Posterior ankle arthroscopy: current state of the art
2017; Elsevier BV; Volume: 2; Issue: 5 Linguagem: Inglês
10.1136/jisakos-2016-000082
ISSN2059-7762
AutoresC. Niek van Dijk, Gwendolyn Vuurberg, Jorge Batista, Pieter D’Hooghe,
Tópico(s)Sports injuries and prevention
ResumoThe most common hindfoot pathologies seen in clinical practice and sports medicine are posterior ankle impingement and osteoarthrosis (OA). Both these—and other pathologies such as insertional tendinitis and Haglund's disease—may cause significant disability, in both everyday life and during sporting activities. Post-traumatic OA alone causes a healthcare burden of over 3 billion US dollars per year. An adequate approach of these pathologies is required to minimise this healthcare burden and additionally to maintain patients' economic productiveness. The aim of this article is to outline the most important evidence-based indications concerning posterior ankle arthroscopy focusing on diagnostics, surgical techniques, complications, geographical differences and future developments in the field of hindfoot arthroscopy. Initially, the treatment of hindfoot pathology is conservative. If adequate conservative treatment does not result in a good response, surgery may be indicated. Over the last three decades, arthroscopy of the ankle joint has become a standardised and important procedure, with numerous indications for both anterior and posterior pathology. Since 2000, a two-portal hindfoot arthroscopic approach has been described and used globally in clinical practice. Some of the indications that may be addressed using this approach are the treatment of posteriorly located osteochondral defects, posterior ankle impingement, pathology of the deep portion of the deltoid ligament, Cedell fracture, tarsal tunnel release, loose bodies and tibiotalar or subtalar arthrodesis. Tendon pathology can also be treated using posterior portals; however, this is beyond the scope of this review. The most common hindfoot pathologies seen in clinical practice and sports medicine are posterior ankle impingement and osteoarthrosis (OA). Both these—and other pathologies such as insertional tendinitis and Haglund's disease—may cause significant disability, in both everyday life and during sporting activities. Post-traumatic OA alone causes a healthcare burden of over 3 billion US dollars per year. An adequate approach of these pathologies is required to minimise this healthcare burden and additionally to maintain patients' economic productiveness. The aim of this article is to outline the most important evidence-based indications concerning posterior ankle arthroscopy focusing on diagnostics, surgical techniques, complications, geographical differences and future developments in the field of hindfoot arthroscopy. Initially, the treatment of hindfoot pathology is conservative. If adequate conservative treatment does not result in a good response, surgery may be indicated. Over the last three decades, arthroscopy of the ankle joint has become a standardised and important procedure, with numerous indications for both anterior and posterior pathology. Since 2000, a two-portal hindfoot arthroscopic approach has been described and used globally in clinical practice. Some of the indications that may be addressed using this approach are the treatment of posteriorly located osteochondral defects, posterior ankle impingement, pathology of the deep portion of the deltoid ligament, Cedell fracture, tarsal tunnel release, loose bodies and tibiotalar or subtalar arthrodesis. Tendon pathology can also be treated using posterior portals; however, this is beyond the scope of this review. Ankle disorders may cause significant burden to both professional athletes and to the non-sports population. Posterior ankle impingement is especially common in both football players and ballet dancers—due to high loads in plantar flexion.1Kerkhoffs G Leeuw PAJd d'Hooghe P Posterior ankle impingement.in: The ankle in football. Sports and traumatology. Springer, France2014Crossref Google Scholar Post-traumatic osteoarthritis is another common, and no less important, entity in orthopaedic practice. However, little data exist regarding its prevalence and relative disease. In 2006, it was reported that approximately 5.6 million individuals suffered from post-traumatic OA in the USA to such a degree that an orthopaedic surgeon was consulted for their symptoms. About 85.5% of the costs associated with arthritis are estimated to be attributable to posttraumatic OA. A database of 662 OA patients showed that 9.8% of all cases of knee OA were post-traumatic, while 1.6% of hip OA was post-traumatic and 79.5% of ankle OA was post-traumatic.2Brown TD Johnston RC Saltzman CL et al.Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease.J Orthop Trauma. 2006; 20: 739-74410.1097/01.bot.0000246468.80635.efCrossref PubMed Scopus (622) Google Scholar Post-traumatic OA, causes an annual financial burden of more than US$3 billion, or 0.15% of the total US healthcare costs.2Brown TD Johnston RC Saltzman CL et al.Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease.J Orthop Trauma. 2006; 20: 739-74410.1097/01.bot.0000246468.80635.efCrossref PubMed Scopus (622) Google Scholar The field of arthroscopic foot and ankle surgery has progressed tremendously since its inception in 1939.3Takagi K The arthroscope.Jpn J Orthop Assn. 1939; 14Google Scholar Access to the posterior compartment of the ankle and subtalar joint historically has been performed in combination with a two-portal anterior approach, with the patient in the supine position. A third posterolateral portal was used mainly for irrigation or for the introduction of a grasper in order to remove a loose body in the posterior compartment. A posteromedial portal was regarded as dangerous because of potential nerve damage and damage to the posterior tibial artery and posteromedial tendons.4Ferkel RD Fischer SP Progress in ankle arthroscopy.Clin Orthop Relat Res. 1989; 240: 210-22010.1097/00003086-198903000-00027PubMed Google Scholar In 2000, van Dijk et al 5van Dijk CN Scholten PE Krips R A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology.Arthroscopy. 2000; 16: 871-87610.1053/jars.2000.19430Abstract Full Text Full Text PDF PubMed Scopus (401) Google Scholar developed a two-portal technique for hindfoot arthroscopy with the patient in the prone position. This approach is currently used as the standard approach for posterior pathology (figure 1). This technique provides excellent access to the posterior ankle compartment, subtalar joint and also the extra-articular structures, thus allowing for the inspection and treatment of posterior ankle pathology such as posterior ankle impingement and flexor hallucis longus (FHL) tendinopathy.5van Dijk CN Scholten PE Krips R A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology.Arthroscopy. 2000; 16: 871-87610.1053/jars.2000.19430Abstract Full Text Full Text PDF PubMed Scopus (401) Google Scholar, 6van Dijk CN Kort N Scholten PE Tendoscopy of the posterior tibial tendon.Arthroscopy. 1997; 13: 692-69810.1016/S0749-8063(97)90002-5Abstract Full Text PDF PubMed Scopus (100) Google Scholar, 7Niek van Dijk C Scholten PE Kort NP Tendoscopy (tendon sheath endoscopy) for overuse tendon injuries.Oper Tech Sports Med. 1997; 5: 170-17810.1016/S1060-1872(97)80039-1Crossref Google Scholar, 8van Bergen CJ de Leeuw PA van Dijk CN Treatment of osteochondral defects of the talus.Rev Chir Orthop Reparatrice Appar Mot. 2008; 94: 398-40810.1016/j.rco.2008.09.003Crossref PubMed Scopus (91) Google Scholar This approach can also be used to treat talar osteochondral defects (OCDs), removal of loose bodies or to perform arthroscopic ankle fusion, subtalar fusion or a combined ankle and subtalar fusion. Additional proceduress are tarsal tunnel release and peroneal groove deepening for recurrent peroneal tendon dislocation. Ankle arthroscopy has expanded to become an important therapeutic technique in the management of disorders of the ankle joint.3Takagi K The arthroscope.Jpn J Orthop Assn. 1939; 14Google Scholar, 9Watanabe M Sefloc-arthroscope (Watanabe no. 24 arthroscope). Monograph. Teishin Hospital, Tokyo1972Google Scholar, 10Burman MS Peltier LF Burman MS Arthroscopy or the direct visualization of Joints: an experimental cadaver study.Clin Orthop Relat Res. 2001; 390: 5-910.1097/00003086-200109000-00003Crossref PubMed Google Scholar As the indications for hindfoot arthroscopy have increased, so