Ankle Arthroscopy: Techniques Developed by the Amsterdam Foot and Ankle School

C. Niek van DijkAnkle Arthroscopy2014Techniques Developed by the Amsterdam Foot and Ankle School10.1007/978-3-642-35989-7_1

© Springer-Verlag Berlin Heidelberg 2014

1. Introduction

C. Niek van Dijk¹ 

(1)

Department of Orthopedic Surgery Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands

Abstract

Arthroscopy of the ankle joint has become an important therapeutic procedure for treatment of chronic and posttraumatic problems. The best and safest approach is without routine joint distraction with the ankle placed in the dorsiflexed position. Most of the pathology like anterior impingement, synovitis, loose bodies, and ossicles are located in the anterior aspect of the joint. Most of the osteochondral defects can be brought into this anterior working area by means of plantar flexion. Posterior ankle pathology is treated by means of a two-portal hindfoot approach. Indications include posterior ankle impingement, posterior osteochondral defects, loose bodies, subtalar arthrodesis, and recurrent peroneal tendon dislocation. Pathology of the peroneal tendons, posterior tibial tendon, flexor hallucis longus, and the Achilles tendon can be treated by tendoscopy.The book is accompanied by a free accessible interactive website (www.​ankleplatform.​com) on which the operative techniques are shown in text, pictures, and videos, including weekly tips and tricks for each procedure. The interactive part concerns the possibility to submit cases to an international expert panel. I hope that reading this book will raise your interest for the ankle joint and will inspire you to apply the operative techniques as described.

Arthroscopy of the ankle should be performed without routine joint distraction.

Posterior ankle pathology is treated by means of a two-portal hindfoot approach.

New techniques include endoscopic subtalar fusion, groove deepening for recurrent peroneal tendon dislocation, and endoscopic treatment of Achilles tendon pathology.

Significant progress has been made in the field of endoscopic foot and ankle surgery over the last 25 years. Arthroscopy of the ankle joint has become an important therapeutic procedure for the detection and treatment of chronic and posttraumatic problems. The place for diagnostic arthroscopy is limited. In the past, routine joint distraction was advocated for every procedure. Arthroscopic procedures of the ankle joint can be performed much better and more effective without routine joint distraction (Van Dijk and Van Bergen 2008). In dorsiflexion the anterior joint capsule is lax. After introduction of saline, the anterior working area opens up, thus allowing for introduction of arthroscope and other instruments. In the dorsiflexed position the talus is concealed in the joint, thereby protecting the cartilage for potential iatrogenic damage. Most of the pathology is located in the anterior aspect of the ankle joint or can be brought into this anterior working area in front of the ankle joint (Van Dijk and Van Bergen 2008). However, there are cases in which a joint distraction eases access to the pathology. A noninvasive distraction device that enables the surgeon to change quickly from the dorsiflexed position to the distracted position and vice versa can then be used.

Concerning diagnostics additional radiographs, such as the anteromedial impingement view, heel rise view, or posterior impingement view, are important for the confirmation of a clinical diagnosis and for planning treatment.

Anterior ankle problems include soft tissue and bony impingement, synovitis, loose bodies, and ossicles. Complaints located more centrally can originate from an osteochondral defect (OCD) or from arthrosis. For preoperative planning, CT scanning offers better information than MR imaging. Therapy is guided mainly by the size of an OCD. For primary lesions, the best option for treatment is currently debridement and bone marrow stimulation (ECBS). Large cystic lesions can be treated by retrograde drilling and bone grafting. Secondary lesions can be treated by osteochondral transplants, a hemicap, or a calcaneal osteotomy.

Because of their nature and their deep location, posterior ankle problems pose a diagnostic and therapeutic challenge. By means of a two-portal hindfoot approach, with the patient in the prone position, posterior ankle joint problems such as loose bodies, ossicles, osteophytes, or osteochondral defects can be treated. In case of a posterior ankle impingement syndrome, bony impediments like an os trigonum can be detached and removed. This approach also offers access to the deep portion of the deltoid ligament, the posterior syndesmotic ligament, the posterior talofibular ligament, the flexor hallucis longus tendon, as well as the posterior ankle compartment of the subtalar joint. Pathology of these structures can be detected and treated.

