now used extensively as a therapeutic and reconstruction tool. New evidence is published for all inside ligament reconstructions, effective management of impingement syndromes, and osteochondral lesions. The indications are being extended to fracture management and arthrodesis.

METHODOLOGY

This narrative review was performed following a literature search in the Pubmed database and Medline using the following keywords: ankle arthroscopy, portals, ankle OCD, functional outcome. Related articles were then reviewed.

CONCLUSION

Complications rate is reduced with a better understanding of the relative anatomy of surrounding neurovascular structures and tendons with regard to the position of ankle joint. This review on ankle arthroscopy focuses on anatomy, indications, and complications. Ankle arthroscopy is a safe and elegant tool as any other joint arthroscopy.

Arthroscopic-Assisted Versus All-Arthroscopic Ankle Stabilization Technique

BACKGROUND

Both the percutaneous technique with arthroscopic assistance, also known as arthroscopic Broström (AB), and the arthroscopic all-inside ligament repair (AI) are widely used to treat chronic lateral ankle instability. The aim of this study was to compare the clinical outcomes of these 2 arthroscopic stabilizing techniques.

METHODS

Thirty-nine consecutive patients were arthroscopically treated for chronic ankle instability by 2 different surgeons. The AB group comprised 20 patients with a mean age of 30.2 (range, 18-42) years and a mean follow-up of 19.6 (range, 12-28) months. The AI group comprised 19 patients with a mean age of 30.9 (range, 18-46) years and mean follow-up of 20.7 (range, 13-32) months. Functional outcomes using the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and visual analog pain scale (VAS) were assessed pre- and postoperatively. Range of motion (ROM) and complications were recorded.

RESULTS

In both groups the AOFAS and VAS scores significantly improved compared with preoperative values (P < .001) with no difference (P > .1) between groups. In the AB group the mean AOFAS score improved from 67 (range, 44-87) to 92 (range, 76-100) and the mean VAS score from 6.4 (range, 3-10) to 1.2 (range, 0-3). In the AI group the mean AOFAS score changed from 60 (range, 32-87) to 93 (range, 76-100) and the mean VAS score from 6.1 (range, 4-10) to 0.8 (range, 0-3). At the final follow-up 8 complications (40%) were recorded in the AB group. In the AI group 1 complication (5.3%) was observed (P < .05).

CONCLUSION

Both the AB and AI techniques are suitable surgical options to treat chronic ankle instability providing excellent clinical results. However, the AB had a higher overall complication rate than the AI group, particularly involving a painful restriction of ankle plantarflexion and neuritis of the superficial peroneal nerve.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Anterocentral Portal in Ankle Arthroscopy

BACKGROUND

The anterocentral portal is not a standard portal in anterior ankle arthroscopy due to its proximity to the anterior neurovascular bundle. However, it provides certain advantages, including a wide field of vision, and portal changes become redundant. The purpose of this study was to evaluate the neurovascular complications after anterior ankle arthroscopy using the anterocentral portal.

METHODS

We retrospectively identified patients who had undergone anterior ankle arthroscopy with an anterocentral portal at our institution from 2013 to 2018. Medical record data were reviewed and patients were invited for clinical follow-up, where a clinical examination, quantitative sensory testing for the deep peroneal nerve, and ultrasonography of the structures at risk were performed. A total of 101 patients (105 arthroscopies) were identified and evaluated at a mean follow-up of 31.5 ± 17.7 months.

RESULTS

Leading indications to surgery were heterogeneous and included anterior impingement (48.6%), osteochondral lesions of the talus (24.8%), chronic ankle instability (14.3%), and fractures (8.6%). The overall complication rate was 7.6%, and no major complications were observed. In 1.9% (2/105) of the cases, the complications were associated with the anterocentral portal and included injury to the medial branch of the superficial nerve (1/105) and to the deep peroneal nerve (1/105). Injury to the deep peroneal nerve was associated with a loss of detection and nociception. There were no injuries to the anterior tibial artery. In 41.9% (44/105) of the cases, only 1 working portal was used in addition to the anterocentral portal, and in 19% (20/105) the anterolateral portal could be avoided. Ultrasonography confirmed the integrity of the deep peroneal nerve, the medial branch of the superficial peroneal nerve, and the anterior tibial artery in all patients. Patients with nerve injuries associated with the anterocentral portal showed no signs of neuroma or pseudoaneurysm.

CONCLUSION

Using a standardized technique, the anterocentral portal in ankle arthroscopy is safe with a low number of neurovascular injuries and can be recommended as a standard portal. The anterolateral portal remains associated with a high number of injuries to the superficial peroneal nerve.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Position of the Posteromedial Ankle Structures in Patients Indicated for Total Ankle Replacement

Background:

The posteromedial ankle structures are at risk during total ankle replacement (TAR). The purpose of our study was to investigate the distance of these structures from the posterior cortex of the tibia and talus in order to determine their anatomy at different levels of bone resection during a TAR and whether plantarflexion of the ankle reliably moved these structures posteriorly.

