- Email: [email protected]
Safety of Ankle Arthroscopy for the Treatment of Anterolateral Soft-Tissue Impingement
Systematic Review with Video Illustration
Safety of Ankle Arthroscopy for the Treatment of Anterolateral Soft-Tissue Impingement Devin C. Simonson, D.P.M., and Thomas S. Roukis, D.P.M., Ph.D.
Purpose: To quantify the overall incidence of complications related to arthroscopic treatment of anterolateral soft-tissue ankle impingement. Methods: Electronic databases and relevant peer-reviewed sources, including OvidSP/Medline (http://ovidsp.tx.ovid.com) and Google Scholar, were systematically searched for the terms “anterolateral” AND “ankle” AND “impingement” OR “soft-tissue impingement” AND “arthroscopy.” In addition, we manually searched common American and European (including British) orthopaedic and podiatric scientific literature for relevant articles. Studies were eligible for inclusion only if they included the following: a standard 2-portal anterior arthroscopic approach, a minimum mean follow-up of 12 months, and detailed descriptions of all complications encountered. Results: After we considered all the potentially eligible articles, 15 (28.8%) met our inclusion criteria for the study. There were a total of 396 patients (397 ankles), with 16 total complications (4%), 3 (0.8%) of which were major. The weighted mean patient age was 31.2 years, and the weighted mean follow-up was 33.7 months. Conclusions: The results of this systematic review showed an overall incidence of complications of 4%. The complications were categorically divided into major and minor complications, with a very low incidence of major complications (0.8%) and an acceptably low incidence of minor complications (3.3%). On the basis of these findings, arthroscopic treatment of anterolateral ankle soft-tissue impingement is a very safe procedure when indicated. Level of Evidence: Level IV, systematic review of Level IV studies.
I
nversion ankle injuries are common and may result in chronic ankle pain due to impingement of soft tissues in approximately 2% of cases.1-4 Anterolateral ankle soft-tissue impingement should be considered in patients with chronic ankle pain when other conditions such as osteochondral lesions of the talus or degenerative arthritis have been ruled out.1-5 There are 3 main etiologies, each involving various intra-articular softtissue pathologies: hypertrophied synovium, meniscoid lesion, and impingement of a distal fascicle of the anterior-inferior tibiofibular ligament.1-7 Other soft-tissue etiologies have been described to cause anterior ankle
From Gundersen Health System Medical Foundation (D.C.S.), and the Department of Orthopaedics, Podiatry and Sports Medicine, Gundersen Health System (T.S.R.), La Crosse, Wisconsin, U.S.A. The authors report the following potential conflict of interest or source of funding: T.S.R. receives support from American College of Foot and Ankle Surgeons: Board of Directors, Executive Committee, President-Elect. Stryker Orthopaedics. Received August 16, 2013; accepted October 29, 2013. Address correspondence to Thomas S. Roukis, D.P.M., Ph.D., Department of Orthopaedics, Podiatry, and Sports Medicine, Gundersen Health System, Second Floor Founders Bldg, Mail Stop FB2-009, 1900 South Ave, La Crosse, WI 54601, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13591/$36.00 http://dx.doi.org/10.1016/j.arthro.2013.10.014
256
impingement, such as an intra-articular fibrous band; however, these patients often present with anteromedial pain.8 Arthroscopic diagnosis and treatment are generally performed after a meaningful course of conservative measures and have been widely reported to yield acceptable results with minimal complications.1-4 It has also been reported that a common population of patients in whom this condition develops are athletes, whether professional, amateur, or recreational.1,2,9-15 Unfortunately, the safety of arthroscopic treatment of anterolateral ankle soft-tissue impingement as determined by the incidence of complications encountered has not been previously reported. Therefore the purpose of this study was to quantify the overall incidence of complications related to arthroscopic treatment of anterolateral ankle soft-tissue impingement, regardless of specific etiology. We hypothesized that the incidence of complications would be comparable with that of anterior ankle arthroscopy for all indications.