Subtalar fusion can be performed by means of a new three-portal technique. Tendoscopy of the peroneal tendons, the posterior tibial tendon, and the Achilles tendon offers elegant access to these tendons. A new three-portal endoscopic technique for treatment of recurrent peroneal tendon dislocation is described. This technique offers a functional after treatment and quick recovery. For chronic retrocalcaneal bursitis, endoscopic calcaneoplasty has demonstrated to show several advantages, including low morbidity, functional aftertreatment, outpatient treatment, excellent scar healing, a short recovery time, and quicker sport resumption, when compared to open techniques. The same advantages apply to most of the endoscopic techniques described in this book. I expect surgeons familiar with the arthroscope, as well as their patients, to find these techniques a more rewarding experience. This book is accompanied by a free accessible interactive website (www.​ankleplatform.​com) on which the operative techniques are shown in text, pictures, and videos, including weekly tips and tricks for each procedure. The interactive part concerns the possibility to submit cases to an international expert panel.

I hope this book will raise your interest for the ankle joint and will inspire you to apply the operative techniques as described.

Reference

Van Dijk CN, Van Bergen CJA (2008) Advancements in ankle arthroscopy. J Am Acad Orthop Surg 16:635–646PubMed

Part 1

General Aspects

C. Niek van DijkAnkle Arthroscopy2014Techniques Developed by the Amsterdam Foot and Ankle School10.1007/978-3-642-35989-7_2

© Springer-Verlag Berlin Heidelberg 2014

2. Preoperative Evaluation and Imaging

C. Niek van Dijk¹ 

(1)

Department of Orthopedic Surgery Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands

Abstract

Gross ankle pathology can be diagnosed by means of routine X-rays. Small and at first sight insignificant lesions demand for accurate radiological detection. This makes orthopedic treatment extremely interesting and challenging. In the diagnostic process we differentiate between acute, posttraumatic, and overuse injuries. Obtaining a medical history and physical examination, including standard X-rays, remains the single most important tool in the diagnostic process. In case of additional diagnostics, appropriate consultation between orthopedic surgeon and radiologist is necessary in order to determine the best strategy.

A proper medical history and physical examination remains the single most important tool in the diagnostic process.

For preoperative planning a CT scan offers better information than MRI.

2.1 Introduction

Significant progress has been made both in the treatment of ankle and hindfoot pathology as well as in the field of imaging. Knowledge and understanding of the developments in both fields are important for proper treatment of our patients (Van Dijk and De Leeuw 2007).

There are a few important considerations in the diagnostic process. First we must differentiate between (sub)acute and chronic injuries by means of obtaining a medical history, physical examination, and standard X-rays. This process can be challenging, since patients with chronic complaints often have a sudden onset of symptoms after a traumatic event. In a substantial number of cases there is a time delay between the trauma and the visit to the clinician. It is therefore not always easy to differentiate between subacute, posttraumatic, and overuse injuries.

2.2 Routine X-Ray

A division has to be made between acute and chronic injuries.

2.2.1 Acute Injuries

In most hospitals a routine X-ray of the ankle is made since the prevalence of an ankle fracture in patients with a painful swollen ankle that visit the First Aid Department of a Western hospital is up to 15 % (Brooks et al. 1981; Diehr et al. 1988; Dunlop et al. 1986; Montague and McQuillan 1985; Sujitkumar et al. 1986; Vargish et al. 1983). Decisional rules have been proposed to minimize the number of routine X-rays. Applying the Ottawa ankle rules (Stiell et al. 1993) results in a decline of the routinely X-rays to about 25 % (Pijnenburg et al. 2002; Stiell et al. 1994, 1995). When the Ottawa ankle rules are routinely applied, this means that the a priori chance of detecting an ankle fracture, in the group of patients where X-rays are made, rises. In spite of this, when dealing with (semi)professional athletes, routine X-rays usually are made in the majority of cases, thereby neglecting the Ottawa ankle rules. Defensive medicine is probably the reason for this phenomenon.

2.2.2 Chronic Injuries

The second issue concerns the routine X-ray. A routine weight-bearing X-ray of both ankles in the anteroposterior (AP) and lateral direction is always the first step in the diagnostic workup (Fig. 2.1). Degenerative changes caused by former accidents or by repetitive high load are often present in the ankle joint. This is especially true in athletes. A routine X-ray of the ankle should always be a weight-bearing view in the anteroposterior and lateral direction, comparing the involved joint to the contralateral unaffected joint.

Fig. 2.1

Routine weight-bearing X-rays of both ankles in AP and lateral direction

2.3 Additional Diagnostics: General Considerations

The orthopedic surgeon should provide the radiologist with sufficient information in order to decide to choose the best imaging technique. Written information is always important but not always sufficient. Mutual consideration of the outcome and direct consultation between the radiologist and orthopedic surgeon can be helpful to choose the best strategy (Van Dijk and De Leeuw 2007).

