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Mini-open Arthroplasty for Anterior Ankle Impingement

Authors:
  • Australasian College of Podiatric Surgeons

Abstract

Osseous or soft tissue impingement of the anterior ankle can result in reduced dorsiflexion, pain and difficulty in walking that can significantly reduce the quality of life. Sometimes, conservative treatments fail and surgical intervention may be indicated. A 34-year-old male, who sustained a severe ankle injury five years earlier whilst waterskiing, complained of ongoing pain and disability. His initial injury had resulted in multiple fracture fragments within the anterior and posterior aspects of his right ankle. Upon performing clinical examination, reduced dorsiflexion with crepitus was noted and plain film radiographs exhibited multiple fragments within the anterior and posterior aspects of his ankle joint. Pain and limitation to motion were primarily affecting the anterior joint. The posterior aspect was only mildly symptomatic and not considered a primary consideration. Treatment involved a mini-open arthroplasty with removal of the osteophytes and margination of the chondral defects. Adequate dorsiflexion without crepitus was noted on the operating table and postoperative radiographs showed adequate removal of the osteophytes. He was kept non-weight bearing in a fibreglass back slab for 10 days before resuming partial weight bearing in a postoperative shoe and crutches. Mini-open arthroplasty may offer a viable alternative to large incision joint procedures or arthroscopy and may be a procrastinatory procedure for patients wishing to delay ankle joint arthrodesis or replacement.
11
Surgery Section
Mini-open Arthroplasty for
Anterior Ankle Impingement
DOI: 10.7860/IJARS/2021/46926:2645
International Journal of Anatomy Radiology and Surgery. 2021 Apr, Vol-10(2): SD01-SD03
Case Report
CASE REPORT
A fit and a healthy 34-year-old male carpenter had been
referred with a five-year history of chronic ankle pain, following a
waterskiing accident, when he was flipped by a wave and came
down hard on his right ankle in shallow water. This injury had
resulted in ongoing and increasing pain and disability that was
preventing him from participating in sports activities and making
his vocational duties difficult. At the time of injury, he was taken
to his local public hospital where he was treated with a Controlled
Ankle Motion (CAM) walker boot and crutches and had been
advised to reduce activity for a period of six weeks. His medical
history was unremarkable, and he did not report any allergies or
sensitivities. Since, the incident he had experienced chronic pain
and swelling that has now been impacting his ability to work. He
had previously enjoyed middle-distance running, however now
had difficulty running short distances. He had trialed various
conservative therapies including physical therapy (stretching and
mobilisation), ankle bracing, corticosteroid injections and non-
prescription orthotics- none of which proffered any discernible
improvement to his pain and function.
Clinically, the right ankle displayed global oedema with crepitus
and reduced dorsiflexion. The osteophytes were palpable. Plain
film radiographs [Table/Fig-1] showed multiple osteophytes
within the anterior and posterior aspects of his ankle, with
the anterior aspect being symptomatic. Whether to approach
the posterior ankle osteophytes concomitantly was discussed
between the primary surgeon (MG) and the patient prior to
surgery. Given the asymptomatic nature of the posterior ankle
pathology, it was agreed that this area would not be approached
in this surgical episode, however it may require review at a
later date.
The patient was positioned on the operating table in the supine
position. Once anaesthesia had been achieved, a pneumatic calf
tourniquet was utilised. His right foot and leg was prepared and
draped in typical fashion. An ankle block was performed using 0.75%
ropivacaine hydrochloride mixed with 1 mL (4 mg) dexamethasone
sodium phosphate.
Utilising anatomic dissection and haemostatic principles the ankle
was approached via a 30 mm curvilinear incision overlying the
anterolateral aspect of the joint approximating the lateral gutter
of the ankle [Table/Fig-2] followed by a 10 mm ankle arthrotomy
[Table/Fig-3]. Notably several loose fragments effectively “popped”
out of the wound once the arthrotomy was performed. Anterior
tibial osteophytes were resected [Table/Fig-4] and margination
of the damaged cartilage of the talar dome and tibial plafond
was performed until smooth joint range of motion with adequate
dorsiflexion was achieved. Copious lavage was performed followed
by layered closure. A Jones compression bandage with fiberglass
back slab was applied and strict non-weight bearing implemented
for 10 days postoperatively.
STEVEN R EDWARDS1, MARK F GILHEANY2, NICHOLAS D RYAN3
Keywords: Ankle injuries, Arthroscopy, Athletic injuries, Minimally invasive surgical procedures, Osteoarthritis
ABSTRACT
Osseous or soft tissue impingement of the anterior ankle can result in reduced dorsiflexion, pain and difficulty in walking that
can significantly reduce the quality of life. Sometimes, conservative treatments fail and surgical intervention may be indicated.