has its usage. It is the procedure of choice for the treatment of chronic and post-traumatic pathologies due to low morbidity rates, more rapid rehabilitation and favourable cosmetic results compared with conventional open surgical procedures.8van Bergen CJ de Leeuw PA van Dijk CN Treatment of osteochondral defects of the talus.Rev Chir Orthop Reparatrice Appar Mot. 2008; 94: 398-40810.1016/j.rco.2008.09.003Crossref PubMed Scopus (91) Google Scholar, 11Coughlin MJ Mann RA Saltzman CL Surgery of the Foot and Ankle.8th rev. ed. Mosby Elsevier, Amsterdam2006Google Scholar 1Kerkhoffs G Leeuw PAJd d'Hooghe P Posterior ankle impingement.in: The ankle in football. Sports and traumatology. Springer, France2014Crossref Google Scholar highlights six articles that the authors profess to be key in the development of posterior ankle arthroscopy. This article is the first state-of-the-art overview on ankle arthroscopy of the posterior ankle joint that discusses the diagnostics prior to arthroscopic treatment, the technique for posterior ankle arthroscopy, the complications, the pitfalls, any regional or geographical differences and future directions. Box 1Key articles on posterior ankle arthroscopy•First description of the two-portal technique with the patient in the prone position by van Dijk et al 5van Dijk CN Scholten PE Krips R A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology.Arthroscopy. 2000; 16: 871-87610.1053/jars.2000.19430Abstract Full Text Full Text PDF PubMed Scopus (401) Google Scholar showing good results with a 2-year follow-up.•In 2006, Pau Golanó published two articles providing detailed insight in the anatomy of the ankle with the focus on the salient facts for arthroscopists.58Golanó P Vega J Pérez-Carro L et al.Ankle anatomy for the arthroscopist. Part II: role of the ankle ligaments in soft tissue impingement.Foot Ankle Clin. 2006; 11: 275-29610.1016/j.fcl.2006.03.003Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 59Golanó P Vega J Pérez-Carro L et al.Ankle anatomy for the arthroscopist. Part I: the portals.Foot Ankle Clin. 2006; 11: 253-27310.1016/j.fcl.2006.03.005Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar•The low complication rate per technique was outlined by the research group of Zengerink et al.23Zengerink M van Dijk CN Complications in ankle arthroscopy.Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1420-143110.1007/s00167-012-2063-xCrossref PubMed Scopus (119) Google Scholar•A recent overview on causes, diagnosis, surgical technique, outcomes and complications is provided by Smyth et al.18Smyth NA Zwiers R Wiegerinck JI et al.Posterior hindfoot arthroscopy: a review.Am J Sports Med. 2014; 42: 225-23410.1177/0363546513491213Crossref PubMed Scopus (57) Google Scholar•In 2015, Hayashi et al 60Hayashi D Roemer FW D'Hooghe P et al.Posterior ankle impingement in athletes: pathogenesis, imaging features and differential diagnoses.Eur J Radiol. 2015; 84: 2231-224110.1016/j.ejrad.2015.07.017Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar provided a radiographic overview on posterior ankle impingement, including the differentials that should be taken into account.•To assess the safety of the posterior approach of ankle arthrodesis, Kerkhoffs et al 61Hendrickx RP de Leeuw PA Golano P et al.Safety and efficiency of posterior arthroscopic ankle arthrodesis.Knee Surg Sports Traumatol Arthrosc. 2015; 23: 2420-242610.1007/s00167-014-3040-3Crossref PubMed Scopus (17) Google Scholar performed a cadaveric study to assess iatrogenic damage after posterior ankle arthroscopic procedure. •First description of the two-portal technique with the patient in the prone position by van Dijk et al 5van Dijk CN Scholten PE Krips R A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology.Arthroscopy. 2000; 16: 871-87610.1053/jars.2000.19430Abstract Full Text Full Text PDF PubMed Scopus (401) Google Scholar showing good results with a 2-year follow-up.