Full Book Sports Injuries in F& A

Sports Injuries of the Foot and Ankle
,
Gian Luigi Canata • Pieter d Hooghe
Kenneth J. Hunt • Gino M. M. J. Kerkhoffs
Umile Giuseppe Longo
Editors
Sports Injuries of the

Foot and Ankle
A Focus on Advanced Surgical
Techniques
Editors
Gian Luigi Canata Pieter d'Hooghe
Koelliker Hospital Department of Orthopaedic Surgery
Centre of Sports Traumatology Aspetar Hospital
Koelliker Hospital Doha
Torino Qatar
Italy
Gino M. M. J. Kerkhoffs
Kenneth J. Hunt Department of Orthopedic Surgery
Department of Orthopedics University of Amsterdam
University of Colorado Hospital Academic Medical Center
Aurora, CO Amsterdam Zuidoost
USA Noord-Holland
The Netherlands
Umile GiuseppeLongo
Orthopaedics and Traumatology Unit
University Campus Biomedico
Roma
Italy
ISBN 978-3-662-58703-4 ISBN 978-3-662-58704-1 (eBook)

https://doi.org/10.1007/978-3-662-58704-1
Library of Congress Control Number: 2019935194
© ISAKOS 2019
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Foreword AU1
This book, Sports Injuries of the Foot and Ankle: A Focus on Advanced
Surgical Techniques by the Leg, Ankle and Foot (LAF) Committee of
ISAKOS, is quintessential ISAKOS. This is a comprehensive book that should
be in the library of every surgeon who operates on injuries to the foot and
ankle, athlete or not. It is edited by an internationally acclaimed group of
sports foot and ankle surgeons, Gian-Luigi Canata from Italy, Pieter
D’Hooghe from Qatar, Ken Hunt from the USA, Giuseppe Longo from Italy,
and Gino Kerkhoff from the Netherlands, and includes contributions from
esteemed and internationally recognized experts from all over the world—
true international authorities on the management of foot and ankle problems
in athletes. The work and effort put into this book by the editors and authors,
along with beautiful original illustrations, will make it the new standard by
which foot and ankle surgical technique books will be measured.
This book represents some of what is best about ISAKOS—international
experts, leaders in the field, not just in their respective country, but recog-
nized all over the world, coming together to share thoughts, ideas, and con-
cepts, to help advance the field and to make the world just a bit closer.
Collaboration, whether at the biennial meeting, at committee meetings, and at
interim offsite meetings, with research, state-of-the-art papers, and publica-
tions, like this one, is the heart of ISAKOS. It is a brotherhood (for lack of a
better gender neutral term), friendship, and sort of family.
The authors provide a comprehensive look at the different parts of the foot
and ankle from a variety of perspectives. They introduce newer, cutting-edge
techniques, along with the standard “tried and true” surgeries. They span the
gamut of techniques, from the basics to complex, in a comprehensive, well-
illustrated methodology. Each technique is described in detail to help the
orthopedic surgeon perform it accurately and safely.
But more than just a surgical technique book, they discuss important top-
ics such as the anatomy, biology, surgical outcomes, and footwear consider-
ations. They also discuss newer areas in evolution, such as tissue engineering,
and the ever important area of rehabilitation following these surgeries.
Drs. Canata, D’Hooghe, Hunt, Longo, and Kerkhoff, as members of the
Leg, Ankle and Foot Committee of ISAKOS, have brought together a talented
and respected group of foot and ankle specialists from the LAF Committee
and other ISAKOS members and must be commended for the exceptional
quality of this book and be congratulated for a job well done. This book will
v
vi Foreword
be valuable to all surgeons who care for foot and ankle problems, particularly
those who care for athletes with foot and ankle problems.
With the help and guidance of João Espregueira-Mendes, the head of the
Publications Committee, it has been a huge endeavor. I am honored that it has
been initiated and completed during my tenure as president. The authors, and
editors, are to be congratulated for a Herculean effort and a book that sets a
new standard.
Marc R. Safran
ISAKOS
Stanford, CA, USA
2017–2019
Preface
This book is an update on current techniques for the treatment of foot and AU2
ankle injuries and conditions in the athletic patient. It is meant to serve as a
current and comprehensive review of the state of the art, with an international
perspective. Each chapter is written by orthopedic surgeons expert in the
field, sharing their experience treating specific injuries and conditions,
cutting-edge surgical procedures, and injury management strategies. Several
different techniques are described step-by-step, easing the reader to thor-
oughly understand what the surgeon is doing getting information on details.
ISAKOS is devoted to its mission of disseminating knowledge to the
world of orthopedics and sports medicine. Through committees like the Leg,
Ankle, and Foot (LAF) Committee represented herein, ISAKOS continu-
ously works to help its membership, and the orthopedic and sports medicine
communities it serves, to strive to improve the art, optimize the delivery of
care worldwide, and seek at all times the best interest and outcomes of the
patient.
The editors extend a sincere thanks to all the authors for their outstanding
contributions and to ISAKOS for its steadfast and unwavering support for this
project.
Torino, Italy Gian Luigi Canata

Doha, Qatar Pieter d’Hooghe
Aurora, CO Kenneth J. Hunt
Amsterdam, Netherlands Gino M. M. J. Kerkhoffs
Rome, Italy Umile Giuseppe Longo
vii
Acknowledgments
We are extremely grateful for the contribution of the authors who dedicated
their time, knowledge, and expertise to this project.
We owe a debt of gratitude to:
Pontus Andersson for his outstanding illustrations.
Catena Cottone who kept close and continuous contacts with the authors
and Springer.
ISAKOS leadership and staff for consistent, constant, and extraordinary
support and encouragement. We wish to extend a special thank you to Marc
Safran, current ISAKOS President; João Espregueira-Mendes, Publications
Committee Chair; Jon Karlsson, Secretary; and Michele Johnson, Executive
Director.
Dhanapal Palanisamy, Gabriele Schroeder, and Springer for their profes-
sional work and dedication.
Our families for their enduring support and patience.
ix
Contents
Part I Ligament Injuries
1 Acute Ankle Ligament Injuries�� 3

Kenneth J. Hunt and Peter Lawson
2 Lateral Endoscopy of the Ankle�� 13
Stéphane Guillo
3 All-Inside Endoscopic Broström-Gould Procedure
for Chronic Ankle Instability�� 21
Haruki Odagiri, Stéphane Guillo, and Thomas Bauer
4 Arthroscopic Ligament Repair and Reconstruction�� 29
Masato Takao, Mai Katakura, and Yasuyuki Jujo
5 Mini-Incision Technique for Lateral Ankle
Ligament Repair in Chronic Instability�� 45
Gian Luigi Canata, Valentina Casale, and Luca Pulici
6 Syndesmosis Injuries �� 57
Pieter D’Hooghe
7 Subtalar Joint Instability�� 77
Vincenzo Candela, Umile Giuseppe Longo,
Giuseppe Salvatore, Alessandra Berton, Nicola Maffulli,
and Vincenzo Denaro
8 Lisfranc Complex Injuries�� 85
Samuel O. Ewalefo, Stephanie M. Jones, Lorraine Boakye,
Arthur R. McDowell, Scott Nimmons, Jorge L. Rocha,
Humza Shaik, and MaCalus V. Hogan
Part II Cartilage
9 Cartilage Techniques for Osteochondral Lesions

of the Talus�� 105
Eoghan T. Hurley, Yoshiharu Shimozono,
and John G. Kennedy
xi
xii Contents
10 Tissue Engineering for the Cartilage Repair of the Ankle �� 119
Alberto Gobbi, Stefan Nehrer, Markus Neubauer,
and Katarzyna Herman
11 New and Emerging Techniques in Cartilage Repair:
Matrix-Induced Autologous Chondrocyte
Implantation (MACI)�� 125
Jonathan J. Berkowitz and Richard D. Ferkel
12 Osteochondral Lesions of the Talus�� 133
P. A. D. van Dijk and C. N. van Dijk
13 Lift, Drill, Fill, and Fix (LDFF): A New Arthroscopic
Treatment for Talar Osteochondral Defects�� 141
Jari Dahmen, J. Nienke Altink, Mikel L. Reilingh,
and Gino M. M. J. Kerkhoffs
14 One-Stage Treatment for Osteochondral Lesion of the Talus�� 149
Bogusław Sadlik, Alberto Gobbi, Karol Pałka,
and Katarzyna Herman
Part III Bone and Joint Injuries
15 Ankle Fractures�� 161

Shinji Isomoto, Kazuya Sugimoto, and Yasuhito Tanaka
16 Ankle Fractures and Return to Sports in Athletes:
“Does Arthroscopy Add Value to the Treatment?” �� 167
Pieter D’Hooghe, Fadi Bouri, Akis Eleftheriou,
Thomas P. A. Baltes, and Khalid Alkhelaifi
17 Arthroscopic Treatment of Anterior
Ankle Impingement �� 183
Thomas Bauer
18 Posterior Impingement and Os Trigonum�� 191
Hélder Pereira, Jorge Batista, Duarte Sousa,
Sérgio Gomes, J. P. Pereira, and Pedro L. Ripoll
19 Advanced Techniques in Arthroscopy of the Foot�� 207
Alastair Younger, Andrea Veljkovic, Michael Symes,
and Wafa Al Baluki
20 Ankle Alignment Procedures�� 223
F. Vannini, A. Mazzotti, A. Panciera, B. D. Bulzacki Bogucki,
S. Giannini, and C. Faldini
21 Current Concepts in the Treatment of Osteoarthritis
of the Ankle�� 237
Yasuhito Tanaka
Contents xiii
22 Jones Fractures�� 249

K. C. Doan and Kenneth J. Hunt
23 Hallux Rigidus�� 259
Stephanie L. Logterman and Kenneth J. Hunt
24 Hallux Valgus for Athletes �� 265
Yasuhito Tanaka
25 Special Consideration and Perioperative Management
for Turf Toe Injuries�� 273
Monique C. Chambers, Lorraine Boakye,
Arthur R. McDowell, Stephanie M. Jones, Alan Y. Yan,
and MaCalus V. Hogan
26 Ankle Arthroplasty�� 281
Jin Woo Lee and Kwang Hwan Park
Part IV Tendons and Biology
27 Biologics in the Foot and Ankle�� 305

Kimberly Allen, Enrique Feria-Arias, Christopher Kreulen,
and Eric Giza
28 Peroneal Tendon Injuries�� 317
P. A. D. van Dijk, G. M. M. J. Kerkhoffs, and C. N. van Dijk
29 Concept of the Hindfoot Endoscopy�� 327
Jin Woo Lee and Bom Soo Kim
30 Foot and Ankle Tendoscopy�� 337
Phinit Phisitkul, Chris C. Cychosz, and Craig C. Akoh
31 Insertional Achilles Tendinopathy�� 349
Gian Luigi Canata and Valentina Casale
32 Non-insertional Achilles Tendinopathy:
State of the Art�� 359
R. Aicale, D. Tarantino, and N. Maffulli
33 Achilles Tendon Ruptures �� 369
Jon Karlsson, Olof Westin, Mike Carmont,
and Katarina Nilsson-Helander
34 Minimally Invasive Repair of Acute Achilles
Tendon Ruptures Using the Percutaneous Achilles
Repair System (PARS) Arthrex Device�� 377
A. Nguyen and J. Calder
xiv Contents
Part V Special Considerations
35 Outcome�� 387
J. Nienke Altink, Jari Dahmen, Gwendolyn Vuurberg,
and Gino M. M. J. Kerkhoffs
36 Outcomes Assessment for the Athlete�� 393
J. Nienke Altink, Jari Dahmen, and Gino M. M. J. Kerkhoffs
37 Advances in Rehabilitation Techniques �� 399
Konstantinos Epameinontidis, Mohsen Abassi,
and Pieter D’Hooghe
38 Foot Orthotic Advances for the Athlete �� 407
Craig Tanner and Pieter D’Hooghe
Author Queries
Chapter No.: 0004275971
Queries Details Required Author's Response

AU1 Please check and confirm if the author affiliation is correct.
AU2 Please check and confirm whether the author names “Pieter d’Hooghe” and “Umile
Giuseppe Longo” are presented correctly.
Part I 1
Ligament Injuries 2
1 Acute Ankle Ligament Injuries
1
2 Kenneth J. Hunt and Peter Lawson
3 1.1 Introduction department admissions [1]. By other estimates, 26

injury to the lateral ligaments of the ankle joint can 27
4 Acute lateral ligament sprains of the ankle are a account for about 1 in 10,000 people a day [2]. 28
5 common injury for patients and athletes and a bur- Generally, lateral ankle sprains are much more 29
6 densome healthcare issue for hospitals. While in common than syndesmotic and medial ankle 30
7 general a relatively well-understood and treatable sprains [3]. 31
8 injury, lateral ankle sprains and recurrent injuries Rates of incidence vary across gender, race, 32
9 are very common and predictive and prognostic and age—black and white adolescent females are 33
10 factors are still not entirely understood. In the recognized as the populations most at risk for 34
11 treatment of these injuries, it is important for pro- ankle sprains. Racially, black patients and white 35
12 viders to have a clear understanding of injury patients have shown incidence rates three times 36
13 mechanisms and identify patients at risk for recur- greater than Hispanic patients [4]. Generally, 37
14 rent injury and chronic instability. In order to females have shown to be at a higher risk for 38
15 select appropriate treatment strategies, the pro- ankle sprain injury than males, reporting 13.6 vs. 39
16 vider must understand not only the severity of the 6.94 ankle sprain injuries per 1000 exposures [3]. 40
17 injury but also the mechanisms and contributing However, there is some evidence that suggests 41
18 factors that lead to lateral ankle ligament injuries that among patients 15–24 years, males present 42
19 and chronic instability. As new surgical and reha- with higher rates of ankle sprains than females, 43
20 bilitation techniques evolve, understanding of but among patients older than 30 years, females 44
21 both natural and injury mechanics is critical. have higher incidence rates than males [4]. It is 45
important to take into consideration that while 46
lateral ankle sprains are more common among 47
22 1.2 Epidemiology female patients, medial and high ankle sprains 48
generally show lesser or no gender differences 49
23 Ankle sprains continue to be a prevalent and costly [5]. Among youth, children are at higher risk than 50
24 healthcare issue with estimates suggesting that adolescents, and adolescents at higher risk than 51
25 ankle sprains account for 7–10% of emergency adults, reporting 2.85, 1.94, and 0.72 ankle sprain 52
injuries per 1000 exposures, respectively [3]. 53
Sports activities are widely recognized as the 54
K. J. Hunt (*) · P. Lawson
environment where participants are most prone to 55
Department of Orthopaedic Surgery, University of
Colorado School of Medicine, Aurora, CO, USA ankle injuries. This is particularly true of sports 56
e-mail: kenneth.j.hunt@ucdenver.edu that involve jumping and changes in direction. 57
© ISAKOS 2019 3
G. L. Canata et al. (eds.), Sports Injuries of the Foot and Ankle,
https://doi.org/10.1007/978-3-662-58704-1_1
4 K. J. Hunt and P. Lawson
58 Among youth sports, injury to the lateral liga- 24 hours [7]. Alternatively, 3.6% of athletes have 103
59 ments of the ankle joint accounts for approxi- higher grade injuries and require more than 104
60 mately one-fourth of all sports-related injuries 21 days before returning to play, with some 105
61 [2]. Half (49.3%) of ankle sprains occur during unable to return [7]. Thus, it is very important to 106
62 athletic activity, 41.1% of which are associated reduce the incidence, severity, and recurrence of 107
63 specifically with basketball [4]. Analysis of LLC sprains [7]. 108
64 injury risk by gender and sport has shown that
65 female basketball athletes are considered most
66 prone to first-time inversion ankle ligament injury 1.3 Anatomy 109
67 [6]. Male basketball athletes and female lacrosse
68 athletes are also considered high risk to injury The ankle joint complex is multiplanar and is 110
69 [6]. Football and soccer also have high associa- made up of the subtalar (talocalcaneal) joint, the 111
70 tions with ankle sprains [4]. tibiotalar joint, and the transverse-tarsal joint 112
71 Collegiate sports are a more unique domain of [8]. Each of these joints has a particular plane of 113
72 interest as it includes large athlete populations motion and a specific function associated with 114
73 commonly recognized for the higher stakes of it. The subtalar joint allows for ankle inversion 115
74 competition, levels of training, greater athlete and eversion, and the joint is primarily linked 116
75 size, strength and speed, and demand to return to via the interosseous talocalcaneal ligament 117
76 play. It is estimated that among the 25 most com- which connects the inferior articular facet of the 118
77 mon NCAA sports in the United States, there are talus to the articulating facet on the superior sur- 119
78 over 16,000 lateral ligament complex (LLC) face of the calcaneus [8]. The tibiotalar joint pri- 120
79 ankle sprains each year—accounting for approxi- marily functions is a hinge joint, in the 121
80 mately 7.3% of all collegiate sport injuries [7]. plantarflexion and dorsiflexion movements of 122
81 LLC sprains are regarded as the most common the foot [8]. The motion of this joint is limited 123
82 injury in college sports in the United States, by three groups of ligaments—the tibiofibular 124
83 occurring at a frequent rate of 1/2020 syndesmosis, the medial collateral ligaments, 125
84 (4.95/10,000) athlete exposures—more specifi- and the lateral collateral ligaments [8]. The 126
85 cally, the most frequent LLC sprain rates are in transverse-tarsal joint is a combination of articu- 127
86 men’s and women’s basketball, which report at lations between the talus, the calcaneus, and the 128
87 1/836 (11.96/10,000) and 1/1052 (9.5/10,000), navicular, and shares an inversion-eversion axis 129
88 respectively [7]. Recurrence of LLC sprains is of motion in the foot [8]. 130
89 well recognized as an area of importance when Ligaments are an essential structural feature in 131
90 monitoring and treating athletes. Studies have the ankle joints, providing stability and con- 132
91 shown that among collegiate athletes 11.9% of trolled range of motion across each specific joint. 133
92 LLC sprains are attributed to recurrence. The lateral ligament complex of the ankle is 134
93 Recurrent injuries are most frequent in women’s made up of the anterior talofibular ligament 135
94 sports—specifically basketball (21.1%), outdoor (ATFL), the calcaneofibular ligament (CFL), and 136
95 track (21.1%), field hockey (20.0%), and tennis the posterior talofibular ligament (PTFL) [1]. The 137
96 (18.2%) [7]. The sports with the most frequent medial (deltoid) ligament complex of the ankle is 138
97 recurrence rate among males include basketball made up of the deep components—the anterior 139
98 (19.1%), tennis (14.3%), outdoor track (14.3%), tibiotalar ligament (ATTL) and the posterior tib- 140
99 and soccer (14.0%) [7]. Rapid identification and iotalar ligament (PTTL)—and the superficial 141
100 treatment of the competitive athlete is paramount. components—the tibionavicular ligament (TNL), 142
101 Reassuringly, 44.4% of athletes who suffer an the tibiospring ligament (TSL), and the tibiocal- 143
102 LLC sprain are able to return to play within caneal ligament (TCL) [9] (Fig. 1.1). 144
1 Acute Ankle Ligament Injuries 5
Deltoid ligament Posterior talotibeal

ligament
Medial talocalcaneal
Talonavicular ligament
ligament
Posterior talocalcaneal
Second dorsal cuneonavicular ligament
ligament
First dorsal cuneonavicular

ligament
Articular capsule
Medial cuneonavicular ligament

Long plantar ligament
Calcaneocuboid ligament Medial cuneonavicular ligament
Anterior talofibular ligament
Interrosseous talocalcaneal ligament
Dorsal talonavicular ligament
Calcaneonavicular part ligament

