- Email: [email protected]
Arthroscopic Taloplasty for an Anterolateral Snapping Ankle
Technical Note
Arthroscopic Taloplasty for an Anterolateral Snapping Ankle Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S.
Abstract: Anterior ankle snapping syndrome is rare. Snapping of the extensor digitorum longus due to attenuated inferior extensor retinaculum and snapping due to hypertrophied or low-lying peroneal tertius muscle have been reported. We reported a new mechanism of anterolateral snapping due to a hypertrophied talar head. Anterolateral snapping ankle can be revealed by active dorsiflexion and plantarflexion of the ankle with the foot inverted. Foot inversion will tension the inferior extensor retinaculum and uncover the dorsolateral prominence of the talar head. The dorsolateral prominence of the talar head will snap over the proximal edge of the inferior extensor retinaculum. This technical note reports the technique of arthroscopic contouring of the talar head via extra-articular ankle arthroscopy. We named this technique arthroscopic taloplasty.
S
napping syndromes result from the sudden impingement of a structure (anatomic and/or heterotopic) against a neighboring one (anatomic and/ or heterotopic), with a subsequent jerky movement that is sometimes associated with an audible pop.1 Snaps are variously perceived by patients, from mild discomfort to significant pain requiring surgical management.1 Snapping phenomena have been reported in various regions of the body, usually in the vicinity of joints that allow sufficient range of motion for an anatomic or heterotopic structure to interact with its close environment.1 The involved structures can be bony structures or a wide range of soft tissue structures that may be ligamentous, tendinous, or fibrocartilaginous.1 The resultant snaps may be intra- or extra-articular.1 Recurrent snaps may lead to damage of the involved structure and surrounding soft tissues.1
From the Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received June 15, 2016; accepted July 21, 2016. Address correspondence to Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16550/$36.00 http://dx.doi.org/10.1016/j.eats.2016.07.020
Arthroscopy Techniques, Vol
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Snapping phenomena in the ankle typically occur in the retromalleolar grooves involving the peroneal tendons on the lateral side and the tibialis posterior tendon on the medial side of the ankle.1-6 Retinacular injury may lead to chronic deficiency with subsequent instability of the peroneal and tibialis posterior tendons.1 Posterior snapping ankle has been reported as a result of intermittent dislocation of the flexor hallucis longus tendon7 or snapping plantaris tendon.8 Anterior ankle snapping syndrome is rare. Snapping of the extensor digitorum longus due to attenuated inferior extensor retinaculum9 and snapping due to hypertrophied or low-lying peroneal tertius muscle10,11 have been reported. Snapping can also be due to impingement of ankle tendons with bone spurs, osteophytes, fracture fragments, or orthopaedic hardware.1 In this technical note, a new mechanism of anterolateral snapping ankle is reported, and the technical details of arthroscopic contouring of the talar head (taloplasty) is described. The indication of this technique is symptomatic anterolateral snapping ankle due to hypertrophied talar head. It is contraindicated if there are other sources of the symptomatic ankle snapping (Table 1).
Technique Preoperative Assessment and Patient Positioning Anterolateral snapping ankle can be revealed by active dorsiflexion and plantarflexion of the ankle with the foot inverted. Foot inversion will tension the
No
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(Month), 2016: pp e1-e4
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Table 1. Indications and Contraindications of Arthroscopic Taloplasty Indications
Contraindications
1. Symptomatic anterolateral ankle snapping due to hypertrophied talar head
1. There are other sources of the symptomatic ankle snapping
inferior extensor retinaculum and uncover the dorsolateral prominence of the talar head. The dorsolateral prominence of the talar head will snap over the proximal edge of the inferior extensor retinaculum. Preoperative lateral radiograph of the foot may reveal the dorsolateral prominence of the talar head. Dynamic ultrasonography has superior capabilities for confirming the existence of a snap and correlating the abnormal behavior of an incriminated structure with patient symptoms.1 The patient is in supine position with the legs spread. A triangular supporting frame (Innomed, Savannah, GA) is put under the knee to flex the knee and hip. A thigh tourniquet is applied to provide a bloodless surgical field. Fluid inflow is by gravity, and arthropump should not be used. A 2.7-mm 30 arthroscope (HenkeSass, Wolf, Tuttlingen, Germany) is used for ankle arthroscopy and a 4.0-mm 30 arthroscope (Dyonics; Smith & Nephew, Andover, MA) is used for extraarticular ankle arthroscopy.