A 34-year-old male, who sustained a severe ankle injury five years earlier whilst waterskiing, complained of ongoing pain and
disability. His initial injury had resulted in multiple fracture fragments within the anterior and posterior aspects of his right ankle.
Upon performing clinical examination, reduced dorsiflexion with crepitus was noted and plain film radiographs exhibited multiple
fragments within the anterior and posterior aspects of his ankle joint. Pain and limitation to motion were primarily affecting the
anterior joint. The posterior aspect was only mildly symptomatic and not considered a primary consideration. Treatment involved
a mini-open arthroplasty with removal of the osteophytes and margination of the chondral defects. Adequate dorsiflexion without
crepitus was noted on the operating table and postoperative radiographs showed adequate removal of the osteophytes. He was
kept non-weight bearing in a fibreglass back slab for 10 days before resuming partial weight bearing in a postoperative shoe and
crutches. Mini-open arthroplasty may offer a viable alternative to large incision joint procedures or arthroscopy and may be a
procrastinatory procedure for patients wishing to delay ankle joint arthrodesis or replacement.
[Table/Fig-1]: Preoperative radiograph showing anterior and posterior ankle
osteophytes.
Steven R Edwards et al., Mini-open Arthroplasty for Anterior Ankle Impingement www.ijars.net
International Journal of Anatomy Radiology and Surgery. 2021 Apr, Vol-10(2): SD01-SD03
22
Postoperative radiographs [Table/Fig-5] showed adequate removal
of the osteophytes. He was able to achieve 10 degrees of dorsiflexion
by his six week review consultation [Table/Fig-6] and was able to
participate in 5 km runs at eight weeks postoperatively.
DISCUSSION
Anterior Ankle Impingement (AAI) refers to the entrapment of the
anterior ankle structures upon dorsiflexion, and is usually due to
osteophyte or soft-tissue impingement [1]. AAI commonly occurs
in athletes, notably soccer players, distance runners or sports
requiring sudden acceleration, thus its sobriquet ‘footballer’s
ankle’ [2]. AAI is also common in the general population and 91%
of patients with AAI report functional limitations and pain [3,4]. Its
aetiology is controversial. AAI may occur from repetitive micro-
trauma or a single traumatic event [5]. Dancers, runners, and soccer
players appear predisposed to micro-trauma induced AAI [6]. This
follows Wolff’s law of bone reaction to damage, whereby there is
a skeletal reaction to repetitive and intermittent injury [5]. A single
traumatic event may disrupt the anterior ankle anatomy resulting
in soft tissue impingement, floating osteophytes, or other damage
[7]. When AAI is chronic it limits ankle function and causes pain
due to compression of the synovium and adipose tissue between
the talus and ankle mortise [3]. This is increased in the presence of
osteophytes, which further limit free range of motion.
Diagnosis is made via clinical and radiographic assessment.
Clinically, pain, inflammation and reduced dorsiflexion are exhibited.
Palpable spurring may be present. Radiographs are the primary
imaging technique for identifying osteophytes at the anterior ankle.
Computed Tomography (CT) and Magnetic Resonance Imaging
(MRI) may also be useful. MRI is the gold standard for identifying
soft-tissue impingement [8-10], although ultrasonography may
still allow visualisation of soft tissue impingement lesions and
the differentiation of the disease from isolated bone involvement
[1]. If pain and limitation to movement is of concern surgical
decompression may be performed as a joint sparing procedure.
This can be achieved via open or arthroscopic means via medially,
laterally, or by both approaches [1].
[Table/Fig-2]: A small 30 mm curvi-linear incision was used.
[Table/Fig-5]: Postoperative radiograph showing removal of the anterior ankle
osteophytes.
[Table/Fig-6]: The patient was able to achieve 10 degrees of dorsiflexion by his six
week postoperative review.
[Table/Fig-3]: A 10 mm arthrotomy was used to access the anterior ankle.
[Table/Fig-4]: The resected osteophytes from the anterior ankle.
www.ijars.net Steven R Edwards et al., Mini-open Arthroplasty for Anterior Ankle Impingement
International Journal of Anatomy Radiology and Surgery. 2021 Apr, Vol-10(2): SD01-SD03 33
There is no current consensus for treatment for AAI [5]. The decision
to implement treatment is based on multiple factors including pain
intensity, functional limitation, and joint osteoarthritis [11]. The aim
of treatment is to increase joint function and reduce pain. Non-
surgical management remains the initial approach, with avoidance
of provoking activities and increased rest recommended [5].
