- Email: [email protected]
Arthroscopic Treatment for Anterior Ankle Impingement: A Systematic Review of the Current Literature
Systematic Review
Arthroscopic Treatment for Anterior Ankle Impingement: A Systematic Review of the Current Literature Ruben Zwiers, M.Sc., Johannes I. Wiegerinck, M.D., Ph.D., Christopher D. Murawski, B.S., Ethan J. Fraser, M.D., John G. Kennedy, M.D., M.Ch., M.M.Sc., F.R.C.S.(Orth), and C. Niek van Dijk, M.D., Ph.D.
Purpose: To provide a comprehensive overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement. Methods: A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was performed. Studies that met the following inclusion criteria were reviewed: studies reporting outcomes of arthroscopic treatment for anterior ankle impingement; studies reporting on more than 20 patients; a study population with a minimum age of 18 years; and studies in the English, Dutch, German, Italian, or Spanish language. Two reviewers independently performed data extraction. Extracted data consisted of population characteristics, in addition to both primary and secondary outcome measures. The Downs and Black scale was used to assess the methodologic quality of randomized and nonrandomized studies included in this review. Results: Twenty articles were included in this systematic review. Overall, good results were found for arthroscopic treatment in patients with anterior ankle impingement. In the studies that reported patient satisfaction rates, high percentages of good to excellent satisfaction were described (74% to 100%). The percentages of patients who would undergo the same procedure again under the same circumstances were also high (94.3% to 97.5%). Complication rates were low (4.6%), particularly with respect to major complications (1.1%). The high heterogeneity of the included studies made it impossible to compare the results of the studies, including between anterolateral impingement and anteromedial impingement. Conclusions: Arthroscopic treatment for anterior ankle impingement appears to provide good outcomes with respect to patient satisfaction and low complication rates. However, on the basis of the findings of this study, no conclusion can be made in terms of the effect of the type of impingement or additional pathology on clinical outcome. Level of Evidence: Level IV, systematic review of Level II and IV studies.
See commentary on page 1597
A
nterior ankle impingement is a syndrome characterized by pain at the anterior aspect of the ankle joint, particularly during hyper-dorsiflexion.1 In addition, patients may present with swelling and
From the Academic Medical Center, University of Amsterdam (R.Z., J.I.W., C.N.v.D.), Amsterdam, The Netherlands; and Hospital for Special Surgery (C.D.M., E.J.F., J.G.K.), New York, New York, U.S.A. The authors report the following potential conflict of interest or source of funding: J.G.K. receives support from Arteriocyte, Ohnell Family Foundation, and Mr. and Mrs. Michael J. Levitt. Industry and philanthropic grants for research given directly to Hospital for Special Surgery. C.N.v.D. receives support from Smith & Nephew. Received September 15, 2014; accepted January 21, 2015. Address correspondence to John G. Kennedy, M.D., M.Ch., M.M.Sc., F.R.C.S.(Orth), Hospital for Special Surgery, 523 E. 72nd Street, Ste 507, New York, NY 10021, U.S.A. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/14786/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.01.023
dorsiflexion may be restricted in some cases.2,3 Anterior ankle impingement is a common source of ankle pain in athletes, especially ballet dancers and soccer players,4,5 which led to the condition being described formerly as “athlete’s ankle”6 and “footballer’s ankle.”7 Presently, the term “anterior impingement” is widely used.8 On the basis of etiology and clinical presentation, differentiation between 2 separate entities is possible: osseous or bony impingement and soft-tissue impingement. A distinction can also be made clinically based on the localization of pathology and symptomatology, which includes anterolateral impingement (ALI) and anteromedial impingement (AMI) (Fig 1).9 Soft-tissue impingement is often located at the anterolateral aspect of the ankle, whereas bony impingement is predominantly located anteromedially (Fig 2).10 Therefore ALI is often referred to as “anterior soft-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 8 (August), 2015: pp 1585-1596
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Fig 1. (A) Standard lateral radiograph shows tibial and talar osteophytes at anterolateral aspect of ankle joint. (B) Oblique anteromedial impingement view radiograph shows anteromedial osteophytes.
tissue impingement,” whereby several types of pathology are described, including synovitis and meniscoid lesions, as well as thickening of the distal fascicle of the anteroinferior tibiofibular ligament.11-14 Conservative treatment, consisting of rest, physical therapy, ankle bracing, shoe modification, and/or local injection, is recommended as the primary treatment strategy for symptoms of anterior ankle impingement. An intra-articular corticosteroid injection can be applied in cases in which conservative treatments are unresponsive to reduce inflammation. Because conservative treatment is often unsuccessful, resection of the soft tissue and/or osteophytes is often required. Historically, good results have been described for open surgical approaches.4,7,15-18 In fact, one study comparing open and arthroscopic resection of osteophytes found that patients treated arthroscopically returned to full activity sooner than those undergoing the open procedure.19 Presently, ankle arthroscopy is recommended as the gold standard for the surgical treatment of anterior ankle impingement. In this regard, several case series, including both AMI and ALI, have shown arthroscopic removal of bony and soft-tissue impediments to be effective.5,20-31 A recent systematic review on evidence-based indications for anterior ankle arthroscopy described evidence-based literature supporting the recommendation for its use in treating anterior ankle impingement.32 Simonson and Roukis33 reported ankle arthroscopy to be a safe treatment option for anterolateral soft-tissue impingement.
However, less is reported on other important outcome measures, including patient satisfaction and return to sport. This study aims to provide a comprehensive overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement.
Methods Search Strategy A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases (with a search date of August 4, 2014) was performed using the following keywords: ((ankle AND impingement) OR (ankle AND impingement AND syndrome) OR ((talar OR talus) AND compres*) OR (ankle AND osteophy*) OR ((talar OR talus OR tibiotalar) AND osteophy*) OR ((talar OR talus) AND impingement)) AND ((arthrosc*) OR (surgery OR procedures) OR (treatment)). In addition, the Cochrane database of clinical and randomized controlled trials was searched using the term “impingement.” A review of the reference lists of relevant articles was performed to identify any additional articles potentially not identified through the database search. Inclusion and Exclusion Criteria Studies that met the following inclusion criteria were reviewed: studies reporting outcomes of arthroscopic
Fig 2. (A) Soft-tissue impingement. (B) Bony impingement.
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ANTERIOR ANKLE IMPINGEMENT
treatment for anterior ankle impingement; studies reporting on more than 20 patients; a study population with a minimum age of 18 years; and studies in the English, Dutch, German, Italian, or Spanish language. Each study had to report at least 2 of the following outcome measures: patient satisfaction, American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) score for pain, return to sport or return to full activity, range of motion, complications, and answering the question whether the patient would undergo the same operation under the same circumstances again. Studies reporting on a combined posterior and anterior arthroscopic approach or anterior arthroscopy combined with an additional open procedure, such as lateral ligament reconstruction, were excluded. In cases in which there were studies that reported on (partially) the same population, only the most recent data were included in our study. All studies not addressing solely anterior ankle impingement, as well as review and expert opinion articles, were also excluded. Studies were selected and independently assessed by 2 reviewers (R.Z., J.I.W.). Differences between the reviewers were discussed until agreement was achieved, and the senior authors (J.G.K., C.N.vD.) were consulted in the event of persistent disagreement. Data Extraction and Analysis Two reviewers (R.Z., J.I.W.) independently performed data extraction. Extracted data consisted of population characteristics, in addition to both primary and secondary outcome measures. Primary outcome measures were patient satisfaction and complication rates. Secondary outcome measures were clinical outcome measures, including the AOFAS AnkleHindfoot scale, VAS score, and range of motion, as well as the time to achieve return to sport or full activity after surgery. Furthermore, we extracted data on clinical outcomes expressed as excellent, good, fair, and poor outcomes, including the criteria on which these categorical outcomes were based. Good and excellent outcomes were considered successful treatment. If necessary, additional information was requested by E-mail from the authors of the studies in question. To simplify the extraction and data analysis, complications were dichotomized as “major” or “minor” complications. Quality Assessment Two reviewers (R.Z., J.I.W.) independently performed a validated quality assessment of the included studies. The Downs and Black scale was used to assess the methodologic quality of randomized and nonrandomized studies included in this review. This tool measures quality in terms of reporting, external validity, internal validity (bias and confounding), and
Fig 3. Flowchart. (CINAHL, Cumulative Index to Nursing and Allied Health Literature.)
power, with a maximum score of 32 points.34 Adapted from Jäkel and von Hauenschild,35 Downs and Black scores of greater than 24 points were considered good; 8 to 24 points, moderate; and less than 8 points, poor. The Downs and Black checklist has been developed to assess the methodologic quality of both randomized and nonrandomized studies. Disagreement was resolved after discussion among the reviewers and in consultation with the senior authors.
Results Search Results After the search results of the different databases were combined and duplicate publications were removed, 950 articles remained for review. Thereafter 826 articles were excluded based on the title or abstract; because of the study design or the size or mean age of the study
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Table 1. Characteristics of Included Studies Study (Level of Evidence) Akseki et al.36 (IV) Arnold37 (IV) Baums et al.38* (IV)
Subgroup
ST B Branca et al.23 (IV) Brennan et al.24 (IV) Cavallo et al.39* (IV) B ST Di Palma et al.40 (IV) Ferkel et al.41 (IV) Hassan42 (II) Jerosch et al.25 (IV) Koczy et al.43* (IV) Liu et al.14 (IV) Mardani-Kivi et al.44 (IV) Murawski and Kennedy9 (IV) Ogilvie-Harris et al.45* (IV) AL Ant Rasmussen and Hjorth30 (IV) Rouvillain et al.46 (IV) Ürgüden et al.47 (IV) van Dijk et al.3z (II) AL AM Tol et al.5z (II) Total or weighted mean
Year 1999 2011 2006 d d 1997 2012 2013 d d 1999 1991 2007 1994 2009 1994 2013 2010 1993 d d 2002 2014 2005 1997 d d 2001
N 21 32 26 12 14 58 41 280 203 77 67y 31 23 35y 22 55 23 35 26 17 11 105 24 41 62 32 30 57 972
Sex (M/F), n 7/14 d 16/10 7/5 9/5 37/21 26/15 174/106 121/82 53/24 45/19y 17/14 18/5 24/19y 33/22 8/15 d d d d 61/44 3/21 25/16 42/20 d d 38/19 536/361
Time to Surgery, mo 24 (4-60) d 20 (11-32) 20.7 (13-29) 19.4 (11-32) d 21 (4-48) d d d d 24 (3-120) 13 (5-60) 15.8 12.2 60 (24-96) d d d d d d 12 (6-60) 21 (5-60) 23.4 (5-132) d d d d 22.5
Follow-up Time, mo 34 (24-48) 49 31 (25-48) 32.8 (25-48) 34.2 (25-45) 21.5 (8-62) 13 39.1 17.3 d d 23.5 (8-60) 33.5 (24-66) 25 (12-38) 32.2 19.4 3 and 12 31.2 (12-54) 3 and 6 d d d d 24 (21-26) 22 (12-92) 83.7 (21-152) 12 and 24 d d 78 (60-96) 35.3
Age at Surgery, yr 31 (11-68) 38 (16-65) 27 (19-32) 25.2 (19-31) 28.1 (19-32) 28.5 (19-47) 31 (16-62) 35.4 12.3 35.3 13.6 31.2 14.2 24.5 (17-42) 34 (16-74) 27.2 (15-53) 25 8.3 (14-43) 34 (17-55) 34 (20-67) 38.13 6.85 d d d d 35 (16-62) 35 (21-54) 33.2 (15-63) 31 (16-52) d d 36 (21-59)x 32.7
NOTE. Data are presented as mean (range), mean SD, or mean SD (range) unless otherwise indicated. e, not reported; AL, anterolateral impingement; AM, anteromedial impingement; Ant, anterior impingement; B, bony impingement; F, female; M, male; ST, soft-tissue impingement. *Additional information was requested from authors. y Incorrect number of patients or sex distribution reported in study. z Studies on same population. x At follow-up.