Fig 2. Arthroscopic taloplasty of the right foot. The anteromedial and anterolateral portals are used as the viewing portal. The ankle joint is assessed arthroscopically. (DDL, deep deltoid ligament; MM, medial malleolus; S, distal tibiofibular syndesmosis; TP, tibial plafond.)
tibialis anterior tendon, and the anterolateral portal is just lateral to the peroneus tertius tendon. Fivemillimeter longitudinal skin incisions are made at the portal sites. The subcutaneous tissue is bluntly dissected down to the ankle capsule by a hemostat. The capsule is perforated by the tip of the hemostat. The perforation should not be dilated by spreading the hemostat; otherwise, fluid extravasation will occur.
Portal Placement Standard anteromedial and anterolateral portals at the ankle joint line are used for this procedure (Fig 1). The anteromedial portal is just medial to the
Fig 1. Arthroscopic taloplasty of the right foot. Ankle arthroscopy is performed via the anteromedial (AMP) and anterolateral (ALP) portals, which are medial to the tibialis anterior tendon and lateral to the peroneus tertius tendon respectively.
Fig 3. Arthroscopic taloplasty of the right foot. The anteromedial portal is the viewing portal. The anterior ankle capsule (C) is stripped from the talar neck (TN) by an arthroscopic shaver (AS).
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ANTEROLATERAL SNAPPING ANKLE Table 2. Pearls and Pitfalls of Arthroscopic Taloplasty
Fig 4. Arthroscopic taloplasty of the right foot. The anteromedial portal is the viewing portal. The dorsolateral prominence of the talar head (TH) can be resected by an arthroscopic acromionizer via anterolateral portal. (TP, tibial plafond.)
Arthroscopic Assessment of the Ankle Joint The anteromedial and anterolateral portals can be switched as the viewing portal. The ankle joint should be assessed (Fig 2) for any intra-articular pathology that may cause ankle snapping, for example, hypertrophied synovium, fibrous bands, or loose bodies.
Pearls
Pitfalls
1. The precise cause of snaps should be identified preoperatively. 2. The shaver cutting end should face the talar neck during the extensive capsular release. 3. The anteromedial and anterolateral portals should be switched during taloplasty to ensure complete reduction of the talar head.
1. Inadequate reduction of the talar head can occur because active snapping motion cannot be assessed intra-operatively. 2. Other extra-articular causes of anterior snapping ankle cannot be assessed.
Arthroscopic Anterior Ankle Capsulotomy The anteromedial portal is the viewing portal. The anterior ankle capsule is stripped from the talar neck by an arthroscopic shaver (Dyonics, Smith & Nephew) via the anterolateral capsule. The cutting edge of the shaver should face the talar neck during capsulotomy to avoid injury to the extensor tendons or anterior tibial neurovascular bundle (Fig 3). Arthroscopic Taloplasty After stripping of the soft tissue from the talar neck and head, the bony prominence of the talar head is exposed. The dorsolateral prominence of the talar head can be resected by an arthroscopic acromionizer (Dyonics, Smith & Nephew) via the anterolateral portal (Fig 4). The bone resection is adequate when the upper border of the talar head is flush with the dorsal border of the navicular while the ankle and the foot are in neutral position. The arthroscope is then switched to the anterolateral portal, and the remaining bony prominence at the dorsomedial side of the talar neck can be resected by the acromionizer via the anteromedial portal (Fig 5, Table 2). Postoperatively, the foot is stabilized in an ankle-foot orthosis for 2 weeks (Fig 6, Video 1), and active and passive mobilization can be started afterward.
Discussion
Fig 5. Arthroscopic taloplasty of the right foot. The anterolateral portal is the viewing portal. After completion of arthroscopic taloplasty, the dorsal prominence of the talar head (TH) is resected, leaving a flat surface (star).