Anterior lateral Bifurcated ligament
Calcaneocuboid part ligament
malleolus ligament
Dorsal cuboideonavicular ligament
Posterior lateral Dorsal cuneonavicular ligament
malleolus ligament
Dorsal intercuneiform ligament
Posterior talofibular Dorsal tarsometatarsal ligament
ligament
Calcaneofibular
ligament
Long plantar ligament Dorsal intermetatarsal ligament

Dorsal calcaneocuboid ligament Dorsal tarsometatarsal ligament
Fig. 1.1 Drawing depicting the ligaments on the medial (a) and lateral (b) side of the ankle joint
145 The stability of the ankle joint is multifacto- variable amounts of inversion-eversion (and 190
146 rial—many intrinsic elements (articular geome- abduction-adduction), allowing for more com- 191
147 try) and extrinsic elements (ligaments) contribute plex motions like supination and pronation [8]. 192
148 to supporting the ankle joint [10]. These primary The degree of multi-axial motion throughout the 193
149 contributing elements also depend upon other tibiotalar, subtalar, and transverse-tarsal joints 194
150 factors such as ground condition, loading level, varies depending primarily on the variance in 195
151 and the direction and magnitude of applied forces talar anatomy and tissue stiffness [8]. However, 196
152 when loading and unloading [10]. When consid- typical range of motion for these joints from a 197
153 ering the articular geometry of the ankle, it is neutral stance has been shown to be as much as 198
154 important to recognize that the talus has the bone 20° of dorsiflexion, 55° of plantarflexion, 23° of 199
155 morphology of a truncated cone, where the inversion, and 12° of eversion [8]. 200
156 medial radius of curvature is lesser to the lateral When assessing athletes with acute or chronic 201
157 radius of curvature, but there is variance in the ligament injuries, it is important to understand 202
158 medial-lateral distribution [11]. These structural the fundamentals of a gait mechanics to appreci- 203
159 variances explain the occurrence of high-risk ate the impact, distribution of force, and flexion 204
160 ankles via their alteration in joint mechanics of muscles throughout the gait phases. A normal 205
161 within the ankle [11]. A relatively high bone con- gait is comprised of a stance phase—which is 206
162 gruency across the tibiotalar joint distributes the further subdivided into heel rocker, ankle rocker, 207
163 applied loads across the large load-bearing sur- and forefoot rocker subphases—and a swing 208
164 face area to mitigate impact stress on the ankle— phase [8]. The heel rocker phase begins when the 209
165 some theorize even more effectively than the hip heel strikes the ground and ends when the foot is 210
166 or knee [8]. Regarding stability of the ankle joint, flat—during which the ankle is in a slight plan- 211
167 the value of the high bone congruency has shown tarflexed position, and the dorsiflexor muscles 212
168 that when loaded (1 BW), articular geometry exhibit eccentric contraction [8]. The ankle 213
169 contributes 100% to translational stability and rocker phase is transitional phase from plan- 214
170 60% to rotational stability [10]. Ligamentous sta- tarflexion to dorsiflexion about the tibiotalar joint 215
171 bility is recognized as the other primary element [8]. The forefoot rocker phase begins when the 216
172 contributing to ankle joint stability. The anterior heel of the calcaneus lifts off of the ground and 217
173 stability of the ankle is approximately 70–80% ends when there is toe-off from the ground—this 218
174 dependent upon the lateral ligaments, when is marked at 50% of the gait cycle during which 219
175 unloaded [10]. The posterior stability of the ankle active plantarflexion generates the maximal joint 220
176 is approximately 50–80% dependent upon the power that propels the walker forward [8]. The 221
177 deltoid ligaments, when unloaded [10]. The rota- swing phase activates slight dorsiflexion to better 222
178 tional stability is 50–80% dependent upon both ensure foot clearance of the ground, before 223
179 the lateral and deltoid ligaments, but medial- returning to plantarflexion in the heel rocker 224
180 lateral stability is not primarily dependent upon phase [8]. Inversion complements the plantarflex- 225
181 these ligaments [10]. Due to the unique geometry ion at heel strike, and eversion compliments the 226
182 of the tibiotalar joint, it is recognized that the plantarflexion throughout the forefoot rocker 227
183 ankle is more stable in dorsiflexion and less sta- phase, as both biplanar motions are enabled by 228
184 ble in plantarflexion [10, 12]. the subtalar joint [8]. 229
The load and applied forces are skillfully dis- 230
tributed about the ankle joint throughout ones 231
185 1.4 nkle Joint Complex
A walking gait. The amplitude of the vertical com- 232
186 Biomechanics ponent of the ground reaction force peaks at 233
approximately 1.0–1.5 body weight, with slight 234
187 Direction and ranges of motion of the ankle joint proportional increase depending on walking 235
188 are complex. The ankle joint primarily moves in speed [13]. On the superior surface of the talus, 236
189 plantarflexion-dorsiflexion, with the addition of the tibiotalar joint bears 83% of the load and the 237
238 fibulotalar joint bears 17% of the load [14]. other complications and sequelae [16]. However 283
239 Seventy-seven to ninety percent of the load on the use of surgical repair techniques for primary 284
240 the tibiotalar joint is applied on the surface of the treatment is growing in popularity given the 285
241 talar dome with an appreciable loss across the effectiveness of modern rehabilitation tech- 286
242 medial and lateral gutter surfaces [15]. The rela- niques, and the lost time and recurrent injury 287
243 tively high bone congruency across the tibiotalar rates associated with high-grade ligament tears 288
244 joint is credited for guiding the distribution of [16, 18]. 289
245 loading forces primarily through the tibiotalar
246 joint to mitigate irregular location and magnitude
247 of impact stress on the ankle [8]. 1.6 Concomitant Injury 290
Considerations 291
248 1.5 Mechanism of Injury Further complications stemming from injury to 292
the lateral ligaments of the ankle joint often 293
249 The most common mechanism of injury to the include acute pain local to the site of injury, 294
250 lateral ligament complex is inversion of the residual complications such as joint instability, 295
251 ankle with the foot in plantarflexion [1, 11]. Of stiffness, swelling, peroneal tendon injury, avul- 296
252 the lateral ligaments, a tear of the anterior sion fractures, cartilage damage, and recurrent 297
253 tibiofibular ligament (ATFL) is most common, injury that increases the risk of long-term joint 298
254 particularly in athletes, followed by the calca- degeneration [2]. Common sequelae that occur in 299
255 neofibular Ligament (CFL) [16]. Other common 10–30% of patients with chronic lateral ligament 300
256 ligaments injured include PTFL, the cervical injuries include synovitis, tendinitis, ankle stiff- 301
257 ligament and the talocalcaneal ligament—which ness, swelling, pain, nerve stretch injury, and 302
258 is more commonly injured when in dorsal-varus- muscle weakness [16]. Pain in the limb, sprain of 303
259 flexion [11]. Common symptoms associated the foot, and abrasion of the hip/leg are complica- 304
260 with the acute ankle sprains include pain, range tions that have been found to be more common in 305
261 of motion deficit, postural control deficit, and lateral ankle sprain events than medial joint 306
262 muscle weakness [17]. injury [5]. 307
263 Ankle sprains are graded, and treated, based
264 on their severity, and the treatment protocol is
265 guided by grading. Severity of ankle sprains is 1.7 Chronic Ankle Instability 308
266 graded I—mild, II—moderate, III—severe [16].
267 Grade I and II injuries are typically successfully Chronic ankle instability (CAI) is classified by 309
268 treated by nonoperative management and func- the persistence of lateral ankle sprain symp- 310
269 tional treatments—this includes the use of RICE toms—including pain, range of motion deficit, 311
270 (rest, ice, compression, elevation), brief immobi- postural control deficit, and muscle weakness— 312
271 lization and protection, early range of motion, however the true cause remains controversial 313
272 neuromuscular training, proprioceptive training, [17]. Chronic mechanical instability is character- 314
273 balance, and weight-bearing exercise [16]. ized by general laxity which is associated with 315
274 Treatment of grade III injuries can be more com- ligament lesions and other complications includ- 316
275 plicated [16]. Grade III “sprains” involve coming impingement, osteochondral lesions, and 317
276 plete tearing of the ATFL and CFL ligaments and fibular tendon pathology [11]. Postural factors 318
277 much or all of the PTFL. Since the ligamentous and proprioceptive deficiencies also favor func- 319
278 complex is completely ruptured, these injuries tional instability and should be evaluated and 320
279 must necessarily be managed differently. considered during treatment of chronic ankle 321
280 Immobilization, swelling reduction, and func- instability [11]. 322
281 tional rehabilitation are initiated to help the ankle There remains debate and uncertainty regard- 323
282 recover more quickly while avoiding risks of ing the factors and mechanisms that contribute to 324
325 chronic ankle instability. Some challenge the high preoperative anterior displacement of the 366
326 theory that kinematic variations are a significant talus (>10 mm) [24]. Further research suggests 367
327 mechanism contributing to CAI—as a study determining additional predictive factors and 368
328 showed lower limb kinematics during forward grading chronic ankle instability to improve 369
329 and side jump landing tasks were not different patient outcomes, and to better evaluate better 370
330 when comparing CAI to healthy subjects [19]. treatment options to prevent early failure, 371
331 Other studies suggest that while proprioceptive including anatomic ligament reconstructions, 372
332 deficits, neuromuscular changes, muscle strength, nonanatomic ligament reconstructions, addi- 373
333 postural changes, and central adaptations have tional augmentations, tendon grafts, and suture 374
334 been shown to contribute towards CAI, the direct tape [24]. 375
335 mechanism by which these factors lead to CAI
336 remains poorly understood [19–21].
1.9 Evaluations and Diagnosis 376
337 1.8 Risk Factors Prompt and thorough examination of the ankle is 377
of great importance when assessing ankle sprain 378
338 Given the ubiquitous nature of ankle ligament injuries. Physical examination within 4–5 days 379
339 injury, and differences in study populations, of traumatic injury provides the highest quality 380
340 there are an array of risk factors for recurrent diagnosis [1]. Diagnostic features often include 381
341 injury and CAI. These include, but are not likely swelling, hematoma, local pain on palpation, 382
342 limited to, sex, weight, height, limb dominance, and a positive anterior door test [1]. When 383
343 ankle joint laxity, anatomical alignment, strength, assessing a patient with an ankle sprain, it is 384
344 reaction time, and postural sway [22]. Factors important to test for ligamentous disruption and 385
345 that have been shown to correlate with an ligament function [16]. There are two main clin- 386
346 increased risk of lateral ankle sprain include ical stability tests used—these include the ante- 387
347 increased body mass index, muscle strength rior drawer test, which tests ATFL function, and 388
348 (slow eccentric inversion strength, and fast con- the inversion tilt test, which tests ATFL and CFL 389
349 centric plantarflexion), proprioception (passive function [16]. Further assessment may include 390
350 inversion joint position sense), and muscle reac- radiographic imaging to assess ligament injuries 391
351 tion time (earlier reaction time of the peroneus [16]. It is important to be cognizant of the situa- 392
352 brevis) [23]. There is inconclusive evidence tional needs of your patient. While the Ottawa 393
353 regarding the associations between decreased rules may be applied, weight-bearing ankle 394
354 ankle eversion strength and delayed ankle ever- radiographs are very helpful to obtain in athletes 395
355 tor reaction time, and lateral ankle ligamentous with higher grade injuries since assessing align- 396
356 sprains [23]. ment and identifying fracture, articular or other 397
357 Generalized ligamentous laxity is considered bony injury can be very useful for treatment. 398
358 a risk factor for instability recurrence following While less common in the lay person, ultrasound 399
359 modified Broström procedure for chronic ankle and MRI are more commonly used to diagnose 400
360 instability [24]. Other metrics that have been associated injury and are routine evaluations in 401
361 shown to be associated with clinical failure fol- athletes [1]. As always, it is important to con- 402
362 lowing use of the modified Broström procedure sider and balance both the timeliness and accu- 403
363 for chronic ankle instability include syndesmo- racy of these evaluations as patients’ risks, 404
364 sis widening, osteochondral lesion of the talus, benefits, costs, and desires vary by injury and by 405
365 high preoperative talar tilt angle (>15°), and individual [1]. 406
407 1.10 Treatment it is important to consider potential risks of each 450

surgical approach [2, 25]. Surgical repair should 451
408 Beneficial treatment methods for acute lateral be considered on an individual basis, particularly 452
409 ligament injuries in the ankle joint include func- for patients with chronic instability and grade III 453
410 tional treatment, immobilization, NSAIDs, and injuries [26]. 454
411 sometimes surgery [2, 25]. The majority of acute Beyond surgical reconstruction and traditional 455
412 lateral ankle ligament injuries can be managed nonsurgical treatment, a few alternative treatment 456
413 without surgery, most commonly protected by a methods are used but effectiveness in improving 457
414 semi-rigid ankle brace [26]. Braces have been symptoms remains poorly understood—these 458
415 shown to reduce risk of reinjury following an treatments include cold treatment, diathermy, 459
416 ankle sprain [22]. homeopathic ointment, physical therapy, and 460
417 Initially, nonsurgical treatment is used to ultrasound [2, 25]. Additionally, neuromuscular 461
418 treat mild, moderate, and severe ankle sprains. balance training has shown to be an effective pre- 462
419 RICE (rest, ice, compression, and elevation) ventative treatment for patients with previous 463
420 therapy is commonly used as it is beneficial in sprains [26]. 464
421 reducing pain and swelling in the first 4–5 days When treating athletes, there is a trend toward 465
422 following injury [1]. Beyond immediate treat- more aggressive treatments such as surgery for 466
423 ment, immobilization (below knee cast or professional athletes with acute grade II or III 467
424 removable boot) provides treatment of pain for injuries, as this may provide better long-term 468
425 5–10 days [1]. It is important to note that while stability and mitigate risk of recurrent injury and 469
426 immobilization is a common and effective treat- asociated injur, or prolonged missed time from 470
427 ment in reducing pain in swelling in the first sports participation [1]. 471
428 7–10 days, it can worsen symptoms if used for
429 more than 4 weeks [2, 25]. RICE, ankle braces,
430 and immobilization remain the most common 1.11 Prognosis 472
431 and effective nonsurgical treatments; however
432 questions still remain concerning which nonsur- The vast majority of patients do well following 473
433 gical treatments are associated with the lowest lateral ligament injury and following lateral liga- 474
434 re-sprain rates [26]. ment repair. Barring major concomitant injury 475
435 Surgical treatment is recommended for severe (e.g., osteochondral injury), most are able to 476
436 ankle sprain injuries that do not resolve with the return to their previous level of function. 477
437 initially conservative nonsurgical treatment Prognostic factors for acute lateral ankle sprains 478
438 methods, chronic ankle instability, and injureis remain somewhat elusive in aggregate [28]. Age 479
439 with certain associated injuries or pathology. The has demonstrated prognostic value in some stud- 480
440 details of these procedures are explored in later ies, but not all [28]. Independent predictors of 481
441 chapters. The goal of ankle ligament repair or poor recovery may include but are not limited to 482
442 reconstruction is to restore soft tissues to the ana- female gender, swelling, pain, limited range of 483
443 tomic condition prior to their instability, trauma, motion and ability, injury severity rating, and 484
444 or arthritis [10]. Modifications of the Broström MRI determined sprained ligaments [28]. Recent 485
445 procedure are the primary technique used for sur- work suggests that generalized ligamentous lax- 486
446 gical treatment of lateral ankle instability, specifi- ity may be an independent predictor of clinical 487
447 cally ATFL repair; however surgical techniques failures and poor radiological outcomes follow- 488
448 continue to warrant need for improvement [27]. ing modified Broström procedure for chronic 489
449 Surgery may provide increased joint stability, but ankle instability [24]. 490
491 1.12 A
nkle Arthritis and Salvage treatments. Emergency room treatment 535
492 Strategies of lateral ankle sprains (US $1025) are 536
relatively more costly than medial ankle sprains 537
493 Post-traumatic osteoarthritis, and other degenera- (US $912), but are comparable in costs for high 538
494 tive processes, can negatively impact the biome- ankle sprains (US $1034) [5]. These numbers do 539
495 chanical functions of the foot and ankle [29, 30]. not include subsequent visits to a specialist, 540
496 Furthermore, a decrease in muscular strength physiotherapy, and related treatments, let alone 541
497 associated with increasing age demonstrates a the costs of those that become chronic and/or 542
498 reduction in the range of motion in the ankle joint require surgical repair. Among sources of 543
499 across both genders [12]. However, while expenses, medial ankle sprains are more likely to 544
500 younger age females (20–39 years) have a higher include diagnostic radiology, lateral ankle sprains 545
501 range of motion than males, elderly women (70– are more likely to include medications, and high 546
502 79 years) demonstrate less dorsiflexion and ankle sprains are more likely to include hospital- 547
503 greater plantarflexion comparatively to elder men izations [5]. 548
504 [12]. These changes in bone strength, muscle When treating patients with an ankle sprain, it 549
505 strength, and range of motion are important con- is important to consider cost-effective treatment 550
506 siderations to take particularly when treating options. One study suggests using the Ottawa 551
507 more elderly patients. ankle rules diagnostic decision aid to exclude 552
508 More complex surgical treatment methods fractures of the ankle and mid-foot, rather than 553
509 arise for patients whose lateral ankle sprain or using radiographs, as a means of reducing radio- 554
510 chronic ankle instability may be complicated by graph expenses [33]. Furthermore, semi-rigid 555
511 other factors such as age and arthritis. Total ankle ankle braces worn during sports activities have 556
512 joint replacement is a common surgical interven- shown to be a more cost-effective secondary 557
513 tion considered for end-stage ankle osteoarthritis, intervention for preventing recurrence of ankle 558
514 as total ankle replacements have shown improve- sprains than neuromuscular exercise training 559
515 ments in walking speed, spatio-temporal f unction, [34]. Additionally, proprioceptive balance board 560
516 and range of motion, in exchange for reductions training programs targeted at players with previ- 561
517 in ankle joint moments and power [29, 30]. Ankle ous ankle sprains that are prone to recurrence 562
518 arthrodesis via fusion of the tibiotalar joint into a may prove to be a cost-effective long-term inter- 563
519 fixed position is another surgical consideration— vention [35]. It has been suggested that preventa- 564
520 this treatment option has been shown to improve tive intervention via use of proprioceptive balance 565
521 walking speed and spatio-temporal function, but training programs targeted at athletes with previ- 566
522 a reduction in the range of motion of the joint ous ankle sprains may reduce costs per player up 567
523 may result in adjacent joint osteoarthritis and to $56 USD [7, 35]. More general estimates sug- 568
524 other complications including malalignment, gest that the cost of preventing one ankle sprain 569
525 non-union, dysfunction, and pain [31, 32]. has been estimated at $483 USD [7]. Overall, 570
preventative and cost-effective treatments for 571
ankle sprain injuries particularly among patients 572
526 1.13 Economics at risk for recurrence can prove to be effective in 573
reducing the financial burden of ankle sprain 574
527 Ankle sprain emergency department admissions injuries. 575
528 can be costly for both the patient and the hospital
529 [1]. A very high recurrence rate of lateral ankle
530 sprains contributes to significant medical 1.14 Summary 576
531 expenses—mainly attributed to care, prevention,
532 and secondary disability [17]. There are nuances Lateral ankle sprains are a very common and 577
533 that differentiate the costs and related care often troublesome injuries in athletes and nonath- 578
534 between various ankle sprain injuries and their letes alike. There is substantial existing evidence 579
580 of anatomic, biomechanical, and ligamentous tis- 10. Watanabe K, et al. The role of ankle ligaments and 630
articular geometry in stabilizing the ankle. Clin 631
581 sue qualities that provide an explanation for lat- Biomech (Bristol, Avon). 2012;27(2):189–95. 632
582 eral ankle sprain injuries; however predictive and 11. Bonnel F, et al. Chronic ankle instability: biome-
633
583 prognostic factors remain incompletely under- chanics and pathomechanics of ligaments injury 634
584 stood. Conservative treatment, such as RICE and and associated lesions. Orthop Traumatol Surg Res. 635
2010;96(4):424–32. 636
585 semi-rigid ankle braces, are common and effec- 12. Nigg BM, Fisher V, Ronsky JL. Gait characteris-
637
586 tive initial treatments for ankle sprain injuries. tics as a function of age and gender. Gait Posture. 638
587 Surgical treatment considerations are reserved 1994;2(4):213–20. 639
588 for more severe injuries that do not resolve and 13. Nilsson J, Thorstensson A. Ground reaction forces at 640
different speeds of human walking and running. Acta 641
589 athletes that demand more stable treatment but Physiol Scand. 1989;136(2):217–27. 642
590 should be used cautiously among elderly patients 14. Calhoun JH, et al. A comprehensive study of pressure 643
591 that present risks of other ankle complications. distribution in the ankle joint with inversion and ever- 644
592 Risk for recurrence is important to consider as sion. Foot Ankle Int. 1994;15:125–33. 645
15. Michael JM, et al. Biomechanics of the ankle joint 646
593 recurrent injuries can be damaging and costly for and clinical outcomes of total ankle replacement. J 647
594 the patient and can be indicative of greater Mech Behav Biomed Mater. 2008;1(4):276–94. 648
595 chronic instability issues at hand. Ultimately, it is 16. Lynch SA, Renstrom PA. Treatment of acute lateral 649
596 important to treat these patients, but also to iden- ankle ligament rupture in the athlete. Conservative 650
versus surgical treatment. Sports Med. 1999;27(1): 651
597 tify patients at risk for injury recurrence to miti- 61–71. 652
598 gate the patient’s potential losses and to ultimately 17. Kobayashi T, Gamada K. Lateral ankle sprain and 653
599 improve their outcome, performance, and quality chronic ankle instability: a critical review. Foot Ankle 654
600 of life. Spec. 2014;7(4):298–326. 655
18. White W, McCollum G, Calder J. Return to sport fol- 656
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602 1. van den Bekerom MP, et al. Management of acute lat- matics in subjects with chronic ankle instability. Clin 661
603 eral ankle ligament injury in the athlete. Knee Surg Biomech (Bristol, Avon). 2015;30(6):585–92. 662
604 Sports Traumatol Arthrosc. 2013;21(6):1390–5. 20. Hertel J. Functional anatomy, pathomechanics, and 663
605 2. Struijs PA, Kerkhoffs GM. Ankle sprain. BMJ Clin pathophysiology of lateral ankle instability. J Athl 664
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607 3. Doherty C, et al. The incidence and prevalence of 21. Hass CJ, et al. Chronic ankle instability alters cen- 666
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703 2014;32(3):377–84. Med. 2005;39(2):111–5. 718
1 Lateral Endoscopy of the Ankle
2
2 Stéphane Guillo
3 2.1 Introduction dissection of the extra-articular structures of the 30