Methods:

Ten feet in 10 patients with end-stage tibiotalar arthritis indicated for a TAR were included. Preoperative magnetic resonance images were obtained with the foot in a neutral position as well as in maximum plantarflexion to measure the distance of posteromedial ankle structures to the closest part of the posterior cortex of the tibia or talus. Wilcoxon signed-rank rests were used to investigate differences in these distances.

Results:

The mean distance from the posterior tibial cortex to the tibial nerve at 14 and 7 mm above the tibial plafond was 8.7 mm (range 5.0-11.8 mm) and 6.7 mm (range 2.7-10.6 mm), respectively, which represented a statistically significant movement anteriorly (P = .021). The posterior tibial artery was, on average, 8.0 mm (range 3.6-13.9 mm) and 7.2 mm (range 3.1-9.4 mm) from the posterior tibial cortex at 14 and 7 mm above the tibial plafond, respectively. Distal to the tibial plafond, the posterior tibial artery and flexor digitorum longus tendons moved posteriorly by less than 1 mm in plantarflexion (all P < .05); otherwise, plantarflexion of the ankle did not affect the position of the tibial nerve, posterior tibial tendon, or flexor hallucis longus.

Conclusion:

In patients with end-stage ankle arthritis, the tibial nerve and posterior tibial artery lie, on average, between 6.5 and 10 mm from the posterior tibial and talar cortices. Plantarflexion of the ankle did not reliably move the posteromedial ankle structures posteriorly.

Level of Evidence:

Level IV, case series, therapeutic

The arthroscopic all-inside ankle lateral collateral ligament repair is a safe and reproducible technique

PURPOSE

Neurovascular structures around the ankle are at risk of injury during arthroscopic all-inside lateral collateral ligament repair for the treatment of chronic ankle instability. This study aimed to evaluate the risk of damage to anatomical structures and reproducibility of the technique amongst surgeons with different levels of expertise in the arthroscopic all-inside ligament repair.

METHODS

Twelve fresh-frozen ankle specimens were used for the study. Two foot and ankle surgeons with different level of experience in the technique performed the procedure on 6 specimens each. The repair was performed following a standardized procedure as originally described. Then, an experienced anatomist dissected all the specimens to evaluate the outcome of the ligament repair, any injuries to anatomical structures and the distance between arthroscopic portals and the superficial peroneal nerve (SPN) and sural nerve.

RESULTS

Dissections revealed no injury to the nerves assessed. Mean distance from the anterolateral portal and the SPN was of 4.8 (range 0.0-10.4) mm. The mean distance from the accessory anterolateral portal to the SPN and sural nerve was of 14.2 (range 7.1-32.9) mm and 28.1 (range 2.8-39.6) mm, respectively. The difference between the 2 surgeons' groups was non-statistically significant for any measurement (mm). In all specimens both fascicles of the anterior talofibular ligament were reattached onto its original fibular footprint. The calcaneofibular ligament was not penetrated in any specimen.

CONCLUSIONS

The all-inside arthroscopic lateral collateral ligament repair is a safe and reproducible technique. The clinical relevance of this study is that this technique provides a safe and anatomic reattachment of the anterior talofibular ligament, with minimal risk of injury to surrounding anatomical structures regardless of the level of experience with the technique.

Arthroscopic treatment of lateral ankle instability. Is there a safe zone? An anatomic study

BACKGROUND

The purpose of this study is to describe the relative location of superficial anatomic landmarks and likely location of structures at risk in order to predict the proximity of the later and avoid their injury during the arthroscopic treatment of lateral ankle instability.

METHODS

Fifteen cadaver ankles were dissected. Based on superficial anatomic landmarks, the location and distances to the structures at risk (extensor tendons, peroneus tertius, peroneal tendons, main branch or intermediate branch of the superficial peroneal nerve, and the sural nerve) were measured.

RESULTS

The distance from the lateral malleolus along the peroneus brevis to its intersection by the sural nerve was 38.5±10.5mm and from it to the superficial peroneal nerve was 32.0±7.4mm. Based on the minimum distances, a rectangular area of 25mm×22mm was obtained. The anterior talofibular ligament and the proximal border of the inferior extensor retinaculum were within this area.

CONCLUSIONS

Our study suggests that based on superficial anatomic landmarks, it is possible to define an anatomic area in order to avoid structures at risk. In addition to the usual precautions, these anatomical references may contribute to lower the complication rate associated to the arthroscopic treatment of lateral ankle instability.