The reported mechanism of anterolateral snapping ankle is very rare and should be confirmed by detailed history taking, careful clinical examination, and dynamic ultrasonographic study. Static investigation using, for example, radiographs, computed tomogram, and magnetic resonance imaging, usually cannot identify the precise cause of snaps.1 The prominent talar head can be reached via ankle arthroscopy or talonavicular arthroscopy.12,13 Talonavicular arthroscopy is technically difficult, and most surgeons are not familiar with it. On the other hand, ankle arthroscopy is a commonly performed procedure and can be handled by average
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T. H. LUI
Fig 6. Arthroscopic taloplasty of the right foot. (A) Preoperative lateral radiograph of the right foot of the illustrated case shows dorsal prominence of the talar head (arrowhead). (B) Postoperative radiograph shows the dorsal prominence of the talar head is resected.
Table 3. Advantages and Risks of Arthroscopic Taloplasty Advantages
Risks
1. Better cosmesis 2. Arthroscopic assessment of the ankle and talonavicular joints is possible 3. Adequate contouring of the talar head is possible
1. Injury to the articular cartilage of the talonavicular joint 2. Injury to the extensor tendons 3. Injury to the anterior tibial neurovascular bundle 4. Injury to the perforating branches of the anterior tibial artery
arthroscopists. After extensive capsular release,14 it provides an excellent working space for arthroscopic taloplasty. To expose the dorsal part of the talar head, the dorsal capsuleeligamentous structures of the talonavicular joint is released. Therefore, a short period of postoperative stabilization with an ankle-foot orthosis is recommended to avoid plantarflexion instability of the joint. The advantages of this technique include better cosmetic result, arthroscopic assessment of the ankle joint, and adequate contouring of the talar head. The potential risks of this technique include injury to the articular cartilage of the talonavicular joint, the extensor tendons, the anterior tibial neurovascular bundle, or its perforating branches at the talar neck (Table 3).
References 1. Guillin R, Marchand AJ, Roux A, Niederberger E, Duvauferrier R. Imaging of snapping phenomena. Br J Radiol 2012;85:1343-1353. 2. Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. J Bone Joint Surg Am 2008;90: 992-999.
3. Raikin SM. Intrasheath subluxation of the peroneal tendons. Surgical technique. J Bone Joint Surg Am 2009;91: 146-155 (suppl 2 pt 1). 4. Lohrer H, Nauck T. Posterior tibial tendon dislocation: A systematic review of the literature and presentation of a case. Br J Sports Med 2010;44:398-406. 5. Ferran NA, Oliva F, Maffulli N. Recurrent subluxation of the peroneal tendons. Sports Med 2006;36:839-846. 6. Godino M, Vides M, Guerado E. Traumatic dislocation of posterior tibial tendon by avulsion of flexor retinacular release. Reconstruction with suture anchors. Rev Esp Cir Ortop Traumatol 2015;59:211-214. 7. Renard M, Simonet J, Bencteux P, Raynaud P, Biga N, Thiébot J. Intermittent dislocation of the flexor hallucis longus tendon. Skeletal Radiol 2003;32:78-81. 8. Han F, Gartner L, Pearce CJ. Snapping plantaris tendon: Case report. Foot Ankle Int 2014;35:1358-1361. 9. Cho J, Lee WC, Park CH. Snapping of the extensor digitorum longus due to attenuated inferior extensor retinaculum: Case report. Foot Ankle Int 2012;33:336339. 10. Sammarco GJ, Henning C. Peroneus tertius muscle as a cause of snapping and ankle pain: A case report. Am J Sports Med 2007;35:1377-1379. 11. Bilgili MG, Kaynak G, Botanlio glu H, et al. Peroneus quartus: Prevalence and clinical importance. Arch Orthop Trauma Surg 2014;134:481-487. 12. Lui TH. New technique of arthroscopic triple arthrodesis. Arthroscopy 2006;22:464.e1-464.e5. 13. Lui TH, Chan LK. Safety and efficacy of talonavicular arthroscopy in arthroscopic triple arthrodesis. A cadaveric study. Knee Surg Sports Traumatol Arthrosc 2010;18:607611. 14. Bauer T, Breda R, Hardy P. Anterior ankle bony impingement with joint motion loss: The arthroscopic resection option. Orthop Traumatol Surg Res 2010;96:462468.
