The use of arthroscopic thermal shrinkage to treat chronic lateral ankle instability in young athletes

Chronic ankle instability: Current perspectives

Ankle sprain is reported to be among the most common recurrent injuries. About 20% of acute ankle sprain patients develop chronic ankle instability. The failure of functional rehabilitation after acute ankle sprain leads to the development of chronic ankle instability. Differentiation between functional and anatomical ankle instability is very essential to guide the proper treatment. Stability testing by varus stress test and anterior drawer test should be carried out. Subtalar instability is an important pathology that is commonly by passed during the assessment of chronic ankle instability. Unlike acute ankle sprain, chronic ankle instability might require surgical intervention. The surgical and conservative management options can be very much developed by in-depth knowledge of the ankle anatomy, biomechanics, and pathology. Anatomical repair, augmentation by tendon, or both are the basic methods of surgical intervention. Arthroscopy is becoming more popular in the management of chronic ankle instability.

A four-step approach improves long-term functional outcomes in patients suffering from chronic ankle instability: a retrospective study with a follow-up of 7-16 years

PURPOSE

The aim of the present study was to assess the long-term outcomes of the treatment of chronic ankle instability (CAI) with a four-step protocol.

METHODS

Fifty-four patients with isolated anterior talo-fibular ligament (ATFL) lesion suffering from CAI who underwent surgical treatment between 2000 and 2009 were assessed. All the patients underwent a four-step protocol including synovectomy, debridement of ATFL lesion borders, capsular shrinkage, and 21-day immobilization and nonweightbearing. Median age at surgery was 31.6 years (18-48). Patients were examined preoperatively and at follow-up. Clinical assessment included the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scoring system, Karlsson-Peterson score, Tegner activity level, and objective examination comprehending range of motion (ROM) and manual laxity tests.

RESULTS

AOFAS (preoperative, 64.8; postoperative, 92.4; p < 0.001) and Karlsson-Peterson score (preoperative, 62.5; postoperative, 88.8; p < 0.001) significantly improved after a median 11 years follow-up (7-16 years). Similarly median Tegner activity level significantly increased at follow-up compared to pre-operatory status (6.0 and 4.0 respectively, p < 0.001). Objective examination documented a statistically significant improvement in terms of ankle stability compared to pre-operative manual laxity tests, with negative anterior drawer test observed in 48 (88.9%) patients (p < 0.001). Sagittal ROM was full in 50 patients (92%). Nine patients had subsequent ankle sprains (15.6%), two patients required further surgery, while seven were treated conservatively. No major complications were reported.

CONCLUSION

Satisfying subjective and objective clinical outcomes in selected patients with isolated ATFL lesion suffering from CAI were reported with a treatment protocol including arthroscopic synovectomy, debridement of ATFL remnants, capsular shrinkage, and immobilization. These findings are of clinical relevance because they provide a suitable minimally invasive method for the treatment of mild to moderate ankle instability.

LEVEL OF EVIDENCE

Level IV.

Does the Association of Microfractures for the Treatment of Osteochondral Lesions of the Talus Affect the Outcome Following Arthroscopic Treatment for Chronic Ankle Instability?

BACKGROUND

The purpose of the present study was to retrospectively compare the outcomes of patients who underwent arthroscopic thermal capsular shrinkage with those who underwent both arthroscopic thermal capsular shrinkage and arthroscopic osteochondral lesion (OCL) treatment with microfractures. Our hypothesis was that the simultaneous treatment does not negatively affect the outcome of the combined surgical procedure by influencing the postoperative rehabilitation protocol and does not significantly differ from capsular shrinkage alone in terms of subjective and objective outcomes.

METHODS

Seventy-six patients with chronic ankle instability were treated at our department from 2004 to 2012 and reviewed retrospectively. Forty-two patients underwent arthroscopic thermal-assisted capsular shrinkage (group A), and 34 patients underwent combined arthroscopic capsular shrinkage and microfractures for OCL lesions of the talus (group B). All patients underwent a four-step surgical procedure including synovectomy, debridement, capsular shrinkage, and bracing and nonweightbearing for 21 days. In patients with OCL lesions, microfractures of the OCL were associated. Clinical assessment included objective examination, the American Orthopaedic Foot and Ankle Society ankle and hindfoot scoring system, Karlsson-Peterson score, Tegner activity level, and Sefton articular stability scale.

RESULTS

The median follow-up was 6 years (range, 2-9 years). The median postoperative visual analogue scale score, American Orthopaedic Foot and Ankle Society score, and Tegner score were improved from the preoperative level for both groups (P < .001). No significant difference was found between the two groups for the subjective scores and satisfaction rate (P = not significant). Similarly, no significant difference regarding the incidence of range-of-motion restriction was reported between the two groups (P = not significant).

CONCLUSIONS

The association of microfractures for the treatment of osteochondral lesions does not affect the outcome following arthroscopic treatment for chronic ankle instability up to 6 years from surgery.

Chronic Lateral Ankle Instability: Topical Review

Chronic ankle instability can result from untreated or badly managed acute lateral ankle ligament injuries. Conservative management is the modality of choice for acute lateral ankle ligament injuries, and operative treatment is reserved for special cases. Failure after strict rehabilitation may be an indication for surgery. Several operative options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Anatomic repair can be performed when the quality of the damaged ligaments permits. Anatomic reconstruction with an autograft or allograft should be considered when the torn ligaments are not adequate. Ankle arthroscopy is a useful adjunct to ligamentous procedures, performed at the time of repair to identify and treat intra-articular conditions that may be associated with chronic ankle instability. Tenodesis techniques are not recommended because of their suboptimal long-term results related to the modification of ankle and hindfoot biomechanics.Level of Evidence: Level V, expert opinion.

Chronic Lateral Ankle Instability: Surgical Management

Surgical management for chronic lateral ankle ligament instability is useful when patients have failed nonoperative modalities. Open anatomic reconstruction is an effective method of stabilization. Ankle arthroscopy is a recommended to address intra-articular disorder before stabilization. An anatomic approach provides full range of motion, stability, and return to sport and activity. Allograft or suture tape augmentation can be useful for patients with generalized ligamentous laxity, patients with high body mass index, and elite athletes. Allograft reconstruction may be especially useful in revision procedures. Arthroscopic approach to lateral ankle ligament stabilization may provide good outcomes, with long-term data still limited.