Conservative treatments for chronic AAI include shoe modifications,
heel lifts, and injection therapy [12]. Physical therapy involving joint
rehabilitation and muscle strengthening has been shown to be a
viable conservative option with research suggesting implementation
for up to six months in the case of acute AAI [13].
Surgery is indicated when conservative measures fail [14,15]. The
aim of the surgery is to increase the functional ability of the ankle and
to reduce pain, and may involve debridement, osteophyte removal,
meniscoid lesion excision, partial capsulectomy, and chondroplasty
[16]. Complications may include infection, nerve damage, and
arthrofibrosis [16]. There are several surgical approaches available for
AAI. Both open and arthroscopic techniques have been described
and are indicated for the removal of osteophytes in AAI [17,18]. Both
of these techniques have their advantages and disadvantages. Open
ankle arthroplasty allows direct visualisation of the ankle mortise for
easier osteophyte removal and joint repair, with the downside being
increased incision size and wound healing required. Arthroscopy
provides access to the ankle joint via two small incisions, but may
make removal of the osteophytes more difficult [19].
Hawkins RB reported three case reports, approaching the anterior
ankle osteophytes in post-traumatic athletic injuries, whilst reshaping
the anterior tibia and/or talus to its original contour in order to
ensure avoiding impingement of the joint space and abrasion of
the adjacent articular cartilage [6]. Performance of punch lesions
into osteochondral defects that were incurred at the time of injury in
order to allow for the regeneration of fibrocartilage which decreases
pain and permits a return to functional and athletic activities was
made with each patient reporting a return to normal activities six
months after post-surgery.
In a study Branca A et al., treated 133 patients with AAI by way
of a tibio-talar arthroscopy. Treatment consisted of the removal of
soft tissue adhesions, chondroplasty and the removal of osseous
impingements with only four cases reporting a return of impingement
62 months postoperatively. The authors concluded that even in
cases with severe cartilage impairment an anterior ankle arthroplasty
may play a therapeutic role and can postpone arthrodesis [4].
Recently, Mosca M et al., performed a case series involving 49
patients (50 feet) who underwent this mini-open technique. They
found a marked improvement to the preoperative American
Orthopaedic Foot and Ankle (AOFAS) scores (47.32) compared
to the follow-up score (70.66) and that in the 36-item Short Form
Survey (SF-36) there was a statistically significant improvement
(p<0.05) in all eight domains. The authors concluded that this mini-
open approach may be considered for AAI and that it may be a
viable procedure for patients with grade 1 or 2 osteoarthritis who
want to delay or prevent arthrodesis or prosthetic ankle replacement
in the future [5].
PARTICULARS OF CONTRIBUTORS:
1. Registrar, Department of Surgery, Australasian College of Podiatric Surgeons, Melbourne, Victoria, Australia.
2. Surgeon, Department of Surgery, Australasian College of Podiatric Surgeons, Melbourne, Victoria, Australia.
3. Registrar, Department of Surgery, Australasian College of Podiatric Surgeons, Melbourne, Victoria, Australia.
PLAGIARISM CHECKING METHODS: [Jain H et al.]
•  Plagiarism X-checker: Sep 26, 2020
•  Manual Googling: Jan 15, 2021
•  iThenticate Software: Jan 27, 2021 (2%)
ETYMOLOGY: Author Origin
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Steven R Edwards,
2/1, Lansdown Street, Hampton, Victoria, Australia.
E-mail: s6edwards@gmail.com
Date of Submission: Sep 25, 2020
Date of Peer Review: Dec 11, 2020
Date of Acceptance: Jan 18, 2021
Date of Publishing: Apr 01, 2021
AUTHOR DECLARATION:
•  Financial or Other Competing Interests:  None
•  Was informed consent obtained from the subjects involved in the study?  Yes
•  For any images presented appropriate consent has been obtained from the subjects.  Yes
In this report, a mini-open approach to the anterior ankle was
performed as a ‘best of both worlds’ approach. Through a mini-
open approach, direct visualisation of the anterior ankle remove all
osteophytes and impingement was achieved, whilst still retaining a
small incision and wound for a quicker recovery time. The mini-open
approach involves a smaller arthrotomy of the joint capsule that will
presumably have a lower risk of postoperative fibrosis, which may
be disabling for young people and active individuals [5]. Future
research in this technique involving multiple patients in a variety of
settings is recommended to help guide future surgical practice.
CONCLUSION(S)
This case report involves an AAI treated with a mini-open arthroplasty
technique. A mini-open ankle arthroplasty may provide a viable
alternative to traditional open techniques and arthroscopy, and
may help to delay or prevent future arthrodesis or prosthetic ankle
replacement procedures.
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ResearchGate has not been able to resolve any citations for this publication.
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