Anatomic lectures on structures at risk prior to cadaveric courses reduce injury to the superficial peroneal nerve, the commonest complication in ankle arthroscopy

PURPOSE

To assess the effectiveness of cadaveric ankle arthroscopy courses in reducing iatrogenic injuries.

METHODS

A total of 60 novice surgeons enrolled in a basic cadaveric ankle arthroscopy course were divided into two groups. Group A (n = 32) was lectured on portal placement and use of the arthroscope, whereas group B (n = 28) was in addition lectured on specific portal-related complications. Following the performance of anterior ankle arthroscopy and hindfoot endoscopy, the specimens were dissected and carefully assessed for detection of any iatrogenic injuries.

RESULTS

The rate of injury to the superficial peroneal nerve (SPN) was reduced from 25 to 3.6%, in group A compared with B (p = 0.033). Injuries to the peroneus tertius or extensor digitorum longus, the flexor hallucis longus and the tibial nerve or the Achilles tendon were also reduced in group B. Overall, the number of uninjured specimens was 50% (n = 30) and higher in group B (57%) than group A (44%). Lesions to the plantaris tendon, the sural nerve or the posterior tibial artery were more common in group B, however, without reaching statistical significance. Overall, 25 (13.9%) anatomic structures were injured in anterior arthroscopy compared to 18 (5%) in hindfoot endoscopy, out of a potential total of 180 and 360, respectively (p = 0.001).

CONCLUSION

Dedicated lectures on portal-related complications have proven useful in reducing the risk of injury to the SPN, the commonest iatrogenic injury encountered in ankle arthroscopy. Hindfoot endoscopy is significantly safer than anterior ankle arthroscopy in terms of injury to anatomical structures.

Arthroscopic all-inside anterior talo-fibular ligament repair with suture augmentation gives excellent results in case of poor ligament tissue remnant quality

PURPOSE

An increasing role of arthroscopy as the definitive treatment for ankle instability has been reported, and assisted or all-arthroscopic techniques have been developed. However, treatment of chronic ankle instability with poor remnant ligament-tissue quality is still challenging. The aim of this study was to describe the technique and report the results of the arthroscopic ATFL all-inside repair with suture augmentation to treat patients with poor remnant ligament-tissue quality.

METHODS

Fifteen patients [9 men and 6 women, median age 30 (19-47) years] with chronic ankle instability and poor remnant ligament-tissue quality were treated by arthroscopic means after failing non-operative management. Median follow-up was 18 (12-23) months. Through an arthroscopic all-inside technique, and using a suture passer and two knotless anchors, the ligament was repaired. Then, the anchor's residual suture limbs were not cut, but were recycled and used for augmentation of the ligament repair.

RESULTS

Arthroscopic examination demonstrated an isolated anterior talofibular ligament (ATFL) injury with poor remnant ligament tissue in the 15 patients. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair and suture augmentation. The median AOFAS score increased from 66 (44-87) preoperatively to 100 (85-100) at the final follow-up.

CONCLUSION

Chronic ankle instability with poor remnant ligament-tissue quality can be successfully treated by an arthroscopic all-inside repair and suture augmentation of the ligament. The clinical relevance of the study is the description of the first arthroscopic all-inside anatomic ATFL repair with suture augmentation that offers the benefit of maintaining the native ligament while reinforcing the repair, especially in patients with poor remnant ligament-tissue quality.

LEVEL OF EVIDENCE

IV, retrospective case series.

[A comparative study of all-arthroscopic technique and modified open Broström technique in repair of anterior talofibular ligament with anchors]

OBJECTIVE

To compare the effectiveness of all-arthroscopic technique and modified open Broström technique in repair of anterior talofibular ligament (ATFL) for lateral instability of the ankle (LIA).

METHODS

A retrospective analysis was made on 65 patients who underwent ATFL repair with anchors for LIA between January 2014 and January 2017. The ATFL was repaired by all-arthroscopic technique in 35 patients (arthroscopic group) and modified open Broström technique in 30 patients (open group). There was no significant difference in age, gender, the side of injured ankle, the time from injury to operation, and preoperative anterior displacement of talus, tilt angle of talus, the Karlsson Ankle Functional (KAF) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Japanese Society for Surgery of the foot ankle-hindfoot (JSSF) scale score between the two groups (P>0.05). The operation time, the intraoperative bleeding volume, and the length of time for surgery recovery were recorded. The anterior displacement of talus, the tilt angle of talus, KAF score, AOFAS score, and JSSF scale score were evaluated at 2 weeks, 3 months, and the last follow-up.