population; or because they did not report on the outcome of anterior arthroscopy. One study was added after review of the reference lists, resulting in a total of 65 full-text articles for the full-text review. On the basis of full-text evaluation, 45 articles were excluded. The remaining 20 articles were included in this systematic review3,5,9,14,23-25,30,36-47 (Fig 3). Population Characteristics One of the 20 studies reported on the long-term follow-up of another study; therefore only 19 unique study populations were included. The number of patients in these studies totaled 905, with a mean age of 32.7 years and a male-female ratio of 536:361. The mean follow-up time was 35.3 months, and the mean time until surgery was 22.5 months (Table 1). Ten studies reported on “anterolateral impingement,” four studies reported on “anterior impingement,” and one study reported the results of the treatment of “anteromedial impingement.” The 4 remaining studies reported on “anterolateral and anterior impingement”
or “anterolateral and anteromedial impingement” (Table 2). Two studies drew distinction between bony and softtissue or fibrous impingement. Two studies reported a mean follow-up time of less than 1 year,43,44 whereas 2 other studies reported a mean follow-up of more than 5 years.5,47 A complete overview of the study characteristics is provided in Tables 1 and 2. Five studies made use of a classification for anterior impingement. Five studies used the Scranton and McDermott scale,19 of which 2 studies excluded stage IV. An osteoarthritis scale3 was used by 2 studies of the same patient population (Table 3). Ten studies excluded patients with signs of osteoarthritis, whereas 10 others either did not exclude or did not report exclusion criteria. Chondral damage was reported in 9 studies, and 6 studies excluded patients with osteochondral defects or related pathology. Five studies excluded patients with ankle instability. Table 3 shows the distribution of arthroscopic findings in the different populations.
Table 2. Exclusion Criteria Localization AL Ant AL/Ant
Invasive Distraction No No No
Surgeons 1 d d
Diagnosis Phys exam, Xap, Xlat, MRI Phys exam, Xap, Xlat, MRI Phys exam, Xap, Xlat, MRI
Branca et al.23 Brennan et al.24
Ant AL
Yes No
d 1
Phys exam, Xlat MRI
Cavallo et al.39 Di Palma et al.40 Ferkel et al.41 Hassan42
AM/AL/W/T AL AL AL
d Yes No No
1 d d 1
Phys exam, Xap, Xlat, MRI Phys exam, Xap, Xlat, CTartro, MRI Phys exam, Xap, Xlat, MRI Phys exam, Xap, Xlat, Xobl, MRI
Ant AL AL AL
No NR No d
d d 4 d
Phys exam, Xap, Xlat, Xstress, bone scan, MRI Phys exam, Xap, Xlat, MRI Phys exam, Xlat, Phys exam, Xlat, Xap, MRI
Murawski and Kennedy9 Ogilvie-Harris et al.45* Rasmussen and Hjorth30 Rouvillain et al.46
AM AL/Ant Ant AL
No No No No
1 d d 2
Phys exam, Xlat, X AMI, MRI, injection Phys exam, Xlat, Xap, Xstress, MRI Phys exam Phys exam, Xlat, Xstress, CTartro, MRI, bone scan
Ürgüden et al.47 van Dijk et al.3y
AL AL/AM
No No
1 1
Phys exam, Xlat, MRI Phys exam, Xap, Xlat
d
d
d
d
Jerosch et al.25 Koczy et al.43* Liu et al.14 Mardani-Kivi et al.44
Tol et al.5y
Exclusion Criteria NR Sc IV Significant instability, severe osteoarthritic changes NR Degenerative changes, osteochondral defects, intra-articular loose bodies, infection, inflammatory arthritis NR Serious chronic lateral instability Associated fracture, <2 yr follow-up Osteochondral lesions, degenerative arthritis, mechanical instability Osteochondritis dissecans NR NR Bilateral, malalignment, osteoarthritis (S&McD grade IV) Degenerative joint disease, rheumatoid arthritis Significant osteoarthritis or joint narrowing Ankle instability Anterior tibial and/or talar osteophytes osteochondral lesions, TOL, degenerative arthritis mechanical instability Loose bodies, osteochondritis dissecans, severe osteoarthritic changes d
Methodologic Quality 1 4 7 2 4
3 5 3 5 5 4 ? 6 7 7 5 2
ANTERIOR ANKLE IMPINGEMENT
Study Akseki et al.36 Arnold37 Baums et al.38
6 5 5
e, not reported; AL, anterolateral impingement; AM, anteromedial impingement; Ant, anterior impingement; CTartro, CT arthrography; MRI, magnetic resonance imaging; NR, not reported; Phys exam, physical examination; S&McD, Scranton & McDermott score; Sc IV, Scranton and McDermott IV; T, osteophytes on tibia; TOL, talar osteochondral lesion; W, widespread impingement; Xap, radiograph in AP direction; X AMI, anteromedial imp; Xlat, radiograph in lateral direction; Xobl, oblique radiograph; Xstress, stress radiography. *Additional information was requested from authors. y Studies on same population.
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Study Akseki et al.36 Arnold37 Baums et al.38*
Loose Meniscoid Subgroup Osteophytes Bodies Lesions e e e e e e e e
Synovitis/ Hypertrophic Synovium 19 e
AITFL/ Distal Fascicle of AITFL 21 e
Synovial Shelves e e
AI Score (Scranton and McDermott)
OA Score (van Dijk)
I e 22
II e 7
III e 3
IV e Excl
0 e e
I e e
II e e
III e e
e e e 15 e e
e e e 23 e e
e e e 13 e e
e e e 7 e e
e e e e e e
e e e e e e
e e e e e e
e e e e e e
e 77 e
112 e e
38 e e
64 e e
e e e
e e e
e e e
e e e
e e
e e
e e
e e
e e
e e
e e
e e
e e e
e e e
e e e
e e e
e e e
e e e
e e e
e e e
8
6
Excl
e
e
e
e ST B e e e
14 e 14 58 e e
e e e e e e
12 12 e e 7 e
26 12 14 e 41 e
e e e e e e
e e e e 1 e
B ST e
e e 0
e e 5
e e 3
e e e
e e e
e e e
Ferkel et al.41 Hassan42
e e
3 e
e e
4 4
31 23
e 5
e e
Jerosch et al.25 Koczy et al.43* Liu et al.14
e e e
5 e 10
e e e
3 e e
35 e e
e e e
e e e
e
e
e
e
e
e
e
e
34
e
e
41
e
e
e
4 OCD
e
e
e
e
e
e
e
e
AL
e
e
e
x
x
e
e
e
e
e
e
e
e
e
e
Ant e
11 44
e 16
e e
e 89
e e
e e
e e
e e
e e
e e
e e
e e
e e
e e
e e
e
e
e
e
24
17
e
16
Often cartilage damage e 20 single osteochondral lesions No chondropathy
e
e
e
e
e
e
e
e
e
e
e
6
41
8
7
e
e
e
e
e
e
e
e
e
e AL AM e
52 e e e
e e e e
e e e e
x e e e
e e e e
e e e e
x e e e
19 cartilage damage grade I-III e e e e
23 11 12 e
3 3 0 e
24 13 11 e
12 5 7 e
10 5 5 10
34 18 16 30
18 9 9 17
Excl Excl Excl Excl
Branca et al.23 Brennan et al.24 Cavallo et al.39
Di Palma et al.40
Mardani-Kivi et al.44 Murawski and Kennedy9 Ogilvie-Harris et al.45* Rasmussen and Hjorth30 Rouvillain et al.46 Ürgüden et al.47 van Dijk et al.3y
Tol et al.5y
e
9
e, not reported; AITFL, antero-inferior talo fibular ligament; AI score, ankle impingement score; AL, anterolateral impingement; AM, anteromedial impingement; Ant, anterior impingement; B, bony impingement; Excl, excluded in study; ICRS, International Cartilage Repair Society; OA score, osteoartritis score; OCD, osteochondral defect; ST, soft-tissue impingement; x, pathology detected during arthroscopy, exact amount of cases not reported. *Additional information was requested from authors. y Studies on same population.