2.3.1 Acute Injuries

In an acute injury the first objective is to detect or rule out a fracture or avulsion. Other important questions are as follows: is the cartilage involved or are there signs of soft tissue pathology as, for instance, ligament damage (Van den Bekerom et al. 2009)? One important question to the radiologist is whether the detected changes are old or new: is the bony fragment a fresh avulsion or is it an older ossicle? Are there signs of edema and a partial rupture or is the thickening of the tissue part of an older fibrosis?

2.3.2 Chronic Injuries

Concerning chronic overuse injuries, it is important to differentiate between:

1.

Articular or periarticular problems

2.

Pathology associated with long bones

3.

Soft tissue injury

Chronic (peri)articular problems are usually posttraumatic. Knowledge about the initial trauma is important. Routine bone imaging involves detection of osteomyelitis, deformities, stress fractures or tumors. Soft tissue injuries can be differentiated in muscle/tendon injuries and bursitis. Concerning muscle/tendon injuries, imaging is directed towards detection of tendinitis, a (partial) rupture, a paratendinitis, fibrosis, or calcifications. The extent and location of the injury as well as the differentiation between old or fresh injuries is important.

Diagnostics in Athletes

Athletes are a special type of patients. In general the athlete is a highly

motivated person that does not want to waste any time with recovering. They are keen to resume their sport activity as soon as possible. When working with athletes there is always a time pressure. Moreover they are surrounded by a group of caring people such as parents, coaches, and sport physiotherapists. They all have their own interest, knowledge, and influence on the patient. As a consequence, any delay in diagnosis is not accepted. Often these patients enter our outpatient department with an MRI that has already been made, while already having made an appointment for a subsequent second or third opinion. When dealing with professional athletes, it is mandatory to provide services without any delay. This can interfere with services that need to be provided to the rest of the orthopedic population. It is therefore important to have agreement on why, how, and for which category of patients these services are applicable. Both the orthopedic department and the radiology department should feel comfortable with the situation.

Why is it interesting to be involved in the treatment of athletes? The success or failure of our treatment can easily be monitored by the completeness and quickness of their return to the former level of competition. This direct feedback is to a lower extent present in ordinary patients. Seemingly small lesions can hinder a patient’s performance. Knowledge of the sometimes sport-specific lesions is important and can easily be overlooked or neglected. Some of these lesions are self-limiting and with time the natural recovery is benign. However, the time span of a professional athlete’s career is short and consequently there is no time to wait for the natural recovery. On the other hand, it is important to realize that posttraumatic injuries and degenerative changes are part of any (professional) sports career.

2.3.3 Chronic Injuries in Athletes

There are several reasons why the orthopedic surgeon asks for radiological diagnostics when dealing with athletes. The reasons can be divided as follows:

1.

Routine X-ray.

2.

X-ray to confirm a clinical diagnosis.

3.

There is no firm clinical diagnosis and the orthopedic surgeon is searching for a clue/pathology.

4.

There is no firm clinical diagnosis and the orthopedic surgeon is searching for confirmation of the negative clinical findings, i.e., medicolegal reasons.

5.

To explain the diagnosis to the patient.

6.

Staging of disease in order to serve as a guideline for prognosis or to direct the treatment.

7.

Preoperative planning.

The radiologist must be informed by the clinician about the reason for additional diagnostic demands. There is a major difference between imaging techniques used for diagnosis and imaging techniques used for preoperative planning. Techniques serving the goal of preoperative planning require the images being easily interpreted by the orthopedic surgeon. Since the orthopedic surgeon is capable of reading plain X-rays, these routine or special X-rays, like oblique views, usually provide the most valuable information. Second best is a CT scan. A spiral CT scan with reconstruction in three directions provides images that can be interpreted by an orthopedic surgeon (Fig. 2.2). In combination with the routine standard X-rays, it is possible for him or her to reconstruct the location and extent of the injury. This facilitates the surgical approach and the detection of the lesion during the surgery. For (peri)articular and bony lesions, MRI bone scan or ultrasound is more difficult to interpret (and reconstruct), resulting in a more difficult guidance in preoperative planning (Fig. 2.3). Assessing the best strategy requires regular consultation between the orthopedic surgeon and the radiologist. Moreover, in specific situations mutual consideration of a specific patient problem can be helpful to use the correct imaging technique.