•In 2006, Pau Golanó published two articles providing detailed insight in the anatomy of the ankle with the focus on the salient facts for arthroscopists.58Golanó P Vega J Pérez-Carro L et al.Ankle anatomy for the arthroscopist. Part II: role of the ankle ligaments in soft tissue impingement.Foot Ankle Clin. 2006; 11: 275-29610.1016/j.fcl.2006.03.003Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 59Golanó P Vega J Pérez-Carro L et al.Ankle anatomy for the arthroscopist. Part I: the portals.Foot Ankle Clin. 2006; 11: 253-27310.1016/j.fcl.2006.03.005Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar•The low complication rate per technique was outlined by the research group of Zengerink et al.23Zengerink M van Dijk CN Complications in ankle arthroscopy.Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1420-143110.1007/s00167-012-2063-xCrossref PubMed Scopus (119) Google Scholar•A recent overview on causes, diagnosis, surgical technique, outcomes and complications is provided by Smyth et al.18Smyth NA Zwiers R Wiegerinck JI et al.Posterior hindfoot arthroscopy: a review.Am J Sports Med. 2014; 42: 225-23410.1177/0363546513491213Crossref PubMed Scopus (57) Google Scholar•In 2015, Hayashi et al 60Hayashi D Roemer FW D'Hooghe P et al.Posterior ankle impingement in athletes: pathogenesis, imaging features and differential diagnoses.Eur J Radiol. 2015; 84: 2231-224110.1016/j.ejrad.2015.07.017Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar provided a radiographic overview on posterior ankle impingement, including the differentials that should be taken into account.•To assess the safety of the posterior approach of ankle arthrodesis, Kerkhoffs et al 61Hendrickx RP de Leeuw PA Golano P et al.Safety and efficiency of posterior arthroscopic ankle arthrodesis.Knee Surg Sports Traumatol Arthrosc. 2015; 23: 2420-242610.1007/s00167-014-3040-3Crossref PubMed Scopus (17) Google Scholar performed a cadaveric study to assess iatrogenic damage after posterior ankle arthroscopic procedure. Thorough history taking and physical examination are the key to ensure a working hypothesis. For each pathology, specific indications may be found, which can be confirmed or excluded by means of history taking and physical examination (table 1). A patient with subtalar pathology has deep ankle pain which cannot be easily reproduced by physical examination. Locking is a sign of a loose body. Hindfoot pain, which aggravates with plantar flexion, is typical for posterior impingement. Numbness is a sign of a tarsal tunnel syndrome. Each examination begins with inspection and malalignment must be looked for specifically. The location of the pain is an important indicator. On physical examination, it is important to look for recognisable tenderness on palpation (figure 2). Not all disorders of the hindfoot can be diagnosed on palpation, but recognisable tenderness over one of the tendons guides the diagnosis in the direction of a tendon disorder.Table 1Key issues of patient selectionIndicationHistoryPhysical examinationAdditional diagnosticsOCD treatmentDeep ankle painThe pain cannot be provoked by palpation with the ankle in a neutral position•In case an X-ray does not show an OCD, a CT scan or MRI may be used.•CT scan for preoperative planning and determination of the size of the lesionPosterior ankle impingementActivity associated posterior ankle painHyper plantar flexion testPosterior impingement view to identify an os trigonumDeltoid ligament/Cedell fracture•Hyperdorsiflexion or eversion trauma•Posteromedial ankle pain aggravated by running or walking on uneven groundRecognisable pain by palpation of the posteromedial (retromalleolar) regionCT scan for affirmation of avulsion/fracture/calcificationTarsal tunnel syndromePosteromedial ankle painSensory and motor nerve examinationElectromyographyLoose bodyActivity associated ankle pain or lockingNo specific findingsCT scan for affirmation of loose bodies and their locationArthrodesis•Deep ankle pain•Failed conservative treatment•No other appropriate surgical option (shared decision-making)ROM limitation Crepitation DeformationStanding X-ray to confirm joint space narrowingOCD, osteochondral defect; ROM, range of motion. Open table in a new tab OCD, osteochondral defect; ROM, range of motion. The posterolateral talar process can be palpated on the posterolateral side of the ankle with the ankle in 15–20o plantar flexion. The posterior medial talar process can be palpated on the posteromedial side of the talus. It is important to determine the range of motion (ROM) of both the ankle joint and the subtalar joint and to compare both sides. At the conclusion of the examination, a posterior impingement test is performed (figure 2) Recognisable posterior pain, confirms the diagnosis of posterior ankle impingement . Finally, the neurological and vascular status of the foot must be determined. For posterior impingement, a lidocaine injection can be used for diagnostics, as it should result in a negative hyperplantar flexion test. The os trigonum is visible on lateral ankle radiographs, but it can be better visualised using a posterior impingement view—made with the ankle in 25o external rotation (PIM-view).12van Dijk CN van Bergen CJ Advancements in ankle arthroscopy.J Am Acad Orthop Surg. 2008; 16: 635-64610.5435/00124635-200811000-00004Crossref PubMed Scopus (139) Google Scholar, 13Wiegerinck JI Vroemen JC van Dongen TH et al.The posterior impingement view: an alternative conventional projection to detect bony posterior ankle impingement.Arthroscopy. 2014; 30: 1311-131610.1016/j.arthro.2014.05.006Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Deep ankle pain is the main symptom of an OCD. Often routine ankle radiographs are negative.14de Leeuw PA van Sterkenburg MN van Dijk CN Arthroscopy and endoscopy of the ankle and hindfoot.Sports Med Arthrosc. 2009; 17: 175-18410.1097/JSA.0b013e3181a5ce78Crossref PubMed Scopus (37) Google Scholar, 15Niek van Dijk C Anterior and posterior ankle impingement.Foot Ankle Clin. 2006; 11: 663-68310.1016/j.fcl.2006.06.003Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar, 16Siparsky PN Kocher MS Current concepts in pediatric and adolescent arthroscopy.Arthroscopy. 2009; 25: 1453-146910.1016/j.arthro.2009.03.011Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar To determine the extent and location of an OCD and to determine if an anterior or a posterior ankle arthroscopic approach is required, a CT scancan be used. Verhagen has shown that both CT scan and MRI have a similar accuracy in detecting an OCD.17Verhagen RA Maas M Dijkgraaf MG et al.Prospective study on diagnostic strategies in osteochondral lesions of the talus. is MRI superior to helical CT?.J Bone Joint Surg Br. 2005; 87: 41-46Crossref PubMed Scopus (59) Google Scholar For preoperative planning, a CT scan is preferable to determine the location and extent of the lesion and location of bony fragments. MRI is the imaging method of choice for evaluating soft tissue injury and bone bruises, but may overestimate the size of an OCD due to bone oedema. Ultrasonography is a relatively inexpensive and reliable alternative to MRI for detecting focal soft tissue damage.18Smyth NA Zwiers R Wiegerinck JI et al.Posterior hindfoot arthroscopy: a review.Am J Sports Med. 2014; 42: 225-23410.1177/0363546513491213Crossref PubMed Scopus (57) Google Scholar In case the diagnosis remains unclear in spite of all additional diagnostics the patient will likely not benefit from (diagnostic) arthroscopy.19M.L R v.S.M.N. deL van Dalen PAJ et al.Ankle arthroscopy: indications, techniques and complications.SA Orthopaedic Journal. 2009; : 51-58Google Scholar In case of suspicion of joint degeneration or OA, a standing radiograph may show joint space narrowing.20Kraus VB Kilfoil TM Hash TW et al.Atlas of radiographic features of osteoarthritis of the ankle and hindfoot.Osteoarthritis Cartilage. 2015; 23: 2059-208510.1016/j.joca.2015.08.008Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Preoperative severity of complaints may be assessed using patient reported outcome measures (table 2). These may additionally be used to evaluate postoperative recovery.Table 2Validated outcome measures and classificationsIndicationOutcome measureClassificationAll indicationsFAOS*Approved by the ISAKOS scientific committee. SF-36*Approved by the ISAKOS scientific committee. AOFAS VAS-FA FAAMNAImpingement•Posterior impingementOsteoarthritis scale, van Dijk et al.10Burman MS Peltier LF Burman MS Arthroscopy or the direct visualization of Joints: an experimental cadaver study.Clin Orthop Relat Res. 2001; 390: 5-910.1097/00003086-200109000-00003Crossref PubMed Google Scholar, 62Tol JL Verheyen CP van Dijk CN Arthroscopic treatment of anterior impingement in the ankle.J Bone Joint Surg