R. ZWIERS ET AL.
Chondral/ Scar Osteochondral Tissue Lesions e NR e 2 chondral flake fractures e NR e e e e e 7 Scranton grade IV 6 e e 82 focal lesions ICRS grade III-IV e e e e 7 20 second-/thirddegree chondritis, 2 chondromalacia 20 16 chondromalacia e 4 cartilage damage grade I-II e NR e NR e No osteochondral fractures e e
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Table 3. Overview of Reported Pathology Found During Arthroscopy
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Patient Satisfaction Patient satisfaction was reported in 6 studies. To compare categorical percentages of satisfied patients, we determined the studies in which satisfaction was rated as excellent, good, fair, or poor. For the purposes of this review, the categories of “excellent” and “good” collectively defined a “satisfied” patient. The percentage of satisfied patients ranged from 74% to 100%. The lowest satisfaction rate was reported in the study with the longest follow-up time5 (Table 4). Complications Complications were recorded in all but 2 studies, resulting in a summed complication rate of 5.1%, 1.2% of which were considered major complications and the remaining 3.9% were minor complications. The most commonly reported complications were mild nerve symptoms (n ¼ 27), superficial infection (n ¼ 4), and deep infection (n ¼ 4) (Table 5). Secondary Outcome Measures AOFAS Score. Postoperative AOFAS scores were reported in 7 studies, 5 of which also reported preoperative scores. The mean preoperative scores ranged between 34 and 75 points. Postoperatively, the mean scores ranged from 83.5 to 92 points (Table 4). VAS Score. Two studies reported VAS scores for pain. In one study the score decreased from 7 of 10 to 2 of 10 in both the bony and soft-tissue impingement groups. In the second study the VAS score decreased by approximately 2.5 points to 4.3 of 10 points for both the AMI and ALI groups. In the long-term follow-up of this population, the reported score was 3.3 of 10 points (Table 4). Return to Sport/Return to Full Activity. Twelve studies reported return to preinjury level of sports, two reported return to full activity, and three reported both. The rate of patients who returned to sports ranged from 24% to 100%, whereas the rate of return to full activity ranged from 81% to 100%. Low return-to-sports rates (24% and 48%) were found in 2 studies, both reporting on unspecified anterior impingement (Table 4). Range of Motion. Range of motion was used as an outcome measure in 7 studies. Hassan42 and Ürgüden et al.47 reported an increase in dorsiflexion of more than 5 in 12 of 23 patients and 20 of 41 patients with ALI, respectively. Van Dijk et al.3 showed that 25% of AMI and ALI patients had an increase of at least 5 after surgery. In the study by Ogilvie-Harris et al.,45 mean dorsiflexion increased from 0 to 10 in the anterior impingement group. Murawski and Kennedy9 reported a normal range of motion in all
patients. Moreover, Rasmussen and Hjorth,30 Arnold,37 and Rouvillain et al.46 reported improved range of motion. Undergoing Operation Again. In 4 studies reporting on ALI, the patients were asked whether they would undergo the same operation under the same circumstances again. All reported a high percentage of patients answering this question positively (94.3% to 97.5%) (Table 4). Clinical Outcome Scores. Eleven studies rated clinical outcomes in patients as excellent, good, fair, or poor. These outcomes were based on 9 different scoring systems for evaluation. The percentage of excellent and good outcomes ranged from 63.8% to 100%. In the study by Mardani-Kivi et al.,44 the score increased from 78.2% at 3 months after surgery to 91.3% at 6 months. In the study by van Dijk et al.,3 the scores were higher in the AMI group compared with the ALI group at all follow-up visits. At long-term follow-up, the combined score for AMI and ALI patients was 65% (Table 6). Because of the high heterogeneity in the inclusion and exclusion criteria, as well as the definition of ankle impingement, among the included studies, pooling of the results and comparison of subtypes of anterior ankle impingement was not possible. However, studies with osteoarthritis as an exclusion criterion appeared to have a higher success rate (81.3% to 100% v 63.8% to 87.6%). Methodologic Quality The Downs and Black score ranged from 1 to 7 points out of a maximum of 32 points, with a median score of 5 points. According to our predefined criteria, on the basis of the Downs and Black score, all studies were of poor methodologic quality.
Discussion In this systematic review, 20 studies were evaluated based on patient satisfaction rates, complication rates, and clinical outcome measures to provide an overview of the current literature. Overall, good results were found for arthroscopic treatment in patients with anterior ankle impingement. In the studies that reported patient satisfaction rates, high percentages of good to excellent satisfaction were described (74% to 100%). The percentages of patients who would undergo the same procedure again under the same circumstances were also high (94.3% to 97.5%). Complication rates were low (5.1%), particularly with respect to major complications (1.2%). In terms of secondary outcome measures, most studies showed good results. Despite these findings, the high heterogeneity of the included studies made it impossible to compare the results of the studies, including between ALI and AMI. Given that both subtypes of anterior impingement have different
AOFAS Score
Study Akseki et al.36 Arnold37 Baums et al.38*
Branca et al.23 Brennan et al.24 Cavallo et al.39*
Liu et al.14 Mardani-Kivi et al.44
6 mo Murawski and Kennedy9 Ogilvie-Harris et al.45*
Return to Full Activity 17 of 21 (81%) d d d d d 39 of 41 (95%) d d d d 29 of 31 (94%) d d d d d d
d 57.62
88.13 (SD, 6.8) 89.84
d d
d d
d 27 of 28 (96.4%)
d d
d 3 (8.6%)
d d
d
d
d d 5 (4.8%) 2 (1.9%)
d 7 (6.7%)
d 94.3%
10 of 11 (90.1%) 24 of 24 (100%) 0 (0.0%) 2 (8.3%)
2 (8.3%)
d
d 3 (4.8%) d d d
97.5% d d d d
AL
76.5%
d
d
d
d
12 of 17 (71%)
d
Ant
81.8% d
d d
d d
d d
d d
9 of 11 (82%) d
d d
100%
d
93
d
d
d d d d 74%
d d d d d
89.6 (60-100) d d d d
d d d d 6.9
d d 4.3 4.3 3.3
Rasmussen and Hjorth30 Rouvillain et al.46 Ürgüden et al.47 van Dijk et al.3y AL AM Tol et al.5y
d d
Return to Preinjury Sports Postoperative Preoperative Postoperative Level d d d 10 of 11 (91%) d d d d d 7 (3-8) 2 (0-5) 25 of 26 (96%) d 7 2 12 of 12 (100%) d 7 2 13 of 14 (93%) d d d 13 of 27 (48%) d d d d d d d d 85.5 (SD, 16.8) d d d 83.5 (SD, 17.6) d d d d d d 21 of 32 (66%) d d d 27 of 31 (87.1%) 89 (60-100) d d 9 of 11 (82%) d d d 9 of 38 (24%) d d d d 92 d d d d d d 84% d d d d
% Who Would Undergo Same Major Minor Total Operation 0 (0.0%) 2 (9.5%) 2 (9.5%) d 0 (0.0%) 3 (9.3%) 3 (9.3%) d 0 (0.0%) 2 (7.7%) 2 (7.7%) d d d d d d d d d 1 (1.7%) 2 (3.4%) 3 (5.1%) d 0 (0.0%) 1 (2.4%) 1 (2.4%) 95.1% 0 (0.0%) 2 (0.7%) 2 (0.7%) d d d d d d d d d 1 (1.5%) 3 (4.5%) 4 (6.0%) d 1 (3.2%) 0 (0.0%) 1 (3.2%) d 0 (0.0%) 3 (13.0%) 3 (13.0%) 95.7% 1 (2.8%) 6 (17.1%) 7 (19.9%) d 0 (0.0%) 1 (4.5%) 1 (4.5%) d d d d d 0 (0.0%) 3 (5.5%) 3 (5.5%) d 0 (0.0%) 1 (4.3%) 1 (4.3%) d
d d d d d
d d d d d
d d 2 (5.7%) 1 (2.9%) d
d
d d 0 (0.0%) 3 (4.8%) d d d d d d
NOTE. In studies with more than 1 follow-up, the longest follow-up is reported in the table. Data are presented as mean (range) unless otherwise indicated. e, not reported; AL, anterolateral impingement; AM, anteromedial impingement; Ant, anterior impingement; AOFAS, American Orthopaedic Foot & Ankle Society; B, bony impingement; SD, standard deviation; ST, soft-tissue impingement; VAS, visual analog scale. *Additional information was requested from authors. y Studies on same population.
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Di Palma et al.40 Ferkel et al.41 Hassan42 Jerosch et al.25 Koczy et al.43*
% Preoperative Subgroup Satisfied 90.5% d d d 100% d AL 100% d Ant 100% d d d d d d d B d 51.1 (SD, 20.8) ST d 40.2 (SD, 21.5) d d d d d 34 (4-57) d d 75.4 12 mo d d 98% d d 59.21 (SD, 10.25)
Complications, n (%)
VAS Score
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Table 4. Outcome Measures
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ANTERIOR ANKLE IMPINGEMENT Table 5. Reported Complications Complication Major Deep infection Reflex sympathetic dystrophy (CPRS) Reoperation needed Severe nerve symptoms Arthrofibrosis Total major complications Minor Mild nerve symptoms Superficial infection Neuroma Disturbed wound healing Instrument breakage Total minor complications Total complications
n 4 3 2 1 1 11 (1.2%) 27 4 2 2 1 36 (3.9%) 47 (5.1%)
CPRS, complex regional pain syndrome.
clinical presentations and etiologies, a difference in prognosis may be expected. Furthermore, because of definitional differences in return to sports or full activity among studies, caution should be taken when one is interpreting these percentages. In this study a selection of outcome measures was made based on our opinion of relevant outcome measures and those most commonly used in the literature.
The decision was made to include only studies that reported on at least 2 of the chosen outcome measures to provide a clear outline of outcomes. Despite this, we found only return to preinjury level of sports frequently reported. We also decided to use a 4-point clinical outcome scale as an outcome measure, even though these outcomes were based on different criteria and therefore, in fact, were not comparable. No radiologic outcome was used because studies have shown recurrence of bony spurs in a majority of patients after successful treatment. However, there is no correlation with recurrence of symptoms.5,17 Three studies compared 2 subtypes of impingement. Baums et al.38 reported no difference between bony and soft-tissue impingement in the VAS score for pain and rate of return to preinjury level of sports. In their study on 280 patients, Cavallo et al.39 found anterolateral bony impingement to have better outcomes based on the AOFAS score compared with anteromedial bony impingement and found bony and soft tissue to have similar results. The location of the bony impingement and extension of the fibrous impingement showed a significant correlation with clinical outcome. Van Dijk et al.3 described, among 62 patients, better outcomes as measured by the Ogilvie-Harris score for the AMI group compared with the ALI group.