Methods We performed a systematic review of electronic databases and relevant peer-reviewed sources including OvidSP/Medline (http://ovidsp.tx.ovid.com) and a scientific search engine (http://scholar.google.com). In addition, we manually searched common American and European (including British) orthopaedic and podiatric
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 30, No 2 (February), 2014: pp 256-259
ANTEROLATERAL SOFT-TISSUE IMPINGEMENT
257
scientific literature for relevant articles. Only articles that used a standard 2-portal anterior arthroscopic approach for diagnosis and treatment of anterolateral ankle softtissue impingement with a minimum mean follow-up of 12 months were considered. We performed our systematic review between March and August 2013, with no restriction on date or language, and used an inclusive text word query (in which the all-uppercase words represent the Boolean operators used): “anterolateral” AND “ankle” AND “impingement” OR “soft-tissue impingement” AND “arthroscopy.” All articles were reviewed by both of us, and complete agreement was necessary for final inclusion, with the lead author being the moderator. Only full-text published articles were considered. Fig 1. Flowchart of reports during selection process.
Results The search for potentially eligible information for inclusion in the systematic review yielded a total of 52 articles. We obtained and reviewed all articles identified. We also completed an updated search for new articles in August 2013, which yielded no further studies. After we considered all the potentially eligible articles, 15 (28.8%) met our inclusion criteria for the study (Fig 1). A total of 396 patients (397 ankles) were included (Table 1). Among the studies that included gender data, there were 250 male patients (66.7%) and 125 female patients (33.3%). The weighted mean age of the patients was 31.2 years (range, 11 to 75 years), and the weighted mean follow-up was 33.7 months (range, 6 to 152 months). The overall incidence of complications was 4% (16 of 397 ankles). Of the reported complications, 13 (81.2%) were considered minor because they had resolved either spontaneously or after conservative treatment by 12 months postoperatively. The remaining 3 complications (18.8%) persisted beyond the aforementioned timeframe or required invasive treatment and thus were considered major. The methodologic quality of included studies was generally fair. Of the studies involving arthroscopic diagnosis and treatment of anterolateral ankle soft-tissue impingement, all were full-text articles and were considered evidence-based medicine Level IV studies. Furthermore, all were published in known peer-reviewed journals.
Discussion The purpose of this systematic review was to determine the overall incidence of complications related to arthroscopic treatment of anterolateral ankle softtissue impingement, regardless of specific etiology. A total of 15 studies could be identified that met our inclusion criteria. All studies described the same general surgical technique, including anterior synovectomy and debridement of all anterolateral ankle soft-tissue impingement (Fig 2, Video 1, available at www.arthroscopyjournal.org). This procedure has
been reported on by a number of authors since the 1980s; however, to our knowledge, the safety of this procedure, as determined through review of the overall incidence of complications, has not been previously examined. Our review yielded a total of 397 arthroscopic procedures, with an overall incidence of complications of 4% and an incidence of major complications of 0.8%. Our hypothesis was confirmed because these results are very similar to those recently published by Zengerink and van Dijk,20 who reported on both anterior and posterior ankle arthroscopy for a variety of indications in 1,305 consecutive patients. Their overall incidence of complications was 3.5%, which they stated was less than half of the previously reported incidence of 10.3%. They concluded that their dorsiflexion technique for ankle arthroscopy is the main reason for their low rate of complications as compared with other case series in which a continuous distraction system was used. The distinction between major and minor complications is important during the preoperative discussion, and the difference in reported incidence in our article may reassure patients considering this procedure for chronic ankle pain due to soft-tissue impingement in the anterolateral aspect of the ankle joint. As mentioned earlier, minor complications were defined as those that resolved either spontaneously or after conservative treatment by 12 months postoperatively. Those reported in the systematic review comprised temporary paresthesia of the superficial peroneal nerve in 7 cases (1.8%), superficial postoperative infection in 5 cases (1.3%), and postoperative hemarthrosis in 1 case (0.3%). Major complications were those that persisted beyond 12 months postoperatively or required invasive treatment. There were 3 major reported complications in the review: 2 iatrogenic incision neuromas that required corticosteroid injections (0.5%) and 1 injury to the superficial peroneal nerve resulting in permanent anesthesia (0.3%). It is important to recognize that the majority of complications, both minor and major,