Br. 2001; 83: 9-1310.1302/0301-620X.83B1.10571Crossref PubMed Scopus (136) Google Scholar*Approved by the ISAKOS scientific committee.OsteoarthritisAnkle osteoarthritis scale9Watanabe M Sefloc-arthroscope (Watanabe no. 24 arthroscope). Monograph. Teishin Hospital, Tokyo1972Google Scholar, 63Domsic RT Saltzman CL Ankle osteoarthritis scale.Foot Ankle Int. 1998; 19: 466-47110.1177/107110079801900708Crossref PubMed Scopus (228) Google ScholarOsteoarthritis scale, van Dijk et al.10Burman MS Peltier LF Burman MS Arthroscopy or the direct visualization of Joints: an experimental cadaver study.Clin Orthop Relat Res. 2001; 390: 5-910.1097/00003086-200109000-00003Crossref PubMed Google Scholar, 62Tol JL Verheyen CP van Dijk CN Arthroscopic treatment of anterior impingement in the ankle.J Bone Joint Surg Br. 2001; 83: 9-1310.1302/0301-620X.83B1.10571Crossref PubMed Scopus (136) Google Scholar *Approved by the ISAKOS scientific committee.OCDCT classification, Ferkel64Ferkel RD SN Del Pizzo W et al.Arthroscopic treatment of osteochondral lesions of the talus: technique and results.Orthop Tran. 1990; 14: 3Google Scholar*Approved by the ISAKOS scientific committee. MRI classification, Hepple65Hepple S Winson IG Glew D Osteochondral lesions of the talus: a revised classification.Foot Ankle Int. 1999; 20: 789-79310.1177/107110079902001206Crossref PubMed Scopus (245) Google ScholarAOFAS, American Orthopaedic Foot and Ankle Society Score67Ibrahim T Beiri A Azzabi M et al.Reliability and validity of the subjective component of the American Orthopaedic Foot and Ankle Society clinical rating scales.J Foot Ankle Surg. 2007; 46: 65-7410.1053/j.jfas.2006.12.002Abstract Full Text Full Text PDF PubMed Scopus (465) Google Scholar; FAAM, Foot and Ankle Ability Measure68Weel H Zwiers R Azim D et al.Validity and reliability of a Dutch version of the foot and ankle ability measure.Knee Surg Sports Traumatol Arthrosc. 2016; 24: 1348-135410.1007/s00167-014-3480-9Crossref PubMed Scopus (21) Google Scholar; FAOS, Foot and Ankle Outcome Score66Roos EM Brandsson S Karlsson J Validation of the foot and ankle outcome score for ankle ligament reconstruction.Foot Ankle Int. 2001; 22: 788-79410.1177/107110070102201004Crossref PubMed Scopus (506) Google Scholar; NA, not available; OCD, osteochondral defect; SF-36, Short Form (36) Health Survey66Roos EM Brandsson S Karlsson J Validation of the foot and ankle outcome score for ankle ligament reconstruction.Foot Ankle Int. 2001; 22: 788-79410.1177/107110070102201004Crossref PubMed Scopus (506) Google Scholar; VAS-FA, Visual Analogue Score Foot and Ankle.69Richter M Zech S Geerling J et al.A new foot and ankle outcome score: questionnaire based, subjective, Visual-Analogue-Scale, validated and computerized.Foot and Ankle Surgery. 2006; 12: 191-19910.1016/j.fas.2006.04.001Crossref Scopus (126) Google Scholar* Approved by the ISAKOS scientific committee. Open table in a new tab AOFAS, American Orthopaedic Foot and Ankle Society Score67Ibrahim T Beiri A Azzabi M et al.Reliability and validity of the subjective component of the American Orthopaedic Foot and Ankle Society clinical rating scales.J Foot Ankle Surg. 2007; 46: 65-7410.1053/j.jfas.2006.12.002Abstract Full Text Full Text PDF PubMed Scopus (465) Google Scholar; FAAM, Foot and Ankle Ability Measure68Weel H Zwiers R Azim D et al.Validity and reliability of a Dutch version of the foot and ankle ability measure.Knee Surg Sports Traumatol Arthrosc. 2016; 24: 1348-135410.1007/s00167-014-3480-9Crossref PubMed Scopus (21) Google Scholar; FAOS, Foot and Ankle Outcome Score66Roos EM Brandsson S Karlsson J Validation of the foot and ankle outcome score for ankle ligament reconstruction.Foot Ankle Int. 2001; 22: 788-79410.1177/107110070102201004Crossref PubMed Scopus (506) Google Scholar; NA, not available; OCD, osteochondral defect; SF-36, Short Form (36) Health Survey66Roos EM Brandsson S Karlsson J Validation of the foot and ankle outcome score for ankle ligament reconstruction.Foot Ankle Int. 2001; 22: 788-79410.1177/107110070102201004Crossref PubMed Scopus (506) Google Scholar; VAS-FA, Visual Analogue Score Foot and Ankle.69Richter M Zech S Geerling J et al.A new foot and ankle outcome score: questionnaire based, subjective, Visual-Analogue-Scale, validated and computerized.Foot and Ankle Surgery. 