Table 6. Clinical Outcome Scores and Success Rates Clinical Outcome, n (%) Study Akseki et al.36 Arnold37 Baums et al.38* Branca et al.23 Brennan et al.24 Cavallo et al.39* Di Palma et al.40 Ferkel et al.41 Hassan42 Jerosch et al.25 Koczy et al.43* Liu et al.14 Mardani-Kivi et al.44 Murawski and Kennedy9 Ogilvie-Harris et al.45* Rasmussen and Hjorth30 Rouvillain et al.46 Ürgüden et al.47 van Dijk et al.3y Tol et al.5y
Subgroup
AL Ant
12 mo 6 mo AL Ant
AL, 24 mo AM, 24 mo
Excellent 15 (71.4) 7 (21.9) d d 37 (63.8) 34 (82.9) d 49 (73.1) 15 (48.4) 7 (30.4) d d 20 (36.4) 12 (52.2) d d d 67 (63.8) 22 (91.6) 21 (51.2) 21 (66) 26 (87)
Good 2 (9.5) 19 (59.4) d d
d 11 (35.5) 14 (60.9) d d 28 (50.9) 9 (39.1) d d d 25 (23.8) 2 (8.3) 16 (39.0)
65%
Fair 2 (9.5) 5 (15.6) d d 13 (22.4) 5 (12.2) d 11 (16.4) 4 (12.9) 2 (8.7) d d 6 (10.9) 2 (8.7) d d d 6 (5.7) 0 (0.0) 2 (4.9) 11 (34) 4 (13) 35%
Poor 2 (9.5) 1 (3.1) d d 8 (13.8) 2 (4.9) d 7 (10.4) 1 (3.2) 0 (0.0) d d 1 (1.8) 0 (0.0) d d d 7 (6.7) 0 (0.0) 2 (4.9)
Classification Kaikonen West Point Ankle d d McGuire Meislin d McGuire Bray AOFAS d d Liu Meislin d d d d Kitaoka Meislin Ogilvie-Harris Ogilvie-Harris Ogilvie-Harris
Success Rate 80.9% 81.3% d d 63.8% 82.9% d 73.1% 83.9% 91.3% d d 87.3% 91.3% d d d 87.6% 100% 90.2% 66.0% 87.0% 65.0%
NOTE. In studies with more than 1 follow-up, the longest follow-up is reported in the table. e, not reported; AL, anterolateral impingement; AM, anteromedial impingement; Ant, anterior impingement; AOFAS, American Orthopaedic Foot & Ankle Society. *Additional information was requested from authors. y Studies on same population.
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Besides the location and cause of impingement, 2 classifications were used to rate the extent of the impingement: the impingement classification of Scranton and McDermott18 and the osteoarthritis classification by van Dijk et al.3 The osteoarthritis classification has been shown to be a predictor of outcome.3,5 The classification of Scranton and McDermott may be useful for diagnostic purposes but has no prognostic value.29,39 Several pathologies are associated with anterior ankle impingement. Regarding instability, there is no agreement as to whether it affects the outcome. We included studies that did not exclude patients with an unstable ankle; however, only 1 study reported on differences in outcomes. Jerosch et al.25 stated that unstable ankles had a worse prognosis. The literature, however, is inconclusive. Hassan42 showed that associated syndesmotic lesions and new inversion injuries are factors that negatively affect outcome. The only comparative study, by Kim et al.,48 found no differences in ankle function and rate of return to sports and work between a group of patients with stable ankles and a group of patients with unstable ankles (i.e., anterior ankle impingement). The effect of associated chondral lesions on the outcome of arthroscopic treatment in patients with anterior impingement is debated. Some authors stated that chondral lesions did not affect the results, whereas others observed that they affected outcomes negatively.12,42,49 In this study the relation between chondral damage and outcome could not be determined. The extent of damage was poorly described in most studies. One would expect mild chondral lesions to be a common finding in ankle impingement, whereas highgrade osteochondral defects can be seen as a separate pathology. Often, these were not distinguished or clearly described. As a result, we did not use chondral damage as an exclusion criterion. We would propose the use of the International Cartilage Repair Society classification to be able to determine the effect of chondral lesions. Mardani-Kivi et al.44 reported no difference in outcome in patients with and without chondral lesions; however, follow-up was short. In the study by Murawski and Kennedy,9 no difference was seen in patients with osteochondral defects treated with microfracture. Hassan42 reported on 4 patients with grade I to II cartilage damage to the anterolateral talar dome; none of these patients had excellent results, whereas 3 had good results. In the study by Ürgüden et al.,47 cartilage damage ranging from grade I to III to the anterolateral aspect of the dome of the talus or at the distal tibia was seen in 19 patients. At follow-up, patients with cartilage damage showed statistically lower AOFAS scores than patients without it. Moreover, when the patients were evaluated according to Meislin’s criteria, statistically better results were obtained in patients without cartilage
damage. Di Palma et al.40 showed the presence of moderate to serious chondral lesions to be responsible for a poor prognosis. A previous systematic review showed that there is fair evidence-based literature to support a recommendation for the use of ankle arthroscopy for the treatment of ankle impingement.32 However, no inclusion or exclusion criteria were reported, and both anterior and posterior ankle impingement studies were included. Good to excellent outcome rates were shown; it is unclear, however, on which criteria these scores were based. A large number of small case series, in particular, have been published over time. An overall complication rate of 5.1% after anterior ankle arthroscopy for anterior impingement was found in this study. This complication rate is comparable with the 4% complication rate described in a recent review on the safety of ankle arthroscopy for the treatment of anterolateral soft-tissue impingement.33 However, it is considerably lower than the complication rates of 9% to 17% mentioned in a recent narrative review on anterior ankle impingement.10 The variation in complication rates among the included studies is remarkable. The hypothesis that these differences are an effect of the experience of the surgeon is supported by the fact that the lowest complication rate was reported in the largest series. Limitations The level of evidence of this study is limited by the heterogeneity of study designs and low methodologic quality of the included studies. Furthermore, most of the included studies had small populations. In addition, osteoarthritis was not used as an exclusion criterion in this study, despite its effect on outcome. In many studies, patients with osteoarthritic changes were not excluded, but in those in which they were, the criteria were often poorly defined. Nevertheless, this study is of clinical importance because it provides an overview of the current literature and underscores the need for high-quality studies with clearly defined inclusion criteria and patient-specific, validated outcome measurements.
Conclusions Arthroscopic treatment for anterior ankle impingement appears to provide good outcomes with respect to patient satisfaction and low complication rates. However, on the basis of the findings of this study, no conclusion can be made in terms of the effect of the type of impingement or additional pathology on clinical outcome.
References 1. Tol JL, van Dijk CN. Anterior ankle impingement. Foot Ankle Clin 2006;11:297-310. vi.
ANTERIOR ANKLE IMPINGEMENT 2. van Dijk CN, Verhagen RAW, Tol JL. Arthroscopy for problems after ankle fracture. J Bone Joint Surg Br 1997;79: 280-284. 3. van Dijk CN, Tol JL, Verheyen CCPM. A prospective study of prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement. Am J Sports Med 1997;25:737-745. 4. O’Donoghue DH. Impingement exostoses of the talus and tibia. J Bone Joint Surg Am 1957;39:835-852. 5. Tol JL, Verheyen CPPM, van Dijk CN. Arthroscopic treatment of anterior impingement in the ankle. J Bone Joint Surg Br 2001;83:9-13. 6. Morris LH. Athlete’s ankle. J Bone Joint Surg 1943;25:220. 7. McMurray T. Footballer’s ankle. J Bone Joint Surg Br 1950;32:68-69. 8. van Dijk CN. Anterior and posterior ankle impingement. Foot Ankle Clin 2006;11:663-683. 9. Murawski CD, Kennedy JG. Anteromedial impingement in the ankle joint: Outcomes following arthroscopy. Am J Sports Med 2010;38:2017-2024. 10. Vaseenon T, Amendola A. Update on anterior ankle impingement. Curr Rev Musculoskelet Med 2012;5: 145-150. 11. Thein R, Eichenblat M. Arthroscopic treatment of sportsrelated synovitis of the ankle. Am J Sports Med 1992;20: 496-498. 12. Bassett FH III, Gates HS III, Billys JB, Morris HB, Nikolaou PK. Talar impingement by the anteroinferior tibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain. J Bone Joint Surg Am 1990;72:55-59. 13. Meislin RJ, Rose DJ, Parisien JS, Springer S. Arthroscopic treatment of synovial impingement of the ankle. Am J Sports Med 1993;21:186-189. 14. Liu SH, Raskin A, Osti L, Baber C, Jacobson K, Finerman G. Arthroscopic treatment of anterolateral ankle impingement. Arthroscopy 1994;10:215-218. 15. Cutsuries AM, Saltrick KR, Wagner J, Catanzariti AR. Arthroscopic arthroplasty of the ankle joint. Clin Podiatr Med Surg 1994;11:449-467. 16. Hensley JP, Saltrick K, Le T. Anterior ankle arthroplasty: A retrospective study. J Foot Surg 1990;29:169-172. 17. Coull R, Raffiq T, James LE, Stephens MM. Open treatment of anterior impingement of the ankle. J Bone Joint Surg Br 2003;85:550-553. 18. Scranton PE Jr. Comparison of open isolated subtalar arthrodesis with autogenous bone graft versus outpatient arthroscopic subtalar arthrodesis using injectable bone morphogenic protein-enhanced graft. Foot Ankle Int 1999;20:162-165. 19. Scranton PE Jr, McDermott JE. Anterior tibiotalar spurs: A comparison of open versus arthroscopic debridement. Foot Ankle 1992;13:125-129. 20. Bauer T, Breda R, Hardy P. Anterior ankle bony impingement with joint motion loss: The arthroscopic resection option. Orthop Traumatol Surg Res 2010;96:462-468. 21. Baumhauer JF. Anterior ankle impingement. Orthopedics 2011;34:789-790. 22. Biedert R. Anterior ankle pain in sports medicine: Aetiology and indications for arthroscopy. Arch Orthop Trauma Surg 1991;110:293-297.