RESULTS

All patients were followed up 24-30 months, with an average of 26 months. The operation time, intraoperative bleeding volume, and the length of time for surgery recovery of arthroscopic group were superior to open group (P<0.05). There were 2 cases of temporary ankle and dorsum numbness and 1 case of thread reaction in arthroscopic group; and there were 2 cases of temporary ankle and dorsum numbness and 2 cases of thread reaction in open group. The AOFAS score, KAF score, and JSSF scale score in arthroscopic group were significantly higher than those in open group (P<0.05) at 2 weeks after operation; there was no significant difference between the two groups at 3 months and the last follow-up (P>0.05). There was no significant difference in the anterior displacement of talus and the tilt angle of talus between the two groups at 2 weeks, 3 months, and last follow-up (P>0.05).

CONCLUSION

Compared with the modified open Broström technique, the all-arthroscopic technique, as a minimally invasive technique, can achieve the same effectiveness, and has the advantages of shorter operation time, less intraoperative bleeding, and less pain in the early stage.

All-inside arthroscopic allograft reconstruction of the anterior talo-fibular ligament using an accesory transfibular portal

BACKGROUND

Anatomic graft reconstruction of the anterior talo-fibular ligament is an alternative for patients who are bad candidates for standard procedures such as a Broström-Gould reconstruction (high-demand athletes, obesity, hyperlaxity or collagen disorders, capsular insufficiency or talar avulsions). The purpose of this study is to describe an all-inside arthroscopic technique for ATFL reconstruction, and the results in a series of patients with chronic ankle instability.

METHODS

We reviewed patients with chronic ATFL ruptures treated with an all-inside arthroscopic allograft reconstruction of the ATFL, with a minimum 2-year follow-up. Twenty-two patients with lateral ankle instability were included. Mean follow-up was 34±2.5 months.

RESULTS

The mean AOFAS score improved from 62.3±6.7 points preoperatively to 97.2±3.2 points at final follow-up. Three patients suffered complications: one case each of ankle rigidity, superficial peroneal nerve injury and fibular fracture.

CONCLUSIONS

Chronic ATFL injuries are amenable to all-inside arthroscopic allograft reconstruction fixed with tenodesis screws. This procedure simplifies other reported techniques in that it facilitates identification and bone tunnel placement of the talar ATFL insertion.

The Distribution Pattern of the Neurovascular Structures for Anterior Ankle Arthroscopy to Minimize Structural Injury: Anatomical Study

Introduction

The aim of this study was to investigate entry points for anterior ankle arthroscopy that would minimize the risk of neurovascular injury.

Methods

Thirty-eight specimens from 21 Korean cadavers (age range from 43 to 92 years, mean age of 62.3 years) were used for the study. For the measurements, the most prominent points of the lateral malleolus (LM) and the medial malleolus (MM) were identified before dissection. A line connecting the LM and MM, known as the intermalleolar line, was used as a reference line. We measured 14 variables passed on the reference line.

Results

This study found that the nerves were located at 40.0%, 50.0%, and 82.0% of the reference line from the lateral malleolus. We also found that the arteries were located at 22.0%, 35.0%, and 60% of the reference line from the lateral malleolus.

Discussion

If all the variables are combined (nerves, arteries, and veins), then there is no safety zone for anterior portal placement. Therefore, we recommend that surgeons concentrate primarily on the arteries and nerves in the clinical setting.

Neurovascular and tendon injuries due to ankle arthroscopy portals: a meta-analysis of interventional cadaveric studies

Neurovascular and tendon structures are considered at risk when performing ankle arthroscopy. Injury rate and distance from portals to such structures varied in the literature. The aim of this meta-analysis is to evaluate the injury risk of these structures in terms of proximity and injury prevalence. Thirteen studies including 184 cadaveric ankle arthroscopy procedures met the inclusion criteria. The antero-central portal exhibited the highest frequencies of nerve/vessel proximity and nerve/vessel missed injuries. Weighted mean distances were as follows: 2.76 ± 2.37 mm for the superficial fibular nerve (SFN) to the antero-lateral portal, 8.13 ± 2.45 mm for the saphenous nerve to the antero-medial portal, 2.1 ± 1.7 mm for the dorsalis pedis artery (DPA) to the antero-central (AC) portal, 6.84 ± 2.59 mm for the sural nerve to the postero-lateral portal. Distances to the postero-medial portal were 7.82 ± 2.98 and 11.03 ± 3.2 mm for the posterior tibial nerve and the posterior tibial artery, respectively. A total of 14 (10.3%) nerve injuries and 17 (12.5%) missed nerve injuries with a cumulative frequency of 22.8% of nerve structure at high risk. The SFN was the most vulnerable (10.3% of injury/missed injury), and it was the closest nerve to a portal. Vascular involvement consisted of 2 (1.5%) injuries and 12 (8.8%) missed injuries with the DPA being the most vulnerable (20%) through the AC portal. Tendon injuries were found in 8.7% procedure acts. The injury rates of extra-articular structures were found to be higher than previously reported in clinical literature. Apart from clinical studies, distance to portals and missed injuries of these structures could be evaluated. This cadaveric meta-analysis yielded more accurate results over the proximity and potential injury risk of ankle noble structure and should incite surgeons for more attention during portal placement. Such anatomical meta-analyses could offer an excellent statistical model of evidence synthesis when assessing injury risk in mini-invasive surgeries.