Arthroscopic anterior talofibular ligament reconstructin in chronic ankle instability: Two years results

PURPOSE

In chronic lateral ankle instability, primary ligament repair is not always possible because of poor quality of the local tissues. A free autologous or allograft tendon graft or synthetic grafts are suitable alternative. We describe middle term results of arthroscopic reconstruction of the anterior talofibular ligament (ATFL) using a free autologous ipsilateral gracilis graft in patients with chronic ankle instability.

METHODS

Eleven patients with chronic lateral ankle instability with imaging evidence of isolated ATFL tear underwent arthroscopic reconstruction of the ATFL using a free ipsilateral gracilis graft. Functional and subjective assessment were performed after an average of 24 months following the index procedure.

RESULTS

At 24 months, all patients showed objective improvements. One patient reported transient dysaesthesiae on the dorsolateral aspect of the foot and heel.

CONCLUSIONS

Arthroscopic isolated reconstruction of the ATFL with a free ipsilateral gracilis grafts is safe, allowing restoration of joint stability and low surgical morbidity.

STUDY DESIGN

Case series.

Electrocautery in arthroscopic surgery: intra-articular fluid temperatures above 43 °C cause potential tissue damage

PURPOSE

The use of electrocautery during arthroscopy may heat intra-articular saline and subsequently damage intra- and extra-articular tissue. Newer electrocautery devices have the ability to measure the outflow fluid temperature and switch off before reaching a certain threshold; however, the scientific evidence establishing these temperature thresholds' potential for inadvertent damage is lacking. The aim of this study was to analyse current available literature on temperature thresholds for tissue damage after exposure to heated fluid and provide a recommendation for the maximum temperature of intra-articular fluid to prevent tissue damage.

METHODS

In February 2018, a systematic literature review was performed using the MEDLINE/PubMed and Embase databases. Inclusion was limited to studies investigating temperature thresholds for thermal damage to at least one of the tissues of interest: skin, bone, cartilage, soft tissues, and nerves. Studies not reporting specific temperature thresholds for thermal damage were excluded.

RESULTS

Twenty articles were selected for the final evaluation and data extraction. Varying temperature thresholds, based on the lowest reported temperature causing tissue damage, were found for the different tissues of interest: 44 °C for dermal tissues, between 47 and 50 °C for bony tissues, 50 °C for cartilage, between 43 and 55 °C for soft tissues, and 43 °C for nerves.

CONCLUSION

Based on the current literature, a temperature threshold for intra-articular fluid of 43 °C during an arthroscopic procedure is recommended to prevent tissue damage. Higher temperatures may cause damage to surrounding intra- and extra-articular tissues. The threshold for irreversible damage is likely to be higher. In clinical practise, one should be aware of possible heating of intra-articular fluid when using electrocautery and related risk of tissue damage.

LEVEL OF EVIDENCE

III.

Arthroscopic Versus Open Broström-Gould Repair for Chronic Ankle Instability

BACKGROUND

The open Broström-Gould procedure for the repair of lateral ankle ligament remains the gold standard in operative management of chronic ankle instability. Nevertheless, the arthroscopic technique has been gaining attention among foot and ankle surgeons in the past decade. Our study aimed to compare the clinical outcomes of patients who underwent the arthroscopic and open Brostom-Gould technique over a 12-month follow-up period.

METHODS

We retrospectively reviewed the database in a tertiary hospital foot and ankle registry from 2015 to 2019. We then performed a 1:1 matching of 26 ankles that underwent the arthroscopic Broström-Gould technique to 26 ankles with the open technique, all performed by a fellowship-trained foot and ankle surgeon, for age, sex, and body mass index. To assess clinical outcomes, visual analog scale scores, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scores, and Short Form 36 Health Survey scores were collected at the preoperative and 6- and 12-month follow-up visits, respectively.

RESULTS

The arthroscopic group demonstrated significantly less pain in the perioperative period (arthroscopic, 1.0 ± 1.2; open, 2.4 ± 2.2; P = .015) and had higher AOFAS scores at 6 months (arthroscopic, 87.2 ± 11.1; open, 73.5 ± 21.9; P = .028) and 12 months (arthroscopic, 94.2 ± 10.0; open, 70.9 ± 33.1; P = .020). No complications were reported in either group. Twenty patients (76.9%) in the arthroscopic group had preoperative intra-articular abnormalities compared with 24 patients (92.3%) in the open group.

CONCLUSION

The arthroscopic Broström-Gould technique produced better clinical outcomes than the open technique at 12 months of follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

All-Inside Arthroscopic Anterior Talofibular Ligament Anatomic Reconstruction With a Gracilis Tendon Autograft for Chronic Ankle Instability in High-Demand Patients

The goal of this study was to evaluate the surgical technique and clinical outcome of all-inside arthroscopic anterior talofibular ligament anatomic reconstruction with a gracilis tendon autograft for chronic ankle instability in high-demand patients. Fifteen consecutive patients (14 [93.3%] males and 1 [6.7%] female, mean age 31.9 ± 7.8 [range 21 to 48] years) with chronic ankle instability were enrolled in this study. Under direct arthroscopic visualization, bone tunnels were created in the fibula and talus by a 4.5-mm cannulated drill system. The gracilis tendon autograft was passed through the tunnels and secured by 5.0-mm interference screws. At the final follow-up, functional evaluation was carried out according to the Ankle-Hindfoot Score by the American Orthopaedic Foot and Ankle Society, Sefton grading system, and visual analog scale score. Complications were also recorded. Mean follow-up was 19.5 ± 1.8 (range 18 to 24) months. No complications of wound infection and nerve injury were noted. No patients experienced recurrent ankle instability. Radiologically, the mean varus tilting angle was 15.2° ± 1.5° before surgery and 4.3° ± 1.2° at the last follow-up (p ≤ .001). The anterior drawer distance was 13.2 ± 1.5 mm before surgery and 4.8 ± 1.1 mm at last follow-up (p ≤ .001). The mean American Orthopaedic Foot and Ankle Society and visual analog scale scores were 56.8 ± 10.5 and 5.7 ± 1.3 before surgery, which became 90.2 ± 6.2 and 0.5 ± 0.8 after surgery. Fourteen (93.3%) patients reported excellent/good functional results according to the Sefton grading system (6 [40.0%] excellent, 8 [53.3%] good, and 1 [6.7%] fair). From our clinical experience, all-inside arthroscopic anterior talofibular ligament anatomic reconstruction with a gracilis tendon is an effective treatment for chronic ankle instability in high-demand patients.