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23. Branca A, Palma LD, Bucca C, Visconti CS, Di Mille M. Arthroscopic treatment of anterior ankle impingement. Foot Ankle Int 1997;18:418-423. 24. Brennan SA, Rahim F, Dowling J, Kearns SR. Arthroscopic debridement for soft tissue ankle impingement. Ir J Med Sci 2012;181:253-256. 25. Jerosch J, Steinbeck J, Schroder M, Halm H. Arthroscopic treatment of anterior synovitis of the ankle in athletes. Knee Surg Sports Traumatol Arthrosc 1994;2:176-181. 26. Lahm A, Erggelet C, Reichelt A. Ankle joint arthroscopy for meniscoid lesions in athletes. Arthroscopy 1998;14: 572-575. 27. Martin DF, Curl WW, Baker CL. Arthroscopic treatment of chronic synovitis of the ankle. Arthroscopy 1989;5: 110-114. 28. Moustafa El-Sayed AM. Arthroscopic treatment of anterolateral impingement of the ankle. J Foot Ankle Surg 2010;49:219-223. 29. Parma A, Buda R, Vannini F, et al. Arthroscopic treatment of ankle anterior bony impingement: The long-term clinical outcome. Foot Ankle Int 2014;35:148-155. 30. Rasmussen S, Hjorth JC. Arthroscopic treatment of impingement of the ankle reduces pain and enhances function. Scand J Med Sci Sports 2002;12:69-72. 31. Reynaert P, Gelen G, Geens G. Arthroscopic treatment of anterior impingement of the ankle. Acta Orthop Belg 1994;60:384-388. 32. Glazebrook MA, Ganapathy V, Bridge MA, Stone JW, Allard J-P. Evidence-based indications for ankle arthroscopy. Arthroscopy 2009;25:1478-1490. 33. Simonson DC, Roukis TS. Safety of ankle arthroscopy for the treatment of anterolateral soft-tissue impingement. Arthroscopy 2014;30:256-259. 34. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52: 377-384. 35. Jäkel A, von Hauenschild P. Therapeutic effects of cranial osteopathic manipulative medicine: A systematic review. J Am Osteopath Assoc 2011;111:685-693. 36. Akseki D, Pinar H, Bozkurt M, Yaldiz K, Arac S. The distal fascicle of the anterior inferior tibio-fibular ligament as a cause of anterolateral ankle impingement: Results of arthroscopic resection. Acta Orthop Scand 1999;70: 478-482. 37. Arnold H. Posttraumatic impingement syndrome of the ankledIndication and results of arthroscopic therapy. Foot Ankle Surg 2011;17:85-88. 38. Baums MH, Kahl E, Schultz W, Klinger H-M. Clinical outcome of the arthroscopic management of sportsrelated “anterior ankle pain”: A prospective study. Knee Surg Sports Traumatol Arthrosc 2006;14:482-486. 39. Cavallo M, Natali S, Ruffilli A, et al. Ankle surgery: Focus on arthroscopy. Musculoskelet Surg 2013;97:237-245. 40. Di Palma L, Bucca C, Di Mille M, Branca A. Diagnosis and arthroscopic treatment of fibrous impingement of the ankle. J Sports Traumatol Relat Res 1999;21:170-177. 41. Ferkel RD, Karzel RP, Del Pizzo W, Friedman MJ, Fischer SP. Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med 1991;19:440-446.
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42. Hassan A-H. Treatment of anterolateral impingements of the ankle joint by arthroscopy. Knee Surg Sports Traumatol Arthrosc 2007;15:1150-1154. 43. Koczy B, Pyda M, Stoltny T, et al. Arthroscopy for anterolateral soft tissue impingement of the ankle joint. Ortop Traumatol Rehabil 2009;11:339-345. 44. Mardani-Kivi M, Mirbolook A, Khajeh-Jahromi S, Hassanzadeh R, Hashemi-Motlagh K, Saheb-Ekhtiari K. Arthroscopic treatment of patients with anterolateral impingement of the ankle with and without chondral lesions. J Foot Ankle Surg 2013;52:188-191. 45. Ogilvie-Harris DJ, Mahomed N, Demaziere A. Anterior impingement of the ankle treated by arthroscopic removal of bony spurs. J Bone Joint Surg Br 1993;75:437-440.
46. Rouvillain JL, Daoud W, Donica A, Garron E, Uzel AP. Distraction-free ankle arthroscopy for anterolateral impingement. Eur J Orthop Surg Traumatol 2014;24:1019-1023. 47. Ürgüden M, Soyuncu Y, Ozdemir H, Sekban H, Akyildiz FF, Aydin AT. Arthroscopic treatment of anterolateral soft tissue impingement of the ankle: Evaluation of factors affecting outcome. Arthroscopy 2005;21: 317-322. 48. Kim SH, Ha KI. Arthroscopic treatment for impingement of the anterolateral soft tissues of the ankle. J Bone Joint Surg Br 2000;82:1019-1021. 49. DeBerardino TM, Arciero RA, Taylor DC. Arthroscopic treatment of soft-tissue impingement of the ankle in athletes. Arthroscopy 1997;13:492-498.
Arthroscopic Treatment for Anterior Ankle Impingement: A Systematic Review of the Current Literature Ruben Zwiers, M.Sc., Johannes I. Wiegerinck, M.D., Ph.D., Christopher D. Murawski, B.S., Ethan J. Fraser, M.D., John G. Kennedy, M.D., M.Ch., M.M.Sc., F.R.C.S.(Orth), and C. Niek van Dijk, M.D., Ph.D.
Purpose: To provide a comprehensive overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement. Methods: A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was performed. Studies that met the following inclusion criteria were reviewed: studies reporting outcomes of arthroscopic treatment for anterior ankle impingement; studies reporting on more than 20 patients; a study population with a minimum age of 18 years; and studies in the English, Dutch, German, Italian, or Spanish language. Two reviewers independently performed data extraction. Extracted data consisted of population characteristics, in addition to both primary and secondary outcome measures. The Downs and Black scale was used to assess the methodologic quality of randomized and nonrandomized studies included in this review. Results: Twenty articles were included in this systematic review. Overall, good results were found for arthroscopic treatment in patients with anterior ankle impingement. In the studies that reported patient satisfaction rates, high percentages of good to excellent satisfaction were described (74% to 100%). The percentages of patients who would undergo the same procedure again under the same circumstances were also high (94.3% to 97.5%). Complication rates were low (4.6%), particularly with respect to major complications (1.1%). The high heterogeneity of the included studies made it impossible to compare the results of the studies, including between anterolateral impingement and anteromedial impingement. Conclusions: Arthroscopic treatment for anterior ankle impingement appears to provide good outcomes with respect to patient satisfaction and low complication rates. However, on the basis of the findings of this study, no conclusion can be made in terms of the effect of the type of impingement or additional pathology on clinical outcome. Level of Evidence: Level IV, systematic review of Level II and IV studies.
See commentary on page 1597
A
nterior ankle impingement is a syndrome characterized by pain at the anterior aspect of the ankle joint, particularly during hyper-dorsiflexion.1 In addition, patients may present with swelling and
From the Academic Medical Center, University of Amsterdam (R.Z., J.I.W., C.N.v.D.), Amsterdam, The Netherlands; and Hospital for Special Surgery (C.D.M., E.J.F., J.G.K.), New York, New York, U.S.A. The authors report the following potential conflict of interest or source of funding: J.G.K. receives support from Arteriocyte, Ohnell Family Foundation, and Mr. and Mrs. Michael J. Levitt. Industry and philanthropic grants for research given directly to Hospital for Special Surgery. C.N.v.D. receives support from Smith & Nephew. Received September 15, 2014; accepted January 21, 2015. Address correspondence to John G. Kennedy, M.D., M.Ch., M.M.Sc., F.R.C.S.(Orth), Hospital for Special Surgery, 523 E. 72nd Street, Ste 507, New York, NY 10021, U.S.A. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/14786/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.01.023
dorsiflexion may be restricted in some cases.2,3 Anterior ankle impingement is a common source of ankle pain in athletes, especially ballet dancers and soccer players,4,5 which led to the condition being described formerly as “athlete’s ankle”6 and “footballer’s ankle.”7 Presently, the term “anterior impingement” is widely used.8 On the basis of etiology and clinical presentation, differentiation between 2 separate entities is possible: osseous or bony impingement and soft-tissue impingement. A distinction can also be made clinically based on the localization of pathology and symptomatology, which includes anterolateral impingement (ALI) and anteromedial impingement (AMI) (Fig 1).9 Soft-tissue impingement is often located at the anterolateral aspect of the ankle, whereas bony impingement is predominantly located anteromedially (Fig 2).10 Therefore ALI is often referred to as “anterior soft-
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Fig 1. (A) Standard lateral radiograph shows tibial and talar osteophytes at anterolateral aspect of ankle joint. (B) Oblique anteromedial impingement view radiograph shows anteromedial osteophytes.
tissue impingement,” whereby several types of pathology are described, including synovitis and meniscoid lesions, as well as thickening of the distal fascicle of the anteroinferior tibiofibular ligament.11-14 Conservative treatment, consisting of rest, physical therapy, ankle bracing, shoe modification, and/or local injection, is recommended as the primary treatment strategy for symptoms of anterior ankle impingement. An intra-articular corticosteroid injection can be applied in cases in which conservative treatments are unresponsive to reduce inflammation. Because conservative treatment is often unsuccessful, resection of the soft tissue and/or osteophytes is often required. Historically, good results have been described for open surgical approaches.4,7,15-18 In fact, one study comparing open and arthroscopic resection of osteophytes found that patients treated arthroscopically returned to full activity sooner than those undergoing the open procedure.19 Presently, ankle arthroscopy is recommended as the gold standard for the surgical treatment of anterior ankle impingement. In this regard, several case series, including both AMI and ALI, have shown arthroscopic removal of bony and soft-tissue impediments to be effective.5,20-31 A recent systematic review on evidence-based indications for anterior ankle arthroscopy described evidence-based literature supporting the recommendation for its use in treating anterior ankle impingement.32 Simonson and Roukis33 reported ankle arthroscopy to be a safe treatment option for anterolateral soft-tissue impingement.
However, less is reported on other important outcome measures, including patient satisfaction and return to sport. This study aims to provide a comprehensive overview of the clinical outcomes of arthroscopic procedures used as a treatment strategy for anterior ankle impingement.
Methods Search Strategy A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases (with a search date of August 4, 2014) was performed using the following keywords: ((ankle AND impingement) OR (ankle AND impingement AND syndrome) OR ((talar OR talus) AND compres*) OR (ankle AND osteophy*) OR ((talar OR talus OR tibiotalar) AND osteophy*) OR ((talar OR talus) AND impingement)) AND ((arthrosc*) OR (surgery OR procedures) OR (treatment)). In addition, the Cochrane database of clinical and randomized controlled trials was searched using the term “impingement.” A review of the reference lists of relevant articles was performed to identify any additional articles potentially not identified through the database search. Inclusion and Exclusion Criteria Studies that met the following inclusion criteria were reviewed: studies reporting outcomes of arthroscopic
Fig 2. (A) Soft-tissue impingement. (B) Bony impingement.