2006; 12: 191-19910.1016/j.fas.2006.04.001Crossref Scopus (126) Google Scholar Most ankle injuries are primarily treated non-operatively. If conservative treatment fails, surgery can be considered. Athletes require a quick return to play and may be eligible for acute surgical treatment.18Smyth NA Zwiers R Wiegerinck JI et al.Posterior hindfoot arthroscopy: a review.Am J Sports Med. 2014; 42: 225-23410.1177/0363546513491213Crossref PubMed Scopus (57) Google Scholar The operative approach to hindfoot pathology can be performed by means of open or arthroscopic surgery. Hindfoot pathology concerning tendons may also require a hindfoot approach. The best approach for this category of pathology is by tendoscopy. Tendoscopy is, however, not the focus of this review. For hindfoot and posterior ankle arthroscopy, a two-portal hindfoot approach is used and is routinely performed as a day care procedure. Generally, no prophylactic antibiotics are given. A 4 mm 30o angle arthroscope or an 11 cm length 2.7 mm scope with high-volume sheath (4.6 mm) is used.5van Dijk CN Scholten PE Krips R A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology.Arthroscopy. 2000; 16: 871-87610.1053/jars.2000.19430Abstract Full Text Full Text PDF PubMed Scopus (401) Google Scholar The procedure is performed under general or neuraxial anaesthesia. A tourniquet is placed around the upper thigh, but arthroscopic surgery can also be performed without the use of a tourniquet.21Zaidi R Hasan K Sharma A et al.Ankle arthroscopy: a study of tourniquet versus no tourniquet.Foot Ankle Int. 2014; 35: 478-48210.1177/1071100713518504Crossref PubMed Scopus (16) Google Scholar Kim et al 22Kim HK Jeon JY Dong Q et al.Ankle arthroscopy in a hanging position combined with hindfoot endoscopy for the treatment of concurrent anterior and posterior impingement syndrome of the ankle.J Foot Ankle Surg. 2013; 52: 704-70910.1053/j.jfas.2013.08.001Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar described a technique for the treatment of concurrent anterior and posterior ankle impingement, in which the patient was placed in a prone position, with the ankle hung in a shoulder-holding traction frame and the application of non-invasive ankle distraction. For posterior ankle arthroscopy, the patient is placed in the prone position, with the ankle overhanging the end of the table, or with a triangular cushion under the distal tibia (figure 3).23Zengerink M van Dijk CN Complications in ankle arthroscopy.Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1420-143110.1007/s00167-012-2063-xCrossref PubMed Scopus (119) Google Scholar, 24van Dijk CN Scholte D Arthroscopy of the ankle joint.Arthroscopy. 1997; 13: 90-9610.1016/S0749-8063(97)90215-2Abstract Full Text PDF PubMed Scopus (113) Google Scholar Using a two-portal approach, posterior ankle pathology can be visualised and subsequently treated.19M.L R v.S.M.N. deL van Dalen PAJ et al.Ankle arthroscopy: indications, techniques and complications.SA Orthopaedic Journal. 2009; : 51-58Google Scholar For subtalar arthrodesis and for a fibular groove deepening procedure, an additional third portal is used.14de Leeuw PA van Sterkenburg MN van Dijk CN Arthroscopy and endoscopy of the ankle and hindfoot.Sports Med Arthrosc. 2009; 17: 175-18410.1097/JSA.0b013e3181a5ce78Crossref PubMed Scopus (37) Google Scholar The posterolateral portal is initially created at the level of the tip of the lateral malleolus and the arthroscope is introduced, with the initial view direction being 30o to the lateral side.25van Dijk CN Hindfoot endoscopy.Foot Ankle Clin. 2006; 11: 391-41410.1016/j.fcl.2006.03.002Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar Care must be taken to avoid damage to the sural nerve. The posteromedial portal is then made at the same level (figure 4). A vertical stab incision is made and a mosquito clamp introduced. If scar tissue or adhesions are present, the mosquito clamp is exchanged for a 4.5 mm or 5.5 mm full radius shaver. Surgical debridement to improve the view is then commenced laterally—at the level of the subtalar joint, subsequently moving slowly tow
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