An anatomical study about the arthroscopic repair of the lateral ligament of the ankle

BACKGROUND

The purpose of this anatomical study to was to determine the relationship of the structures involved in the arthroscopic repair of the anterior talofibular ligament.

METHODS

Dissection of fifteen lower leg cadaveric specimens was made and distances in the anterior direction from the reference-point at the lateral malleolus origin of the anterior talofibular ligament were measured, to the talar insertion of the ligament, to the superficial peroneal nerve at 60° and 90° in relation to the lateral malleolus axis in the sagittal plane, and to the inferior extensor retinaculum.

RESULTS

The mean±SD distance to superficial peroneal nerve from the reference-point was 25±6 (range 17-35) mm at 60°, and 32±9 (range 24-48) mm at 90° in relation to the lateral malleolus axis. The mean±SD distance to the inferior extensor retinaculum was 20±5 (range 14-29) mm. The mean±SD length of the anterior talofibular ligament was 21±4 (range 13-29) mm.

CONCLUSIONS

The superficial peroneal nerve demonstrated the greatest variance in its anatomy. An accessory incision to include the inferior extensor retinaculum in the repair should not surpass the 22mm distance from the lateral malleolus in the anterior direction, due to the risk of damaging the nerve.

Arthroscopic Lateral Ligament Repair Through Two Portals in Chronic Ankle Instability

Objectives:

Injury to the lateral ligament complex of the ankle is one of the most common sports-related injury.

Usually lateral ankle evolves with excellent clinical recovery with non surgical treatment, however, near about 30% develop a lateral chronic instability sequela.

Several open and arthroscopic surgical techniques have been described to treat this medical condition.

Material and Methods:

Of the 22 patients who were treated; 18 males and 4 females, and aged from 17-42 years (mean 28 years).

All patients presented a history of more than three ankle sprains in the last two years and presented positive anterior drawer and talar tilt test of the ankle in the physical examination.

We perform an anterior arthroscopy of the ankle in order to treat asociated disease and then we performed “All inside¨ lateral ligament repair through two portals (anteromedial and anterolateral) using an anchor knotless suture.

Results:

Clinical outcome evaluations were performed at a mean follow up of 25 months. (R: 17-31).

Overall results has been shown by means of the American Orthopaedic Foot and Ankle Society (AOFAS). Mean AOFAS scores improved from 63 points (range 52–77) preoperatively to 90 points (range 73–100) at final follow up.

No recurrences of ankle instability were found in the cases presented.

Conclusion:

Several surgical procedures have been described during the last years in order to treat chronic ankle instability. ¨All inside¨ lateral ligament reconstruction presents lower local morbidity than open procedures with few complications. Moreover, it is a reproductible technique, with high clinical success rate, few complications and relatively quick return to sports activities. A high knowledge of the anatomic landmarks should be essential to avoid unwated injuries.

Cadaver study of anatomic landmark identification for placing ankle arthroscopy portals

BACKGROUND

Arthroscopy-assisted surgery is now widely used at the ankle for osteochondral lesions of the talus, anterior and posterior impingement syndromes, talocrural or subtalar fusion, foreign body removal, and ankle instability. Injuries to the vessels and nerves may occur during these procedures.

OBJECTIVE

To determine whether ultrasound topographic identification of vulnerable structures decreased the risk of iatrogenic injuries to vessels, nerves, and tendons and influenced the distance separating vulnerable structures from the arthroscope introduced through four different portals.

HYPOTHESIS

Ultrasonography to identify vulnerable structures before or during arthroscopic surgery on the ankle may be useful.

MATERIAL AND METHOD

Twenty fresh cadaver ankles from body donations to the anatomy institute in Strasbourg, France, were divided into two equal groups. Preoperative ultrasonography to mark the trajectories of vessels, nerves, and tendons was performed in one group but not in the other. The portals were created using a 4-mm trocar. Each portal was then dissected. The primary evaluation criterion was the presence or absence of injuries to vessels, nerves, and tendons. The secondary evaluation criterion was the distance between these structures and the arthroscope.

RESULTS

No tendon injuries occurred with ultrasonography. Without ultrasonography, there were two full-thickness tendon lesions, one to the extensor hallucis longus and the other to the Achilles tendon. Furthermore, with the anterolateral, anteromedial, and posteromedial portals, the distance separating the vessels and nerves from the arthroscope was greater with than without ultrasonography (P=0.041, P=0.005, and P=0.002), respectively; no significant difference was found with the anterior portal.