lateral side and it makes endoscopic treatment of 31
4 Endoscopy of the hindfoot has long been limited chronic lateral instability of the ankle a potential 32
5 to arthroscopy of the anterior part of the ankle. option. 33
6 More recently, the posterior route described
7 15 years ago [1] has resulted in a great step for-
8 ward by making it possible to reach the posterior 2.2 Indications 34
9 intra-articular as well as the extra-articular struc-
10 tures. Tendoscopy of the peroneal tendons has by Tendoscopy has first of all been described to treat 35
11 now been described more than 10 years ago [2] tendinopathies. Adhesions linked with inflamma- 36
12 for the treatment of tendinopathies. This tech- tory phenomena are readily treated by simple 37
13 nique has, however, been used very little to date. passage of the trocar of the optical device (can- 38
14 Nonetheless, it offers an exceptionally good view dlelight effect). Other than this candlelight effect, 39
15 of the lateral part of the hindfoot. By following tendinopathy of the peroneal tendon can be 40
16 the peroneal tendons, and using accessory por- treated by straightforward debridement using a 41
17 tals, it can be used to find, explore, and reach the shaver. By means of a supplemental mini-open, 42
18 lateral ligaments of the ankle, the rear side of the one can perform a repair of a possible 43
19 lateral malleolus, the entire lateral side of the fissuration. 44
20 anterior and posterior subtalar joints, the sinus Tendoscopy of the peroneal tendons is also a 45
21 tarsi, as well as the upper side of the calcaneus to way to reach the lateral side of the calcaneus, as 46
22 its apophyseal. well as the lateral side of the subtalar joint. In 47
23 Building on tendoscopy, by considering the addition to the treatment of ligament pathologies, 48
24 container but not the content, this new concept of it therefore allows treatment of possible lateral 49
25 lateral ankle endoscopy hence emerged that now- impingement by the bony spur as well as rectifi- 50
26 adays constitutes one of the foremost tools for cation of certain fragmented fractures of this 51
27 investigation when treating a greater number of region (lateral tubercle of the talus, calcaneal 52
28 pathologies of the hindfoot. Just like endoscopy apophyseal edge,…). 53
29 of the shoulder, it allows a bona fide endoscopic Tendoscopy also allows peroneal tendon 54
instability to be treated [3, 4]. Lastly, it can con- 55
stitute the first part of exploration or a procedure 56
S. Guillo (*)
Orthopaedic Surgeon, Bordeaux-Mérignac Sports at the level of the sinus tarsi. It then allows 57
Clinic, Bordeaux, France systemization of the dissection. 58
© ISAKOS 2019 13
https://doi.org/10.1007/978-3-662-58704-1_2
14 S. Guillo
59 2.3 Surgical Anatomy Area B corresponds with the part comprised 86

between the malleolus at the level of the lateral 87
60 The peroneus longus tendon inserts on the proxi- side of the calcaneus and the cuboid bone. At this 88
61 mal two-thirds of the lateral side of the fibula, level, the two tendons are at first free and their 89
62 while the peroneus brevis tendon emerges at the
63 level of the distal third and on the adjacent inter-
64 osseous membrane. The peroneus longus tendon
65 extends the fleshy body of the muscle 3–4 cm
66 above the malleolus while the muscle fibres of
67 the peroneus brevis tendon very often descend up
68 to fibula tip. This feature can be the basis for gen-
69 uine impingements between the two peroneal
70 tendons [5].
71 They are generally described as having three
72 different areas (A, B, and C) [6] to which
73 Sammarco [7] has added a fourth (D) (Fig. 2.1).
74 Area A corresponds with the posterior side of
75 the malleolus, featuring a gutter in 8 out of 10.
76 The absence of a gutter at this level is recognized 1
77 as being a risk of dislocation of the peroneal ten-
78 dons [2]. In this part, the tendons are held back by 2
79 their sheath, which provides a reinforcement that 3
80 provides a great deal of stability: the superior
81 peroneal retinaculum, distinct and wide along its
82 entire retromalleolar trajectory (Fig. 2.2). The
83 peroneus brevis tendon is anterior and flattened
Fig. 2.2 Retinaculum of the peroneal tendon (lateral
84 distally, while the peroneus longus tendon behind view): (a) Superior retinaculum. (b) Inferior retinaculum.
85 has a more round cross-section. (c) Tubercle of the peroneal tendons
a b
1
2
3
4
b 5
6
7
c
Fig. 2.1 The four areas of the peroneal tendons. (a) Lateral view. (b) Plantar view
2 Lateral Endoscopy of the Ankle 15
90 trajectory crosses the calcaneofibular ligament PT. In this trajectory, each tendon marks a furrow 99
91 (which stands out in tendoscopy) while following at the lateral side of the calcaneus. The inferior 100
92 the edge of the posterior subtalar joint. In this retinacular ligament marks the end of these 101
93 part, the peroneus brevis tendon is on top and the osteofibrous gutters (Fig. 2.3). 102
94 peroneus longus tendon underneath. More dis- Area C: Situated facing the cuboid bone, this 103
95 tally, the two tendons each enter into their own area is that of the plantar crossing of the peroneus 104
96 tunnel. This very special area is situated at the longus tendon, while the peroneus brevis tendon 105
97 level of the peroneal tubercle (PT). The tunnels remains on the lateral side. In 20% of cases, there 106
98 are separated by a septum that arises from the is an accessory fibular bone in this area. 107
Mall.
LF
CF
LF
CF
Cal.
CF
CF va
Ret.
LF
LF
Fig. 2.3 Arthroscopic anatomy. Layered sections of the different areas

16 S. Guillo
2.4 Technique 140
2.4.1 Setup 141
A tourniquet is placed above the knee, so as to take 142

the path of the tendons into account. Rather than 143
1 the supine position with a cushion under the prone 144

buttock that is used by some, we preferentially use 145
a sideways recumbent position with the foot raised. 146
Nonetheless, it is sometimes useful to have an 147
intermediate setup in the case where arthroscopy 148
of the ankle is to be undertaken, so as to allow a 149
sideways and an anterior position [7, 8]. The 150
Fig. 2.4 Synovial sheath of the peroneal tendons patient is placed lying on their side with their pel- 151
vis tilted slightly backward by approximately 30°. 152
The hip and the knee are free. The ankle is held in 153
108 Area D corresponds to the trajectory of the line with the hip by support placed 10–20 cm more 154
109 peroneus longus tendon. proximal. It is important to carefully verify the 155
110 Tendoscopy is made possible thanks to the setup of the patient that by means of three different 156
111 presence of a synovial sheath. The sheath is a positions needs to allow anterior arthroscopy of 157
112 single entity from the proximal part up to the the ankle (position 1), a lateral endoscopy of the 158
113 peroneal tubercle (Fig. 2.4). While this does not ankle (position 2), and possibly removal of the 159
114 have genuine therapeutic implications at present, gracilis (position 3) to be performed. 160
115 it should be noted that on this entire trajectory, Position 2 is obtained by performing an exter- 161
116 the two tendons remain connected first to the pos- nal rotation of the hip to place the anterior side of 162
117 terior side of the malleolus, then to the lateral the ankle as the highest point. Position 3 is 163
118 side of the calcaneus, each by their own vincula. obtained by resting the ankle on the support. 164
119 It lies in alignment with the muscle fibres and Position 1 is obtained by performing a flexion 165
120 represents the vinculum of the tendons. and an external rotation of the hip (Fig. 2.5). 166
121 The main neurological risk is in regard to the
122 sural nerve, which after having crossed the
123 superficial aponeurosis, typically in the upper 2.4.2 The Instruments 167
124 third of the leg, rejoins the lesser saphenous vein
125 in the lateral third of the leg, between the fibula The instrumentation is conventional with an 168
126 and the calcaneal tendon. It crosses the trajectory arthroscope of 4 mm and an arthroscopy shaver 169
127 of the peroneal tendons in area B to then inner- of 3.5–4 mm. It is not essential to use an arthro- 170
128 vate the dorsolateral skin of the foot and the toes. pump or even electrocoagulation as the interven- 171
129 At the level of the malleolus, it gives rise to a tion is carried out using a tourniquet. 172
130 cutaneous branch that is important for innerva- A basket forceps is very useful to start debrid- 173
131 tion of the heel (the calcaneal branch). The ing a fissure tendinopathy. Among the small 174
132 superficial fibular nerve does not constitute a instruments, we prefer a N°15 scalpel blade, 175
133 risk. It runs in the lateral side of the leg, in front safer and less traumatizing than a blade of 11, 176
134 of the peroneal tendons, but typically pierces the and we recommend generating the first portal by 177
135 superficial fascia 7–8 cm above the malleolus. Its employing two small Gillies hooks. It is further- 178
136 superficial trajectory is then more forward, in more indispensable to have a small curved 179
137 front of the malleolus, constituting a risk primar- Halstead forceps. This allows trauma to the sub- 180
138 ily with the anterolateral route for arthroscopy of cutaneous nerves to be avoided after incision of 181
139 the ankle. the skin. 182
a b c
Fig. 2.5 The three positions for the setup. (a) Position 1; (b) position 2; (c) position 3
a b
Fig. 2.6 Initial performance of the proximal portal between 2.5 and 3 cm above the malleolar tip. (a) Landmarks. (b)
Opening of the sheath under visual control, equipped with Gillies hooks
183 2.4.3 The Actual Tendoscopy tendons, which is thicker at this level. The risk of 202
184 Technique for the Peroneal nerve injury is much less, it is not necessary to 203
185 Tendons dilate the peritendinous space, and the descent of 204
the arthroscope in the sheath of the peroneal ten- 205
186 The intervention can generally be performed dons is easier than when going up as the wall 206
187 under general or locoregional anaesthesia. becomes thinner distally and there is more room. 207
188 Performing the procedure under local anaesthesia A subcentimeter longitudinal incision using a 208
189 is also an option, with the major advantage of blade of 15 therefore only opens the skin 209
190 being able to carry out a dynamic test, which is 2.5–3 cm above the malleolar tip for the sheath of 210
191 useful in the diagnosis of certain forms of pero- the peroneal tendons. We recommend going 211
192 neal instability [2]. down 1 cm when the intervention is in regard to 212
the sinus tarsi (Fig. 2.6). 213
193 2.4.3.1 The Approach Routes Using Gillies hook-type spreaders, and under 214
194 It is possible to generate the portals along the full visual control, the sheath of the peroneal tendons 215
195 length of the tendon behind the fibula but also is then exposed for the longitudinal incision. It is 216
196 distally on the lateral side of the hindfoot. In the then very easy to control and then to introduce 217
197 vast majority of cases, however, two portals, one the soft arthroscopy trocar into the sheath. The 218
198 3 cm above and the other 3 cm below the malleo- arthroscope is then pushed distally, beyond the 219
199 lus, are sufficient. The proximal portal is per- tip of the malleolus. It is then possible to position 220
200 formed first. It offers the advantage of allowing the second portal using a needle. Transillumination 221
201 easier identification of the sheath of the peroneal allows the sural nerve to be avoided (Fig. 2.7). 222
18 S. Guillo
Fig. 2.7 Performance of the distal portal by Fig. 2.8 Performance of the sinus tarsi portal
transillumination
2.4.4 T
he Actual Lateral Endoscopy 254
223 An initial inspection can then start from the Technique 255
224 distal emergence of the tendons, each from their
225 own groove, up to the posterior side of the mal- The intervention takes place under general anaes- 256
226 leolus. It allows nearly all of the area to be thesia only because locoregional anaesthesia 257
227 visualized. does not allow for easing of the external rotation 258
228 The vast majority of fissure tendinopathies are of the hip necessary for performing the anterior 259
229 situated in the tendon reflection areas, under the arthroscopy. 260
230 malleolar tip.
231 By distally continuing the exploration after 2.4.4.1 Placement of the Portals 261
232 the malleolar groove, the base of the calcaneo- Three portals are required to perform this sur- 262
233 fibular ligament can be visualized. Its debride- gery. The conventional anteromedial portal is 263
234 ment with a shaver allows the posterior subtalar called portal N° 1. The second portal (route N° 2) 264
235 articulation to be visualized on its lateral and is not drawn on the skin; it is performed using 265
236 anterior side. It is then possible to perfectly con- transillumination after having placed the arthro- 266
237 trol the resection of small fragments or exostoses scope. The third portal (route N° 3) is that of the 267
238 of this region by this arthroscopic portal. As was sinus tarsi. It is necessary to draw two lines on the 268
239 shown recently, arthroscopic treatment of the lat- skin: The upper edge of the peroneus brevis is a 269
240 eral impingement, proposed by Lui [9], particu- line passing through the malleolar insertion point 270
241 larly after fracture of the calcaneus, has proven to of the anterior talofibular ligaments (ATFL) and 271
242 be an interesting conservative alternative both as of the calcaneofibular ligament (CFL) and ori- 272
243 a result of its efficacy and of its absence of mor- ented at 10° relative to the axis of the malleolus. 273
244 bidity [10]. Portal N° 3 is situated at the intersection of these 274
245 This same route moreover allows access to the two lines (Fig. 2.8). 275
246 sinus tarsi to be fully secured: it suffices to perfo-
247 rate the adipose tissue right after the base of the 2.4.4.2 Stage N° 1 276
248 calcaneofibular ligament. It amounts to a bona The arthroscope is placed in the anteromedial 277
249 fide conversion of a tendoscopy into subtalar portal (N° 1). In order to obtain a good view of 278
250 arthroscopy since one can thereby reach the ante- the lateral talofibular gutter, it is very important 279
251 rior part of this joint, as well as the calcaneal to position portal N° 1 correctly, that is to say, in 280
252 apophyseal edge and even the calcaneocuboid dorsal hyperflexion and as close as possible to 281
253 joint. the anterior tendon. The positioning of the view 282
Fig. 2.9 View of the lateral gutter with the talus to the
right and the malleolus to the left Fig. 2.10 View of the lateral gutter after preparation
283 spot needs to allow the anterolateral gutter to be calcaneofibular ligament (CFL) is sought behind 312
284 seen (Fig. 2.9). The luminous spot generated by and within the fibular tendons while taking 313
285 the arthroscope on the skin then allows the good care to remain in contact with the lateral 314
286 anterolateral approach to be performed (portal cortex of the calcaneus and by moving from the 315
287 N° 2). Using a shaver placed in this portal, front to the back. This stage needs to be done 316
288 debridement of all of the lateral gutter is per- carefully in order to identify the CFL at its 317
289 formed. This preparation needs to allow all of the insertion. 318
290 scar tissue between the anterior tibiofibular liga-
291 ment and the anterior talofibular ligament 2.4.4.4 Stage N° 3 319
292 (ATFL) to be withdrawn. The preparation contin- The arthroscope is introduced in N° 3. Using a 320
293 ues with the release of the ATFL on its malleolar shaver placed in portal N° 2 it is possible to pur- 321
294 insertion. It is then possible to fully expose the sue the dissection and full visualization of the 322
295 ATFL by preparing it in the same way as a ten- talar insertion of the ATFL (Fig. 2.11). 323
296 don of the cuff on its upper side but also on its
297 lateral edge (Fig. 2.10).
2.5 Conclusion 324
298 2.4.4.3 Stage N° 2
299 The arthroscope is placed in portal N° 2. An In addition to a lateral approach of the bone and 325
300 instrumental portal (portal N° 3) is performed at joint structures of the hindfoot, lateral endoscopy 326
301 the level of the sinus tarsi using previously allows for full exposure of the lateral ligamen- 327
302 drawn cutaneous marks. A shaver is then intro- tous apparatus and of the tendons. It hence con- 328
303 duced through this portal to complete the prepa- stitutes a minimally invasive way to treat a 329
304 ration at the level of the malleolar insertion of considerable number of pathologies of this 330
305 the ATFL and of all of its lateral side and its region. It allows a targeted treatment by à la carte 331
306 lower edge. The dissection is then pursued by endoscopic dissection. The indications are 332
307 following the lateral articular surface of the broader nowadays with the treatment of lateral 333
308 talus until encountering the subtalar joint. The impingement, fragment fractures (resection), 334
309 lateral edge of the calcaneus is identified below subtalar arthrodesis, instability of the peroneal 335
310 the joint. By staying in contact with the calca- tendons, and above all treatment of instability of 336
311 neus with the shaver, the calcaneal insert of the the ankle. 337
20 S. Guillo
ATFL
CFL
S t ep
Ste
pha
han
ne
eG
NT
JOI
G
UI
UI
O LAR
LL
LL
BTA
SU
Fig. 2.11 Visualization after arthroscopic dissection of the anterior talofibular ligament and the calcaneofibular
ligament
6. Brandes CB, Smith RW. Characterization of patients 352