Fig. 2.2

A spiral CT scan with axial (a) slices 0.5 mm and sagittal (b) and coronal (c) reconstruction (MPR) of 2 mm provides images that can be interpreted by the orthopedic surgeon. In this case an osteochondral defect of the lateral talus (arrowheads) is present in all three directions

Fig. 2.3

Sagittal image of the ankle in a patient with an osteochondral defect and additionally an intra-articular loose body. (a) Sagittal CT reconstruction showing the exact size of the osteochondral defect in the talus (arrowhead) including a small (more posterior located) intra-articular loose body (small arrow). (b) MRI image at the same location demonstrates the osteochondral defect (arrowhead). Because of bone edema, the size and location are more difficult to judge. The intra-articular loose body (small arrow) is better visualized on the CT scan

2.4 Additional Diagnostics Subdivided for Type of Pathology

In the following paragraph, some considerations and examples are given concerning additional diagnostics in specific problems like ankle impingement, osteochondral defect, lateral ankle instability, and syndesmotic instability.

2.4.1 Ankle Impingement

Anterior ankle impingement is a pain syndrome. It is characterized by anterior ankle pain on activity. On investigation, there is pain on palpation at the anteromedial and/or anterolateral aspect of the ankle joint. Some swelling and/or limitation of dorsiflexion is present. A plain radiograph can disclose the cause of the impingement. In case of spurs or osteophytes, the diagnosis is anterior bony impingement. In an early stage the lateral X-ray shows roughening of the anterior aspect of the lower end of the distal tibia (Fig. 2.4). Later a bony ridge may extend forward (Fig. 2.5). A similar bony outgrowth can be seen projecting upward and slightly backward from the neck of the talus (Fig. 2.6). The radiographic appearance is suggestive of osteoarthritis with lipping of the articular margin of the tibia, but in fact there is no involvement of the articular surfaces and there is usually no joint space narrowing (McMurray 1950) (Fig. 2.7). In absence of spurs or osteophytes, the diagnosis is anterior soft tissue impingement. In patients with anteromedial impingement, the plain radiographs are often false negative. On the standard lateral radiograph, medially located talar osteophytes and medially located tibial osteophytes may remain undetected due to overprojection or superimposition of the lateral part of the talar neck and body, which results in a diagnosis of anterior soft tissue impingement, although an osteophyte, ossicle, or posttraumatic calcification may be present. Ossicles or bone spurs may also remain undetected at arthroscopy due to the overlying synovitis and scar tissue that often accompany these bone lesions (Ray et al. 1994; Van Dijk et al. 2002).

Fig. 2.4

AP and lateral X-ray with roughening of the anterior cortex of the distal tibia (arrowhead) as a first stage of bony anterior ankle impingement

Fig. 2.5

Lateral X-ray in a patient with an anterior ankle impingement after an ankle fracture: a clear anterior bony ridge (arrowheads) is present

Fig. 2.6

Patient with talar osteophytes (arrowheads) as a cause of a bony anterior ankle impingement

Fig. 2.7

Patient with bony anterior ankle impingement. On the lateral X-ray the typical anterior bony spur is visible (arrowhead). There is no joint space narrowing

Detection of these osteophytes, ossicles, or posttraumatic calcification is important for a precise diagnosis and preoperative planning. The oblique anteromedial impingement view (AMI view) is recommended in these patients. In this view, the beam is tilted in a 45° craniocaudal direction with the leg in 30° external rotation and the foot in slight plantar flexion in relation to the standard lateral radiograph position (Fig. 2.8).

Fig. 2.8

Model of an ankle joint with red clay representing an anteromedial osteophyte on the anteromedial surface of the distal tibia and the anterior part of the medial malleolus. A K-wire is applied through the center of the medial malleolus and the center of the lateral malleolus. The direction of this K-wire is the direction of the X-ray beam in a standard lateral ankle X-ray (also see Fig. 2.1). (a) As seen on the lateral projection, the red osteophyte is invisible (arrow). (b) View as seen from a proximal direction: the K-wire is clearly visible. The most anterior part of the distal tibia is the lateral anterior cortex (arrow). The anteromedial cortex is located more posterior. The anteromedial osteophyte is therefore not visible on the lateral X-ray. (c) Oblique view of the same specimen without osteophyte. (d) Oblique view of the same specimen with osteophyte. The osteophyte now is clearly present. (e) The direction of view as represented in (d) is shown here. The 45/30° ankle AMI view: position of the foot relative to the radiograph beam. Starting from a standard lateral view, the radiographic beam is tilted into a 45° craniocaudal position with the foot in 30° of external rotation. The patient is asked to place the foot in the plantar-flexed position. The heel is placed on a 2 cm high shelf. (f) The camera is rotated 10°, parallel to the anterior contour of the foot/ankle. The radiographic beam is centered just anterior to the lateral malleolus. A high-contrast mammography film is used. This film is underexposed to 50 % of a standard ankle radiograph

It has been shown that the standard lateral projection is capable of detecting only 40 % of the tibial and 32 % of the talar osteophytes (Tol et al. 2004). With the combination of AMI view radiographs, the percentage of detected tibial and talar osteophytes increased to 85 and 73 %, respectively, due to the high sensitivity of the AMI view radiographs for detecting anteromedial osteophytes (specificity 93 and 67 %) These AMI view radiographs have a high accuracy for detecting anteromedially located osteophytes.