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treatment for anterior ankle impingement; studies reporting on more than 20 patients; a study population with a minimum age of 18 years; and studies in the English, Dutch, German, Italian, or Spanish language. Each study had to report at least 2 of the following outcome measures: patient satisfaction, American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) score for pain, return to sport or return to full activity, range of motion, complications, and answering the question whether the patient would undergo the same operation under the same circumstances again. Studies reporting on a combined posterior and anterior arthroscopic approach or anterior arthroscopy combined with an additional open procedure, such as lateral ligament reconstruction, were excluded. In cases in which there were studies that reported on (partially) the same population, only the most recent data were included in our study. All studies not addressing solely anterior ankle impingement, as well as review and expert opinion articles, were also excluded. Studies were selected and independently assessed by 2 reviewers (R.Z., J.I.W.). Differences between the reviewers were discussed until agreement was achieved, and the senior authors (J.G.K., C.N.vD.) were consulted in the event of persistent disagreement. Data Extraction and Analysis Two reviewers (R.Z., J.I.W.) independently performed data extraction. Extracted data consisted of population characteristics, in addition to both primary and secondary outcome measures. Primary outcome measures were patient satisfaction and complication rates. Secondary outcome measures were clinical outcome measures, including the AOFAS AnkleHindfoot scale, VAS score, and range of motion, as well as the time to achieve return to sport or full activity after surgery. Furthermore, we extracted data on clinical outcomes expressed as excellent, good, fair, and poor outcomes, including the criteria on which these categorical outcomes were based. Good and excellent outcomes were considered successful treatment. If necessary, additional information was requested by E-mail from the authors of the studies in question. To simplify the extraction and data analysis, complications were dichotomized as “major” or “minor” complications. Quality Assessment Two reviewers (R.Z., J.I.W.) independently performed a validated quality assessment of the included studies. The Downs and Black scale was used to assess the methodologic quality of randomized and nonrandomized studies included in this review. This tool measures quality in terms of reporting, external validity, internal validity (bias and confounding), and
Fig 3. Flowchart. (CINAHL, Cumulative Index to Nursing and Allied Health Literature.)
power, with a maximum score of 32 points.34 Adapted from Jäkel and von Hauenschild,35 Downs and Black scores of greater than 24 points were considered good; 8 to 24 points, moderate; and less than 8 points, poor. The Downs and Black checklist has been developed to assess the methodologic quality of both randomized and nonrandomized studies. Disagreement was resolved after discussion among the reviewers and in consultation with the senior authors.
Results Search Results After the search results of the different databases were combined and duplicate publications were removed, 950 articles remained for review. Thereafter 826 articles were excluded based on the title or abstract; because of the study design or the size or mean age of the study
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Table 1. Characteristics of Included Studies Study (Level of Evidence) Akseki et al.36 (IV) Arnold37 (IV) Baums et al.38* (IV)
Subgroup
ST B Branca et al.23 (IV) Brennan et al.24 (IV) Cavallo et al.39* (IV) B ST Di Palma et al.40 (IV) Ferkel et al.41 (IV) Hassan42 (II) Jerosch et al.25 (IV) Koczy et al.43* (IV) Liu et al.14 (IV) Mardani-Kivi et al.44 (IV) Murawski and Kennedy9 (IV) Ogilvie-Harris et al.45* (IV) AL Ant Rasmussen and Hjorth30 (IV) Rouvillain et al.46 (IV) Ürgüden et al.47 (IV) van Dijk et al.3z (II) AL AM Tol et al.5z (II) Total or weighted mean
Year 1999 2011 2006 d d 1997 2012 2013 d d 1999 1991 2007 1994 2009 1994 2013 2010 1993 d d 2002 2014 2005 1997 d d 2001
N 21 32 26 12 14 58 41 280 203 77 67y 31 23 35y 22 55 23 35 26 17 11 105 24 41 62 32 30 57 972
Sex (M/F), n 7/14 d 16/10 7/5 9/5 37/21 26/15 174/106 121/82 53/24 45/19y 17/14 18/5 24/19y 33/22 8/15 d d d d 61/44 3/21 25/16 42/20 d d 38/19 536/361
Time to Surgery, mo 24 (4-60) d 20 (11-32) 20.7 (13-29) 19.4 (11-32) d 21 (4-48) d d d d 24 (3-120) 13 (5-60) 15.8 12.2 60 (24-96) d d d d d d 12 (6-60) 21 (5-60) 23.4 (5-132) d d d d 22.5
Follow-up Time, mo 34 (24-48) 49 31 (25-48) 32.8 (25-48) 34.2 (25-45) 21.5 (8-62) 13 39.1 17.3 d d 23.5 (8-60) 33.5 (24-66) 25 (12-38) 32.2 19.4 3 and 12 31.2 (12-54) 3 and 6 d d d d 24 (21-26) 22 (12-92) 83.7 (21-152) 12 and 24 d d 78 (60-96) 35.3
Age at Surgery, yr 31 (11-68) 38 (16-65) 27 (19-32) 25.2 (19-31) 28.1 (19-32) 28.5 (19-47) 31 (16-62) 35.4 12.3 35.3 13.6 31.2 14.2 24.5 (17-42) 34 (16-74) 27.2 (15-53) 25 8.3 (14-43) 34 (17-55) 34 (20-67) 38.13 6.85 d d d d 35 (16-62) 35 (21-54) 33.2 (15-63) 31 (16-52) d d 36 (21-59)x 32.7
NOTE. Data are presented as mean (range), mean SD, or mean SD (range) unless otherwise indicated. e, not reported; AL, anterolateral impingement; AM, anteromedial impingement; Ant, anterior impingement; B, bony impingement; F, female; M, male; ST, soft-tissue impingement. *Additional information was requested from authors. y Incorrect number of patients or sex distribution reported in study. z Studies on same population. x At follow-up.
population; or because they did not report on the outcome of anterior arthroscopy. One study was added after review of the reference lists, resulting in a total of 65 full-text articles for the full-text review. On the basis of full-text evaluation, 45 articles were excluded. The remaining 20 articles were included in this systematic review3,5,9,14,23-25,30,36-47 (Fig 3). Population Characteristics One of the 20 studies reported on the long-term follow-up of another study; therefore only 19 unique study populations were included. The number of patients in these studies totaled 905, with a mean age of 32.7 years and a male-female ratio of 536:361. The mean follow-up time was 35.3 months, and the mean time until surgery was 22.5 months (Table 1). Ten studies reported on “anterolateral impingement,” four studies reported on “anterior impingement,” and one study reported the results of the treatment of “anteromedial impingement.” The 4 remaining studies reported on “anterolateral and anterior impingement”
or “anterolateral and anteromedial impingement” (Table 2). Two studies drew distinction between bony and softtissue or fibrous impingement. Two studies reported a mean follow-up time of less than 1 year,43,44 whereas 2 other studies reported a mean follow-up of more than 5 years.5,47 A complete overview of the study characteristics is provided in Tables 1 and 2. Five studies made use of a classification for anterior impingement. Five studies used the Scranton and McDermott scale,19 of which 2 studies excluded stage IV. An osteoarthritis scale3 was used by 2 studies of the same patient population (Table 3). Ten studies excluded patients with signs of osteoarthritis, whereas 10 others either did not exclude or did not report exclusion criteria. Chondral damage was reported in 9 studies, and 6 studies excluded patients with osteochondral defects or related pathology. Five studies excluded patients with ankle instability. Table 3 shows the distribution of arthroscopic findings in the different populations.
Table 2. Exclusion Criteria Localization AL Ant AL/Ant
Invasive Distraction No No No
Surgeons 1 d d
Diagnosis Phys exam, Xap, Xlat, MRI Phys exam, Xap, Xlat, MRI Phys exam, Xap, Xlat, MRI
Branca et al.23 Brennan et al.24
Ant AL
Yes No
d 1
Phys exam, Xlat MRI
Cavallo et al.39 Di Palma et al.40 Ferkel et al.41 Hassan42
AM/AL/W/T AL AL AL
d Yes No No
1 d d 1
Phys exam, Xap, Xlat, MRI Phys exam, Xap, Xlat, CTartro, MRI Phys exam, Xap, Xlat, MRI Phys exam, Xap, Xlat, Xobl, MRI
Ant AL AL AL
No NR No d
d d 4 d
Phys exam, Xap, Xlat, Xstress, bone scan, MRI Phys exam, Xap, Xlat, MRI Phys exam, Xlat, Phys exam, Xlat, Xap, MRI
Murawski and Kennedy9 Ogilvie-Harris et al.45* Rasmussen and Hjorth30 Rouvillain et al.46
AM AL/Ant Ant AL
No No No No
1 d d 2
Phys exam, Xlat, X AMI, MRI, injection Phys exam, Xlat, Xap, Xstress, MRI Phys exam Phys exam, Xlat, Xstress, CTartro, MRI, bone scan
Ürgüden et al.47 van Dijk et al.3y
AL AL/AM
No No
1 1
Phys exam, Xlat, MRI Phys exam, Xap, Xlat
d
d
d
d
Jerosch et al.25 Koczy et al.43* Liu et al.14 Mardani-Kivi et al.44
Tol et al.5y
Exclusion Criteria NR Sc IV Significant instability, severe osteoarthritic changes NR Degenerative changes, osteochondral defects, intra-articular loose bodies, infection, inflammatory arthritis NR Serious chronic lateral instability Associated fracture, <2 yr follow-up Osteochondral lesions, degenerative arthritis, mechanical instability Osteochondritis dissecans NR NR Bilateral, malalignment, osteoarthritis (S&McD grade IV) Degenerative joint disease, rheumatoid arthritis Significant osteoarthritis or joint narrowing Ankle instability Anterior tibial and/or talar osteophytes osteochondral lesions, TOL, degenerative arthritis mechanical instability Loose bodies, osteochondritis dissecans, severe osteoarthritic changes d
Methodologic Quality 1 4 7 2 4
3 5 3 5 5 4 ? 6 7 7 5 2
ANTERIOR ANKLE IMPINGEMENT
Study Akseki et al.36 Arnold37 Baums et al.38
6 5 5
e, not reported; AL, anterolateral impingement; AM, anteromedial impingement; Ant, anterior impingement; CTartro, CT arthrography; MRI, magnetic resonance imaging; NR, not reported; Phys exam, physical examination; S&McD, Scranton & McDermott score; Sc IV, Scranton and McDermott IV; T, osteophytes on tibia; TOL, talar osteochondral lesion; W, widespread impingement; Xap, radiograph in AP direction; X AMI, anteromedial imp; Xlat, radiograph in lateral direction; Xobl, oblique radiograph; Xstress, stress radiography. *Additional information was requested from authors. y Studies on same population.