338 References with primary peroneus longus tendinopathy: a 353
review of twenty-two cases. Foot Ankle Int. 2000;21: 354
339 1. van Dijk CN, Kort N, Scholten PE. Tendoscopy of the 462–8. 355
340 posterior tibial tendon. Arthroscopy. 1997;13:692–8. 7. Sammarco VJ. Peroneal tendoscopy: indications and 356
341 2. van Dijk CN, Kort N. Tendoscopy of the peroneal ten- techniques. Sports Med Arthrosc Rev. 2009;17:94–9. 357
342 dons. Arthroscopy. 1998;14:471–8. 8. Guillo S, Archold P, Perera A, Bauer T, Sonnery- 358
343 3. Guillo S, Calder JD. Treatment of recurring peroneal Cottet B. Arthroscopic anatomic reconstruction of the 359
344 tendon subluxation in athletes: endoscopic repair of lateral ligaments of the ankle with gracilis autograft. 360
345 the retinaculum. Foot Ankle Clin. 2013;18:293–300. Arthrosc Tech. 2014;3(5):e593–8. 361
346 4. Vega J, Batista JP, Golano P, Dalmau A, Viladot R. 9. Lui TH. Endoscopic lateral calcaneal ostectomy for 362
347 Tendoscopic groove deepening for chronic subluxation calcaneofibular impingement. Arch Orthop Trauma 363
348 of the peroneal tendons. Foot Ankle Int. 2013;34:832–40. Surg. 2007;127:265–7. 364
349 5. Michels F, Jambou S, Guillo S, Van Der Bauwhede 10. Bauer T, Deranlot J, Hardy P. Endoscopic treatment 365
350 J. Endoscopic treatment of intrasheath peroneal ten- of calcaneo-fibular impingement. Knee Surg Sports 366
351 don subluxation. Case Rep Med. 2013;2013:4. Traumatol Arthrosc. 2011;19:131–6. 367
1
2
All-Inside Endoscopic Broström-
Gould Procedure for Chronic Ankle
3
3 Instability
4 Haruki Odagiri, Stéphane Guillo,
5 and Thomas Bauer
6 3.1 Introduction with retensioning and direct suturing of the 27

ATFL. Augmentation by advancing the exten- 28
7 Ankle sprains are the most common sports- sor retinaculum as described by Gould et al. [8] 29
8 related injury. The main complication is the can be added. A Broström-Gould procedure 30
9 development of chronic ankle instability (CAI), seems to remain the gold standard for CAI [9]. 31
10 which occurs in about 20% of patients [1, 2]. In recent years, several studies reported good 32
11 Surgery to stabilize the ankle is indicated when short-term outcomes of arthroscopic repair tech- 33
12 nonoperative treatment fails. The goal of surgery niques [10–18]. The arthroscopic technique of 34
13 is not only to restore stability but also to prevent the Broström-Gould repair technique for CAI is 35
14 the development of lesions due to chronic insta- described. Although the role for arthroscopy in 36
15 bility such as osteo-chondral lesions at the talar the management of CAI remains controversial, 37
16 dome and, most importantly, tibio-talar osteoar- these arthroscopic procedures may improve the 38
17 thritis [3–6]. detection of ligament lesions, as well as of con- 39
18 There are basically two main groups of sur- comitant lesions amenable to same-stage treat- 40
19 gical procedures for CAI, with many variants ment [19–21]. Theoretical advantages of 41
20 and modifications: repair techniques (reten- arthroscopic surgery for CAI include lower rates 42
21 sioning and direct suturing of the anterior talo- of cutaneous and infectious complications and a 43
22 fibular ligament [ATFL] and calcaneo-fibular shorter time to recovery. However, these tech- 44
23 ligament [CFL]) and reconstruction techniques niques were introduced only recently, and further 45
24 (in which a tendon graft is used to rebuild the studies are needed to assess their reliability, 46
25 ATFL and CFL). The most popular repair tech- reproducibility, and potential for iatrogenic injury 47
26 nique was described by Broström in 1966 [7] [22–24]. 48
H. Odagiri
Department of Orthopedic Surgery, Hotakubo 3.2 Tools (Fig. 3.1) 49
Orthopedic Hospital, Kumamoto, Japan
S. Guillo The technique is performed with the 4 mm 30° 50
Clinique du Sport Bordeaux-Mérignac, angle arthroscope because of a better view, and 51
Mérignac, France the laxity usually allows a complete exploration 52
T. Bauer (*) of the joint. Arthroscopic dissection is performed 53
Orthopedic Department, Ambroise Paré University using a 4.5 mm bone/soft tissue shaver blade. 54
Hospital, West Paris University, Suture passers and push knot are helpful. This 55
Boulogne-Billancourt, France
© ISAKOS 2019 21
https://doi.org/10.1007/978-3-662-58704-1_3
22 H. Odagiri et al.
Fig. 3.1 Standard tools
56 technique can be performed with different types

57 of anchors: with knot and knotless [10–17]
58 (Fig. 3.1).
59 3.2.1 Patient Positioning
60 Two installations are possible: in a prone position

61 or in lateral decubitus. If the patient is placed in a Fig. 3.2 Patient setting in lateral position
62 prone position, a bag must be positioned under
63 the buttock to have the foot in a vertical position
64 and avoid automatic external rotation and having arthroscope is positioned in portal 1 and viewing 87
65 access to the lateral aspect of the ankle. In case of the lateral gutter. The placement of this portal is 88
66 lateral decubitus position the patient is placed between the spotlight and malleolus (Fig. 3.3). 89
67 with the pelvis slightly rotated 30° posterior. The third portal is the sinus tarsi portal (portal 3). 90
68 Position 1 is used for anterior arthroscopy. The Through the sinus tarsi portal, it is possible to 91
69 hip is externally rotated. Position 2 is used for the have a full access to the lateral aspect of the ankle 92
70 lateral hindfoot endoscopy. The hip is internally and to have a complete vision of the inferior 93
71 rotated (Fig. 3.2). extensor retinaculum (IER). Portal 3 is made 94
1 cm anteriorly to the mid-distance point between 95
the tip of the fibula and the proximal tip of the 96
72 3.2.2 Landmarks: Identification fifth metatarsal (Fig. 3.4). 97
73 and Marking of Portals
74 Three portals are usually created to perform the 3.2.3 S

tep 1: Anterior Arthroscopy, 98
75 procedure. The anteromedial portal is the first Making the Broström Repair 99
76 portal (portal 1). It has to be made medial to the
77 tibialis anterior tendon, in hyperdorsal flexion of The arthroscope is introduced in portal 1. Once 100
78 the ankle in order to have the portal as much lat- the arthroscope is perfectly well centered on the 101
79 eral as possible. In this way, the anterior working external gutter, portal 2 is positioned between the 102
80 area is bigger, the cartilage is protected because spotlight and the lateral malleolus. For the real- 103
81 of the dorsiflexion, and the tibialis anterior ten- ization of this portal, we can use a needle. The 104
82 don is at the most lateral position. position should be anteriorly to the malleolus in 105
83 After ankle joint exploration, the second por- the external gutter above the ATFL (Fig. 3.5). A 106
84 tal is the accessory anterolateral portal (portal 2) mosquito clamp is introduced using the nick and 107
85 which is not marked on the skin as it is made spread technique. A debridement is then begun 108
86 under transillumination guidance when the with the shaver. The resection starts with the scar 109
3 All-Inside Endoscopic Broström-Gould Procedure for Chronic Ankle Instability 23
Fig. 3.3 Portal 2 by transillumination
is then peeled off from its malleolar origin (as 130

usually the avulsion is from the malleolar side 131
with scar tissue at this location). The anterior 132
facet of the distal malleolus, at the ATFL foot- 133
print, is then prepared with a burr, to enable a 134
good healing of the ATFL reinsertion on the distal 135
malleolus. This preparation of the malleolus is 136
extended from the most distal to the distal inser- 137
tion of the anterior tibiofibular ligament. The infe- 138
rior part of the final malleolar preparation is going 139
to receive the ATFL reinsertion and the superior 140
Fig. 3.4 Portal 3 part will receive the retinaculum augmentation 141
(Fig. 3.6). The first anchor is positioned in the 142
110 tissue in the lateral gutter. The first anatomical footprint of the ATFL, always with the arthro- 143
111 landmark is the distal fascicle of the anterior tib- scope in portal 1, instruments and the anchor by 144
112 iofibular ligament (Basset ligament) that always portal 2. The second and/or third anchor will be 145
113 appears as an oblique structure between the placed for the Gould augmentation with IER. 146
114 anterolateral edge of the distal tibia and the lateral The first suture is passed through the 147
115 malleolus (Fig. 3.5a). Following this ligament ATFL. The stand from the ligament is passed into 148
116 from medial to lateral and from proximal to distal, the loop to obtain a lasso around the portion of 149
117 it is easy to reach the malleolar insertion of the ligament (Fig. 3.7) [11–17]. This technical pearl 150
118 anterior talo-fibular ligament (ATFL) [25]. It is is made to reinforce the suture. The ATFL is then 151
119 important then to move backward the scope in reinserted on the malleolus, with the anchor, with 152
120 order to visualize the talar neck and have a gen- the ankle in a neutral position. 153
121 eral vision. The other important landmark is the
122 anterolateral corner of the talar dome without car-
123 tilage. This landmark is constant and is just above 3.2.4 S
tep 2: Lateral Hindfoot 154
124 the talar insertion of the ATFL. Then a capsulot- Endoscopy, Making the Gould 155
125 omy is performed with a beaver blade between Augmentation 156
126 the ATFL and the capsule, at the lateral aspect of
127 the ATFL, from proximal to distal, to get a com- From the sinus tarsi portal (portal 3) the smooth 157
128 plete vision of the ATFL from its malleolar inser- trocar of the arthroscope is introduced and passed 158
129 tion to its talar insertion (Fig. 3.5b, c). The ATFL between the IER and the skin to create a working 159
Fig. 3.5 Lateral gutter dissection: visualization of the distal part of the Basset ligament (a) and superior bundle of the
ATFL (b)
Fig. 3.7 Lasso loop on the ATFL
area around the IER. In this way, the cutaneous 160

nerve stays with the fatty subcutaneous tissue and 161
as it is avascular, there is no vascular or neuro- 162
logical danger (Fig. 3.8). 163
Fig. 3.6 ATFL footprint preparation: positioning for the The arthroscope is then positioned in portal 3, 164
anchor for ATFL repair (1) and for IER augmentation (2) looking at portal 2 from inferior to superior. A 165
Fig. 3.8 Preparation of the working area for IER dissection
166 shaver introduced by portal 2 is finishing the prepared zone. Once the anchor is inserted, the 183
167 preparation and dissection of the IER. The win- suture is passed into the IER. By passing the 2 184
168 dow of the shaver must always be under strands, it is possible to realize a mattress suture. 185
169 arthroscopic vision. It is important to obtain a It is possible to add a second anchor more inferi- 186
170 perfect visualization of the IER as well as the orly to have two fixations in the IER. In this case, 187
171 hole created in step 1 via the portal 2 to know it is important to put the anchor before doing the 188
172 where the augmentation has to be placed with knot of the first one. The suture is tight on the 189
173 accuracy and safety. It is important to see on one malleolus to create the augmentation on the 190
174 side the prepared malleolus and on the other side ATFL repair (Fig. 3.10). 191
175 the IER, ready to be sutured on the malleolus
176 above the ATFL repair. More deeply, it is possi-
177 ble to have a vision of the Broström repair and 3.2.5 Postoperative Care 192
178 more superiorly the lateral side of the talus
179 (Fig. 3.9). ATFL repair is performed in outpatients. The 193
180 The second anchor is then introduced by por- patient is immobilized in a normal brace with 194
181 tal 2 and placed on the anterior part of the malleo- immediate full weight bearing as tolerated. Foot 195
182 lus at 1 cm superior to the previous anchor in the elevation and ice are required for the first 2 weeks 196
Fig. 3.9 Suture in the IER
to avoid swelling and pain. Rehabilitation is 197

begun after 3–4 weeks for mobilization and pro- 198
prioception. Return to sports activities is allowed 199
after 6 weeks depending on the pain. 200
3.3 Discussion 201
Arthroscopy is gradually moving to a central 202

position in the management of CAI, as it allows 203
the diagnosis and treatment of concomitant 204
lesions and, most importantly, provides a more 205
accurate assessment of ATFL lesions, thereby 206
guiding the treatment decision. Although 207
arthroscopic techniques have not been proven 208
superior over conventional open ligament repair 209
Fig. 3.10 Gould augmentation: Anchor in the malleolus and reconstruction, arthroscopy deserves to be 210
(mal). Suture in the IER (ret) viewed as a technique of choice for the treatment 211
212 of CAI, as it provides a comprehensive assess- advancement or with versus without knots [24, 260
213 ment of the ligament lesions and helps to choose 33–36]. 261
214 the optimal surgical technique [19]. The main difficulty is the patients selection in 262
215 Arthroscopy improves the evaluation of order to know if ATFL repair remains the best 263
216 lesions to the lateral ligament complex. option for each case. Further assessment with lon- 264
217 Arthroscopic findings have modified the concept ger follow-up is in progress to have better indica- 265
218 of anterolateral impingement by showing that the tions and results of this arthroscopic technique. 266
219 cause is micro-instability or rotational instability,
220 which cannot be detected on imaging studies
221 [26–28]. Arthroscopic exploration of the talo- References 267
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359 J, Colin F, Thès A, Elkaïm M, Boniface O, Guillo S, 35. Guelfi M, Zamperetti M, Pantalone A, Usuelli FG, 417
360 Bauer T, French Arthroscopy Society. Arthroscopic Salini V, Oliva XM. Open and arthroscopic lateral lig- 418
361 treatment of chronic ankle instability: prospective ament repair for treatment of chronic ankle instability: 419
362 study of outcomes in 286 patients. Orthop Traumatol a systematic review. Foot Ankle Surg. 2018;24(1):11– 420
363 Surg Res. 2018;104(8S):S199–205. https://doi. 8. https://doi.org/10.1016/j.fas.2016.05.315. 421
364 org/10.1016/j.otsr.2018.09.005. 36. Cottom JM, Baker J, Plemmons BS. Analysis of two 422
365 25. Thès A, Klouche S, Ferrand M, Hardy P, Bauer T. different arthroscopic Broström repair constructs for 423
366 Assessment of the feasibility of arthroscopic visualiza- treatment of chronic lateral ankle instability in 110 424
367 tion of the lateral ligament of the ankle: a cadaveric study. patients: a retrospective cohort study. J Foot Ankle 425
368 Knee Surg Sports Traumatol Arthrosc. 2016;24(4): Surg. 2018;57(1):31–7. https://doi.org/10.1053/j. 426
369 985–90. https://doi.org/10.1007/s00167-015-3804-4. jfas.2017.05.045. 427
370 26. Vega J, Allmendinger J, Malagelada F, Guelfi M,