2.4.2 Osteoarthritis

Osteophytes without joint space narrowing are not a manifestation of osteoarthritis, and subsequently a normal joint remains after removal of these spurs. Since none of the existing scoring systems take this aspect into account, we developed a classification for ankle osteoarthritic changes that is different from existing systems grading for osteoarthrosis (Bargon 1978; Hermodsson 1983). Two categories with (grade II) or without (grade 0/I) joint space narrowing on the radiographs were compared and tested for the various variables (Figs. 2.9, 2.10 and 2.11). In accordance with the literature, patients with grade III arthrosis were considered to be unsuitable for arthroscopic debridement (Biedert 1991; Demazière and Ogilvie-Harris 1991). Validation of these scoring systems for anterior ankle impingement was performed in a prospective study which included 69 consecutive patients (Van Dijk et al. 1997b).

Fig. 2.9

Routine anterior medial impingement view (AMI view) in a normal patient. There is no osteophyte on the talus or medial malleolus

Fig. 2.10

Patient with posttraumatic anteromedial ankle pain. (a) The lateral X-ray does not show an osteophyte (maybe just minimally) on the distal tibia (arrowhead). (b) The anteromedial impingement (AMI) view clearly shows an osteophyte on the medial border of the distal tibia, on the anterior side of the medial malleolus, and on the talus as well (arrowheads)

Fig. 2.11

AP and lateral (a and b) X-ray of a patient 17 years after ankle fracture. On the lateral, as well as on the AP X-ray, there is joint space narrowing and osteophytes in the anterior aspect of the ankle joint (arrowheads). This represents a grade II lesion

Results of this study showed that the osteoarthritic classification proved to be more discriminative than the existing impingement classification as a predicting value for the outcome of arthroscopic surgery for anterior ankle impingement (Table 2.1).

Table 2.1

Classification of osteoarthritic changes of the ankle joint (Van Dijk 1997b)

2.4.3 Osteochondral Defect

The patient typically experiences deep ankle pain on or after activity. On examination chronic cases can show surprisingly little abnormality (Van Dijk et al. 2010). These ankles can have a normal range of motion with absence of swelling and absence of recognizable tenderness on palpation. The standard radiographs may show an area of detached bone, surrounded by a radiolucency. Initially the damage may be too small to be visualized on a routine X-ray. Often a routine AP and lateral X-ray is negative. An anterior to posterior (AP) weight-bearing mortise view with a heel rise of 4 cm has demonstrated to be the best strategy for detection of an osteochondral defect (Verhagen et al. 2005) (Figs. 2.12 and 2.13).

Fig. 2.12

(a, b) Lateral and AP X-ray of a patient with deep ankle pain caused by an osteochondral defect of the medial talar dome. (c) Heel rise view of the same patient, clearly showing the osteochondral defect of the medial talar dome (arrowhead). Note the difference with the routine AP view (b)

Fig. 2.13

Anatomical dissection (osteoarticular layer) showing an osteochondral defect in the medial talar dome. 1 Osteochondral defect. 2 Lateral malleolus. 3 Medial malleolus. 4 Notch of Harty. 5 Superior articular surface of the talus (talar dome). 6 Medial articular surface of the talus. 7 Anterior tibiofibular ligament. 8 Distal fascicle of the anterior tibiofibular ligament. 9 Anterior talofibular ligament. 10 Superficial layer of the medial collateral ligament. 11 Deep layer of the medial collateral ligament. 12 Tibialis posterior tendon (With kind permission of © Pau Golanó 2013)

In our study routine radiographs missed 41 % of the osteochondral defects. This is comparable with the findings in other studies (Flick and Gould 1985, Hepple et al. 1999).