Lateral ligament reconstruction and augmented direct anatomical repair restore ligament laxity in patients suffering from chronic ankle instability up to 15 years from surgery

PURPOSE

The purpose of the present study was to compare the outcomes of patients who underwent augmented direct anatomical repair using a Broström-Gould procedure with those who underwent lateral ligament reconstruction using a split peroneus brevis tendon for the treatment of chronic ankle instability.

METHODS

Forty patients aged 18-40 years underwent surgical treatment for chronic lateral ankle instability between 1997 and 1998: 20 patients underwent direct anatomical repair using Broström-Gould procedure (Group A); 20 patients underwent lateral tenodesis using a split peroneus brevis tendon (Group B). Median age at surgery was 22.6 years (range 18-40). Patients were assessed pre-operatively and 15 years after surgery with functional assessment including AOFAS scale, Karlsson-Peterson score, Tegner activity level, Sefton stability scale, and objective examination comprehending ROM, anterior drawer sign and talar tilt test. Telos Stress equipment was used for pre- and post-operative radiographic laxity testing.

RESULTS

No major complications were reported. Mean overall AOFAS, Karlsson-Peterson and Tegner scores significantly increased at follow-up compared to pre-operatory status, although no statistically significant differences concerning these variables were reported between the two groups. Sagittal ROM was full in 36 patients: 4 subjects in the Group B experienced 5 degrees dorsiflexion limitation compared to the contralateral side. Patients treated with lateral tenodesis reported a statistically significant reduction in the values of radiographic anterior talar translation (1.4 mm, SD: 0.9) compared to patients in Group A (5.7 mm, SD: 1.1, p < 0.001).

CONCLUSION

Augmented direct anatomical repair and lateral tenodesis provide satisfying long-term outcomes in terms of subjective and objective parameters up to 15 years from surgery in patients with chronic ankle instability without leading to significant artrhitic changes. Objectively, lateral tenodesis appears to improve more effectively restoration of laxity; the reduced ROM reported in 20% of patients did not considerably affect the overall functional outcome.

LEVEL OF EVIDENCE

Comparative case series, Level III.

Clinical Guidelines for the Surgical Management of Chronic Lateral Ankle Instability: A Consensus Reached by Systematic Review of the Available Data

Background:

The surgical management of chronic lateral ankle instability (CLAI) has evolved since the 1930s, but for the past 50 years, the modified Broström technique of ligament repair has been the gold standard. However, with the development of arthroscopic techniques, significant variation remains regarding when and how CLAI is treated operatively, which graft is the optimal choice, and which other controversial factors should be considered.

Purpose:

To develop clinical guidelines on the surgical treatment of CLAI and provide standardized guidelines for indications, surgical techniques, rehabilitation strategies, and assessment measures for patients with CLAI.

Study Design:

A consensus statement of the Chinese Society of Sports Medicine.

Methods:

A total of 14 physicians were queried for their input on guidelines for the surgical management of CLAI. After 9 clinical topics were proposed, a comprehensive systematic search of the literature published since 1980 was performed for each topic through use of China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), PubMed, Web of Science, EMBASE, and the Cochrane Library. The recommendations and statements were drafted, discussed, and finalized by all authors. The recommendations were graded as grade 1 (strong) or 2 (weak) based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Based on the input from 28 external specialists independent from the authors, the clinical guidelines were modified and finalized.

Results:

A total of 9 topics were covered with regard to the following clinical areas: surgical indications, surgical techniques, whether to address intra-articular lesions, rehabilitation strategies, and assessments. Among the 9 topics, 6 recommendations were rated as strong and 3 recommendations were rated as weak. Each topic included a statement about how the recommendation was graded.

Conclusion:

This guideline provides recommendations for the surgical management of CLAI based on the evidence. We believe that this guideline will provide a useful tool for physicians in the decision-making process for the surgical treatment of patients with CLAI.

The use of a hydrogel implant in the repair of osteochondral defects of the knee: A biomechanical evaluation of restoration of native contact pressures in cadaver knees

BACKGROUND

Osteochondral injuries have been treated by a variety of methods, each having its own drawbacks. The purpose of this study was to determine the biomechanical feasibility of using a hydrogel implant replacement for an osteochondral core defect. The hypothesis of this study was that the contact pressure of the native knee can be recreated with the use of a hydrogel implant.

METHODS

Six cadaver knees were tested in a knee simulator while contact pressures were measured on the tibial plateau. Pressure data was collected in the intact knee, after coring of the condyle and after insertion of a hydrogel implant. Following 1000 gait cycles of fatigue testing, each knee was taken through axial loading indentation testing where the stiffness of the in situ implant was compared to the contralateral condyle.

FINDINGS

While coring significantly reduced the peak pressure at the coring site from 1.8 MPa in the intact knee to 0.0 MPa after coring, implant insertion significantly increased it to 1.2 MPa. There was no significant difference in the peak pressures or the average pressures at the hole location between the intact knee and following implant insertion. After fatigue testing, no macroscopic loosening or implant damage was observed. Based on indentation testing, the stiffness of the medial condyle, 157 N/mm, was significantly less than the lateral condyle, 696 N/mm.

INTERPRETATION

The insertion of the hydrogel implant was able to achieve restoration of contact pressures in the knee supporting the viability of hydrogel implants in the treatment of osteochondral lesions of the knee.

A comparison of the "All-Inside" arthroscopic Broström procedure with the traditional open modified Broström-Gould technique: A review of 62 patients

BACKGROUND

The open Broström-Gould lateral ankle stabilization procedure has been the gold standard for primary lateral ankle stabilization. A new minimally invasive all-inside arthroscopic technique has been described for the correction of lateral ankle instability.

METHODS

We performed a review of patients who underwent lateral ankle stabilization by either the traditional open Broström-Gould (BG) or the All-Inside Bröstrom (AIB) technique to compare and identify any discrepancies between functional and/or patient satisfaction outcomes. A total of 62 patients underwent a lateral ankle stabilization. Of those 62 patients, 32 received a traditional open Broström-Gould procedure and 30 patients underwent an All-Inside Bröstrom type procedure. The two groups were compared preoperatively with AOFAS ankle-hindfoot scoring system and Visual Analog Score (VAS) for pain. Postoperatively, AOFAS, Karlsson Peterson and VAS scores were compared.