371 Dalmau-Pastor M. Combined arthroscopic all-inside
1
2
Arthroscopic Ligament Repair
and Reconstruction
4
3 Masato Takao, Mai Katakura, and Yasuyuki Jujo
4 Surgical treatment is sometimes required to treat remain, and anatomical reconstruction of the lat- 28
5 the chronic lateral instability of the ankle to pre- eral ligament of the ankle (AntiRoLL) is selected 29
6 vent the development of articular cartilage dam- if there is no ligament fiber. 30
7 age [1–3] and to prevent performance
8 deterioration especially in toe-off phase.
9 Recently, arthroscopic repair/reconstruction sur- 4.2 Arthroscopic Broström- 31
10 gery for lateral instability of the ankle has been Gould Repair 32
11 rapidly developing.
12 In this chapter, I describe about how to decide 4.2.1 Position 33
13 whether repair or reconstruction before surgery,
14 the technique of all inside arthroscopic Broström The position is supine, and the lower leg is held 34
15 repair with a reinforcement by inferior extensor with a leg holder (Fig. 4.3a). If it is needed to 35
16 retinaculum (arthroscopic Broström-Gould treat the intra-articular concomitant lesions 36
17 repair) [4–6], and the technique of anatomical including osteochondral lesions of the ankle and/ 37
18 reconstruction of the lateral ligament of the ankle or free body, distraction device is used according 38
19 (AntiRoLL). to the condition of the lesions (Fig. 4.3b). The 39
tourniquet is not normally used, but it should be 40
worn on the thigh for use when the field of vision 41
20 4.1 ow to Decide Repair or
H is hindered by bleeding. The ankle position 42
21 Reconstruction should be kept slightly dorsiflexion by surgeon’s 43
belly to widen the lateral pouch for pleasant view 44
22 Choice of a surgical procedure is done by evalu- and enough working space (Fig. 4.4a). If the sur- 45
23 ating the quality of the residual ligament with geon doesn’t have adequate round belly, applying 46
24 stress ultrasonography before surgery (Fig. 4.1a, towel and corset is effective (Fig. 4.4b, c). 47
25 b), and determined with arthroscopic evaluation
26 during surgery (Fig. 4.2). Arthroscopic Broström-
27 Gould repair is selected if the ligament fibers 4.2.2 Surgical Procedure 48
4.2.2.1 Step 1: Making Portals 49

M. Takao (*) · M. Katakura · Y. Jujo Medial midline (MML) portal as viewing portal 50
Clinical and Research Institute for Foot and Ankle and accessory anterolateral (AAL) portal as 51
Surgery, Jujo Hospital, Kisarazu, Chiba, Japan working portal are used (Fig. 4.5). MML is put 52
e-mail: m.takao@carifas.com
© ISAKOS 2019 29
https://doi.org/10.1007/978-3-662-58704-1_4
30 M. Takao et al.
a b
F F
T
T
Fig. 4.1 Stress ultrasonography. (a) Before applying talofibular ligament. ATFL is ruptured at its fibular attach-
stress. (b) After applying stress. F fibula, T talus, red ment. After applying stress, fibular and talus separate
arrow: direction of stress force, white arrows: anterior from each other
a b
F
T T
ATFL ATFL
Fig. 4.2 Arthroscopic view of ATFL (same case to Fig. 4.1). (a) Talar attachment. (b) Fibular attachment. F fibula, T
talus. ATFL is ruptured at its fibular attachment
53 just lateral of anterior tibial tendon at the level of arthroscope (2.7 mm in diameter, 30° perspective 57
54 talocrural joint space. After putting a 5 mm verti- scope) is inserted via the MML portal and viewed 58
55 cal incision through the skin only, capsule is pen- in the lateral gutter. In this process, ankle should 59
56 etrated by a straight mosquito pean. The be in slightly dorsiflexed position for extending 60
4 Arthroscopic Ligament Repair and Reconstruction 31
a 4.2.2.2 Step 2: Insert a Suture Anchor 79

After confirming that the ligament fiber of ATFL 80
remains, insert suture anchor for suturing the 81
remaining ligament to fibula attachment. A drill 82
hole is drilled about 5 mm proximally from the 83
distal end of the articular surface of the lateral 84
malleolus and about 5 mm outward from the lat- 85
eral side of the articular surface (Fig. 4.7). After 86
inserting the anchor suture, it is confirmed that 87
b the thread slides. 88
4.2.2.3 Step 3: Suture Relay Technique 89

Insert an 18G needle through 2-0 nylon thread 90
via AAL portal and penetrate ATFL remnant fiber 91
from front to back as deeply as possible 92
(Fig. 4.8a). Rotate the needle forward for several 93
times and reverse rotate the same number of 94
times to enlarge the nylon loop (Fig. 4.8b). After 95
that, insert a hook probe from the AAL portal and 96
guide the nylon loop from the AAL portal to the 97
outside (Fig. 4.8c, d). 98
Fig. 4.3 Position. (a) In arthroscopic repair. The position is

supine, and the lower leg is held with a leg holder. (b) In 4.2.2.4 Step 4: Suture the Remnant— 99
treating the intra-articular concomitant lesions. Distraction Modified Lasso-Loop Stitch 100
device is used according to the condition of the lesions Pass one thread of anchor suture to the nylon 101
including osteochondral lesions of the ankle and/or free body loop about 2/3 from the distal end. By pulling 102
both ends of the nylon thread, the thread of 103
61 the lateral pouch, turning the light cable upside to anchor suture is looped through the remaining 104
62 face the scope for directing the field of view of ligament (Fig. 4.9a). Rotate this loop half a turn; 105
63 the arthroscope to the back to obtain a good field first pass the anchor suture thread on the oppo- 106
64 of view. site side (Fig. 4.9b). Then turn the loop again, 107
65 Next an AAL portal is made. A 22G needle pass the anchor suture thread on the same side 108
66 is inserted at about 10 mm medial to the fibular through this second loop (Fig. 4.9c), pull the 109
67 obscure tubercle and make sure that the tip end of the anchor suture thread on the same side 110
68 of the needle is in the proper position to easily as the loop, and lightly tighten the loop 111
69 approach the fibular attachment of the ATFL (Fig. 4.9d). Finally, make the ankle at 0° neutral 112
70 with arthroscopy (Fig. 4.6a) and to put a position and strongly pull the end of the anchor 113
71 5 mm vertical incision through the capsule suture thread on the opposite side. Then the 114
72 (Fig. 4.6b). stump of the remaining ligament is crimped 115
73 If the field of vision is hindered by hypertro- onto the fibular attachment, and at the same time 116
74 phic synovium, minimum resection is done using the thread is appropriately slipped in the nodule 117
75 a 3.5 mm motorized shaver so as not to damage and the knot is tighten strongly (Fig. 4.9e). After 118
76 the joint capsule and residual ligament. three more knot sutures are added, unnecessary 119
77 If it is needed to treat the intra-articular threads are removed using a line cutter 120
78 lesions, we add anterolateral (AL) portal. (Fig. 4.9f). 121
32 M. Takao et al.
b c
Fig. 4.4 Position of the ankle. (a) The ankle position enough working space. (b, c) If the surgeon doesn’t have
should be kept slightly dorsiflexed by surgeon’s round adequate round belly, applying towel and corset is
belly to widen the lateral pouch for pleasant view and effective
ATFL and CFL are connected with lateral fibular attachment [8] (Fig. 4.10b). Accordingly,
talocalcaneal ligament [7] and attach together to CFL is automatically moved to its fibular attach-
fibula (Fig. 4.10a). And the rupture site in most ment and will recover to work well after ATFL
cases of lateral instability of the ankle is close to suture alone (Fig. 4.10c).
122 4.2.2.5 Step 5: Gould Augmentation Insert second suture anchor about 5 mm 126
123 Recently we add a Gould augmentation to proximal from the first suture anchor insertion 127
124 Broström repair to reduce the stress for repaired (Fig. 4.11a). Since the upper edge of the infe- 128
125 ligament in early phase after surgery. rior extensor retinaculum is close to the AAL 129
portal, blunt dissection is performed on the sur- 130
face layer and the deep layer of the inferior 131
extensor retinaculum using mosquito pean or a 132
blunt rod. And after touching the upper edge of 133
Lateral edge Fibular the inferior extensor retinaculum, it is grasped 134
of the anterior obscure by mosquito pean (Fig. 4.11b). After attaching 135
MML tubercle
tibial tendon the end of one thread of second suture anchor to 136
a semicircular needle (Fig. 4.11c), insert the tip 137
of the needle from the AAL portal and penetrate 138
Anterolateral from the deep side of the inferior extensor reti- 139
corner of the AAL naculum to the skin (Fig. 4.11d). Pull out the 140
talar dome
thread on the skin, remove the needle 141
(Fig. 4.11e), then grip this thread with mosquito 142
pean inserted subcutaneously from the AAL 143
portal, and pull it out of the AAL portal 144
(Fig. 4.11f). At this point, one thread of second 145
suture anchor penetrates the inferior extensor 146
retinaculum from the deep layer to the surface 147
layer and is led out from the AAL portal. Then, 148
a sliding knot technique (Navy knot) is per- 149
Fig. 4.5 Portals. MML medial midline portal, AAL acces-
sory anterolateral portal formed. It is desirable to use as small a sliding 150
a b
Fig. 4.6 Make an AAL portal. (a) Insert a needle. A 22G in the proper position to easily approach the fibular attach-
needle is inserted at about 10 mm medial to the fibular ment of the ATFL with arthroscopy. (b) Put a 5 mm verti-
obscure tubercle and make sure that the tip of the needle is cal incision through the capsule
34 M. Takao et al.
a b
Fig. 4.7 Placement of the suture anchor for ATFL suture. (a) Viewing portal is MML and working portal is AAL. (b)
Arthroscopic view. Arrow shows an inserted suture anchor
a b
c d
Fig. 4.8 Suture relay technique. (a) Insert an 18G needle to enlarge the nylon loop. (c) Insert a hook probe from the
through 2-0 nylon thread from AAL portal and penetrate AAL portal. (d) Guide the nylon loop from the AAL por-
ATFL remnant fiber. (b) Rotate the needle forward for tal to the outside
several times and reverse rotate the same number of times
knot method as possible to prevent nodules mum plantar flexion cannot be achieved pas-
from touching subcutaneously after surgery sively. But in almost all cases it improves to
(Fig. 4.11g). Tighten the sliding knot and cut normal range within 4 weeks after surgery. This
the thread with a knot cutter (Fig. 4.11h). If the is because the inferior extensor retinaculum is
Gould augmentation is completed, the ankle loosened within 4 weeks after surgery. So,
moves about 10° in the dorsiflexion direction Gould augmentation should be regarded as a
when knotting, and after tightening the maxi- temporary reinforcement after the operation.
b c d e
Fig. 4.9 Modified lasso-loop stitch. (a) Pass one thread anchor suture thread on the same side and lightly tighten
of anchor suture to the nylon loop about 2/3 from the dis- the loop. (e) Strongly pull the end of the anchor suture
tal end. By pulling both ends of the nylon thread, the thread on the opposite side. Then the stump of the remain-
thread of anchor suture is looped through the remaining ing ligament is crimped onto the fibular attachment and at
ligament. (b) Rotate the loop half a turn, and first pass the the same time the thread is appropriately slipped in the
anchor suture thread on the opposite side. (c) Then turn nodule and the knot is tightened strongly. (f) Cut the
the loop again, and pass the anchor suture thread on the suture anchor threads
same side through this second loop. (d) Pull the end of the
36 M. Takao et al.
Fig. 9 (continued)
a b c
Fibula
ATFL
CFL
Lateral talo-
calcaneal
ligament
Fig. 4.10 Actual anatomy of the lateral ligament com- rupture site in most cases of chronic lateral instability of
plex. (a) ATFL and CFL are connected with lateral talo- the ankle is close to fibular attachment. (c) CFL is auto-
calcaneal ligament and attached together to fibula. (b) The matically moved to its fibular attachment and will recover
to work well after ATFL suture alone
151 If enough stability is obtained with the from 2 weeks postoperatively and return to sports 159
152 arthroscopic Broström method, there is no need without external fixation shall be after 5 weeks 160
153 to add Gould augmentation. postoperatively. 161
154 4.2.3 Postoperative Management 4.3 Arthroscopic Reconstruction 162

(A-AntiRoLL) 163
155 After surgery, the elastic bandage is applied for
156 2 days, and the full weight-bearing walking is AntiRoLL is the word made by Dr. Glazebrook, 164
157 allowed according to pain from a day after sur- aligning underlined parts of the phrase 165
158 gery. Jogging and proprioceptive training will be “Anatomical Reconstruction of the Lateral 166
a b c
A drill
hole for
2nd suture
anchor
d e f
g h
Fig. 4.11 Gould augmentation (reinforcement by inferior lar needle. (d) Insert the tip of the needle from the AAL
extensor retinaculum). (a) Insert a second suture anchor at portal and penetrate from the deep side of the inferior
5 mm proximal to the first suture anchor. (b) Blunt dissec- extensor retinaculum to the skin. (e) Pull out the thread on
tion is performed on the surface layer and the deep layer of the skin and remove the needle. (f) Grip the thread with
the inferior extensor retinaculum using mosquito pean via mosquito pean inserted subcutaneously from the AAL
AAL portal. (c) The upper edge of the inferior extensor portal and pull it out of the AAL portal. (g) Sliding knot
retinaculum is grasped by mosquito pean, and attach the technique (Navy knot) is performed. (h) Tighten the slid-
end of one thread of second suture anchor to a semicircu- ing knot and cut the thread with a knot cutter
38 M. Takao et al.
b c d
Fig. 4.12 Steps of AntiRoLL. (a) Make a Y-shaped graft. (b) Make the bone tunnels at each attachment to fibula, talus,
and calcaneus. (c) Introduce a Y-shaped graft into the bone tunnels. (d) Fix with the interference screw
167 Ligament of the ankle” [9]. There are three types

168 of AntiRoLL, arthroscopic (A-AntiRoLL) [9],
169 percutaneous [10] (P-AntiRoLL), and open
170 AntiRoLL [11].
Anterior
tibial
tendon
MML
171 4.3.1 Surgical Procedure
AAL
172 The position is supine, and the lower leg is held
173 with a leg holder. The tourniquet is not normally ST
174 used, but it should be worn on the thigh for use Lateral
malleolus
175 when the field of vision is hindered by
176 bleeding.
177 There are four steps for AntiRoLL; in step 1
178 make a Y-shaped graft (Fig. 4.12a); in step 2 Fig. 4.13 Portals. MML medial midline portal, AAL
accessory anterolateral portal, ST subtalar portal
179 make the portals; in step 3 make the bone tun-
180 nels at each attachment to fibula, talus, and
181 calcaneus (Fig. 4.12b); and in step 4 introduce 4.3.1.1 Make Portals 185
182 a Y-shaped graft into the bone tunnels Medial midline (MML) portal, accessory antero- 186
183 (Fig. 4.12c) and fix with the interference screw lateral (AAL) portal, and subtalar portal (ST) are 187
184 (Fig. 4.12d). used (Fig. 4.13). If it is needed to treat the intra- 188
189 articular lesions, we add additional anterolateral about 40% inferior point from anterolateral cor- 235
190 (AL) portal. ner of the talar body is the center of the footprint 236
of the ATFL. But in actual cases, there remains a 237
191 4.3.1.2 Make a Y-Shaped Graft ligament fiber at the attachment of the ATFL to 238
192 An autologous gracilis tendon is harvested from the talus in most cases and it is a good landmark 239
193 ipsilateral knee (Fig. 4.14a). Marking is done to make a talar bone tunnel. A guide wire for can- 240
194 nine times every 15 mm; the resulting 135 mm nulated drill is inserted via AAL portal and it 241
195 length tendon should be needed as a tendon graft penetrates the center of the footprint at talus 242
196 (Fig. 4.14b). Next fold back at the site 60 mm (Fig. 4.17b) toward the direction to tip of the 243
197 from the end, pass the guide thread through this medial malleolus, and finally penetrates the skin. 244
198 fold, and then suture the tendons with the 3-0 bio- Next an overdrilling 6 mm in diameter and 245
199 absorbable thread at the position 15 mm from the 20 mm in depth is done using cannulated drill. 246
200 turning point. Finally fold back at 15 mm from Finally, a guide wire is replaced to guide thread. 247
201 both ends, pass guide thread through folded back, In making a calcaneal bone tunnel, a viewing 248
202 and then suture the tendons with 3-0 bioabsorb- portal is ST and a working portal is AAL 249
203 able thread (Fig. 4.14c). The short leg of the (Fig. 4.18a). A landmark for calcaneal bone tun- 250
204 Y-shaped tendon graft is ATFL and the long leg is nel is the posterior facet of the talocalcaneal joint 251
205 CFL. (Fig. 4.15). On the line perpendicular bisector of 252
the posterior facet, 17 mm inferior point from 253
206 4.3.1.3 Make the Bone Tunnels at Each posterior facet is the center of the footprint of the 254
207 Attachment to Fibula, Talus, CFL. But in actual cases, peroneal tendons run 255
208 and Calcaneus just over the insertion of the CFL. To avoid the 256
209 Positioning of each fibular, talar, and calcaneal damage to the peroneal tendons, the authors 257
210 bone tunnels is made by using the landmarks make a calcaneal bone tunnel proximal to the 258
211 existing on the bone surface as shown in peroneal tendon sheath, about 10 mm inferior 259
212 Fig. 4.15 [12]. point from posterior facet (Fig. 4.15). A guide 260
213 In making a fibular bone tunnel, a viewing wire for cannulated drill is inserted via AAL por- 261
214 portal is MML and a working portal is ST tal and it penetrates the calcaneus as the direction 262
215 (Fig. 4.16a). A landmark for fibular bone tunnel of center of the posterior corner of the calcaneus, 263
216 is fibular obscure tubercle (FOT) which exists at and finally penetrates the posterior heel skin 264
217 the border of the footprints of the ATFL and the (Fig. 4.18b). Next an overdrilling 6 mm in diam- 265
218 CFL (Fig. 4.16b). After to identify a FOT to eter and 20 mm in depth is done using cannulated 266
219 remove a part of remnant of ATFL using motor- drill. Finally, a guide wire is replaced to guide 267
220 ized shaver, a guide wire for cannulated drill is thread. 268
221 inserted via ST portal and it penetrates the center In this time, a guide thread of the fibular bone 269
222 of the fibula at FOT toward the direction of tunnel is inserted via ST portal. This thread is 270
223 proximal-posterior fibular cortex as 30° to the grasped by forceps via AAL portal inside the 271
224 axis of fibula, and finally penetrates the posterior joint and introduced to the AAL portal. 272
225 leg skin (Fig. 4.16a). Next an overdrilling 6 mm Accordingly, all guide threads come out from an 273
226 in diameter and 20 mm in depth is done using AAL portal. 274
227 cannulated drill. Finally, a guide wire is replaced
228 to guide thread. 4.3.1.4 Introduce a Y-Shaped Graft into 275
229 In making a talar bone tunnel, a viewing portal the Bone Tunnels and Fix 276
230 is MML and a working portal is AAL (Fig. 4.17a). with the Interference Screw 277
231 A landmark for talar bone tunnel is anterolateral A Y-shaped graft is introduced and fixed into the 278
232 and posterolateral corners of the talar body bone tunnels, firstly fibula, next talus, and finally 279
233 (Fig. 4.15). On the line to connect the anterolat- calcaneus. It is important to insert a guide wire 280
234 eral and posterolateral corners of the talar body, for interference screw before introducing a graft 281
40 M. Takao et al.
Gracilis
tendon
b 135mm
15mm 15mm 15mm 15mm 15mm 15mm 15mm 15mm 15mm
2 1 2
Into the talar Into the fibular Into the calcaneal