DISCUSSION

Preoperative ultrasound topographic identification decreases the risk of iatrogenic injury to the vessels, nerves, and tendons during ankle arthroscopy and places these structures at a safer distance from the arthroscope. Our hypothesis was confirmed.

LEVEL OF EVIDENCE

IV, cadaver study.

Is the Arthroscopic Transillumination Test Effective in Localizing the Superficial Peroneal Nerve?

PURPOSE

To evaluate the transillumination test in showing the position of the superficial peroneal nerve (SPN) to quantify the effectiveness of this test.

METHODS

Prospectively, we selected 53 ankle arthroscopy patients (71 patients were excluded because of the invisible SPN). Demographic data including gender, weight, height, and body mass index were recorded. The intraoperative transillumination test was performed during portal establishment and recorded as positive if the SPN was visible via transillumination. The data were analyzed as mean, standard deviation, and percentage. Wilson's method was used as 95% confidence interval for proportion of the positive transillumination test.

RESULTS

The intraoperative transillumination test was positive in 0 of 53 patients (0%) with 95% confidence interval ranging from 0% to 6.7%.

CONCLUSIONS

The transillumination test has no value for showing the SPN.

LEVEL OF EVIDENCE

Level II, prospective diagnostic study.

Complications after ankle and hindfoot arthroscopy

OBJECTIVE

To evaluate the percentage of complications associated with ankle and hindfoot arthroscopy in our hospital and to compare the results with those reported in the literature.

MATERIAL AND METHOD

A retrospective descriptive review was conducted on the complications associated with ankle and hindfoot arthroscopy performed between May 2008 and April 2013. A total of 257 arthroscopy were performed, 23% on subtalar joint, and 77% of ankle joint. An anterior approach was used in 69%, with 26% by a posterior approach, and the remaining 5% by combined access.

RESULTS

A total of 31 complications (12.06%) were found. The most common complication was neurological damage (14 cases), with the most affected nerve being the superficial peroneal nerve (8 cases). Persistent drainage through the portals was found in 10 cases, with 4 cases of infection, and 3 cases of complex regional pain syndrome type 1.

DISCUSSION

There have been substantial advances in arthroscopy of ankle and hindfoot in recent years, expanding its indications, and also the potential risk of complications. The complication rate (12.06%) found in this study is consistent with that described in the literature (0-17%), with neurological injury being the most common complication.

CONCLUSIONS

Ankle and hindfoot arthroscopy is a safe procedure. It is important to make a careful preoperative planning, to use a meticulous technique, and to perform an appropriate post-operative care, in order to decrease the complication rates.

Current Diagnosis and Treatment of Superficial Fibular Nerve Injuries and Entrapment

The superficial peroneal nerve is now known as the superficial fibular nerve (SFN). Identification and treatment of entrapment of the SFN are important topics of discussion for foot and ankle surgeons, because overlooking the diagnosis can lead to permanent nerve damage. With the proper tools and skills, surgeons are able to help patients with symptomatic SFN entrapment, patients who often present in some degree of desperation, with the peripheral nerve surgeon as a last resort.

Use of superficial peroneal nerve graft for treating peripheral nerve injuries

Objective

To evaluate the clinical results from treating chronic peripheral nerve injuries using the superficial peroneal nerve as a graft donor source.

Methods

This was a study on eleven patients with peripheral nerve injuries in the upper limbs that were treated with grafts from the sensitive branch of the superficial peroneal nerve. The mean time interval between the dates of the injury and surgery was 93 days. The ulnar nerve was injured in eight cases and the median nerve in six. There were three cases of injury to both nerves. In the surgery, a longitudinal incision was made on the anterolateral face of the ankle, thus viewing the superficial peroneal nerve, which was located anteriorly to the extensor digitorum longus muscle. Proximally, the deep fascia between the extensor digitorum longus and the peroneal longus muscles was dissected. Next, the motor branch of the short peroneal muscle (one of the branches of the superficial peroneal nerve) was identified. The proximal limit of the sensitive branch was found at this point.

Results

The average space between the nerve stumps was 3.8 cm. The average length of the grafts was 16.44 cm. The number of segments used was two to four cables. In evaluating the recovery of sensitivity, 27.2% evolved to S2+, 54.5% to S3 and 18.1% to S3+. Regarding motor recovery, 72.7% presented grade 4 and 27.2% grade 3. There was no motor deficit in the donor area. A sensitive deficit in the lateral dorsal region of the ankle and the dorsal region of the foot was observed. None of the patients presented complaints in relation to walking.

Conclusions

Use of the superficial peroneal nerve as a graft source for treating peripheral nerve injuries is safe and provides good clinical results similar to those from other nerve graft sources.