Arthroscopic Taloplasty for an Anterolateral Snapping Ankle Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S.
Abstract: Anterior ankle snapping syndrome is rare. Snapping of the extensor digitorum longus due to attenuated inferior extensor retinaculum and snapping due to hypertrophied or low-lying peroneal tertius muscle have been reported. We reported a new mechanism of anterolateral snapping due to a hypertrophied talar head. Anterolateral snapping ankle can be revealed by active dorsiflexion and plantarflexion of the ankle with the foot inverted. Foot inversion will tension the inferior extensor retinaculum and uncover the dorsolateral prominence of the talar head. The dorsolateral prominence of the talar head will snap over the proximal edge of the inferior extensor retinaculum. This technical note reports the technique of arthroscopic contouring of the talar head via extra-articular ankle arthroscopy. We named this technique arthroscopic taloplasty.
S
napping syndromes result from the sudden impingement of a structure (anatomic and/or heterotopic) against a neighboring one (anatomic and/ or heterotopic), with a subsequent jerky movement that is sometimes associated with an audible pop.1 Snaps are variously perceived by patients, from mild discomfort to significant pain requiring surgical management.1 Snapping phenomena have been reported in various regions of the body, usually in the vicinity of joints that allow sufficient range of motion for an anatomic or heterotopic structure to interact with its close environment.1 The involved structures can be bony structures or a wide range of soft tissue structures that may be ligamentous, tendinous, or fibrocartilaginous.1 The resultant snaps may be intra- or extra-articular.1 Recurrent snaps may lead to damage of the involved structure and surrounding soft tissues.1
From the Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received June 15, 2016; accepted July 21, 2016. Address correspondence to Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16550/$36.00 http://dx.doi.org/10.1016/j.eats.2016.07.020
Arthroscopy Techniques, Vol
-,
Snapping phenomena in the ankle typically occur in the retromalleolar grooves involving the peroneal tendons on the lateral side and the tibialis posterior tendon on the medial side of the ankle.1-6 Retinacular injury may lead to chronic deficiency with subsequent instability of the peroneal and tibialis posterior tendons.1 Posterior snapping ankle has been reported as a result of intermittent dislocation of the flexor hallucis longus tendon7 or snapping plantaris tendon.8 Anterior ankle snapping syndrome is rare. Snapping of the extensor digitorum longus due to attenuated inferior extensor retinaculum9 and snapping due to hypertrophied or low-lying peroneal tertius muscle10,11 have been reported. Snapping can also be due to impingement of ankle tendons with bone spurs, osteophytes, fracture fragments, or orthopaedic hardware.1 In this technical note, a new mechanism of anterolateral snapping ankle is reported, and the technical details of arthroscopic contouring of the talar head (taloplasty) is described. The indication of this technique is symptomatic anterolateral snapping ankle due to hypertrophied talar head. It is contraindicated if there are other sources of the symptomatic ankle snapping (Table 1).
Technique Preoperative Assessment and Patient Positioning Anterolateral snapping ankle can be revealed by active dorsiflexion and plantarflexion of the ankle with the foot inverted. Foot inversion will tension the
No
-
(Month), 2016: pp e1-e4
e1
e2
T. H. LUI
Table 1. Indications and Contraindications of Arthroscopic Taloplasty Indications
Contraindications
1. Symptomatic anterolateral ankle snapping due to hypertrophied talar head
1. There are other sources of the symptomatic ankle snapping
inferior extensor retinaculum and uncover the dorsolateral prominence of the talar head. The dorsolateral prominence of the talar head will snap over the proximal edge of the inferior extensor retinaculum. Preoperative lateral radiograph of the foot may reveal the dorsolateral prominence of the talar head. Dynamic ultrasonography has superior capabilities for confirming the existence of a snap and correlating the abnormal behavior of an incriminated structure with patient symptoms.1 The patient is in supine position with the legs spread. A triangular supporting frame (Innomed, Savannah, GA) is put under the knee to flex the knee and hip. A thigh tourniquet is applied to provide a bloodless surgical field. Fluid inflow is by gravity, and arthropump should not be used. A 2.7-mm 30 arthroscope (HenkeSass, Wolf, Tuttlingen, Germany) is used for ankle arthroscopy and a 4.0-mm 30 arthroscope (Dyonics; Smith & Nephew, Andover, MA) is used for extraarticular ankle arthroscopy.