RESULTS

The mean preoperative VAS pain score for the open Broström-Gould was 7.28, the All-Inside Broström was 8.18. The mean postoperative VAS pain score for the open Broström-Gould was 1.2, the All-Inside Broström was 1.5. The mean preoperative AOFAS score for the Broström-Gould was 35.44, the All-Inside Broström was 35.07. The mean postoperative AOFAS score for the open Broström-Gould was 93.53, the All-Inside Broström was 95.33. The mean postoperative Karlsson Peterson score for the open Broström-Gould was 93.41, the All-Inside Broström was 91.80. The mean time to weight bearing for the Broström-Gould was 22 days, the All-Inside Broström was 12 days.

CONCLUSION

There were no statistically significant differences identified in any of the functional or patient satisfaction outcome scores using either technique. This review suggests the minimally invasive arthroscopic technique using bone anchors for lateral ankle stabilization may be comparable to the traditional open Broström-Gould with the added advantage of earlier time to weight bearing.

Arthroscopic Treatment of Ankle Instability: Brostrom

Over the last 10 years, significant advances have been made and successful techniques have now been developed that effectively treat ankle instability via the arthroscope.Currently arthroscopic lateral ligament repair techniques can be grouped into "arthroscopic-assisted techniques," "all-arthroscopic techniques," and "all-inside techniques." Recent studies have proven these arthroscopic techniques to be a simple, safe, and biomechanically equivalent, stable alternative to open Brostrom Gould lateral ligament reconstruction.

Arthroscopic Capsular Shrinkage for Treatment of Chronic Lateral Ankle Instability

BACKGROUND

Capsular shrinkage is an arthroscopic stabilization technique that can be used in patients with chronic ankle instability (CAI), if desired in addition to primary arthroscopic procedures. Despite positive short-term results, long-term follow-up of these patients has not yet been performed. Therefore, our objective was to assess whether capsular shrinkage still provided functional outcome after 12-14 years compared to preoperative scores.

METHODS

This study was a retrospective long-term follow-up of a prospectively conducted longitudinal multicenter trial. The study duration was from February 2002 to September 2016, including a preoperative assessment and short-, mid-, and long-term follow-up. At the time of inclusion, patients were diagnosed with CAI, >18 years old, were unresponsive to conservative treatment, and had confirmed mechanical ankle joint laxity. Patients were excluded if the talar tilt was greater than 15 degrees, if they had received previous operative treatment, or had constitutional hyperlaxity, systemic diseases, or osteoarthritis grade II or III. The primary outcome was the change in functional outcome as assessed by the Karlsson score.

RESULTS

Twenty-five patients of the initial 39 were available for this follow-up. This group had a mean age of 43.2 years (SD±11.1) and included 15 males. A statistically significant improvement was found in the Karlsson score at 12-14 years (76.6 points; SD±25.5) relative to the preoperative status (56.4 points; SD ±13.3; P < .0005). Although 17 patients (68%) reported recurrent sprains, 23 patients (92%) stated that they were satisfied with the procedure.

CONCLUSIONS

Despite improved functional outcome and good satisfaction in patients with CAI after capsular shrinkage, recurrence rates and residual symptoms were high. For this reason, arthroscopic capsular shrinkage is not recommended as joint stabilization procedure in patients with CAI.

LEVEL OF EVIDENCE

Level IV, case series.

Arthroscopic Capsular Shrinkage for Treatment of Chronic Lateral Ankle Instability

BACKGROUND

Capsular shrinkage is an arthroscopic stabilization technique that can be used in patients with chronic ankle instability (CAI), if desired in addition to primary arthroscopic procedures. Despite positive short-term results, long-term follow-up of these patients has not yet been performed. Therefore, our objective was to assess whether capsular shrinkage still provided functional outcome after 12-14 years compared to preoperative scores.

METHODS

This study was a retrospective long-term follow-up of a prospectively conducted longitudinal multicenter trial. The study duration was from February 2002 to September 2016, including a preoperative assessment and short-, mid-, and long-term follow-up. At the time of inclusion, patients were diagnosed with CAI, >18 years old, were unresponsive to conservative treatment, and had confirmed mechanical ankle joint laxity. Patients were excluded if the talar tilt was greater than 15 degrees, if they had received previous operative treatment, or had constitutional hyperlaxity, systemic diseases, or osteoarthritis grade II or III. The primary outcome was the change in functional outcome as assessed by the Karlsson score.

RESULTS

Twenty-five patients of the initial 39 were available for this follow-up. This group had a mean age of 43.2 years (SD±11.1) and included 15 males. A statistically significant improvement was found in the Karlsson score at 12-14 years (76.6 points; SD±25.5) relative to the preoperative status (56.4 points; SD ±13.3; P < .0005). Although 17 patients (68%) reported recurrent sprains, 23 patients (92%) stated that they were satisfied with the procedure.

CONCLUSIONS

Despite improved functional outcome and good satisfaction in patients with CAI after capsular shrinkage, recurrence rates and residual symptoms were high. For this reason, arthroscopic capsular shrinkage is not recommended as joint stabilization procedure in patients with CAI.

LEVEL OF EVIDENCE

Level IV, case series.

Chronic ankle instability: Current perspectives

Ankle sprain is reported to be among the most common recurrent injuries. About 20% of acute ankle sprain patients develop chronic ankle instability. The failure of functional rehabilitation after acute ankle sprain leads to the development of chronic ankle instability. Differentiation between functional and anatomical ankle instability is very essential to guide the proper treatment. Stability testing by varus stress test and anterior drawer test should be carried out. Subtalar instability is an important pathology that is commonly by passed during the assessment of chronic ankle instability. Unlike acute ankle sprain, chronic ankle instability might require surgical intervention. The surgical and conservative management options can be very much developed by in-depth knowledge of the ankle anatomy, biomechanics, and pathology. Anatomical repair, augmentation by tendon, or both are the basic methods of surgical intervention. Arthroscopy is becoming more popular in the management of chronic ankle instability.