Correlation Between Visual Inspection and Ultrasonography to Identify the Distal Branches of the Superficial Peroneal Nerve: A Cadaveric Study

The anatomy of the superficial peroneal nerve (SPN) and, more precisely, of the distal branches of the SPN at the ankle has attracted interest owing to the possibility of injury when performing ankle arthroscopy. The anterolateral portal is one of the most commonly used portals in ankle arthroscopy, and the intermediate dorsal cutaneous nerve can easily be injured during portal placement. The purpose of the present study was to assess whether visual inspection and palpation of the cutaneous nerves at the ankle differed from examination with ultrasonography and whether the 2 examination techniques correlated with the anatomic location of the SPN, which was verified by cadaver dissection. First, visual examination and palpation was performed to identify the SPN, after which 12 cadaver legs from separate specimens were examined with ultrasonography to mark the course of the SPN. We then measured the distance between the nerve as identified with gross visualization/palpation and ultrasound examination, and compared these with the precise location determined by anatomic dissection. The use of ultrasonography to determine the course of the SPN was good or excellent in 11 of the 12 legs (91.7%) studied. In contrast, gross visualization/palpation was good or excellent in 4 legs (33.3%). Excellent agreement was observed between the ultrasound markings and the anatomic dissection results. However, the visual examination poorly identified the course and the anatomic variations of the nerve branches evidenced in the anatomic dissection. From these findings in cadaver specimens, ultrasound identification of the SPN and its branches is likely preferable to gross visualization/palpation before placement of the anterolateral arthroscopic portal to the ankle.

Early recovery after arthroscopic repair compared to open repair of the anterior talofibular ligament for lateral instability of the ankle

INTRODUCTION

To compare the early result between arthroscopic and traditional open repair of the anterior talofibular ligament (ATFL) with inferior extensor retinaculum (IER) reinforcement for lateral instability of the ankle (LIA).

MATERIALS AND METHODS

We retrospectively reviewed cases that had been surgically treated for LIA and compared two treatment groups: those treated with an open procedure (Group O) vs those treated with an arthroscopic procedure (Group A). The parameters compared between the groups were visual analog scale (VAS) score at 3 days and 2 weeks after surgery, duration of surgery, time to return to daily activities and sports activities, postoperative complications, recurrence of the instability, and Japanese Society for Surgery of the foot ankle-hindfoot (JSSF) scale score before and at 1 year after surgery.

RESULTS

Significant differences were seen in the mean duration of surgery, mean VAS score at 3 days, and mean time to return to daily activities between the groups. Two patients had temporary numbness in Group A, while 3 patients had wound irritation and 1 patient had temporary numbness in Group O. Ankle instability did not recur in either group. There was no significant difference in either preoperative or postoperative JSSF scale score between the groups.

CONCLUSIONS

Compared with the open procedure, arthroscopic ATFL repair with IER reinforcement for LIA had an equivalent clinical result at the 1-year follow-up and allowed early recovery after surgery.

Identification of the superficial peroneal nerve: Anatomical study with surgical implications

PURPOSE

To prevent iatrogenic damage to the superficial peroneal nerve during ankle arthroscopy, it needs to be identified. The purpose of the present study was to determine which clinical test identified the superficial peroneal nerve most frequently and which determinants negatively affected the identification.

METHODS

A total of 198 ankles (99 volunteers) were examined for identification of the superficial peroneal nerve. Race, gender, body mass index (BMI), shoe size and frequency of physical activity were collected.

RESULTS

The best method to identify the superficial peroneal nerve was the maximal combined ankle plantar flexion and inversion test. In this position, the nerve was identified in 57% of the ankles by palpation. BMI was the only independently influential factor in the identification of the superficial peroneal nerve.

CONCLUSION

Since in nearly six out of the ten ankles the superficial peroneal nerve can be identified, it is advised to assess its anatomy prior to portal placement. A higher BMI negatively influences the identification of the superficial peroneal nerve.

LEVEL OF EVIDENCE

Diagnostic study, Level III.

Anterior ankle arthroscopy: indications, pitfalls, and complications

Anterior ankle arthroscopy is a useful, minimally invasive technique for diagnosing and treating ankle conditions. Arthroscopic treatment offers the benefit of decreased surgical morbidity, less postoperative pain, and earlier return to activities. Indications for anterior ankle arthroscopy continue to expand, including ankle instability, impingement, management of osteochondritis dissecans, synovectomy, and loose body removal. Anterior ankle arthroscopy has its own set of inherent risks and complications. Surgeons can decrease the risk of complications through mastery of ankle anatomy and biomechanics, and by careful preoperative planning and meticulous surgical technique.

Entrapment of the superficial peroneal nerve: an anatomical insight

Entrapment of the superficial peroneal nerve is an uncommon neuropathy that may occur because of mechanical compression of the nerve, usually at its exit from the crural fascia. The symptoms include sensory alterations over the distribution area of the superficial peroneal nerve. Clinical examination, electrophysiologic findings, and imaging techniques can establish the diagnosis. Variations in the superficial peroneal sensory innervation over the dorsum of the foot may lead to variable results during neurologic examination and variable symptomatology in patients with nerve entrapment or lesions. Knowledge of the nerve's anatomy at the lower leg, foot, and ankle is of essential significance for the neurologist and surgeon intervening in the area.