Fig 2. Arthroscopic taloplasty of the right foot. The anteromedial and anterolateral portals are used as the viewing portal. The ankle joint is assessed arthroscopically. (DDL, deep deltoid ligament; MM, medial malleolus; S, distal tibiofibular syndesmosis; TP, tibial plafond.)
tibialis anterior tendon, and the anterolateral portal is just lateral to the peroneus tertius tendon. Fivemillimeter longitudinal skin incisions are made at the portal sites. The subcutaneous tissue is bluntly dissected down to the ankle capsule by a hemostat. The capsule is perforated by the tip of the hemostat. The perforation should not be dilated by spreading the hemostat; otherwise, fluid extravasation will occur.
Portal Placement Standard anteromedial and anterolateral portals at the ankle joint line are used for this procedure (Fig 1). The anteromedial portal is just medial to the
Fig 1. Arthroscopic taloplasty of the right foot. Ankle arthroscopy is performed via the anteromedial (AMP) and anterolateral (ALP) portals, which are medial to the tibialis anterior tendon and lateral to the peroneus tertius tendon respectively.
Fig 3. Arthroscopic taloplasty of the right foot. The anteromedial portal is the viewing portal. The anterior ankle capsule (C) is stripped from the talar neck (TN) by an arthroscopic shaver (AS).
e3
ANTEROLATERAL SNAPPING ANKLE Table 2. Pearls and Pitfalls of Arthroscopic Taloplasty
Fig 4. Arthroscopic taloplasty of the right foot. The anteromedial portal is the viewing portal. The dorsolateral prominence of the talar head (TH) can be resected by an arthroscopic acromionizer via anterolateral portal. (TP, tibial plafond.)
Arthroscopic Assessment of the Ankle Joint The anteromedial and anterolateral portals can be switched as the viewing portal. The ankle joint should be assessed (Fig 2) for any intra-articular pathology that may cause ankle snapping, for example, hypertrophied synovium, fibrous bands, or loose bodies.
Pearls
Pitfalls
1. The precise cause of snaps should be identified preoperatively. 2. The shaver cutting end should face the talar neck during the extensive capsular release. 3. The anteromedial and anterolateral portals should be switched during taloplasty to ensure complete reduction of the talar head.
1. Inadequate reduction of the talar head can occur because active snapping motion cannot be assessed intra-operatively. 2. Other extra-articular causes of anterior snapping ankle cannot be assessed.
Arthroscopic Anterior Ankle Capsulotomy The anteromedial portal is the viewing portal. The anterior ankle capsule is stripped from the talar neck by an arthroscopic shaver (Dyonics, Smith & Nephew) via the anterolateral capsule. The cutting edge of the shaver should face the talar neck during capsulotomy to avoid injury to the extensor tendons or anterior tibial neurovascular bundle (Fig 3). Arthroscopic Taloplasty After stripping of the soft tissue from the talar neck and head, the bony prominence of the talar head is exposed. The dorsolateral prominence of the talar head can be resected by an arthroscopic acromionizer (Dyonics, Smith & Nephew) via the anterolateral portal (Fig 4). The bone resection is adequate when the upper border of the talar head is flush with the dorsal border of the navicular while the ankle and the foot are in neutral position. The arthroscope is then switched to the anterolateral portal, and the remaining bony prominence at the dorsomedial side of the talar neck can be resected by the acromionizer via the anteromedial portal (Fig 5, Table 2). Postoperatively, the foot is stabilized in an ankle-foot orthosis for 2 weeks (Fig 6, Video 1), and active and passive mobilization can be started afterward.
Discussion
Fig 5. Arthroscopic taloplasty of the right foot. The anterolateral portal is the viewing portal. After completion of arthroscopic taloplasty, the dorsal prominence of the talar head (TH) is resected, leaving a flat surface (star).