As ATFL As CFL
bone tunnel bone tunnel bone tunnel
c
Guide thread
ATFL
Suture CFL
Suture
Guide thread
Guide thread
Fig. 4.14 Make a Y-shaped tendon graft. (a) An autolo- fold back, green arrow: marking suture for fibular bone
gous gracilis tendon is harvested from ipsilateral knee. (b) tunnel, blue arrow: marking suture for talar bone tunnel,
Marking on the harvested graft. Marking is done nine yellow arrow: marking suture for calcaneal bone tunnel.
times every 15 mm; the resulting 135 mm length tendon (c) The short leg of the Y-shaped tendon graft is ATFL and
should be needed as a tendon graft. Black arrow: point to the long leg is CFL
282 into the bone tunnels to prevent the graft from with inside-out technique at the level of the suture 288
283 being penetrated by a guide wire following graft which ties the graft at the position 15 mm from 289
284 damage by an interference screw. the turning point (Fig. 4.19a, b). A graft is fixed 290
285 Viewing a fibular bone tunnel via MML por- into the bone tunnel with an interference screw 291
286 tal, a fibular end of a Y-shaped graft is introduced 6 mm in diameter and 15 or 20 mm in length 292
287 into the fibular bone tunnel using guide thread (Fig. 4.19c, d). 293
Viewing a talar bone tunnel via MML portal, a 294
talar end of a Y-shaped graft is introduced into the 295
talar bone tunnel using guide thread with inside- 296
out technique at the level of the suture which ties 297
Anterolateral the graft at the position 15 mm from the turning 298
corner of the
point. Tension the transplantation tendon by 299
talar body 10mm FOT
manually pulling the guide thread with the ankle 300
at the position of 0 degrees in axial motion, a 301
10mm graft is fixed into the bone tunnel with an inter- 302
ference screw 6 mm in diameter and 15 or 20 mm 303
in length (Fig. 4.19e). 304
Viewing a calcaneal bone tunnel via ST por- 305
tal, a calcaneal end of a Y-shaped graft is intro- 306
duced into the calcaneal bone tunnel using guide 307
thread with inside-out technique at the level of 308
Fig. 4.15 Landmarks for each bone tunnel. A landmark the suture which ties the graft at the position 309
for fibular bone tunnel is fibular obscure tubercle (FOT) 15 mm from the turning point. As ankle posi- 310
which exists at the border of the footprints of the ATFL tioned in 0° neutral position and to tensile the 311
and the CFL. For talar bone tunnel, on the line to connect
the anterolateral and posterolateral corners of the talar tendon graft pulling a guide thread manually, a 312
body, about 40% inferior point from anterolateral corner graft is fixed into the bone tunnel with an inter- 313
of the talar body is the center of the footprint of the ference screw 6 mm in diameter and 15 or 314
ATFL. For calcaneal bone tunnel, on the line perpendicu- 20 mm in length (Fig. 4.19f). 315
lar bisector of the posterior facet, 10 mm inferior point
from posterior facet should be a landmark for calcaneal All guide thread can be removed easily to cut 316
bone tunnel to avoid damage to the peroneal tendons the one end near the skin and pull the other end 317
manually. 318
a b
Fig. 4.16 Make a fibular bone tunnel. (a) A viewing portal is MML and a working portal is ST. (b) Arthroscopic view
of the fibular obscure tubercle (FOT)
42 M. Takao et al.
a b
Fig. 4.17 Make a talar bone tunnel. (a) A viewing portal is MML and a working portal is AAL. (b) Arthroscopic view
of the remaining ligament fiber at the attachment of the ATFL to the talus
a b
Fig. 4.18 Make a calcaneal bone tunnel. (a) A viewing portal is ST and a working portal is AAL. (b) Arthroscopic view
of the posterior facet and the point to make a bone tunnel
4.3.2 Postoperative Management the strength of biological bonding and becomes

nearly normal strength at 4 weeks postoperatively
After surgery, the elastic bandage is applied for [13]. Accordingly, jogging and proprioceptive
2 days, and the full weight-bearing walking is training will be from 4 weeks postoperatively and
allowed according to pain from a day after surgery. return to sports without external fixation shall be
The bone tendon attachment gradually increases after 6–8 weeks postoperatively.
a b
Guide wire for

interference screw
c d
Interference
screw
Interference
screw
e f
Fig. 4.19 Introduce a Y-shaped graft into the bone tun- 15 mm from the turning point. (c, d) A graft is fixed into
nels and fix with the interference screw. (a, b) A fibular the bone tunnel with an interference screw 6 mm in
end of a Y-shaped graft is introduced into the fibular bone diameter and 15 or 20 mm in length. (e, f) Fix a graft into
tunnel using guide thread with inside-out technique at talar bone tunnel. (f) Fix a graft into calcaneal bone
the level of the suture which ties the graft at the position tunnel
3. Valderrabano V, Hintermann B, Horisberger M, Fung

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355
335 ment ruptures. Acta Chir Scand. 1966;132:248–53. Warren RF. Tendon-healing in a bone tunnel. A bio- 356
336 9. Takao M, Glazebrook MA, Stone JW, Guillo S, Ankle mechanical and histological study in the dog. J Bone 357
337 Instability Group. Ankle arthroscopic reconstruction Joint Surg Am. 1993;75:1795–803. 358
338 of lateral ligaments (Ankle Anti-ROLL). Arthrosc
339 Tech. 2015;4:e595–600.
1
2
Mini-Incision Technique for Lateral
Ankle Ligament Repair in Chronic
5
3 Instability
4 Gian Luigi Canata, Valentina Casale,
5 and Luca Pulici
6 Abbreviations Three-quarters of the ankle injuries comprise 23

the lateral ligamentous complex [6, 7] (Fig. 5.1). 24
7 ATFL Anterior talofibular ligament Among the three lateral ankle ligaments, the 25
8 CFL Calcaneofibular ligament anterior talofibular ligament (ATFL) torn occurs 26
9 FAAM Foot and ankle ability measure in 80% of cases, while the other 20% of ankle 27
10 MRI Magnetic resonance imaging lateral sprains involve both the ATFL and the cal- 28
11 PTFL Posterior talofibular ligament caneofibular ligament (CFL) [8]. The posterior 29
12 ROM Range of movement talofibular ligament (PTFL) is less commonly 30
injured [8]. 31
Over the years, many classifications of ankle 32
sprains and ligamentous injuries have been pro- 33
13 5.1 Background posed [9, 10]. 34
14 and Classification Traditionally, ankle sprains are classified as 35
grade I (mild), II (moderate), or III (severe) [11– 36
15 Ankle sprain is one of the most common injuries 13]. This classification incorporates anatomical 37
16 sustained during sports activities [1]. It is most damage with patient’s symptoms [14]. 38
17 frequently reported by basketball, soccer, run- The grade I sprain is characterized by the 39
18 ning athletes and ballet/dancers [2] accounting stretch of the ATFL, minimal swelling, or tender- 40
19 for 40% of all athletic injuries [3, 4]. In the sys- ness, without functional loss or joint instability 41
20 tematic review of Fong et al., the ankle was the [14]. The grade II injury is a partial microscopic 42
21 most commonly injured area of the body in 24 of tear of the ATFL, with or without the involvement 43
22 70 sports analyzed [5]. of the CFL; a moderate swelling, pain, and ten- 44
derness develop, and the range of motion reduces 45
with an initial joint instability. In the grade III 46
G. L. Canata (*) · V. Casale
sprain, a complete ligamentous rupture is pres- 47
Centre of Sports Traumatology, Koelliker Hospital,
Torino, Italy ent; both the ATFL and CFL are involved, with or 48
without a capsular tear and a PTFL tear; swelling 49
L. Pulici
Sports Traumatology Unit, Department of Knee and tenderness are intense and hemorrhage is 50
Orthopedic, Humanitas Research Hospital, usually present. A marked alteration of motion is 51
Milan, Italy evident, as well as the loss of function and the 52
FC Internazionale Medical Staff, Milan, Italy severe joint instability [14]. 53
© ISAKOS 2019 45
https://doi.org/10.1007/978-3-662-58704-1_5
46 G. L. Canata et al.
Fibularis longus
muscle
Superior extensor
reinaculum
Inferior extensor
Fibula reinaculum
Achilles Tendon
Anterior talofibular
ligament
Calcaneo fibular
ligament
Calcaneus
Peroneal tendons
Fig. 5.1 Anatomy of the ankle
54 Chronic ankle instability persists in 5–20% of instability, the main complaint includes intermit- 74
55 acute injuries, and it is defined as an instability tent “giving out of the ankle” with a history of at 75
56 lasting more than 6 months [1]. least two or three severe lateral ankle sprains. 76
57 Ankle instability may be classified as caused The most important features of physical 77
58 by lateral, medial, and syndesmotic ligament examination are tenderness, hematoma, pain, 78
59 injuries [15]. swelling, and difficulty in weight-bearing. 79
The diagnosis requires a thorough history of 80
the triggering event and the recurrent traumatic 81
60 5.2 Diagnosis episodes, as well as an accurate physical exami- 82
nation [16]. 83
61 The “on field” assessment is not accurate The Ottawa ankle rules have been developed 84
62 enough to diagnose the grade of injury; how- to exclude fractures after an acute trauma; how- 85
63 ever it is important to provide initial first care ever, most athletes are examined using radio- 86
64 to protect the athlete from further injury or stop graphs despite the fact that the incidence of ankle 87
65 him from continuing the match. In the outpa- fractures is less than 15% [17]. 88
66 tient setting, a careful history and physical It is fundamental to observe any foot and ankle 89
67 examination is fundamental when evaluating a malalignment, to palpate the ankle expecting 90
68 patient both with an acute ankle sprain and pain and tenderness especially around the lateral 91
69 chronic ankle instability. gutter. 92
70 In the most acute stage, the patient usually Two provocative tests are essential to assess 93
71 describes “rolling over” of the ankle often due to stability of the lateral ankle ligaments, and they 94
72 an inversion movement of the ankle. When elicit- must be performed in comparison with the unin- 95
73 ing the history from a patient with chronic ankle jured leg. If increased laxity is present, the tests 96
5 Mini-Incision Technique for Lateral Ankle Ligament Repair in Chronic Instability 47
a b
Fig. 5.2 (a, b) Positive Talar Tilt test
97 are considered positive. The anterior drawer test

98 evaluates the integrity of ATFL, while the talar 5.3 onservative vs. Surgical
C 130
99 tilt test assesses the integrity of CFL [18–21] Treatment 131
100 (Fig. 5.2a, b).
101 The gold standard in the diagnosis of acute As for the treatment of grade I and II ankle 132
102 lateral ligament injury is the delayed physical sprains, conservative management remains the 133
103 examination (4–5 days post-trauma). This tim- gold standard; the treatment for grade III ankle 134
104 ing provides a diagnostic modality of high sprains is instead less standardized. 135
105 quality to perform the tests with a better sensi- The Cochrane review of Kerkhoffs et al. [23] 136
106 tivity and specificity compared with an earlier regarding the comparison of surgical versus con- 137
107 examination, though limited due to pain and servative treatment for acute lateral ankle liga- 138
108 swelling [19, 21]. A positive anterior drawer ment injuries fails to demonstrate a clearly 139
109 test in combination with pain on palpation at superior treatment approach. The likelihood of 140
110 the ATFL and hematoma has a sensitivity of operative complications, stiffness of the ankle 141
111 98% and a specificity of 84% for having an joint and the higher costs associated with surgical 142
112 ATFL injury [21]. treatment, would suggest functional treatment as 143
113 Standard antero-posterior and lateral weight- the best available option for most patients [23]. A 144
114 bearing radiographs are important to evaluate further motivation to not recommend surgery is 145
115 joints’ morphology, alignment, and the possible that delayed surgery is equally effective as pri- 146
116 presence of arthritis [16]. The use of stress radio- mary surgery [24]. 147
117 graphs is controversial, because they are useful to Surgery seems to provide better outcomes 148
118 assess the joint, but concerns remain on their only in objective ankle stability without func- 149
119 reproducibility and on which values should be tional differences [23]. 150
120 considered as normal [18, 22]. The most recent guidelines [25] for the con- 151
121 Ultrasound and magnetic resonance imaging servative treatment of ankle sprains suggest that 152
122 (MRI) can be useful in diagnosing associated 3–5 days of rest, ice, compression, and elevation 153
123 lesions like bone, chondral, or tendon injuries with early weight-bearing, after which active 154
124 and they are routinely performed in professional exercise is commenced, lead to a fastest resump- 155
125 athletes. MRI has a very high specificity but a tion of work and daily life activities compared 156
126 relatively low sensitivity [18, 19]. with any other kind of treatment. For prevention, 157
127 Peroneal muscle strength and proprioception both tape and brace may be used and the choice 158
128 should be also assessed during physical of modality should always be based on patient 159
129 examination. preferences. Supervised exercises are advised 160
161 with the focus on proprioception, strength, coor- For this reason, in order to restore the normal 209
162 dination, and function [25]. ankle and subtalar mechanics, it is fundamental 210
163 Eighty percent of acute ankle sprains make a to recreate the anatomy and the orientation of the 211
164 full recovery with conservative management, but lateral ankle complex, including the repair of the 212
165 20% develop mechanical or functional instability CFL ([2, 31]). 213
166 resulting in chronic ankle instability [26].
167 Although for general population conservative
168 treatment is preferred over surgical options, in 5.4 Surgical Techniques 214
169 professional players remains a lack of consensus.
170 Athletes have greater load and demand on their It has been reported that since 1966 over 60 dif- 215
171 ankle joints, and they could easily develop resid- ferent procedures for treating ankle instability 216
172 ual complaints [2]. have been described [34], including the use of 217
173 For high-level sports teams, absence of key autologous or synthetic grafts [35] and the 218
174 players due to injury may result in defeat and arthroscopic approach [16]. 219
175 economic loss. Since increased objective insta- Numerous surgical procedures have been 220
176 bility is a predictor for future ankle sprains [27], described for lateral ankle instability, which can 221
177 an acute reconstruction should be taken into con- be divided into three categories: nonanatomic 222
178 sideration in professional athletes. reconstruction, anatomic reconstruction, and 223
179 The time of the season, athlete’s expectations, anatomic repair. The first surgical procedures 224
180 and stage of his career are all features to take described in literature were nonanatomical recon- 225
181 into account when considering an operative struction techniques. 226
182 treatment of lateral ankle injuries in a competi-
183 tive athlete. • Nonanatomic reconstruction was the first 227
184 Modern post-surgical treatment protocols reported procedure for the treatment of lateral 228
185 report that the time to return to sport will be simi- ankle instability and described by Elmslie in 229
186 lar, with or without surgery. 1934 using fascia lata graft to reconstruct the 230
187 Conservative treatment is usually preferred in lateral ankle ligaments [36]. In 1952, Watson- 231
188 case of acute lesions, while surgery is recom- Jones used the peroneus brevis and re-routed 232
189 mended for chronic instability [1, 23, 28] or in the tendon in a posterior to anterior fashion 233
190 presence of osteochondral lesions [29]. through the fibula and securing it onto the talar 234
191 Conservative treatment aims to restore neck [37]. In 1953, Evans reported a modified 235
192 mechanical joint stability and consists in neuro- version of the Watson-Jones procedure by 236
193 muscular reprogramming, foot evertor muscles routing the peroneal brevis tendon obliquely 237
194 reinforcement, and muscular pre-activation. If through the distal fibula in an anterior-distal to 238
195 these procedures have been unsuccessful, a surgi- posterior-proximal fashion [38]. In the 239
196 cal stabilization is required [30]. Chrisman-Snook reconstruction, the peroneus 240
197 Furthermore, the role of the CFL in the man- brevis tendon is split and transferred through 241
198 agement of chronic ankle instability is an evolv- the fibula and into the calcaneus [39]. 242
199 ing concept [31]. It is the only ligament bridging • Anatomic reconstruction: Colville described 243
200 both the talocrural and the subtalar joints [32], a reconstruction using a split peroneus brevis 244
201 and it has been demonstrated that the CFL can be tendon to augment a repaired ATFL and 245
202 tensioned while approaching the ATFL, due to CFL. The peroneus brevis is placed into 246
203 the presence of connecting fibers between these the anatomic origins and insertions of the 247
204 two ligaments [33]. ligaments. The indications for this technique 248
205 Due to the stabilizing function of both the require poor tissue quality or revision 249
206 ankle and the subtalar joints, an injury of the CFL surgery [40]. 250
207 may cause increased subtalar laxity in addition to • Anatomic repair include the original Broström 251
208 ankle instability [2]. technique [8]. Broström first described a 252
253 id-substance repair of the ATFL in 1966. In