The diagnostic odds ratio more than doubled by adding a mortise view (Verhagen et al. 2005). In case of clinical suspicion of an osteochondral defect and negative routine X-rays for further diagnostic evaluation, a CT scan and MRI have demonstrated to have a similar accuracy. In our study 81 % of osteochondral defects were identified on CT scan correctly (Verhagen et al. 2005). Only five false-negative cases were found in 29 OCD patients. Four of these were pure chondral lesions without bony involvement. Since the cause of the pain lies in the bone, the relevance of detecting these lesions is questionable (Van Dijk et al. 2010; Madry et al. 2010). MRI allows visualization of the overlying abnormalities in the cartilage, but it is not as useful in showing the exact cortical outlines. The true extent of the lesion can be obscured by concomitant bone marrow edema. The diameter of the osteochondral defect as measured on MRI can exceed the true diameter (Lahm et al. 2000) (Fig. 2.3).

Detection of the exact location and size of the lesions is important to guide the surgical approach and type of treatment. The size and location of the lesion determine whether to use:

1.

Mechanical distraction

2.

Treatment of the osteochondral defect in the anterior working area by full plantar flexion of the ankle

3.

Approach from posterior by means of a two-portal hindfoot approach

4.

Open approach by means of a malleolar osteotomy for medial lesions or detachment of ATFL for lateral lesions

A posterior osteochondral defect cannot be reached in the plantar-flexed position in patients having a diminished range of motion (diminished plantar flexion compared to the other ankle) or when the defect is in an extreme posterior location. In these cases we must decide between a two-portal arthroscopic hindfoot approach or an open approach by means of a malleolar osteotomy for medial lesions or detachment of ATFL for lateral lesions.

Concerning diagnostics we have shown that compared to CT scan and MRI, diagnostic arthroscopy by an experienced orthopedic surgeon has the highest sensitivity (1, 0) and specificity (0, 97). The advantage of diagnostic arthroscopy over radiological methods is that not only inspection of the cartilage is possible, but palpation with a probe can determine whether a soft spot or delaminated areas are present (Lahm et al. 2000).

Furthermore, once an osteochondral defect has been determined, it can be treated during the same procedure. In general we advise not to go for a diagnostic arthroscopy in case of OCD suspicion. For preoperative planning we advise to perform a CT scan with reconstruction in the coronal and sagittal plane (Figs. 2.14 and 2.15).

Fig. 2.14

Patient with deep ankle pain. The routine AP X-ray shows a radiolucent area in the medial talar dome (arrowhead) (a). The axial view (b), coronal view (c), and sagittal view (d) clearly show the exact location and size of the lesion (arrowheads)

Fig. 2.15

Patient with deep ankle pain and recognizable tenderness at the level of the medial malleolus. The AP view (a) shows a lucent area in the lateral talar dome (arrowhead) and an ossicle at the level of the medial malleolus (asterisk). The CT scan shows the extent of the lesion (arrowheads) (b–d). The CT scan shows the exact location of the ossicle underneath the medial malleolus (asterisk) (e). The deep ankle pain is caused by the OCD (arrowheads). The recognizable tenderness on palpation is caused by the ossicle (asterisk)

MRI Protocol

MRI without intravenous or intra-articular contrast is performed with the ankle placed in a circularly polarized head coil. This coil provides the best signal-to-noise ratio (Maas et al. 1999). The imaging protocol consists of a sagittal STIR; T1-weighted SE; sagittal, coronal, and axial FSE (fast spin echo) dual-echo sequences (3 mm); and DESS (dual-echo steady state) 3D with reformatted images in the coronal and axial planes (2 mm).

Helical CT Scan

High-resolution multi-detector helical CT is performed using a dual-helix CT (Elscint Twin Flash, Haifa, Israel or Picker MX Twin Flash, Cleveland, Ohio). Axial data acquisition was performed with 0.5-mm slices. Both coronal and sagittal reformatted images of 2 mm were reconstructed.

2.4.4 Acute Lateral Ankle Ligament Lesion

Until the 1960s physical examination was used to distinguish between a distortion and a lateral ankle ligament rupture. Physical examination was thought to give an unreliable outcome (Percy et al. 1969; Sanders 1976; Volkov et al. 1973; Broström et al. 1965; Rechfeld 1976; Lindstrand 1977) which resulted in the development of stress radiographs. Stress radiographs have shown a poor reliability with a sensitivity of 50 % and a specificity of 96 %. In the 1970s operative treatment became the treatment of choice. Since stress radiographs were found to be unreliable, arthrography of the ankle was introduced (Ahuovuo et al. 1977; Johannsen 1978; Van Moppes and Van den Hoogenband 1982). Arthrography is an invasive examination and therefore not without risks. Potential complications are bacterial arthritis, allergic reactions, or chemical arthritis. Concerning treatment, in the 1980s functional treatment was found to be cost-effective. This led to the development of new noninvasive investigations as echography and MRI. The reliability of physical examination can be enhanced when the investigation is repeated a few (4–5) days after the trauma. The specificity and sensitivity of this delayed physical examination for the presence or absence of a lateral ankle ligament rupture have been determined to be 84 and 96 %, respectively (Van Dijk et al. 1996a, b, 1997a; Van Dijk 1994).