The "All-Inside" Arthroscopic Broström Procedure With Additional Suture Anchor Augmentation: A Prospective Study of 45 Consecutive Patients

Lateral ankle sprains are a common injury that typically respond well to nonoperative therapy. When nonoperative therapy fails and patients develop chronic lateral ankle instability, they become candidates for surgical repair. The present study examined 45 consecutive patients (45 ankles) with chronic lateral ankle instability who underwent arthroscopic Broström repair using a double-row suture anchor construct. The 45 patients (27 females and 18 males) were followed up for a mean of 14 (range 12 to 20) months. The mean time to weightbearing with crutches was 3.3 (range 2 to 4) days, and full weightbearing was initiated at a mean of 14.4 (range 12 to 16) days. All patients participated in structured physical therapy, which was started at 21.6 (range 18 to 23) days. Patients were transitioned to regular shoe gear with a stirrup-style ankle brace at 28.7 (range 26 to 31) days. The American Orthopaedic Foot and Ankle Society scale scores improved from an average preoperative score of 48.7 (range 45 to 55) to 95.4 (range 90 to 100) postoperatively. The average visual analog scale decreased from 8 (range 6 to 10) preoperatively to 0.6 (range 0 to 5) postoperatively at the last follow-up visit. The Karlsson-Peterson score postoperatively was 87 of 100. We have shown that patients with this new arthroscopic Broström technique modified with a proximal suture anchor can begin weightbearing earlier than previously reported, without adverse effects in terms of pain, functional outcomes scores, and clinical outcomes.

Operative Treatment of Lateral Ankle Instability

Chronic lateral ankle instability can occur in a subset of patients following ankle inversion sprains. Operative treatment to restore stability in the ankle and hindfoot and to prevent further degenerative changes may be indicated in cases in which nonoperative treatment has failed. Anatomical direct repair with use of native ligament remnants with or without reinforcement of the inferior retinaculum is the so-called gold standard operative strategy for the treatment of lateral ankle instability. The procedure has shown promising short and long-term outcomes. Candidates for the procedure have ligament remnants of sufficient quality that are amendable to direct repair. Anatomical reconstruction with use of autograft or allograft is reserved for patients with insufficient ligament remnants to fashion a direct repair, failed previous lateral ankle repair, high body mass index, or generalized ligamentous laxity. A wide variety of autografts have been described, each with potential advantages and disadvantages. These procedures can provide good-to-excellent short-term outcomes. However, there is no available information on their long-term clinical results. Non-anatomical lateral ligament reconstruction typically involves the use of the adjacent peroneal brevis tendon and has been applied in cases in which only poor-quality ligament remains. The procedure can provide good to excellent short-term outcomes, although reported long-term outcomes have differed among studies. The particular tendon used for the graft should be carefully considered given the potential alterations in the kinematics of the ankle and hindfoot. Arthroscopic ligament repair is becoming increasingly popular as it is minimally invasive. This procedure is restricted to patients who have good-quality ligament remnants. Good-to-excellent clinical outcomes have been reported after short and long-term follow-up, although a relatively high rate of complications-including nerve damage-has been reported following the procedure and therefore warrants further investigation before widespread adoption can be advocated.

Minimally invasive surgical treatment for chronic ankle instability: a systematic review

PURPOSE

The purpose of this study was to determine the evidence-based support for the treatment for chronic ankle instability (CAI) using minimally invasive surgery (MIS) techniques.

METHODS

A systematic comprehensive review of the literature was performed on 4 September 2015 using PubMed, EMBASE, Cochrane databases and Web of Science along with the two search concepts: lateral ligament of the ankle (patients) and minimally invasive surgical procedure (intervention). Articles of clinical study on MIS for CAI were included in this review and classified into four MIS categories (arthroscopic repair, non-arthroscopic minimally invasive repair, arthroscopic reconstruction and non-arthroscopic minimally invasive reconstruction) based on the adopted surgical procedure. Included articles were reviewed and assigned a classification according to the research method quality of evidence (Level I-V evidence). Analysis of these studies was then conducted to provide a grade of recommendation for each MIS category.

RESULTS

The systematic literature review generated 430 articles, and 33 articles met our inclusion criteria. The highest recommendation was Grade C (poor-quality evidence) to support the use of the arthroscopic repair, arthroscopic reconstruction and non-arthroscopic minimally invasive reconstruction. Insufficient evidence was currently available to make any recommendation (Grade I) for non-arthroscopic minimally invasive repair category.

CONCLUSIONS

Despite recent increases in publications on MIS for the treatment for CAI, there was currently poor quality of evidence that was insufficient to allow a high grade of recommendation to support the use of the MIS. This paper should stimulate those surgeons performing higher quality studies in the form of prospective and preferably randomized comparative studies that will be necessary to allow better recommendations for the treatment for CAI with MIS. The present study showed thorough evidence-based recommendation for the clinical use of the MIS based on the comprehensive review of the literature.

LEVEL OF EVIDENCE

Systematic review, Level IV.

All-inside arthroscopic modified Broström operation for chronic ankle instability: a biomechanical study

PURPOSE

The all-inside arthroscopic modified Broström operation has been developed for lateral ankle instability. We compared the biomechanical parameters of the all-inside arthroscopic procedure to the open modified Broström operation.

METHODS

Eleven matched pairs of human cadaver specimens [average age 71.5 (range 58-98) years] were subject to the arthroscopic modified Broström operation using a suture anchor and the open modified Broström operation. The ligaments were loaded cyclically 20 times and then tested to failure. Torque to failure, degrees to failure, and stiffness were measured. A matched-pair analysis was performed.

RESULTS

There was no significant difference in torque to failure between the open and arthroscopic modified Broström operation (19.9 ± 8.9 vs. 23.3 ± 12.1 Nm, n.s). The degrees to failure did not differ significantly between the open and arthroscopic modified Broström operations (46.8 ± 9.9° vs. 46.7 ± 7.6°, n.s). The working construct stiffness (or stiffness to failure) was no significant difference in the two groups (0.438 ± 0.21 vs. 0.487 ± 0.268 Nm/deg for the open and arthroscopic modified Broström operations, respectively, n.s).

CONCLUSION

The all-inside arthroscopic modified Broström operation and the open modified Broström operation resulted in no significantly different torque to failure, degrees to failure, and working construct stiffness with no significant differences (n.s, n.s, and n.s, respectively). Our results indicate that the arthroscopic modified Broström operation is a reasonable alternative procedure for chronic ankle instability.

[Treatment of lateral ankle joint instability. Open or arthroscopic?]

Chronic ankle joint instability often necessitates operative treatment. Operative treatment methods are classified into non-anatomical tenodesis, anatomical reconstruction and direct repair. In addition to open approaches, arthroscopic techniques are increasingly becoming established. This article describes the various operative treatment procedures, their advantages and disadvantages and in particular the arthroscopic feasibility.