m These data allow Petrera et al. [55] to demon- 300
254 30% of cases, the CFL repair was also per- strate that immediate, protected, full weight- 301
255 formed. Subsequently, Gould modified the bearing after a modified Broström surgery with 302
256 Broström procedure adding the mobilization an accelerated rehabilitation could allow athletes 303
257 and the reattachment of the lateral portion of an early return to sport. Another study [56] pub- 304
258 the extensor retinaculum to the fibula in order lished in 2016 reports excellent results in athletes 305
259 to obtain an additional talocrural and a sec- affected by chronic ankle instability treated with 306
260 ondary subtalar joint stability [41]. this type of repair also in long-term follow-up 307
261 Furthermore, in 1988 Karlsson proposed the (10–15 years). 308
262 reattachment of the ATFL to its anatomical It may be summarized that the anatomic pro- 309
263 peroneal insertion through drill holes [42]. cedures consist in either a direct repair of the 310
injured structures or an anatomic reconstruction 311
264 Nonanatomic procedures show excellent with auto- or allografts [57]. 312
265 results in the initial period, but in the long run The first option is usually preferred in pres- 313
266 they develop persistent instability, abnormal ence of adequate ligamentous remnants, while 314
267 kinematics, stiffness, loss of movement, and reconstruction is suggested in cases of constitu- 315
268 weak eversion [39, 42–46]. Also the extensive tional ligamentous laxity, obesity, failed prior sta- 316
269 incision required for the procedure heightens the bilization, and poor or insufficient ligamentous 317
270 risk of wound infection and sural nerve damage remnants [58]. 318
271 [47, 48]. However, these invasive procedures To date, the Broström-Gould reconstruction 319
272 required long immobilization time and were technique is still considered the “gold standard” 320
273 responsible for joint stiffness and secondary for the treatment of chronic ankle instability [49, 321
274 muscle imbalance because of the sacrifice of the 59, 60]. 322
275 peroneal tendons [16, 49]. Anatomic repair is largely supported in the lit- 323
276 Anatomic procedures show fewer complica- erature [61–64]. 324
277 tions and less restriction in mobility compared to After an initial skepticism due to the high 325
278 the nonanatomic ones as reported by Sammarco complexity, more complications, a longer surgi- 326
279 in his study [50]. cal time, and controversial results compared to 327
280 In 1996, Hennrikus [51] compared the the open techniques, the arthroscopic stabiliza- 328
281 Chrisman-Snook with the Broström-Gould pro- tion first introduced by Hawkins [65] and Ferkel 329
282 cedure. Both groups showed same good results [66] has been recently revalued [16, 67]. 330
283 but in the nonanatomic operation were found The reasons are less invasive, a faster return to 331
284 more complications. Wainright et al. [52] recently sports activities, and the opportunity to treat other 332
285 reported improved ankle joint kinematics in intra-articular associated problems simultane- 333
286 unstable ankles after modified Broström-Gould ously, such as osteochondral lesions or synovitis 334
287 repair, with a significant decrease in anterior [16]. In fact, it has been proved that the poor 335
288 translation and internal rotation of the talus. accuracy of MRI in showing the intra-articular 336
289 Cadaveric studies have shown greater mechani- lesions is often associated with chronic instabil- 337
290 cal stability obtained with this anatomic tech- ity [68]. 338
291 nique as opposed to Watson-Jones and Nevertheless, it has been highlighted how the 339
292 Chrisman-Snook reconstructions [53, 54]. arthroscopic fixation devices increase the risk of 340
293 The reported advantages of the modified nerve or tendon entrapment [69], thus requiring 341
294 Broström-Gould procedure mainly concern the the identification of an inter-nervous and inter- 342
295 preservation of ankle kinematics and the native tendon safe zone before surgery [70]. 343
296 ATFL fibers, fundamental for proprioceptive With reference to the several techniques 344
297 function as they ensure a stronger fixation and the described, the treatment of CFL should not be 345
298 absence of peroneal weakness observed in non- undervalued. It is a primary stabilizer of the tibio- 346
299 anatomic reconstruction. talar and subtalar joints [57], especially in 347
348 d orsiflexion [71]. CFL is four times stronger than a tourniquet placed on the proximal lower thigh, 368
349 ATFL; thus its reinforcement should be mandatory and a sandbag under the ipsilateral buttock to 369
350 during the stabilization of chronic ankle instability improve the access to both lateral and medial side 370
351 where talar tilt test is constantly positive while of ankle. 371
352 anterior drawer test is frequently negative [71], The surgeon performs a longitudinal incision 372
353 though some authors do not agree [72, 73]. that passes over the distal fibula for 3 cm towards 373
the talar neck. The capsule and the lateral liga- 374
ments are exposed by retracting the peroneal ten- 375
354 5.5 he Lateral Reefing
T dons. During the tissue dissection, it is important 376
355 Procedure to avoid damages to the lateral cutaneous branch 377
of the superficial peroneal nerve and the branches 378
356 It is not unfrequently that patients undergoing of the short saphenous vein. 379
357 surgery for lateral ankle instability have associ- The ATFL and CFL are then plicated and 380
358 ated intra-articular pathology; therefore possible sutured to the periosteum of the inner distal fibula 381
359 associated lesions are arthroscopically treated (Figs. 5.3, 5.4, 5.5, 5.6, 5.7, 5.8). 382
360 before proceeding with the stabilization if Two or three nonabsorbable sutures are passed 383
361 detected preoperatively by an MRI or in presence from inside to outside the capsulo-ligamentous 384
362 of intra-articular symptoms. complex. Ankle stability is intraoperatively 385
363 This procedure addresses chronic instabilities. checked, and further sutures are eventually added. 386
364 It may be performed in local or peripheral anes- Before tying the suture knots, the ankle is held by 387
365 thesia, with or without the use of a tourniquet. the assistant in dorsiflexion and eversion. 388
366 The patient is positioned supine with the heel The Gould modification is added in specific 389
367 at the very bottom of the table and knee extended, cases, if the previous sutures do not restore full 390
Fig. 5.3 Surgical technique: reefing of the lateral capsulo-ligamentous complex to the peroneal periosteum with mul-
tiple stitches
Fig. 5.4 Surgical access: retinaculum is incised and

peroneal tendons are exposed
Fig. 5.6 Second suture: the needle is passed through the
calcaneofibular ligament
Fig. 5.5 Peroneal tendons are retracted posteriorly,

below the fibula. The lateral capsulo-ligamentous com-
plex is exposed and the reefing is started grasping the lax
tissue
391 ankle stability and consist in inserting sutures

392 from the fibular periosteum into the inferior
393 extensor retinaculum.
394 If a gentle anterior drawer and talar tilt tests
395 confirm the stability of the ankle, after an irriga-
396 tion with 0.9% saline, the peroneal retinaculum Fig. 5.7 After suturing, the peroneal tendons are reposi-
397 and the skin incision can be sutured. Steri strips tioned anatomically
re-establish the bone-ligament interface and an 418

excessive load could damage the repairing inser- 419
tion site, although there is much basic scientific 420
evidence that an insufficient load could lead to a 421
catabolic environment [75, 76]. 422
For this reason, an approach based on a short 423
period of immobilization followed by gradually 424
increased movement and load bearing seems to 425
be reasonable. In their paper, the members of the 426
ESSKA-AFAS Ankle Instability Group recom- 427
mend the patient fully weight-bearing with the 428
boot on after 10–14 days of immobilization [77]. 429
At this time, mobilization of the ankle under safe 430
conditions with a limited ROM is also possible; 431
however walking without protection until week 6 432
should not be admitted. 433
The goals of the next phase (after week 6) 434
include the increase of strength, range of motion, 435
and the possibility to achieve daily activities 436
pain-free. Ankle and foot strengthening should 437
include exercises to address tibialis anterior, tibi- 438
alis posterior, gastrocnemius, and foot intrinsics 439
Fig. 5.8 Suture of the peroneal retinaculum but the emphasis must be put on the peroneal 440
muscles, progressing from isometric to isotonic 441
to resistive exercises. Ankle strengthening can 442
398 are applied and a brace is added to keep the ankle also progress from non-weight-bearing to weight- 443
399 in slight dorsiflexion and eversion. bearing positions and in this phase of recovery 444
proprioception and balance exercises should also 445
be initiated. 446
400 5.6 Postoperative Management The late rehabilitation phase typically occurs 447
401 and Return to Sport between weeks 8 and 12 post-surgery, and to 448
enter this phase, patient should demonstrate sym- 449
402 The management after a surgical reconstruction metrical gait patterns, ankle strength at least 90% 450
403 should always be a balanced approach with an ini- of the contralateral side, and the ability to per- 451
404 tial protection of the repair and an early rehabilita- form the functional tests described. 452
405 tion in order to prevent the complications of a Running should begin at slow speed and prog- 453
406 longer immobilization. A recent case series, cited ress to higher speed and longer distances. Agility 454
407 above, showed good results and no increased rates drills are also included in this period. During the 455
408 of complication with immediate weight-bearing late rehabilitation stage, functional tests can be 456
409 and early range of motion exercises after this sur- particularly useful in identifying when to advo- 457
410 gery technique [55], but it is still very risky to cate the return to play phase. These tests include 458
411 rehabilitate a patient too quickly. In a study about the single leg hop test, the triple hop test, the ver- 459
412 foot injuries conducted in professional rugby play- tical jump, the drop jump, the 6-meter timed hop 460
413 ers [74], it was found that rehabilitating a relapse test, the Star Excursion Balance Test, and the 461
414 can be three and a half times longer than rehabili- Foot and Ankle Ability Measure (FAAM) ques- 462
415 tating the original injury. When performing an tionnaire [77]. 463
416 anatomic repair, as in the modified Broström pro- The return to sport phase typically falls 464
417 cedure, we need to remember that we are trying to between 12 weeks and 4 months following 465
466 s urgery. The use of taping or bracing is recom- 14. Kannus P, Renström P. Treatment for acute tears of 515
the lateral ligaments of the ankle. Operation, cast, or 516
467 mended in the early phases of return to full sports early controlled mobilization. J Bone Joint Surg Am. 517
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469 tant to underline that these recommendations are 15.
McCriskin BJ, Cameron KL, Orr JD, et al. 519
470 a general guide for management, but it is always Management and prevention of acute and chronic lat- 520
eral ankle instability in athletic patient populations. 521
471 necessary to consider individual response to World J Orthop. 2015;6(2):161–71. 522
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arthroscopic lateral ligament repair for treatment of 524
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473 5.7 Conclusions 17. Bachmann LM, Kolb E, Koller MT, et al. Accuracy of 527
Ottawa ankle rules to exclude fractures of the ankle and 528
474 Minimally invasive surgery for chronic lateral mid-foot: systematic review. BMJ. 2003;326:417–23. 529
475 ankle instability is rapidly evolving. 18. Usuelli FG, Mb LM, Mrcs B, et al. Foot and ankle 530
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479 time than other open or arthroscopic approaches. nostic strategies for patients with severe ankle sprains. 535
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713 of the ankle. ISAKOS Newsletter. 2008;2:19–21.
1 Syndesmosis Injuries
6
2 Pieter D’Hooghe
3 6.1 Introduction externally and moves posteriorly and laterally. 28

This mechanism then separates the distal tibia and 29
4 Syndesmotic injuries, or high ankle sprains, com- fibula and sequentially tears the AITFL, deep del- 30
5 prise 10% of all ankle sprains [1]. These injuries toid ligament (or causes a malleolar fracture), the 31
6 are frequently sustained during athletic competi- inferior oblique ligament (IOL), and finally the 32
7 tion, particularly soccer [1, 2]. However, as imag- posterior inferior talo-fibular ligament (PITFL) 33
8 ing studies suggest that up to 20% of acute ankle [10, 13]. When there is a combined syndesmotic 34
9 sprains involve the syndesmosis, the prevalence of injury with a deltoid ligament disruption, talar 35
10 syndesmotic injuries may be underestimated [3, instability occurs [14]. 36
11 4]. Syndesmotic injuries often require twice as Less commonly, the injury may occur in 37
12 long to return to sport as compared to isolated lat- forced dorsiflexion without rotation since the 38
13 eral ligament sprains and can lead to prolonged anterior part of the talus is wider than the poste- 39
14 pain and disability [5–8]. Further, the most com- rior part. The magnitude and duration of force 40
15 mon cause of chronic ankle dysfunction 6 months application appear to be predictive factors of 41
16 from an ankle trauma is related to syndesmotic lesion severity [9]. Syndesmotic injuries are clas- 42
17 injuries [7]. Recurrent and undiagnosed ankle sified in three grades, ranging from a partially 43
18 instability is known to ensue and eventually lead torn AITFL to a complete disruption of all liga- 44
19 to premature ankle arthritis [9]. Therefore, a ments with mortise widening [15]. 45
20 timely diagnosis of unstable syndesmotic injuries Stress radiographs and magnetic resonance 46
21 is essential. A rapid pivoting and forced ankle dor- imaging (MRI) can be helpful in the diagnosis of 47
22 siflexion of the ankle with a forceful external rota- these injuries, but currently there is no best 48
23 tion and pronation of the foot is the most common evidence-based test available that can identify 49
24 mechanism of a high ankle sprain [10]. Planovalgus syndesmotic instability (especially in grade II 50
25 foot alignment, high competitive sports level, and lesions). This is particularly relevant in the ath- 51
26 male gender are potential risk factors [9, 11, 12]. letic population, where appropriate management 52
27 As the talus rotates in the mortise, the fibula rotates is crucial for the player to return to the team [3]. 53
There is a consensus to use arthroscopy in the 54
evaluation of syndesmotic stability in doubtful 55
P. D’Hooghe (*) cases, but there is no validated surgical protocol 56
Department of Orthopaedic Surgery,
available (except expert opinion) to identify syn- 57
Aspetar Orthopaedic and Sports Medicine Hospital,
Doha, Qatar desmotic stability under direct visualization with 58
e-mail: Pieter.Dhooghe@aspetar.com arthroscopy [16]. 59
© ISAKOS 2019 57
https://doi.org/10.1007/978-3-662-58704-1_6
58 P. D’Hooghe
60 6.2 Anatomy disrupted with joint space widening or frank 107

diastasis [17, 18]. 108
61 A syndesmosis is defined as a fibrous joint in It is often multifascicular, and its most inferior 109
62 which two adjacent bones are linked by a strong fascicle has been described as a discrete structure 110
63 membrane or ligaments [17, 18]. The distal tibio- called the accessory AITF ligament. 111
64 fibular joint is a syndesmotic joint between the The fibers can be seen during ankle arthros- 112
65 tibia and fibula, linked by four ligaments: the copy and have been reported to be a source of 113
66 anterior inferior tibiofibular ligament (AITFL), impingement [17, 25]. The PITFL originates on 114
67 the interosseous ligament (IOL), the posterior the posterior aspect of the fibula and runs hori- 115
68 inferior tibiofibular ligament (PITFL), and the zontally to Volkmann’s tubercle. This ligament 116
69 inferior transverse ligament (ITL). The distal tib- has an approximate width of 18 mm and a thick- 117
70 iofibular joint employs both its bony and liga- ness of 6 mm and is the strongest component of 118
71 mentous structure for stability (Fig. 6.1). the syndesmosis. 119
72 The architecture of the bony components of Because of its extensive breadth of attachment 120
73 the syndesmosis provides significant stability to coupled with elasticity, the PITFL is able to with- 121
74 this joint. The fibula sits in a groove created by stand greater forces without failure than the 122
75 bifurcation of the lateral ridge of the tibia into AITFL and reaches maximal tension during dor- 123
76 the anterior and posterior margins of the tibia, siflexion [17, 19, 26]. 124
77 approximately 6–8 cm above the level of the The inferior transverse ligament is deep and 125
78 talocrural joint [17, 19]. The anterior margin inferior to the PITFL, extending over to the pos- 126
79 ends in the anterolateral aspect of the tibial pla- terior aspect of the medial malleolus. The inferior 127
80 fond called the anterior tubercle, or Chaput’s transverse ligament is often difficult to distin- 128
81 tubercle. guish from the PITFL as it runs just distally in the 129
82 The posterior margin ends in the posterolat- same plane. 130
83 eral aspect of the tibial plafond called the poste- It forms the most distal aspect of the articula- 131
84 rior tubercle, or Volkmann’s tubercle. The apex tion (Fig. 6.2). A portion of this ligament lies 132
85 of this fibular notch is the incisura tibialis, which below the posterior tibial margin preventing pos- 133
86 has a depth that varies from concave (60–75%) to terior translation of the talus and deepening the 134
87 shallow (25–40%) [17, 20, 21]. Its depth varies ankle mortise to increase joint stability by func- 135
88 from 1.0 to 7.5 mm [17, 22, 23] and is a little less tioning as a labrum. 136
89 in women than in men [17, 24]. The interosseous ligament spans the space 137
90 A shallow notch may predispose to recurrent between the lateral tibia and medial fibula and is 138
91 ankle sprains or syndesmotic injury with fracture confluent with the proximal interosseous mem- 139
92 dislocation [18]. The bony architecture of the brane. It is the main restraint to proximal migra- 140
93 fibula mirrors that of the fibular notch. tion of the talus between the tibia and the fibula 141
94 The medial aspect of the fibula forms a convex [9, 17] (Fig. 6.2). 142
95 structure that complements that of the tibia, with
96 an anterior and posterior margin, as well as a
97 ridge that bifurcates that margins and aligns itself 6.3 Epidemiology 143
98 with the incisura tibialis.
99 The AITFL originates from the anterior tib- Syndesmosis or “high ankle” sprains are reported 144
100 ial tubercle and runs distally and laterally in an to occur in 1–18% of patients with an ankle 145
101 oblique fashion to insert onto the anteromedial sprain [27, 28]. However, this is probably an 146
102 distal fibula (Figs. 6.1 and 6.2). This ligament underestimate, as 20% of athletes with an acute 147
103 has a width of approximately 18 mm, length ankle sprain have evidence of syndesmotic injury 148
104 between 20 and 30 mm, and a thickness of on MRI [28]. 149
105 2–4 mm. It is the most commonly sprained This variation can be explained by the fact 150
106 ligament in syndesmotic injuries and is always that some sports have extrinsic risk factors asso- 151
6 Syndesmosis Injuries 59
Interosseous
membrane
Anterior inferior
tibiofibular ligament
ligament Deltoid ligament
Calcaneofibular
ligament
Posterior inferior Tibia

tibiofibular ligament Fibula
Anterior inferior
Inferior transverse tibiofibular ligament
tibiofibular ligament
ligament
Calcaneofibular
ligament
Fig. 6.1 Antero-posterior and lateral view of the ankle ligamentous complex
60 P. D’Hooghe
IOL
IOL PITFL PITFL
TL
AITFL AITFL PITFL

AITFL
Anterior view Posterior view Lateral view
Fig. 6.2 Detailed antero-posterior and lateral view of the ankle syndesmosis ligaments
152 ciated with syndesmosis injury. Skiers and ice