258
D. C. SIMONSON AND T. S. ROUKIS
Table 1. Study Data Included in Systematic Review Author McCarroll et al.9 (1987) Martin et al.16 (1989) Bassett et al.6 (1990) Ferkel et al.1 (1991) Thein and Eichenblat10 (1992) Meislin et al.17 (1993) Liu et al.11 (1994) Ogilvie-Harris et al.12 (1997) DeBerardino et al.2 (1997) Akseki et al.18 (1999) Kim and Ha13 (2000) Urgüden et al.4 (2005) Hassan14 (2007) Koczy et al.19 (2009) Moustafa El-Sayed3 (2010) Total
Level of Evidence IV IV IV IV IV IV IV IV IV IV IV IV IV IV IV
No. of Patients 4 16 2 31 3 29 55 17 60 21 52 41 23 22 20 396
No. of Ankles 5 16 2 31 3 29 55 17 60 21 52 41 23 22 20 397
Mean Age (Range) (yr) NA 28 (12-54) 28 (24-31) 34 (16-74) NA 37 (17-66) 34 (20-67) 29 (17-54) 24 (13-45) 31 (11-68) 31 (16-49) 33 (15-63) 27 (15-53) 34 (17-55) 36 (26-49) 31.2 (11-75)
Mean Follow-up (Range) (mo) 24 (12-36) 30 (25-40) 15 (6-24) 34 (24-66) 34 (28-44) 25 (6-41) 31 (12-54) 33 (12-72) 27 (6-64) 34 (24-48) 30 (25-45) 83.7 (21-152) 25 (12-38) 12 (12) 21.3 (12-47) 33.7 (6-152)
No. of Major Complications 0 0 0 0 0 0 0 0 0 2 0 1 0 0 0 3
Total No. of Complications (%) 0 (0%) 3 (18.8%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 3 (5.5%) 0 (0%) 3 (5%) 2 (9.5%) 0 (0%) 1 (0.2%) 3 (13%) 1 (4.5%) 0 (0%) 16 (4%)
NA, not available.
were nerve-related injuries. Meticulous surgical technique is mandatory when one is performing anterior ankle arthroscopy because it may reduce the incidence of nerve-related injury. Limitations Numerous weaknesses of this study were considered. First, we performed the search for articles that met the inclusion criteria through electronic databases. It is inherently possible that pertinent references may have been inadvertently overlooked or excluded. Moreover, the
search did not include every potential electronic database and was restricted to only full-text articles. A more expansive search may have yielded supplementary articles for inclusion. In addition, the inclusion criteria were quite narrow. This produced a small subset of articles for evaluation. A number of studies were excluded because of their inclusion of indications for ankle arthroscopy outside the scope of our study and failure to identify in which specific treatment group the reported complications were encountered. The additional 59 arthroscopic procedures for anterolateral ankle soft-tissue impingement would
Fig 2. Arthroscopic visualization of specific intracapsular pathologies that may lead to anterolateral ankle softtissue impingement. All images show a right ankle in the supine position with the arthroscope in the anteromedial portal (A, B, and C) or anterolateral portal (D). (A) Acute synovitis. (B) Meniscoid lesion. (C) Isolated impinging distal fascicle of anterior-inferior tibiofibular ligament. (D) Impinging distal fascicle of anterior-inferior tibiofibular ligament and meniscoid lesion.
ANTEROLATERAL SOFT-TISSUE IMPINGEMENT
have increased our total number of patients to 456 and, if these were without complication, would have lowered the overall incidence of complications to 3.5%. In these studies all reported complications would have been considered minor, and as such, the incidence of major complications would have been decreased by only onetenth of a percent (from 0.8% to 0.7%). However, we considered this potential decrease in the incidence of complications insignificant.
Conclusions We performed a systematic review using electronic databases to determine the incidence of complications after arthroscopic treatment of anterolateral ankle softtissue impingement. On the basis of the inclusion criteria, a total of 15 studies were included in the analysis. The overall incidence of complications was 4% (16 of 397 ankles) after arthroscopic treatment of anterolateral ankle soft-tissue impingement using a standard 2portal anterior technique. The complications were categorically divided into major and minor complications, with a very low incidence of major complications (0.8%) and an acceptably low incidence of minor complications (3.3%). On the basis of these findings, arthroscopic treatment of anterolateral ankle soft-tissue impingement is a very safe procedure when indicated.
References 1. 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. 2. DeBerardino TM, Arciero RA, Taylor DC. Arthroscopic treatment of soft tissue impingement of the ankle in athletes. Arthroscopy 1997;13:492-498. 3. Moustafa El-Sayed AM. Arthroscopic treatment of anterolateral impingement of the ankle. J Foot Ankle Surg 2010;49: 219-223. 4. Urgüden M, Söyüncü 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. 5. van den Bekerom MP, Raven EE. The distal fascicle of the anterior inferior tibiofibular ligament as a cause of tibiotalar impingement syndrome: A current concepts review. Knee Surg Sports Traumatol Arthrosc 2007;15:465-471.