Ankle instability and arthroscopic lateral ligament repair

Over the last 50 years, the surgical management of chronic lateral ankle ligament insufficiency has focused on 2 main categories: local soft-tissue reconstruction and tendon grafts/transfer procedures. There is an increasing interest in the arthroscopic solutions for chronic instability of the ankle. Recent biomechanical studies suggest the at least one of the arthroscopic techniques can provide equivalent results to current open local soft-tissue reconstruction (such as the modified Brostrom technique). Arthroscopic lateral ankle ligament reconstruction is becoming an increasingly acceptable method for the surgical management of chronic lateral ankle instability.

Biomechanical Comparison of an Open vs Arthroscopic Approach for Lateral Ankle Instability

BACKGROUND

The current clinical standard for the surgical treatment of ankle instability remains the open modified Broström procedure. Modern advents in arthroscopic technology have allowed physicians to perform certain foot and ankle procedures arthroscopically as opposed to traditional open approaches.

METHODS

Twenty matched lower extremity cadaver specimens were obtained. Steinman pins were inserted into the tibia and talus with 6 sensors affixed to each pin. Specimens were placed in a Telos ankle stress apparatus in an anteroposterior and then lateral position, while a 1.7 N-m load was applied. For each of these tests, movement of the sensors was measured in 3 planes using the Optotrak Computer Navigation System. Changes in position were calculated and compared with the unloaded state. The anteriortalofibular ligament and the calcaneofibular ligament were thereafter sectioned from the fibula. The aforementioned measurements in the loaded and unloaded states were repeated on the specimens. The sectioned ligaments were then repaired using 2 corkscrew anchors. Ten specimens were repaired using a standard open Broström-type repair, while the matched pairs were repaired using an arthroscopic technique. Measurements were repeated and compared using a paired t test.

RESULTS

There was a statistically significant difference between the sectioned state and the other 3 states (P < .05). There were no statistically significant differences between the intact state and either the open or arthroscopic state (P > .05). There were no significant differences between the open and arthroscopic repairs with respect to translation and total combined motion during the talar tilt test (P > .05). Statistically significant differences were demonstrated between the 2 methods in 3 specific axes of movement during talar tilt (P = .04).

CONCLUSION

Biomechanically effective ankle stabilization may be amenable to a minimally invasive approach.

CLINICAL RELEVANCE

A minimally invasive, arthroscopic approach can be considered for treating patients with lateral ankle instability who have failed conservative treatment.

Arthroscopic repair of lateral ankle ligament complex by suture anchor

PURPOSE

Arthroscopic repair of the lateral ligament complex with suture anchors is increasingly used to treat chronic ankle instability (CAI). Our aims are (1) to analyze and evaluate the literature on arthroscopic suture anchor repair of the anterior talofibular ligament and (2) to conduct a systematic review of the clinical evidence on the reported outcomes and complications of treating CAI with this technique.

METHODS

We performed a systematic review of the literature using PubMed, Ovid, Elsevier ScienceDirect, Web of Science-Conference Proceedings Citation Index, and the Cochrane Database of Systematic Reviews from 1987 to September 2013. Clinical studies using the arthroscopic suture anchor technique to treat CAI were included. Outcome measures consisted of clinical assessment of postoperative ligament stability and complications. In addition, the methodologic quality of the included studies was assessed by use of the modified Coleman Methodology Score.

RESULTS

After reviewing 371 studies, we identified 6 studies (5 retrospective case series and 1 prospective case series, all Level IV) that met the inclusion criteria, with a mean Coleman Methodology Score of 71.8 ± 7.52 (range, 63 to 82). In these studies 178 patients (179 ankles) underwent arthroscopic suture anchor repair of the anterior talofibular ligament with a mean follow-up period of 38.9 months (range, 6 to 117.6 months). All patients were reported to have subjective improvement of their ankle instability, with complications in 31 cases.

CONCLUSIONS

Studies of arthroscopic suture anchor technique to treat CAI are sparse, with moderate mean methodologic quality. The included studies suggest that the arthroscopic technique is a feasible procedure to restore ankle stability; however, on the basis of our review, this technique seems to be associated with a relatively high complication rate. Extensive cadaveric studies, clinical trials, and comparative studies comparing arthroscopic and open repair should be performed in the future.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Lateral ligament reconstruction with allograft in patients with severe chronic ankle instability

INTRODUCTION

Chronic ankle instability is a condition of perception of giving way and persistent pain usually following multiple ankle sprains. In case of severe joint laxity, surgical treatment with reconstruction of the lateral ligamental complex is recommended. The aim of this study was to evaluate the functional outcome of patients treated with lateral ligament reconstruction with allograft for severe chronic lateral ankle instability.

MATERIALS AND METHODS

We performed a retrospective cohort study of ten patients who underwent allograft external non-anatomic ligamentoplasty for severe chronic lateral ankle instability between 2009 and 2011, with an average follow-up of 16.3 months (SD 8.2). Median age at surgery was 29 years (range 25-35). All patients presented both ATFL and CFL lesion. Patients were evaluated using American Orthopaedic Foot and Ankle Society score, Karlsson-Peterson score, Tegner activity level, Sefton stability scale, and objective examination comprehending range of motion, anterior drawer sign and talar tilt test. Telos stress equipment was used for pre- and post-operative radiographic laxity testing.

RESULTS

Follow-up examination at an average of 16.3 months (SD 8.2) after surgery showed significant improvement of all variables compared to pre-operative values (p < 0.001). Most patients rated their outcome as good/excellent. Telos stress radiographs documented improvement in joint stability.

CONCLUSIONS

Lateral ligament reconstruction with allograft represents a valid treatment option in patients with severe chronic lateral ankle instability.

Thromboembolic complications in arthroscopic surgery

Venous thromboembolism (VTE) is a relatively rare complication of arthroscopic surgery but has the potential to cause significant morbidity and even mortality. VTE has been reported after shoulder and knee arthroscopy prompting controversial guidelines to be proposed. More limited studies are available regarding hip and ankle arthroscopy and 1 case of deep venous thrombosis in the contralateral leg status after hip arthroscopy exists. No reports have been published regarding VTE after elbow or wrist arthroscopy to these authors' knowledge. In this article, a systematic review of the literature was conducted to analyze the incidence, treatment, and prevention of thromboembolic complications in arthroscopy.