The interobserver variation is good with an average kappa value of 0.7.

2.4.4.1 History Taking

Systematic analysis of the history and physical signs after a supination trauma has shown the following: A cracking sound at the time of injury does not discriminate between a rupture and no rupture. The feeling that the ankle bent double during injury does not discriminate between a rupture and no rupture. There is a difference in intensity of pain: patients with ruptures are more frequently compelled to stop with their activity, while patients without a rupture more frequently can continue their activity. Concerning the extent of swelling, patients with a rupture report more frequent immediate swelling, while in patients without a rupture, the swelling appears later.

2.4.4.2 Physical Examination

Until the 1960s physical examination was used to distinguish between a distortion and a lateral ankle ligament rupture. Physical examination was thought to give an unreliable outcome (Percy et al. 1969; Sanders 1976; Volkov et al. 1973; Broström et al. 1965; Rechfeld 1976; Lindstrand 1977). The reliability of physical examination can be enhanced when the investigation is repeated a few (4–5) days after the trauma. The specificity and sensitivity of this delayed physical examination for the presence or absence of a lateral ankle ligament rupture have been determined to be 84 and 96 %, respectively (Van Dijk et al. 1996a, b, 1997a; Van Dijk 1994).

The interobserver variation is good with an average kappa value of 0.7.

Delayed physical examination (4–5 days after trauma) is currently regarded to be the gold standard in diagnostics for detection of an acute lateral ankle ligament rupture.

The following observations can be made at delayed physical examination:

1.

Single findings related to the presence or absence of a lateral ligament rupture:

(a)

Swelling: patients with a rupture have more swelling than patients without a rupture PV+: 70–87 %.

(b)

Pain on palpation: if there is no pain on palpation over the ATFL, there is no acute lateral ankle ligament rupture! Pain over the ATFL on the other hand has a low specificity.

2.

Combination of findings related to the diagnosis of a rupture:

The combination of pain on palpation over the ATFL, positive hematoma discoloration, and a positive anterior drawer test has a high sensitivity of 98 % and a good specificity of 84 % for the prediction of acute lateral ankle ligament rupture. These results are not surpassed by the result of arthrography. Delayed physical examination is therefore recommended to distinguish between a patient with an acute ankle ligament rupture and a patient with intact ligament (see Figs. 9.​9, 9.​10, 9.​12, and 9.​13).

3.

Findings in patients with an acute lateral ligament rupture not related to the diagnosis:

(a)

Medial pain: 60 % of patients with an acute lateral ankle ligament rupture have pain on palpation at the level of the medial malleolus (Fig. 2.16).

Fig. 2.16

Patient with persistent medial ankle pain after supination trauma 12 weeks before. The lateral ligament rupture has healed, but there is recognizable tenderness at the tip of the medial malleolus. (a) The X-ray shows a small avulsion of the medial talar facet (arrowhead). (b) The technetium bone scan shows a hot spot at the tip of the medial malleolus and the medial talar facet. The two hot spots as seen on the bone scan are the result of compression at the time of the supination trauma (kissing lesion). (c) Demonstrates the mechanism of compression on the medial side that takes place with every supination trauma (arrowheads). (d) Represents the result of 30 consecutive patients on which ankle arthroscopies were performed 5 days after trauma. Cartilage damage was present in the majority of cases and especially on the tip of the medial malleolus (15 cases) and the opposite medial talar facet (10 cases). One patient had a cartilage flake on the medial side of the talar dome and one on the lateral side. These were pure chondral lesions. In 6 patients there was a loose cartilage fragment floating inside the joint. (e) Example of a patient 4 days after acute lateral ligament rupture. Arthroscopy was performed 7 days after the trauma, showing the cartilage lesion on the tip of the medial malleolus (arrowheads)

(b)

Syndesmotic pain: 40 % of patients with an acute lateral ankle ligament rupture have pain over the anterior syndesmotic ligament without a rupture of this ligament being present.

(c)

Hematoma: hematoma discoloration is a predictor for a lateral ankle ligament rupture—86 % sensitivity and 68 % specificity.

(d)

Anterior drawer test: the sensitivity of the anterior drawer test is 74 % with a specificity of 77 %. The anterior drawer test is best performed with the knee in 90° of flexion and full relaxation of the surrounding muscles.