259
6. Bassett FH, Gates HS, 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. 7. Wolin I, Glassman F, Sideman F, Levinthal DH. Internal derangement of talofibular component of the ankle. Surg Gynecol Obstet 1950;91:193-200. 8. Valkering KP, Golanó P, van Dijk CN, Kerkhoffs GM. “Web impingement” of the ankle: A case report. Knee Surg Sports Traumatol Arthrosc 2013;21:1289-1292. 9. McCarroll JR, Schrader JW, Shelbourne KD, Rettig AC, Bisesi MA. Meniscoid lesions of the ankle in soccer players. Am J Sports Med 1987;15:255-257. 10. Thein R, Eichenblat M. Arthroscopic treatment of sportsrelated synovitis of the ankle. Am J Sports Med 1992;20: 496-498. 11. Liu SH, Raskin A, Osti L, Baker C, Jacobson K, Finerman G. Arthroscopic treatment of anterolateral ankle impingement. Arthroscopy 1994;10:215-218. 12. Ogilvie-Harris DJ, Gilbart MK, Chorney K. Chronic pain following ankle sprains in athletes: The role of arthroscopic surgery. Arthroscopy 1997;13:564-574. 13. 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. 14. Hassan AH. Treatment of anterolateral impingements of the ankle joint by arthroscopy. Knee Surg Sports Traumatol Arthrosc 2007;15:1150-1154. 15. van Dijk CN, Scholte D. Arthroscopy of the ankle joint. Arthroscopy 1997;13:90-96. 16. Martin DF, Curl WW, Baker CL. Arthroscopic treatment of chronic synovitis of the ankle. Arthroscopy 1989;5: 110-114. 17. Meislin RJ, Rose DJ, Parisien JS, Springer S. Arthroscopic treatment of synovial impingement of the ankle. Am J Sports Med 1993;21:186-189. 18. Akseki D, Pinar H, Bozkurt M, Yaldiz K, Araç 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. 19. Koczy B, Pyda M, Stołtny T, et al. Arthroscopy for anterolateral soft tissue impingement of the ankle joint. Ortop Traumatol Rehabil 2009;11:339-345. 20. Zengerink M, van Dijk CN. Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2012;20: 1420-1431.
Safety of Ankle Arthroscopy for the Treatment of Anterolateral Soft-Tissue Impingement Devin C. Simonson, D.P.M., and Thomas S. Roukis, D.P.M., Ph.D.
Purpose: To quantify the overall incidence of complications related to arthroscopic treatment of anterolateral soft-tissue ankle impingement. Methods: Electronic databases and relevant peer-reviewed sources, including OvidSP/Medline (http://ovidsp.tx.ovid.com) and Google Scholar, were systematically searched for the terms “anterolateral” AND “ankle” AND “impingement” OR “soft-tissue impingement” AND “arthroscopy.” In addition, we manually searched common American and European (including British) orthopaedic and podiatric scientific literature for relevant articles. Studies were eligible for inclusion only if they included the following: a standard 2-portal anterior arthroscopic approach, a minimum mean follow-up of 12 months, and detailed descriptions of all complications encountered. Results: After we considered all the potentially eligible articles, 15 (28.8%) met our inclusion criteria for the study. There were a total of 396 patients (397 ankles), with 16 total complications (4%), 3 (0.8%) of which were major. The weighted mean patient age was 31.2 years, and the weighted mean follow-up was 33.7 months. Conclusions: The results of this systematic review showed an overall incidence of complications of 4%. The complications were categorically divided into major and minor complications, with a very low incidence of major complications (0.8%) and an acceptably low incidence of minor complications (3.3%). On the basis of these findings, arthroscopic treatment of anterolateral ankle soft-tissue impingement is a very safe procedure when indicated. Level of Evidence: Level IV, systematic review of Level IV studies.