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.

Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy

Ankle sprains are the most common injuries sustained during sports activities. Most ankle sprains recover fully with non-operative treatment but 20-30% develop chronic ankle instability. Predicting which patients who sustain an ankle sprain will develop instability is difficult. This paper summarises a consensus on identifying which patients may require surgery, the optimal surgical intervention along with treatment of concomitant pathology given the evidence available today. It also discusses the role of arthroscopic treatment and the anatomical basis for individual procedures.

Ankle surgery: focus on arthroscopy

BACKGROUND

The ankle joint can be affected by several diseases, with clinical presentation varying from mild pain or swelling to inability, becoming in some cases a serious problem in daily life activities. Arthroscopy is a widely performed procedure in orthopedic surgery, due to the low invasivity compared to the more traditional open field surgery. The ankle joint presents anatomical specificities, like small space and tangential view that make arthroscopy more difficult.

METHODS

From 2000 more than 600 ankle arthroscopies were performed at our institution. The treated pathologies were mostly impingement syndrome and osteochondral lesions, and in lower percentage instabilities and ankle fractures.

RESULTS

In the impingement, the AOFAS scores at FU showed an increase compared to scores collected preoperatively, with improvement of symptoms in most of the cases, good or excellent results in 80 % of cases. In ligament injuries, AOFAS score significatively improved at the maximum follow-up. In fractures all patients had an excellent AOFAS score at maximum follow-up, with complete return to their pre-injury activities. In osteochondral injuries, the clinical results showed a progressive improvement over time with  the different performed procedures. Control MRI and bioptic samples showed a good regeneration of the cartilage and bone tissue in the lesion site.

CONCLUSIONS

The encouraging obtained clinical results, in line with the literature, show how the arthroscopic technique, after an adequate learning curve, may represent a precious aid for the orthopedic surgeon and for the patient's outcome.

LEVEL OF EVIDENCE

Case series, Level IV.

The "all inside" arthroscopic Broström procedure: a prospective study of 40 consecutive patients

Lateral ankle sprains are the most common injury in sports. Nonoperative therapy is recommended initially, including functional rehabilitation. Surgery might be an option for those patients in whom nonoperative attempts fail. Various surgical approaches have been described in published studies for treating chronic lateral ankle instability. The procedures are typically grouped into 2 main categories: anatomic and nonanatomic repair of the lateral ligament complex. The open modified Broström-Gould anatomic repair technique is widely accepted as the reference standard for lateral ankle stabilization. In the present study, we used an arthroscopic approach to treat chronic anterior talofibular ligament tears without the extensive open incisions common in the traditional modified Broström-Gould procedure. Our hypothesis was that the use of an all-inside arthroscopic Broström procedure would provide a minimally invasive technique with acceptable patient outcomes. We also wished to explore the complication rates and interval to return to weightbearing activity. A total of 40 ankles in 40 consecutive patients were included in the cohort.

Arthroscopic four-step treatment for chronic ankle instability

BACKGROUND

Chronic lateral ankle instability is a condition of perception of giving way and persistent pain usually following multiple ankle sprains. Open reconstructive procedures carry the disadvantages of subtalar joint stiffness and potential morbidity at the harvesting site. Recently, arthroscopic treatment of chronic lateral ankle instability has been proposed in order to minimize invasiveness, reduce operating time, and allow a faster rehabilitation period. The purpose of our paper was to assess the outcomes in terms of postoperative recovery and return to sport following arthroscopic reconstruction of lateral ankle instability.

METHODS

Ninety patients with chronic lateral ankle instability were treated at our Department from 2004 to 2009. Mean age was 32.4 (range, 17 to 56) years. All patients underwent a four-step operative procedure, including: synovectomy, debridement of ATFL lesion borders, capsular shrinkage, and 21-day immobilization and nonweightbearing.

RESULTS

Followup examination at an average of 4~years after surgery showed significant improvement of mean AOFAS scale (preoperative, 63.5; postoperative, 92.3; p < 0.001) and average Karlsson score (preoperative, 61.8; postoperative, 88.4; p < 0.001). Mean Tegner rating changed from 3.6 preoperatively to 4.9 at followup (p < 0.001). Articular stability as assessed by Sefton scale significantly improved from a preoperative value of 4.0 to 1.8 (p < 0.001). Most patients (96.6%) rated the success of their surgery as good to excellent.

CONCLUSION

Based on our results, we propose arthroscopic treatment as a suitable option for moderate chronic ankle joint laxity in patients with a complete ATFL lesion.

Arthroscopic anterior talofibular ligament repair for chronic ankle instability with a suture anchor technique

The goal of this study was to retrospectively evaluate the clinical outcomes of arthroscopic repair for chronic ankle instability using a bioabsorbable anchor with 2 sutures. We evaluated the results of 28 ankles treated with arthroscopic anterior talofibular ligament repair using bioabsorbable anchors with a FiberWire and TigerWire suture (Arthrex, Inc, Naples, Florida) placed on the fibula from March 2008 to January 2009. Average follow-up was 15.9 months (range, 13-25 months). Patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot ankle score and stress radiographs. Mean AOFAS hindfoot ankle score was 92.48 ± 6.14 at last follow-up compared to the mean preoperative score of 60.78 ± 16.38 (P=.041). Mean postoperative anterior draw test score difference between 2 ankles was 0.61 ± 0.75 compared to the mean preoperative score difference of 3.59 ± 0.68 (P=.00). There was a 14% complication rate, including 3 cases of portal site irritation and 1 case of superficial infection. Stress radiographs revealed 3 cases of anterior displacement >3 mm compared to the other side. All patients returned to their previous activity level.Arthroscopic ligament reconstruction for chronic lateral ankle instability using suture anchors is effective in returning patients to their preinjury function levels. Good clinical results were obtained with some minor complications. This minimally invasive technique is a reasonable alternative to other open surgical procedures for chronic ankle instability.

Arthroscopy and endoscopy of the ankle and hindfoot

Ankle arthroscopy provides the surgeon with a minimally invasive treatment option for a wide variety of indications such as impingement, osteochondral defects, loose bodies, ossicles, synovitis, adhesions, and instability. Posterior ankle pathology can be treated using endoscopic hindfoot portals. These posteromedial and lateral hindfoot portals provide excellent access to the posterior aspect of the ankle and subtalar joint. Also extra-articular structures in the hindfoot, for instance recurrent peroneal tendon dislocation, can be treated by creating an additional portal. The endoscopic hindfoot portals are safe and reliable, both anatomically and clinically. It compares favorably to open surgery with regard to less morbidity and a quicker recovery.