2.4.4.3 Additional Diagnostics?

In case of the clinical diagnosis of an acute lateral ankle ligament rupture, it is questionable whether additional diagnostics should be asked for. It has been demonstrated that delayed physical examination has the highest accuracy (Van Dijk et al. 1996a, b). The average sensitivity of stress X-rays with the anterior drawer test is 49 % with an average specificity of 82 % and an average false-negative value of 37 %. The average sensitivity of stress X-rays with the talar tilt test is 52 % with an average specificity of 93 % and an average false-negative value of 32 % (Pijnenburg 2006). A recent meta-analysis has shown to favor functional treatment with a lace-up brace or semirigid brace (Kerkhoffs et al. 2003). With this type of treatment, our diagnostic strategy should have a high sensitivity with a reasonable specificity. Overtreatment is less of an issue than undertreatment. Delayed physical examination serves this goal and there is no need for additional diagnostics. In high-demand patients, such as athletes, however, it has been shown that operative treatment of an acute lateral ligament rupture is beneficial (Pijnenburg et al. 2000, 2003). To decide for operative treatment, our diagnostic strategy requires a high specificity. Arthrography serves this goal (Van Dijk et al. 1998). MRI has not been investigated extensively, but it can be expected to be acquainted with a high specificity.

2.4.5 Chronic Ankle Instability

Clinical tests for acute and chronic ankle instability can be divided into the talar tilt test and anterior drawer test. The talar tilt test is clinically impracticable and most often unreliable (Van Dijk et al. 1996a; Van Dijk 1994, 1999).

The anterior talofibular ligament is the most important stabilizer of the ankle joint. It is the first ligament to rupture during an inversion trauma. Therefore, the anterior drawer test is the most important test for detection of acute and chronic ankle instability (Van Dijk 1994; Van Dijk et al. 1996a). Increased anterior translation of the talus in the talocrural joint can occur when the anterior talofibular ligament is ruptured or elongated. There are several ways of performing an anterior drawer test (Van Dijk 1994). In most test situations the foot is moved only anteriorly relative to the tibia. The ankle is placed in slight plantar flexion. This is an incorrect way to perform the anterior drawer test and is associated with a higher risk of false-negative test results. It has been shown that the anterior drawer is not a straightforward translation of the talus in relation to the tibia but that it is a rotatory movement (Van Dijk 1994). This rotation is caused by the intact deltoid ligament which prevents the talus to move forward on the medial side. The anterior drawer test should therefore be a combination of a straightforward translation and internal rotation movement (Kerkhoffs et al. 2005).

Standardized stress radiographs can be used in both differential diagnostic evaluation and assessment of therapy. Their main drawback is the limited correlation between functional stability and increased laxity.

The two radiographic tests which are used are the lateral instability/laxity test (talar tilt) and the anterior instability/laxity test (anterior talar translation). Increased laxity can be defined either as a single value of anterior talar translation >10 mm or talar tilt >9°. Another way of defining increased laxity is a difference of anterior talar translation >3 mm. This is the difference in anterior talar translation between the functionally unstable ankle and the contralateral ankle. Concerning talar tilt the ankle is unstable if there is a talar tilt >3° in patients with unilateral instability (Karlsson 1989; Karlsson et al. 1991). A good correlation between functional and mechanical instability has been shown in some studies, but this correlation is highly variable, since several factors other than mechanical instability can be responsible for the development of functional instability. Several studies have questioned the reliability of stress radiographs, especially the measurements of talar tilt (Karlsson 1989; Karlsson et al. 1991). Ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) have been used to delineate the extent of damage to the ankle ligaments. US can be useful as a screening modality, especially when there is a discrepancy between clinical and radiological examinations after trauma. US is cheap and noninvasive (Friedrich et al. 1993; Van Dijk et al. 1996b). However, like CT and MRI, US is unable to demonstrate ligament laxity. Both these modalities are rather little used in patients with chronic ankle instability.

2.4.6 Syndesmotic Injuries

Syndesmotic injuries can be divided into acute and chronic injuries.

2.4.6.1 Acute Syndesmotic Injuries

To differentiate between a total rupture and a partial rupture, the history of the injury is the most important. It is only the patient that can tell you the problem: the patient is always right. The typical injury mechanism for a total rupture is external rotation of the foot and (hyper)dorsiflexion of the ankle in combination with axial loading (Fig. 2.17). A partial rupture can be a result of a supination trauma. Was the patient able to stand on the leg (Ottawa ankle rules), was there any