1589
Study Akseki et al.36 Arnold37 Baums et al.38*
Loose Meniscoid Subgroup Osteophytes Bodies Lesions e e e e e e e e
Synovitis/ Hypertrophic Synovium 19 e
AITFL/ Distal Fascicle of AITFL 21 e
Synovial Shelves e e
AI Score (Scranton and McDermott)
OA Score (van Dijk)
I e 22
II e 7
III e 3
IV e Excl
0 e e
I e e
II e e
III e e
e e e 15 e e
e e e 23 e e
e e e 13 e e
e e e 7 e e
e e e e e e
e e e e e e
e e e e e e
e e e e e e
e 77 e
112 e e
38 e e
64 e e
e e e
e e e
e e e
e e e
e e
e e
e e
e e
e e
e e
e e
e e
e e e
e e e
e e e
e e e
e e e
e e e
e e e
e e e
8
6
Excl
e
e
e
e ST B e e e
14 e 14 58 e e
e e e e e e
12 12 e e 7 e
26 12 14 e 41 e
e e e e e e
e e e e 1 e
B ST e
e e 0
e e 5
e e 3
e e e
e e e
e e e
Ferkel et al.41 Hassan42
e e
3 e
e e
4 4
31 23
e 5
e e
Jerosch et al.25 Koczy et al.43* Liu et al.14
e e e
5 e 10
e e e
3 e e
35 e e
e e e
e e e
e
e
e
e
e
e
e
e
34
e
e
41
e
e
e
4 OCD
e
e
e
e
e
e
e
e
AL
e
e
e
x
x
e
e
e
e
e
e
e
e
e
e
Ant e
11 44
e 16
e e
e 89
e e
e e
e e
e e
e e
e e
e e
e e
e e
e e
e e
e
e
e
e
24
17
e
16
Often cartilage damage e 20 single osteochondral lesions No chondropathy
e
e
e
e
e
e
e
e
e
e
e
6
41
8
7
e
e
e
e
e
e
e
e
e
e AL AM e
52 e e e
e e e e
e e e e
x e e e
e e e e
e e e e
x e e e
19 cartilage damage grade I-III e e e e
23 11 12 e
3 3 0 e
24 13 11 e
12 5 7 e
10 5 5 10
34 18 16 30
18 9 9 17
Excl Excl Excl Excl
Branca et al.23 Brennan et al.24 Cavallo et al.39
Di Palma et al.40
Mardani-Kivi et al.44 Murawski and Kennedy9 Ogilvie-Harris et al.45* Rasmussen and Hjorth30 Rouvillain et al.46 Ürgüden et al.47 van Dijk et al.3y
Tol et al.5y
e
9
e, not reported; AITFL, antero-inferior talo fibular ligament; AI score, ankle impingement score; AL, anterolateral impingement; AM, anteromedial impingement; Ant, anterior impingement; B, bony impingement; Excl, excluded in study; ICRS, International Cartilage Repair Society; OA score, osteoartritis score; OCD, osteochondral defect; ST, soft-tissue impingement; x, pathology detected during arthroscopy, exact amount of cases not reported. *Additional information was requested from authors. y Studies on same population.
R. ZWIERS ET AL.
Chondral/ Scar Osteochondral Tissue Lesions e NR e 2 chondral flake fractures e NR e e e e e 7 Scranton grade IV 6 e e 82 focal lesions ICRS grade III-IV e e e e 7 20 second-/thirddegree chondritis, 2 chondromalacia 20 16 chondromalacia e 4 cartilage damage grade I-II e NR e NR e No osteochondral fractures e e
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Table 3. Overview of Reported Pathology Found During Arthroscopy
1591
ANTERIOR ANKLE IMPINGEMENT
Patient Satisfaction Patient satisfaction was reported in 6 studies. To compare categorical percentages of satisfied patients, we determined the studies in which satisfaction was rated as excellent, good, fair, or poor. For the purposes of this review, the categories of “excellent” and “good” collectively defined a “satisfied” patient. The percentage of satisfied patients ranged from 74% to 100%. The lowest satisfaction rate was reported in the study with the longest follow-up time5 (Table 4). Complications Complications were recorded in all but 2 studies, resulting in a summed complication rate of 5.1%, 1.2% of which were considered major complications and the remaining 3.9% were minor complications. The most commonly reported complications were mild nerve symptoms (n ¼ 27), superficial infection (n ¼ 4), and deep infection (n ¼ 4) (Table 5). Secondary Outcome Measures AOFAS Score. Postoperative AOFAS scores were reported in 7 studies, 5 of which also reported preoperative scores. The mean preoperative scores ranged between 34 and 75 points. Postoperatively, the mean scores ranged from 83.5 to 92 points (Table 4). VAS Score. Two studies reported VAS scores for pain. In one study the score decreased from 7 of 10 to 2 of 10 in both the bony and soft-tissue impingement groups. In the second study the VAS score decreased by approximately 2.5 points to 4.3 of 10 points for both the AMI and ALI groups. In the long-term follow-up of this population, the reported score was 3.3 of 10 points (Table 4). Return to Sport/Return to Full Activity. Twelve studies reported return to preinjury level of sports, two reported return to full activity, and three reported both. The rate of patients who returned to sports ranged from 24% to 100%, whereas the rate of return to full activity ranged from 81% to 100%. Low return-to-sports rates (24% and 48%) were found in 2 studies, both reporting on unspecified anterior impingement (Table 4). Range of Motion. Range of motion was used as an outcome measure in 7 studies. Hassan42 and Ürgüden et al.47 reported an increase in dorsiflexion of more than 5 in 12 of 23 patients and 20 of 41 patients with ALI, respectively. Van Dijk et al.3 showed that 25% of AMI and ALI patients had an increase of at least 5 after surgery. In the study by Ogilvie-Harris et al.,45 mean dorsiflexion increased from 0 to 10 in the anterior impingement group. Murawski and Kennedy9 reported a normal range of motion in all
patients. Moreover, Rasmussen and Hjorth,30 Arnold,37 and Rouvillain et al.46 reported improved range of motion. Undergoing Operation Again. In 4 studies reporting on ALI, the patients were asked whether they would undergo the same operation under the same circumstances again. All reported a high percentage of patients answering this question positively (94.3% to 97.5%) (Table 4). Clinical Outcome Scores. Eleven studies rated clinical outcomes in patients as excellent, good, fair, or poor. These outcomes were based on 9 different scoring systems for evaluation. The percentage of excellent and good outcomes ranged from 63.8% to 100%. In the study by Mardani-Kivi et al.,44 the score increased from 78.2% at 3 months after surgery to 91.3% at 6 months. In the study by van Dijk et al.,3 the scores were higher in the AMI group compared with the ALI group at all follow-up visits. At long-term follow-up, the combined score for AMI and ALI patients was 65% (Table 6). Because of the high heterogeneity in the inclusion and exclusion criteria, as well as the definition of ankle impingement, among the included studies, pooling of the results and comparison of subtypes of anterior ankle impingement was not possible. However, studies with osteoarthritis as an exclusion criterion appeared to have a higher success rate (81.3% to 100% v 63.8% to 87.6%). Methodologic Quality The Downs and Black score ranged from 1 to 7 points out of a maximum of 32 points, with a median score of 5 points. According to our predefined criteria, on the basis of the Downs and Black score, all studies were of poor methodologic quality.
Discussion In this systematic review, 20 studies were evaluated based on patient satisfaction rates, complication rates, and clinical outcome measures to provide an overview of the current literature. Overall, good results were found for arthroscopic treatment in patients with anterior ankle impingement. In the studies that reported patient satisfaction rates, high percentages of good to excellent satisfaction were described (74% to 100%). The percentages of patients who would undergo the same procedure again under the same circumstances were also high (94.3% to 97.5%). Complication rates were low (5.1%), particularly with respect to major complications (1.2%). In terms of secondary outcome measures, most studies showed good results. Despite these findings, the high heterogeneity of the included studies made it impossible to compare the results of the studies, including between ALI and AMI. Given that both subtypes of anterior impingement have different
AOFAS Score
Study Akseki et al.36 Arnold37 Baums et al.38*
Branca et al.23 Brennan et al.24 Cavallo et al.39*
Liu et al.14 Mardani-Kivi et al.44
6 mo Murawski and Kennedy9 Ogilvie-Harris et al.45*
Return to Full Activity 17 of 21 (81%) d d d d d 39 of 41 (95%) d d d d 29 of 31 (94%) d d d d d d
d 57.62
88.13 (SD, 6.8) 89.84
d d
d d
d 27 of 28 (96.4%)
d d
d 3 (8.6%)
d d
d
d
d d 5 (4.8%) 2 (1.9%)
d 7 (6.7%)
d 94.3%
10 of 11 (90.1%) 24 of 24 (100%) 0 (0.0%) 2 (8.3%)
2 (8.3%)
d
d 3 (4.8%) d d d
97.5% d d d d
AL
76.5%
d
d
d
d
12 of 17 (71%)
d
Ant
81.8% d
d d
d d
d d
d d
9 of 11 (82%) d
d d
100%
d
93
d
d
d d d d 74%
d d d d d
89.6 (60-100) d d d d
d d d d 6.9
d d 4.3 4.3 3.3
Rasmussen and Hjorth30 Rouvillain et al.46 Ürgüden et al.47 van Dijk et al.3y AL AM Tol et al.5y
d d
Return to Preinjury Sports Postoperative Preoperative Postoperative Level d d d 10 of 11 (91%) d d d d d 7 (3-8) 2 (0-5) 25 of 26 (96%) d 7 2 12 of 12 (100%) d 7 2 13 of 14 (93%) d d d 13 of 27 (48%) d d d d d d d d 85.5 (SD, 16.8) d d d 83.5 (SD, 17.6) d d d d d d 21 of 32 (66%) d d d 27 of 31 (87.1%) 89 (60-100) d d 9 of 11 (82%) d d d 9 of 38 (24%) d d d d 92 d d d d d d 84% d d d d
% Who Would Undergo Same Major Minor Total Operation 0 (0.0%) 2 (9.5%) 2 (9.5%) d 0 (0.0%) 3 (9.3%) 3 (9.3%) d 0 (0.0%) 2 (7.7%) 2 (7.7%) d d d d d d d d d 1 (1.7%) 2 (3.4%) 3 (5.1%) d 0 (0.0%) 1 (2.4%) 1 (2.4%) 95.1% 0 (0.0%) 2 (0.7%) 2 (0.7%) d d d d d d d d d 1 (1.5%) 3 (4.5%) 4 (6.0%) d 1 (3.2%) 0 (0.0%) 1 (3.2%) d 0 (0.0%) 3 (13.0%) 3 (13.0%) 95.7% 1 (2.8%) 6 (17.1%) 7 (19.9%) d 0 (0.0%) 1 (4.5%) 1 (4.5%) d d d d d 0 (0.0%) 3 (5.5%) 3 (5.5%) d 0 (0.0%) 1 (4.3%) 1 (4.3%) d
d d d d d
d d d d d
d d 2 (5.7%) 1 (2.9%) d
d
d d 0 (0.0%) 3 (4.8%) d d d d d d
NOTE. In studies with more than 1 follow-up, the longest follow-up is reported in the table. Data are presented as mean (range) unless otherwise indicated. e, not reported; AL, anterolateral impingement; AM, anteromedial impingement; Ant, anterior impingement; AOFAS, American Orthopaedic Foot & Ankle Society; B, bony impingement; SD, standard deviation; ST, soft-tissue impingement; VAS, visual analog scale. *Additional information was requested from authors. y Studies on same population.