Evidence-based indications for ankle arthroscopy

PURPOSE

The purpose of this study was to review the literature to provide a comprehensive description of the Level of Evidence available to support the surgical technique of ankle arthroscopy for the current generally accepted indications and assign a grade of recommendation for each of them.

METHODS

A comprehensive review of the literature was performed (in August 2008) by use of the PubMed database. The abstracts from these searches were reviewed to isolate literature that described therapeutic studies investigating the results of different ankle arthroscopic treatment techniques. All articles were reviewed and assigned a classification (I-IV) of Level of Evidence. An analysis of the literature reviewed was used to assign a grade of recommendation for each current generally accepted indication for ankle arthroscopy.

RESULTS

There exists fair evidence-based literature (grade B) to support a recommendation for the use of ankle arthroscopy for the treatment of ankle impingement and osteochondral lesions and for ankle arthrodesis. Ankle arthroscopy for ankle instability, septic arthritis, arthrofibrosis, and removal of loose bodies is supported with only poor-quality evidence (grade C). Treatment of ankle arthritis, excluding isolated bony impingement, is not effective and therefore this indication is not recommended (grade C against). Finally, there is insufficient evidence-based literature to support or refute the benefit of arthroscopy for the management of synovitis and fractures (grade I).

CONCLUSIONS

There exists adequate evidence-based literature to support the surgical technique of ankle arthroscopy for most current generally accepted indications; however, further studies in this area are needed.

LEVEL OF EVIDENCE

Level IV, systematic review.

Arthroscopic repair of chronic lateral ankle instability

BACKGROUND

The current "gold standard'' for treatment of chronic lateral ankle instability is the Broström-Gould procedure. Most authors recommend this type of operation even after an arthroscopic inspection of the joint. We review our results with an arthroscopic method of lateral ankle ligament repair.

MATERIALS AND METHODS

A method of arthroscopic lateral ligament repair with an anchor placed in the fibula is described. We used this technique on 31 consecutive patients (28 were available for followup). Twenty-one patients had work or traffic accidents, four suffered casual falls. and three had sport-related lesions. The patients were evaluated after 24.5 month average followup.

RESULTS

The average postoperative AOFAS score was 85.3 (82.3 in the workers-compensation group and 94.4 in the others) and average satisfaction was 3.8 (3.5 to workers-compensation and 4.6 for the others). Complications occurred in nine patients (29%), but only three cases had ongoing problems. We had two recurrences (another sprain without instability on the stress radiograph). Three patients had some wound healing problems and three had injuries of the superficial peroneal nerve, one of which is persistent. One patient developed a deep venous thrombosis postoperatively.

CONCLUSION

With this method, we achieved good clinical results. We had several complications but most of them were minor. It was a simple procedure with less morbidity to most patients. We believe it produced an anatomical repair of the lateral ligament with clinical and functional results similar to other techniques.

Management of acute and chronic ankle instability

Acute lateral ankle ligament injuries are common. If left untreated, they can result in chronic instability. Nonsurgical measures, including functional rehabilitation, are the management methods of choice for acute injuries, with surgical intervention reserved for high-demand athletes. Chronic lateral ankle instability is multifactorial. Failed nonsurgical management after appropriate rehabilitation is an indication for surgery. Of the many surgical options available, anatomic repair of the anterior talofibular and calcaneofibular ligaments is recommended when the quality of the ruptured ligaments permits. Anatomic reconstruction with autograft or allograft should be performed when the ruptured ligaments are attenuated. Ankle arthroscopy is an important adjunct to ligamentous repair and should be performed at the time of repair to identify and address intra-articular conditions associated with chronic ankle instability. Tenodesis procedures are not recommended because they may disturb ankle and hindfoot biomechanics.

Venous thromboembolism in lower extremity arthroscopy

Venous thromboembolism (VTE) is a relatively rare complication of arthroscopic surgery of the lower extremity, but it does have the potential to result in significant morbidity and possible mortality. VTE has been reported to occur with knee arthroscopy, and guidelines for VTE prophylaxis before and after knee arthroscopy have been proposed. There are much fewer data regarding the incidence of VTE occurring after arthroscopy of the ankle and the hip. This article reviews the literature on the incidence, treatment, and prevention of VTE in association with arthroscopy of the lower extremity.

Arthroscopy and endoscopy of the foot and ankle: indications for new techniques

The scope of arthroscopy and endoscopy of the foot and ankle is expanding. New techniques are emerging to deal with diverse ankle pathology. Some of the conditions that can be dealt with arthroscopically are as follows: hallux valgus deformity, lesser toe deformity, first metatarsophalangeal instability, cock-up deformity of the big toe, peroneal tendon instability, lateral ankle and subtalar instability, hindfoot deformity or arthrosis, first metatarsocuneiform hypermobility, Lisfranc joint arthrosis, various stages of posterior tibial tendon insufficiency, foot and ankle arthrofibrosis, late complications after calcaneal fracture, acute and chronic Achilles tendon rupture, insertional Achilles tendinopathy, entrapment of the first branch of the lateral plantar nerve, Freiberg's infarction, flexor digitorum longus tenosynovitis, flexor hallucis longus pathology, calcaneonavicular coalition or "too-long" anterior process of the calcaneus, and ganglions. With sound knowledge regarding the indications, merits, and potential risks of new techniques, they will be powerful tools in foot and ankle surgery.

Arthroscopic thermal capsulorrhaphy for palmar midcarpal instability

Midcarpal instability is an uncommon problem in which deficient static and dynamic wrist stabilisers cause sudden, uncontrolled movement of the proximal carpal row. We studied 15 wrists prospectively in 13 patients who underwent arthroscopic thermal capsulorrhaphy for palmar midcarpal instability. Capsulorrhaphy was performed using standard wrist arthroscopic techniques and a small diameter monopolar radiofrequency probe. One hundred percent follow-up was achieved at a mean of 42 (range 14 - 67) months. With regards to instability, all wrists showed improvement or resolution of instability. Functional improvement was confirmed by an improvement in the mean DASH score from 38 pre-operatively to 17 at final follow-up. Our early results show that thermal capsulorrhaphy is effective in reducing the instability symptoms of palmar midcarpal instability.