I
nversion ankle injuries are common and may result in chronic ankle pain due to impingement of soft tissues in approximately 2% of cases.1-4 Anterolateral ankle soft-tissue impingement should be considered in patients with chronic ankle pain when other conditions such as osteochondral lesions of the talus or degenerative arthritis have been ruled out.1-5 There are 3 main etiologies, each involving various intra-articular softtissue pathologies: hypertrophied synovium, meniscoid lesion, and impingement of a distal fascicle of the anterior-inferior tibiofibular ligament.1-7 Other soft-tissue etiologies have been described to cause anterior ankle
From Gundersen Health System Medical Foundation (D.C.S.), and the Department of Orthopaedics, Podiatry and Sports Medicine, Gundersen Health System (T.S.R.), La Crosse, Wisconsin, U.S.A. The authors report the following potential conflict of interest or source of funding: T.S.R. receives support from American College of Foot and Ankle Surgeons: Board of Directors, Executive Committee, President-Elect. Stryker Orthopaedics. Received August 16, 2013; accepted October 29, 2013. Address correspondence to Thomas S. Roukis, D.P.M., Ph.D., Department of Orthopaedics, Podiatry, and Sports Medicine, Gundersen Health System, Second Floor Founders Bldg, Mail Stop FB2-009, 1900 South Ave, La Crosse, WI 54601, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13591/$36.00 http://dx.doi.org/10.1016/j.arthro.2013.10.014
256
impingement, such as an intra-articular fibrous band; however, these patients often present with anteromedial pain.8 Arthroscopic diagnosis and treatment are generally performed after a meaningful course of conservative measures and have been widely reported to yield acceptable results with minimal complications.1-4 It has also been reported that a common population of patients in whom this condition develops are athletes, whether professional, amateur, or recreational.1,2,9-15 Unfortunately, the safety of arthroscopic treatment of anterolateral ankle soft-tissue impingement as determined by the incidence of complications encountered has not been previously reported. Therefore the purpose of this study was to quantify the overall incidence of complications related to arthroscopic treatment of anterolateral ankle soft-tissue impingement, regardless of specific etiology. We hypothesized that the incidence of complications would be comparable with that of anterior ankle arthroscopy for all indications.
Methods We performed a systematic review of electronic databases and relevant peer-reviewed sources including OvidSP/Medline (http://ovidsp.tx.ovid.com) and a scientific search engine (http://scholar.google.com). In addition, we manually searched common American and European (including British) orthopaedic and podiatric
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 30, No 2 (February), 2014: pp 256-259
ANTEROLATERAL SOFT-TISSUE IMPINGEMENT
257
scientific literature for relevant articles. Only articles that used a standard 2-portal anterior arthroscopic approach for diagnosis and treatment of anterolateral ankle softtissue impingement with a minimum mean follow-up of 12 months were considered. We performed our systematic review between March and August 2013, with no restriction on date or language, and used an inclusive text word query (in which the all-uppercase words represent the Boolean operators used): “anterolateral” AND “ankle” AND “impingement” OR “soft-tissue impingement” AND “arthroscopy.” All articles were reviewed by both of us, and complete agreement was necessary for final inclusion, with the lead author being the moderator. Only full-text published articles were considered. Fig 1. Flowchart of reports during selection process.
Results The search for potentially eligible information for inclusion in the systematic review yielded a total of 52 articles. We obtained and reviewed all articles identified. We also completed an updated search for new articles in August 2013, which yielded no further studies. After we considered all the potentially eligible articles, 15 (28.8%) met our inclusion criteria for the study (Fig 1). A total of 396 patients (397 ankles) were included (Table 1). Among the studies that included gender data, there were 250 male patients (66.7%) and 125 female patients (33.3%). The weighted mean age of the patients was 31.2 years (range, 11 to 75 years), and the weighted mean follow-up was 33.7 months (range, 6 to 152 months). The overall incidence of complications was 4% (16 of 397 ankles). Of the reported complications, 13 (81.2%) were considered minor because they had resolved either spontaneously or after conservative treatment by 12 months postoperatively. The remaining 3 complications (18.8%) persisted beyond the aforementioned timeframe or required invasive treatment and thus were considered major. The methodologic quality of included studies was generally fair. Of the studies involving arthroscopic diagnosis and treatment of anterolateral ankle soft-tissue impingement, all were full-text articles and were considered evidence-based medicine Level IV studies. Furthermore, all were published in known peer-reviewed journals.
