SLR - October 2011 - Peter M. Stasko
Reference: Murawski C, Kennedy JG. (2010). Anteromedial Impingement in the Ankle Joint: Outcomes Following Arthroscopy. Am J Sports Med, 38(10), 2017-2024.
Scientific Literature Review
Reviewed by: Peter M. Stasko, DPM
Residency Program: The Western Pennsylvania Hospital, Pittsburgh, PA
Podiatric Relevance:
Arthroscopic debridement is a very useful, well-accepted method for minimally invasive treatment of various pathologies associated with the ankle including osseous and/or soft tissue impingement.
Methods:
Arthroscopic surgery was performed on 43 patients (26 male and 17 female) from January 2005 to July 2007 with 41 of the patients (26 male and 15 female) included in the study group. The patients were diagnosed with anteromedial impingement (AMI) of the ankle joint. The exclusion criteria consisted of those patients with pre-existing degenerative joint disease and/or rheumatoid arthritis. The patients included in the study completed pre-operative and post-operative AOFAS hindfoot and Short Form 36 outcome scores. The ankle joint range of motion in dorsiflexion was also recorded both pre-operatively and post-operatively. This was compared to the contralateral side in terms of a positive or negative expression. The intraoperative arthroscopic findings which were noted from the video recordings were presence/absence of synovial hyperplasia, presence/absence of anteromedial tibial osteophytes, and the presence/absence of anteromedial talar osteophytes. A return to play was calculated and defined as the time period elapsed between the date of surgery and the athletic patient’s return to competition. The patients who did not have a specific sporting activity were seen post-operatively until they reported the ability perform the required daily activities without pain.
Standard anteromedial and anterolateral arthroscopy portals were used. A 3.5-mm oscillating resector was used to remove scar, soft tissue synovial hyperplasia, and cicatrization from recurrent injury. All tibial exostoses were removed with a 3.5-mm resector and in certain cases, anterior fibers of the deltoid ligament were trimmed due to impingement. Patients were nonweightbearing for 2 days, and after 2 days, increased weightbearing as tolerated. Physical therapy was started one week to 10 days after surgery as sport-specific training was allowed 2 weeks after surgery. The symptoms of the patient then determined the active participation in sports.
Results:
Ninety-three percent of the patients who underwent arthroscopic resection for AMI were satisfied with the procedure and wou;d undergo the procedure again or recommend it to a friend. The patients AOFAS scores also improved from a mean of 62.83 preoperatively to 91.17 postoperatively. The patients mean SF-36 scores improved from 61.54 preoperatively to 92.21 postoperatively. It should be noted that 10 patients underwent additional procedures at the time of arthroscopic debridement which included 6 open lateral ligament reconstructions for mechanical instability of the lateral ankle ligament complex and 3 arthroscopic microfracture to repair an osteochondral lesion. Following the surgical repair of AMI, all but 1 patient who was involved in competitive sports before surgery returned to the same level of play. The return to play in the athletic population in patients receiving only arthroscopic debridement for AMI was a mean of 7 weeks. Of the 7 patients not involved in competitive sports, 6 returned to their daily activities without pain at a mean of 9 weeks. Those receiving lateral ligament reconstruction in addition to AMI resection returned to play at 15 weeks with those receiving the additional microfracture procedure returning at a mean time of 14 weeks. Three patients had complications after surgery consisting of neuropraxia, arthrofibrosis, and complex regional pain syndrome.
Conclusions:
Arthroscopic resection of AMI provides excellent functional outcomes, with few complications and reproducible results. Diagnosis and treatment of this pathology should occur in a timely manner. This will allow the competitive athlete to return to sport without significant delay.