Arthroscopic Treatment of Osteochondral Talar Defects

INTRODUCTION

Arthroscopic debridement and bone marrow stimulation (i.e., drilling or microfracturing) is considered the primary surgical treatment of osteochondral defects of the talus.

STEP 1 POSITION THE PATIENT

For anterior ankle arthroscopy, position the patient supine; for posterior arthroscopy, position the patient prone.

STEP 2 ARTHROSCOPIC APPROACH

For anterior ankle arthroscopy, place the portals medial to the tibialis anterior tendon and lateral to the peroneus tertius tendon at the level of the ankle joint; for posterior arthroscopy, place the portals lateral and medial to the Achilles tendon just above the level of the tip of the lateral malleolus.

STEP 3 DEBRIDEMENT AND BONE MARROW STIMULATION

Fully debride the osteochondral defect and create multiple microfractures in the bottom of the defect.

STEP 4 CLOSURE AND POSTOPERATIVE CARE

Prescribe partial weight-bearing for six weeks.

RESULTS

A systematic review of the literature identified eighteen studies on bone marrow stimulation that included a total of 388 patients3. The study weighted success rate was 85% (range, 46% to 100%).

WHAT TO WATCH FOR

IndicationsContraindicationsPitfalls & Challenges.

All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique

BACKGROUND

Recently, arthroscopic-assisted techniques have been described to treat lateral ankle instability with excellent results. However, complications including neuritis of the superficial peroneal or sural nerve, and pain or discomfort due to a prominent anchor or suture knot have been reported. The aim of this study was to describe a novel technique, the "all-inside arthroscopic lateral collateral ankle ligament repair," and its results for treating patients with ankle instability.

METHODS

Sixteen patients (10 men and 6 women, mean age 29.3 years, 17-46) with lateral ankle instability were treated with an arthroscopic procedure. Using a suture passer and a knotless anchor, the ligaments were repaired with an all-inside technique. The right ankle was affected in 10 cases. Mean follow-up was 22.3 (12-35) months.

RESULTS

On arthroscopic examination, 13 patients had an isolated anterior talofibular ligament (ATFL) injury, and in 3 patients, both the ATFL and calcaneofibular ligament (CFL) were affected. All-inside arthroscopic anatomic repair of the lateral collateral ligament complex was performed in all cases. All patients reported subjective improvement of their ankle instability. The mean AOFAS score increased from 67 preoperatively to 97 at final follow-up. No major complications were reported.

CONCLUSION

The all-inside arthroscopic ligament repair was a safe, reliable, and reproducible technique that both provided an anatomic repair of the lateral collateral ligament complex and restored ankle stability while preserving all the advantages of an arthroscopic technique.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Open and arthroscopic surgical anatomy of the ankle

Ankle-related complaints are among the most commonly encountered problems for musculoskeletal clinicians. Ankle pathology is widely variable, including, but not limited to, fractures, deformity, infection, oncologic diseases, neuromuscular conditions, and arthritis. While nonoperative management with activity modification, bracing and/or shoe modifications, and medications is usually indicated as first line of treatment, surgical intervention may become necessary. A thorough understanding of the complex anatomy and biomechanics of the ankle, and in particular, the potential neurovascular structures that may be encountered, is important to reduce complications and obtain good surgical outcomes. The purpose of this review is to discuss the most common open and arthroscopic exposures to the ankle with a focus on surgically relevant anatomy for each approach.

Endoscopic versus open bursectomy of lateral malleolar bursitis

PURPOSE

Compare the result of endoscopic versus open bursectomy in lateral malleolar bursitis.

MATERIALS AND METHODS

Prospective evaluation of 21 patients (22 ankles) undergoing either open or endoscopic excision of lateral malleolar bursitis. The median age was 64 (38-79) years old. The median postoperative follow-up was 15 (12-18) months.

RESULTS

Those patients undergoing endoscopic excision showed a higher satisfaction rate (excellent 9, good 2) than open excision (excellent 4, good 3, fair 1). The wounds also healed earlier in the endoscopic group although the operation time was slightly longer. One patient in the endoscopic group had recurrence of symptoms but complications in the open group included one patient with skin necrosis, one patient with wound dehiscence, and two patients of with superficial peroneal nerve injury.

CONCLUSIONS

Endoscopic resection of the lateral malleolar bursitis is a promising technique and shows favorable results compared to the open resection.

LEVEL OF EVIDENCE

Therapeutic studies-Investigating the result of treatment, Level II.