Discussion The purpose of this systematic review was to determine the overall incidence of complications related to arthroscopic treatment of anterolateral ankle softtissue impingement, regardless of specific etiology. A total of 15 studies could be identified that met our inclusion criteria. All studies described the same general surgical technique, including anterior synovectomy and debridement of all anterolateral ankle soft-tissue impingement (Fig 2, Video 1, available at www.arthroscopyjournal.org). This procedure has
been reported on by a number of authors since the 1980s; however, to our knowledge, the safety of this procedure, as determined through review of the overall incidence of complications, has not been previously examined. Our review yielded a total of 397 arthroscopic procedures, with an overall incidence of complications of 4% and an incidence of major complications of 0.8%. Our hypothesis was confirmed because these results are very similar to those recently published by Zengerink and van Dijk,20 who reported on both anterior and posterior ankle arthroscopy for a variety of indications in 1,305 consecutive patients. Their overall incidence of complications was 3.5%, which they stated was less than half of the previously reported incidence of 10.3%. They concluded that their dorsiflexion technique for ankle arthroscopy is the main reason for their low rate of complications as compared with other case series in which a continuous distraction system was used. The distinction between major and minor complications is important during the preoperative discussion, and the difference in reported incidence in our article may reassure patients considering this procedure for chronic ankle pain due to soft-tissue impingement in the anterolateral aspect of the ankle joint. As mentioned earlier, minor complications were defined as those that resolved either spontaneously or after conservative treatment by 12 months postoperatively. Those reported in the systematic review comprised temporary paresthesia of the superficial peroneal nerve in 7 cases (1.8%), superficial postoperative infection in 5 cases (1.3%), and postoperative hemarthrosis in 1 case (0.3%). Major complications were those that persisted beyond 12 months postoperatively or required invasive treatment. There were 3 major reported complications in the review: 2 iatrogenic incision neuromas that required corticosteroid injections (0.5%) and 1 injury to the superficial peroneal nerve resulting in permanent anesthesia (0.3%). It is important to recognize that the majority of complications, both minor and major,
258
D. C. SIMONSON AND T. S. ROUKIS
Table 1. Study Data Included in Systematic Review Author McCarroll et al.9 (1987) Martin et al.16 (1989) Bassett et al.6 (1990) Ferkel et al.1 (1991) Thein and Eichenblat10 (1992) Meislin et al.17 (1993) Liu et al.11 (1994) Ogilvie-Harris et al.12 (1997) DeBerardino et al.2 (1997) Akseki et al.18 (1999) Kim and Ha13 (2000) Urgüden et al.4 (2005) Hassan14 (2007) Koczy et al.19 (2009) Moustafa El-Sayed3 (2010) Total
Level of Evidence IV IV IV IV IV IV IV IV IV IV IV IV IV IV IV
No. of Patients 4 16 2 31 3 29 55 17 60 21 52 41 23 22 20 396
No. of Ankles 5 16 2 31 3 29 55 17 60 21 52 41 23 22 20 397
Mean Age (Range) (yr) NA 28 (12-54) 28 (24-31) 34 (16-74) NA 37 (17-66) 34 (20-67) 29 (17-54) 24 (13-45) 31 (11-68) 31 (16-49) 33 (15-63) 27 (15-53) 34 (17-55) 36 (26-49) 31.2 (11-75)
Mean Follow-up (Range) (mo) 24 (12-36) 30 (25-40) 15 (6-24) 34 (24-66) 34 (28-44) 25 (6-41) 31 (12-54) 33 (12-72) 27 (6-64) 34 (24-48) 30 (25-45) 83.7 (21-152) 25 (12-38) 12 (12) 21.3 (12-47) 33.7 (6-152)
No. of Major Complications 0 0 0 0 0 0 0 0 0 2 0 1 0 0 0 3
Total No. of Complications (%) 0 (0%) 3 (18.8%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 3 (5.5%) 0 (0%) 3 (5%) 2 (9.5%) 0 (0%) 1 (0.2%) 3 (13%) 1 (4.5%) 0 (0%) 16 (4%)
NA, not available.
were nerve-related injuries. Meticulous surgical technique is mandatory when one is performing anterior ankle arthroscopy because it may reduce the incidence of nerve-related injury. Limitations Numerous weaknesses of this study were considered. First, we performed the search for articles that met the inclusion criteria through electronic databases. It is inherently possible that pertinent references may have been inadvertently overlooked or excluded. Moreover, the
search did not include every potential electronic database and was restricted to only full-text articles. A more expansive search may have yielded supplementary articles for inclusion. In addition, the inclusion criteria were quite narrow. This produced a small subset of articles for evaluation. A number of studies were excluded because of their inclusion of indications for ankle arthroscopy outside the scope of our study and failure to identify in which specific treatment group the reported complications were encountered. The additional 59 arthroscopic procedures for anterolateral ankle soft-tissue impingement would
Fig 2. Arthroscopic visualization of specific intracapsular pathologies that may lead to anterolateral ankle softtissue impingement. All images show a right ankle in the supine position with the arthroscope in the anteromedial portal (A, B, and C) or anterolateral portal (D). (A) Acute synovitis. (B) Meniscoid lesion. (C) Isolated impinging distal fascicle of anterior-inferior tibiofibular ligament. (D) Impinging distal fascicle of anterior-inferior tibiofibular ligament and meniscoid lesion.