R. ZWIERS ET AL.
Di Palma et al.40 Ferkel et al.41 Hassan42 Jerosch et al.25 Koczy et al.43*
% Preoperative Subgroup Satisfied 90.5% d d d 100% d AL 100% d Ant 100% d d d d d d d B d 51.1 (SD, 20.8) ST d 40.2 (SD, 21.5) d d d d d 34 (4-57) d d 75.4 12 mo d d 98% d d 59.21 (SD, 10.25)
Complications, n (%)
VAS Score
1592
Table 4. Outcome Measures
1593
ANTERIOR ANKLE IMPINGEMENT Table 5. Reported Complications Complication Major Deep infection Reflex sympathetic dystrophy (CPRS) Reoperation needed Severe nerve symptoms Arthrofibrosis Total major complications Minor Mild nerve symptoms Superficial infection Neuroma Disturbed wound healing Instrument breakage Total minor complications Total complications
n 4 3 2 1 1 11 (1.2%) 27 4 2 2 1 36 (3.9%) 47 (5.1%)
CPRS, complex regional pain syndrome.
clinical presentations and etiologies, a difference in prognosis may be expected. Furthermore, because of definitional differences in return to sports or full activity among studies, caution should be taken when one is interpreting these percentages. In this study a selection of outcome measures was made based on our opinion of relevant outcome measures and those most commonly used in the literature.
The decision was made to include only studies that reported on at least 2 of the chosen outcome measures to provide a clear outline of outcomes. Despite this, we found only return to preinjury level of sports frequently reported. We also decided to use a 4-point clinical outcome scale as an outcome measure, even though these outcomes were based on different criteria and therefore, in fact, were not comparable. No radiologic outcome was used because studies have shown recurrence of bony spurs in a majority of patients after successful treatment. However, there is no correlation with recurrence of symptoms.5,17 Three studies compared 2 subtypes of impingement. Baums et al.38 reported no difference between bony and soft-tissue impingement in the VAS score for pain and rate of return to preinjury level of sports. In their study on 280 patients, Cavallo et al.39 found anterolateral bony impingement to have better outcomes based on the AOFAS score compared with anteromedial bony impingement and found bony and soft tissue to have similar results. The location of the bony impingement and extension of the fibrous impingement showed a significant correlation with clinical outcome. Van Dijk et al.3 described, among 62 patients, better outcomes as measured by the Ogilvie-Harris score for the AMI group compared with the ALI group.
Table 6. Clinical Outcome Scores and Success Rates Clinical Outcome, n (%) Study Akseki et al.36 Arnold37 Baums et al.38* Branca et al.23 Brennan et al.24 Cavallo et al.39* Di Palma et al.40 Ferkel et al.41 Hassan42 Jerosch et al.25 Koczy et al.43* Liu et al.14 Mardani-Kivi et al.44 Murawski and Kennedy9 Ogilvie-Harris et al.45* Rasmussen and Hjorth30 Rouvillain et al.46 Ürgüden et al.47 van Dijk et al.3y Tol et al.5y
Subgroup
AL Ant
12 mo 6 mo AL Ant
AL, 24 mo AM, 24 mo
Excellent 15 (71.4) 7 (21.9) d d 37 (63.8) 34 (82.9) d 49 (73.1) 15 (48.4) 7 (30.4) d d 20 (36.4) 12 (52.2) d d d 67 (63.8) 22 (91.6) 21 (51.2) 21 (66) 26 (87)
Good 2 (9.5) 19 (59.4) d d
d 11 (35.5) 14 (60.9) d d 28 (50.9) 9 (39.1) d d d 25 (23.8) 2 (8.3) 16 (39.0)
65%
Fair 2 (9.5) 5 (15.6) d d 13 (22.4) 5 (12.2) d 11 (16.4) 4 (12.9) 2 (8.7) d d 6 (10.9) 2 (8.7) d d d 6 (5.7) 0 (0.0) 2 (4.9) 11 (34) 4 (13) 35%
Poor 2 (9.5) 1 (3.1) d d 8 (13.8) 2 (4.9) d 7 (10.4) 1 (3.2) 0 (0.0) d d 1 (1.8) 0 (0.0) d d d 7 (6.7) 0 (0.0) 2 (4.9)
Classification Kaikonen West Point Ankle d d McGuire Meislin d McGuire Bray AOFAS d d Liu Meislin d d d d Kitaoka Meislin Ogilvie-Harris Ogilvie-Harris Ogilvie-Harris
Success Rate 80.9% 81.3% d d 63.8% 82.9% d 73.1% 83.9% 91.3% d d 87.3% 91.3% d d d 87.6% 100% 90.2% 66.0% 87.0% 65.0%
NOTE. In studies with more than 1 follow-up, the longest follow-up is reported in the table. e, not reported; AL, anterolateral impingement; AM, anteromedial impingement; Ant, anterior impingement; AOFAS, American Orthopaedic Foot & Ankle Society. *Additional information was requested from authors. y Studies on same population.
1594
R. ZWIERS ET AL.
Besides the location and cause of impingement, 2 classifications were used to rate the extent of the impingement: the impingement classification of Scranton and McDermott18 and the osteoarthritis classification by van Dijk et al.3 The osteoarthritis classification has been shown to be a predictor of outcome.3,5 The classification of Scranton and McDermott may be useful for diagnostic purposes but has no prognostic value.29,39 Several pathologies are associated with anterior ankle impingement. Regarding instability, there is no agreement as to whether it affects the outcome. We included studies that did not exclude patients with an unstable ankle; however, only 1 study reported on differences in outcomes. Jerosch et al.25 stated that unstable ankles had a worse prognosis. The literature, however, is inconclusive. Hassan42 showed that associated syndesmotic lesions and new inversion injuries are factors that negatively affect outcome. The only comparative study, by Kim et al.,48 found no differences in ankle function and rate of return to sports and work between a group of patients with stable ankles and a group of patients with unstable ankles (i.e., anterior ankle impingement). The effect of associated chondral lesions on the outcome of arthroscopic treatment in patients with anterior impingement is debated. Some authors stated that chondral lesions did not affect the results, whereas others observed that they affected outcomes negatively.12,42,49 In this study the relation between chondral damage and outcome could not be determined. The extent of damage was poorly described in most studies. One would expect mild chondral lesions to be a common finding in ankle impingement, whereas highgrade osteochondral defects can be seen as a separate pathology. Often, these were not distinguished or clearly described. As a result, we did not use chondral damage as an exclusion criterion. We would propose the use of the International Cartilage Repair Society classification to be able to determine the effect of chondral lesions. Mardani-Kivi et al.44 reported no difference in outcome in patients with and without chondral lesions; however, follow-up was short. In the study by Murawski and Kennedy,9 no difference was seen in patients with osteochondral defects treated with microfracture. Hassan42 reported on 4 patients with grade I to II cartilage damage to the anterolateral talar dome; none of these patients had excellent results, whereas 3 had good results. In the study by Ürgüden et al.,47 cartilage damage ranging from grade I to III to the anterolateral aspect of the dome of the talus or at the distal tibia was seen in 19 patients. At follow-up, patients with cartilage damage showed statistically lower AOFAS scores than patients without it. Moreover, when the patients were evaluated according to Meislin’s criteria, statistically better results were obtained in patients without cartilage
damage. Di Palma et al.40 showed the presence of moderate to serious chondral lesions to be responsible for a poor prognosis. A previous systematic review showed that there is fair evidence-based literature to support a recommendation for the use of ankle arthroscopy for the treatment of ankle impingement.32 However, no inclusion or exclusion criteria were reported, and both anterior and posterior ankle impingement studies were included. Good to excellent outcome rates were shown; it is unclear, however, on which criteria these scores were based. A large number of small case series, in particular, have been published over time. An overall complication rate of 5.1% after anterior ankle arthroscopy for anterior impingement was found in this study. This complication rate is comparable with the 4% complication rate described in a recent review on the safety of ankle arthroscopy for the treatment of anterolateral soft-tissue impingement.33 However, it is considerably lower than the complication rates of 9% to 17% mentioned in a recent narrative review on anterior ankle impingement.10 The variation in complication rates among the included studies is remarkable. The hypothesis that these differences are an effect of the experience of the surgeon is supported by the fact that the lowest complication rate was reported in the largest series. Limitations The level of evidence of this study is limited by the heterogeneity of study designs and low methodologic quality of the included studies. Furthermore, most of the included studies had small populations. In addition, osteoarthritis was not used as an exclusion criterion in this study, despite its effect on outcome. In many studies, patients with osteoarthritic changes were not excluded, but in those in which they were, the criteria were often poorly defined. Nevertheless, this study is of clinical importance because it provides an overview of the current literature and underscores the need for high-quality studies with clearly defined inclusion criteria and patient-specific, validated outcome measurements.
Conclusions Arthroscopic treatment for anterior ankle impingement appears to provide good outcomes with respect to patient satisfaction and low complication rates. However, on the basis of the findings of this study, no conclusion can be made in terms of the effect of the type of impingement or additional pathology on clinical outcome.
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