The reported mechanism of anterolateral snapping ankle is very rare and should be confirmed by detailed history taking, careful clinical examination, and dynamic ultrasonographic study. Static investigation using, for example, radiographs, computed tomogram, and magnetic resonance imaging, usually cannot identify the precise cause of snaps.1 The prominent talar head can be reached via ankle arthroscopy or talonavicular arthroscopy.12,13 Talonavicular arthroscopy is technically difficult, and most surgeons are not familiar with it. On the other hand, ankle arthroscopy is a commonly performed procedure and can be handled by average
e4
T. H. LUI
Fig 6. Arthroscopic taloplasty of the right foot. (A) Preoperative lateral radiograph of the right foot of the illustrated case shows dorsal prominence of the talar head (arrowhead). (B) Postoperative radiograph shows the dorsal prominence of the talar head is resected.
Table 3. Advantages and Risks of Arthroscopic Taloplasty Advantages
Risks
1. Better cosmesis 2. Arthroscopic assessment of the ankle and talonavicular joints is possible 3. Adequate contouring of the talar head is possible
1. Injury to the articular cartilage of the talonavicular joint 2. Injury to the extensor tendons 3. Injury to the anterior tibial neurovascular bundle 4. Injury to the perforating branches of the anterior tibial artery
arthroscopists. After extensive capsular release,14 it provides an excellent working space for arthroscopic taloplasty. To expose the dorsal part of the talar head, the dorsal capsuleeligamentous structures of the talonavicular joint is released. Therefore, a short period of postoperative stabilization with an ankle-foot orthosis is recommended to avoid plantarflexion instability of the joint. The advantages of this technique include better cosmetic result, arthroscopic assessment of the ankle joint, and adequate contouring of the talar head. The potential risks of this technique include injury to the articular cartilage of the talonavicular joint, the extensor tendons, the anterior tibial neurovascular bundle, or its perforating branches at the talar neck (Table 3).
References 1. Guillin R, Marchand AJ, Roux A, Niederberger E, Duvauferrier R. Imaging of snapping phenomena. Br J Radiol 2012;85:1343-1353. 2. Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. J Bone Joint Surg Am 2008;90: 992-999.
3. Raikin SM. Intrasheath subluxation of the peroneal tendons. Surgical technique. J Bone Joint Surg Am 2009;91: 146-155 (suppl 2 pt 1). 4. Lohrer H, Nauck T. Posterior tibial tendon dislocation: A systematic review of the literature and presentation of a case. Br J Sports Med 2010;44:398-406. 5. Ferran NA, Oliva F, Maffulli N. Recurrent subluxation of the peroneal tendons. Sports Med 2006;36:839-846. 6. Godino M, Vides M, Guerado E. Traumatic dislocation of posterior tibial tendon by avulsion of flexor retinacular release. Reconstruction with suture anchors. Rev Esp Cir Ortop Traumatol 2015;59:211-214. 7. Renard M, Simonet J, Bencteux P, Raynaud P, Biga N, Thiébot J. Intermittent dislocation of the flexor hallucis longus tendon. Skeletal Radiol 2003;32:78-81. 8. Han F, Gartner L, Pearce CJ. Snapping plantaris tendon: Case report. Foot Ankle Int 2014;35:1358-1361. 9. Cho J, Lee WC, Park CH. Snapping of the extensor digitorum longus due to attenuated inferior extensor retinaculum: Case report. Foot Ankle Int 2012;33:336339. 10. Sammarco GJ, Henning C. Peroneus tertius muscle as a cause of snapping and ankle pain: A case report. Am J Sports Med 2007;35:1377-1379. 11. Bilgili MG, Kaynak G, Botanlio glu H, et al. Peroneus quartus: Prevalence and clinical importance. Arch Orthop Trauma Surg 2014;134:481-487. 12. Lui TH. New technique of arthroscopic triple arthrodesis. Arthroscopy 2006;22:464.e1-464.e5. 13. Lui TH, Chan LK. Safety and efficacy of talonavicular arthroscopy in arthroscopic triple arthrodesis. A cadaveric study. Knee Surg Sports Traumatol Arthrosc 2010;18:607611. 14. Bauer T, Breda R, Hardy P. Anterior ankle bony impingement with joint motion loss: The arthroscopic resection option. Orthop Traumatol Surg Res 2010;96:462468.