ANTEROLATERAL SOFT-TISSUE IMPINGEMENT
have increased our total number of patients to 456 and, if these were without complication, would have lowered the overall incidence of complications to 3.5%. In these studies all reported complications would have been considered minor, and as such, the incidence of major complications would have been decreased by only onetenth of a percent (from 0.8% to 0.7%). However, we considered this potential decrease in the incidence of complications insignificant.
Conclusions We performed a systematic review using electronic databases to determine the incidence of complications after arthroscopic treatment of anterolateral ankle softtissue impingement. On the basis of the inclusion criteria, a total of 15 studies were included in the analysis. The overall incidence of complications was 4% (16 of 397 ankles) after arthroscopic treatment of anterolateral ankle soft-tissue impingement using a standard 2portal anterior technique. The complications were categorically divided into major and minor complications, with a very low incidence of major complications (0.8%) and an acceptably low incidence of minor complications (3.3%). On the basis of these findings, arthroscopic treatment of anterolateral ankle soft-tissue impingement is a very safe procedure when indicated.
References 1. 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. 2. DeBerardino TM, Arciero RA, Taylor DC. Arthroscopic treatment of soft tissue impingement of the ankle in athletes. Arthroscopy 1997;13:492-498. 3. Moustafa El-Sayed AM. Arthroscopic treatment of anterolateral impingement of the ankle. J Foot Ankle Surg 2010;49: 219-223. 4. Urgüden M, Söyüncü 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. 5. van den Bekerom MP, Raven EE. The distal fascicle of the anterior inferior tibiofibular ligament as a cause of tibiotalar impingement syndrome: A current concepts review. Knee Surg Sports Traumatol Arthrosc 2007;15:465-471.
259
6. Bassett FH, Gates HS, 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. 7. Wolin I, Glassman F, Sideman F, Levinthal DH. Internal derangement of talofibular component of the ankle. Surg Gynecol Obstet 1950;91:193-200. 8. Valkering KP, Golanó P, van Dijk CN, Kerkhoffs GM. “Web impingement” of the ankle: A case report. Knee Surg Sports Traumatol Arthrosc 2013;21:1289-1292. 9. McCarroll JR, Schrader JW, Shelbourne KD, Rettig AC, Bisesi MA. Meniscoid lesions of the ankle in soccer players. Am J Sports Med 1987;15:255-257. 10. Thein R, Eichenblat M. Arthroscopic treatment of sportsrelated synovitis of the ankle. Am J Sports Med 1992;20: 496-498. 11. Liu SH, Raskin A, Osti L, Baker C, Jacobson K, Finerman G. Arthroscopic treatment of anterolateral ankle impingement. Arthroscopy 1994;10:215-218. 12. Ogilvie-Harris DJ, Gilbart MK, Chorney K. Chronic pain following ankle sprains in athletes: The role of arthroscopic surgery. Arthroscopy 1997;13:564-574. 13. 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. 14. Hassan AH. Treatment of anterolateral impingements of the ankle joint by arthroscopy. Knee Surg Sports Traumatol Arthrosc 2007;15:1150-1154. 15. van Dijk CN, Scholte D. Arthroscopy of the ankle joint. Arthroscopy 1997;13:90-96. 16. Martin DF, Curl WW, Baker CL. Arthroscopic treatment of chronic synovitis of the ankle. Arthroscopy 1989;5: 110-114. 17. Meislin RJ, Rose DJ, Parisien JS, Springer S. Arthroscopic treatment of synovial impingement of the ankle. Am J Sports Med 1993;21:186-189. 18. Akseki D, Pinar H, Bozkurt M, Yaldiz K, Araç 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. 19. Koczy B, Pyda M, Stołtny T, et al. Arthroscopy for anterolateral soft tissue impingement of the ankle joint. Ortop Traumatol Rehabil 2009;11:339-345. 20. Zengerink M, van Dijk CN. Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2012;20: 1420-1431.