153 hockey players wear boots causing rigid immo-
154 bilization of the ankle leading to high-torque
155 external rotation of the foot [28–31] and
156 American football is often played on artificial
157 turf instead of natural surfaces [28, 32–35].
158 Another plausible explanation is that an isolated
159 syndesmotic injury can be frequently misdiag-
160 nosed as an ankle sprain [28].
161 A recent epidemiological overview on iso-
162 lated syndesmosis injuries in elite football indi-
163 cated a significant increase in the incidence of
164 these injuries with an average return to play time
165 following injury that exceeded 5 weeks. Also, no
166 change in injury burden was found over 15 con-
167 secutive football seasons. This was primarily
168 linked to the more aggressive playing style dur-
169 ing matchplay [28].
170 Male gender, elite performance, and a pla-
171 novalgus alignment are risk factors for syndes-
172 mosis injury in athletes [36, 37]. Syndesmosis
173 injuries can occur with an ankle sprain only, with
174 fractures or as a combination of both. In fact,
175 23% of ankle fractures are reported to have com-
176 bined syndesmosis injuries [36, 37].
177 The associated fractures are commonly either
178 of the fibula or of the posterior and medial mal-
179 leoli. Syndesmosis injury should be increasingly
180 suspected if there is an associated fracture of the
181 proximal fibula (Maisonneuve fracture, Fig. 6.3)
182 and they are associated with prolonged pain, dis-
183 ability, and an unpredictable time away from Fig. 6.3 Antero-posterior X-ray image of a Maisonneuve
184 sports [27, 37]. fracture
185 6.4 Mechanism of Injury be used [15, 27]. The combination of tenderness on 230
palpation over the ATFL, a positive fibular transla- 231
186 The general mechanism of injury for syndesmo- tion test, and positive Cotton test is considered 232
187 sis ankle sprains is a forceful external rotation of highly clinically suspicious [16, 27]. 233
188 the foot and ankle with the ankle in dorsiflexion Although the squeeze test has been shown to 234
189 and the foot pronated [27, 38]. While the talus be highly sensitive, there is no one “gold stan- 235
190 rotates in the mortise, the fibula rotates externally dard” for the clinical diagnosis of syndesmotic 236
191 and moves posteriorly and laterally, separating instability [27, 42]. In case of clinical suspicion, 237
192 the distal tibia and fibula. advanced imaging, such as MRI, is warranted. 238
193 This will sequentially cause tears of the ante- It has been shown that there is a significant 239
194 rior inferior tibiofibular ligament (AITFL), the correlation between how far this tenderness radi- 240
195 deep deltoid ligament, or might alternatively ates proximally in the leg and the severity of the 241
196 cause a malleolar fracture. This shall be in turn injury and, consequently, the time to return to 242
197 followed by a tear of the interosseous ligament sports [27, 37]. 243
198 (IOL) and finally the posterior inferior tibiofibu- Patients with high ankle sprains may complain 244
199 lar ligament (PITFL) [27, 38, 39]. of the inability to bear weight, swelling, pain dur- 245
200 Severity of syndesmosis injury varies, ranging ing the push-off phase of gait, and pain anteriorly 246
201 from a partially torn AITFL to a complete disrup- between distal tibia and fibula, as well as postero- 247
202 tion of all ligaments with mortise widening. It medially at the level of the ankle joint [15, 27]. 248
203 has been shown that combined deltoid and syn- Ankle ROM will often be limited, with pain felt 249
204 desmosis injury will critically compromise talar more at terminal dorsiflexion [27, 42]. Numerous 250
205 stability [14, 27]. The magnitude of force and its special tests are used to detect syndesmosis inju- 251
206 duration will determine the extension of syndes- ries. However, a recent systematic review on 252
207 mosis and interosseous injury proximally [9] and eight different tests reported a low diagnostic 253
208 this may eventually lead to a Maisonneuve frac- accuracy of these tests [43]. The squeeze test was 254
209 ture (Fig. 6.3). Another injury mechanism for the only test with a clinical significance [43]. 255
210 syndesmosis ankle sprains is hyper-dorsiflexion. Diagnosing an athlete with a syndesmotic 256
211 Forced dorsiflexion of the ankle causes the injury can however still be difficult. 257
212 wider anterior talus to act as a wedge that can The pain is often diffuse and difficult to dif- 258
213 cause injury to the syndesmosis ligaments [27]. ferentiate from a lateral ankle sprain. Additionally, 259
as previously noted, there can be overlap in injury 260
patterns. This can further cloud the diagnosis and 261
214 6.5 Clinical Evaluation potentially lead to missed syndesmotic injuries. 262
However, a thorough history might uncover a 263
215 Athletes frequently present with an inability to mechanism that would increase the treating phy- 264
216 bear weight, anterolateral pain between the distal sician’s suspicion. A thorough physical examina- 265
217 tibia and fibula, medial ankle pain, ankle effu- tion includes visual inspection for swelling, 266
218 sion, and pain during gait push off [40, 41]. palpation for tenderness, and evaluation of the 267
219 However, anterolateral pain is not specific, as up proximal extent of the tenderness. 268
220 to 40% of patients with an ATFL tear describe The latter physical examination finding, 269
221 pain over the AITFL. Clinically it has been sug- known as “syndesmosis tenderness length” (the 270
222 gested that the more proximal the patient’s pain, most proximal site of tenderness measured from 271
223 the more significant the injury [40, 41]. the distal tip of the fibula), has been shown to cor- 272
224 Several clinical tests can be used in the evalua- relate with the time to return to sports [40, 44]. 273
225 tion of a syndesmotic injury. The external rotation The typical location of tenderness in a syndes- 274
226 test and the squeeze test are the most commonly motic injury is at the anterolateral and/or postero- 275
227 described tests, but the Cotton test, the fibular trans- medial joint line. 276
228 lation test, the heel thump test, the dorsiflexion All current clinical syndesmosis tests have 277
229 compression test, and the cross-legged test can also been shown to be difficult to interpret with a low 278
62 P. D’Hooghe
279 predictive value in the presence of a painful or most reliable indicators of syndesmotic disruption 298
280 swollen ankle [45]. Although the squeeze test has [41]. This distance is measured at 1 cm proximal 299
281 most clinical significance in recent literature [15, to the tibial plafond and should not exceed 6 mm 300
282 27, 43], the external rotation test has been shown in both the AP and mortise views [41]. 301
283 to be most sensitive with the lowest false positive In the case of a suspected syndesmotic injury, 302
284 rate [40, 46]. This is performed with the ankle in radiographs must be carefully scrutinized. Signs 303
285 neutral or slight dorsiflexion and the heel in neu- of syndesmotic injury include avulsion fractures 304
286 tral or varus position, with subsequent external of the anterior tubercle of the tibia (Tillaux- 305
287 rotation of the foot relative to the tibia to the Chaput fragment, Fig. 6.4a–d), anterior fibula 306
288 point of resistance and pain. (Wagstaffe le Fort fragment), and posterior mal- 307
289 Additionally, a stress radiograph can be leolus (Volkmann fragment). 308
290 obtained to evaluate for medial clear space Radiographs should be evaluated for the tibio- 309
291 (MCS) or tibiotalar widening [40, 47]. fibular clear space (TFCS) (normal = mean 310
4.4 ± 0.8 mm on antero-posterior view and 311
3.9 ± 0.9 mm on mortise view, respectively), the 312
292 6.6 Imaging tibiofibular overlap (normal = mean 8.8 ± 2.4 mm 313
on antero-posterior view and 4.6 ± 2.1 mm on mor- 314
293 Plain radiographs should still always be obtained tise view, respectively), and for any increased MCS 315
294 when there is concern for syndesmotic injury. The (normal <5 mm) [48]. However, it has been shown 316
295 tibiofibular clear space, defined as the distance that tibiofibular overlap and TFCS do not correlate 317
296 between the medial border of the fibula and the with syndesmotic injury seen on magnetic reso- 318
297 lateral border of the posterior tibia, is one of the nance imaging (MRI) [49]. Additionally, MCS 319
a b
Fig. 6.4 (a–d) Avulsion fracture of the antero-lateral tubercle (a, b) of the tibia (Tillaux-Chaput) and after mini-open
fixation fracture treatment (c, d)
c d
Fig. 6.4 (continued)
320 measurements have been shown to have poor accu- be helpful in assessing the integrity of the syn- 344
321 racy and precision even among experienced provid- desmosis and of the deltoid ligament. Still, there 345
322 ers. In a recent cadaver study, three specimens were is no standardized technique or amount of force 346
323 evaluated with a known amount of displacement (6, applied and the quality of the test can be signifi- 347
324 4, and 1.7 mm). Measurement errors ranged from cantly limited by the patient’s pain [40, 41]. One 348
325 16% at 5° of internal rotation to 36% at 15° of recent study found that gravity stress radiographs 349
326 external rotation for the specimen with 6 mm of (with the foot suspended via a bump under the 350
327 known MCS widening but were even greater rang- calf allowing gravity to pull the foot in external 351
328 ing from 3% at neutral to 100% at 5° external rota- rotation) resulted in equivalent MCS widening to 352
329 tion for the intact specimen with 1.7 mm of MCS manual stress radiographs [41]. Conversely, if 353
330 [40]. Although the sensitivity and specificity of there is an operative fracture, then stress radio- 354
331 detecting a syndesmotic injury on MRI has been graphs can be postponed until surgery. 355
332 shown to be up to 100%, determining the severity Computed tomography (CT) scanning can be 356
333 of that injury and the need for surgery is not helpful in identifying minor diastasis and small 357
334 straightforward and often only when frank diastasis avulsion fractures [55]. Although its value still 358
335 is seen on radiography is the final determination for needs further evaluation, promising new diagnos- 359
336 operative intervention made [41, 50–52] tic types of bilateral standing CT scan stress view 360
337 Stress radiographs are no longer routinely rec- are useful [56]. Magnetic resonance imaging 361
338 ommended in the routine evaluation of syndes- (MRI) can identify most ligamentous syndesmotic 362
339 motic instability since biomechanical studies injuries and combined injuries [53]. MRI shows a 363
340 have not shown significant advantage over plain sensitivity of 100% and a specificity of 93% for 364
341 radiographs [53, 54]. AITFL injuries (positive likelihood ratio of 14, 365
342 If an injury could potentially be managed non- Fig. 6.5) and a sensitivity and specificity of 100% 366
343 operatively, then stress radiographs can however for PITFL injuries (infinite positive likelihood 367
64 P. D’Hooghe
Fig. 6.6 Arthroscopic view of a grade III syndesmosis

injury
represents a complete rupture of all three syndes- 387

motic ligaments with evident instability [15, 54]. 388
The severity of the syndesmotic instability 389
guides the choice of treatment. Grade I injuries 390
are treated nonsurgically [59] while the treat- 391
Fig. 6.5 Axial MRI image of an AITFL rupture in an ment of grade II injuries depends on the pre- 392
elite football player sented syndesmotic (in)stability testing [16]. 393
Stable syndesmotic injuries (type I and IIa) 394
368 ratio) [57] and has a high degree of interobserver should be treated conservatively, whereas unsta- 395
369 reliability [49]. Ultrasonography is a fast and inex- ble injuries (type IIb and III) warrant surgical 396
370 pensive tool to evaluate distal tibiofibular stability fixation. A recent study found that a positive 397
371 and does not expose the athlete to radiation. squeeze test and combined injury to the ATFL 398
372 Further, it enables a dynamic assessment of the and deep deltoid ligament are key factors in dif- 399
373 ligamentous injury, which is useful in cases of ferentiating stable (type IIa) from unstable grade 400
374 subtle instability. Patients with an acute AITFL II injuries (type IIb). 401
375 rupture (confirmed on MRI) show a 100% sensi- Nowadays, there is a consensus to perform an 402
376 tivity and specificity on dynamic ultrasound examination under anesthesia and arthroscopic 403
377 evaluation [58]. The disadvantages are that ultra- evaluation of the syndesmosis in case of a grade 404
378 sonography cannot detect associated injuries and II injury with clinical and/or radiological suspi- 405
379 is proven to be investigator dependent [41, 53]. cion of dynamic instability (type IIb) [16, 60, 406
61]. In case of 2 mm or more dynamic distal tib- 407
iofibular diastasis, arthroscopic-assisted surgical 408
380 6.7 Classification and Treatment fixation is warranted [59] (Fig. 6.6). 409
Grade III injuries often present with associ- 410
381 6.7.1 Classification of Syndesmotic ated injuries and are inherently unstable. Surgical 411
382 Injuries fixation by means of screws or suture buttons 412
can be used to reduce the mortise and stabilize 413
383 Syndesmotic injuries are divided into three grades. the syndesmosis [16, 62]. The Hook or Cotton 414
384 Grade I represents an AITFL sprain without insta- test is regarded as reliable intraoperative stress 415
385 bility. Grade II represents an AITFL tear and a tests to evaluate syndesmotic (in)stability [63] 416
386 partial IOL tear with mild instability. Grade III (Fig. 6.7b). 417
a b
Fig. 6.7 (a) Intraoperative fluoroscopy of ankle fixation. Right: Radiograph following syndesmotic screw fixation.
Left: Stress radiograph following fixation of a Weber B (b) Hook test performed in which the fibula is pulled lat-
fibula fracture with medial clear space widening [40]. eral to assess for medial clear space widening [40]
418 Cadaveric studies have shown that the syndes- tion = 5 ± (0.93 × [tenderness length in 448
419 mosis becomes unstable (opens more than 5 mm centimeters]) ± 3.72 days. 449
420 in tibiofibular clear space) when a force above Rehabilitation is implemented in three phases. 450
421 87–100 N is applied [63]. Arthroscopy is consid- Phase I is the acute phase. Goals include joint 451
422 ered ‘the golden standard’ in the diagnostic protection, minimization of inflammation, and 452
423 assessment of syndesmotic (in)stability [64] and pain control. Phase II is the subacute phase in 453
424 in case of doubt, fixation is advised because of which restoration of mobility, strength, and gait 454
425 the problems caused by chronic syndesmotic is emphasized. Finally, in phase III, emphasis is 455
426 instability [63]. placed on strengthening, neuromuscular control, 456
and sports-specific tasks [68]. 457
A recent cohort-controlled study by Samra 458
427 6.7.2 Management of Syndesmotic et al. suggested that ten rugby players with MRI- 459
428 Injuries confirmed syndesmosis injury (involvement of 460
the AITFL, IOL, and PITFL) treated without sur- 461
429 6.7.2.1 Purely Ligamentous Injuries gery who received a single autologous PRP injec- 462
430 In the case of sprains without diastasis, nonop- tion into the AITFL had significantly shorter time 463
431 erative management has been shown to result in to return to play than a historical cohort (20.7 days 464
432 good functional outcomes [65]. However, there less for the intervention group vs. historical con- 465
433 is currently no consensus on the nonoperative trol). Following return, these patients had higher 466
434 regimen, with treatments ranging from taping to agility, increased vertical jump, and lower level 467
435 fracture boots to non-weight-bearing cast immo- of fear avoidance [69]. However, although they 468
436 bilization. Other interventions such as injections, reported similar baseline characteristics between 469
437 physical therapy, ultrasonography, and nonste- groups, the intervention was not blinded and 470
438 roidal anti-inflammatory drugs are discussed there was no placebo control, both of which 471
439 throughout the literature without consensus. could have resulted in bias. 472
440 Reported lengths of immobilization vary from 1 In contrast, all injuries with frank diastasis 473
441 to 6 weeks [46, 66]. require syndesmotic fixation [70]. Taylor et al. 474
442 Athletes should be informed that return to full reported on six intercollegiate athlete patients 475
443 sport takes longer compared to lateral ankle with grade III syndesmosis injuries treated 476
444 sprains. with a 4.5-mm stainless steel cortical screw 477
445 The syndesmosis tenderness length can be and reported good to excellent clinical out- 478
446 used to estimate the time loss from sports using comes in all patients with a mean return to 479
447 the equation [67]: Days lost from competi- sports at 40.7 days [71]. In their series, all 480
66 P. D’Hooghe
481 hardware was removed at an average of 74 days toid ligament in which the stronger deep compo- 528
482 (range 52–97) [40]. nent has been ruptured and the weaker superficial 529
component, which attaches to the anterior collic- 530
483 6.7.2.2 Fractures with Syndesmotic ulus, remains intact. If this occurs in conjunction 531
484 Instability with a syndesmotic injury, it has the potential to 532
485 Carr et al. recently performed a large database present as late syndesmotic widening and signifi- 533
486 analysis of ankle fracture and syndesmotic fixa- cant instability [74]. 534
487 tion between 2007 and 2011 and found no signifi-
488 cant increase in procedures for all ankle fracture 6.7.2.3 Syndesmotic Fixation 535
489 types (lateral malleolus, bimalleolar, and trimal-
490 leolar) during that time [72]. However, the num- Syndesmotic Screws 536
491 ber of procedures to treat isolated syndesmotic Syndesmotic screws have long been considered 537
492 injuries increased by 18% during that time period. the gold standard for fixation of syndesmotic 538
493 In addition, the rate of syndesmotic fixation that injuries (Fig. 6.7a). Most authors prefer 3.5 or 4.5 539
494 accompanied fixation of ankle fractures signifi- cortical screws which have equivalent biome- 540
495 cantly increased with a nearly twofold increase chanical characteristics [75]. 541
496 among bimalleolar fractures. The authors also While some cadaveric studies have shown 542
497 reported that the rate of implant removal after increased resistance to an applied load, specifi- 543
498 syndesmotic fixation significantly decreased. cally in shear stress, with a larger diameter screw 544
499 This suggests an overall increase in recognition [55] this has not been reproduced in clinical stud- 545
500 and operative treatment of isolated syndesmotic ies [66, 75]. In Europe, most surgeons utilize a 546
501 injuries and those associated with ankle fractures. single 3.5-mm tricortical screw, 2.1–4 cm above 547
502 Although factors associated with higher energy the joint line for stabilization of Weber B or C 548
503 ankle fractures (e.g., bimalleolar involvement or fractures [46]. However, a cadaveric study sug- 549
504 the need for initial external fixation) are associ- gested that two screws provide a superior biome- 550
505 ated with delayed union, the need for syndes- chanical construct compared to one [76]. 551
506 motic screw fixation has not been shown to be Location of screw placement is often debated. 552
507 associated with delayed union of ankle fractures McBryde et al. reported less syndesmotic widen- 553
508 that undergo fixation. ing when the screw was placed at 2 cm above the 554
509 Nevertheless, although bony union can be fol- joint compared to 3 cm [77]. However, other 555
510 lowed via routine radiographs, the healing of the studies have reported that screw placement at 2, 556
511 syndesmosis is significantly slower, requiring 3, or 5 cm above the joint line shows no differ- 557
512 prolonged periods of non-weight-bearing up to ence in functional outcome [77]. 558
513 12 weeks [73]. Following fixation of medial and/ Tricortical screws (3.5 mm) were compared to 559
514 or lateral malleolus fractures, an intraoperative quadricortical lag screws (both 3.5 and 4.5 mm) 560
515 stress radiograph can assess the integrity of the in terms of compression force in a 2012 cadav- 561
516 syndesmosis and guide the decision of whether eric study. The lag screws maintained a signifi- 562
517 or not syndesmotic fixation is of benefit cantly greater compression force after forceps 563
518 (Fig. 6.7a). removal compared to the tricortical screw. 564
519 Special consideration should be given to cases Additionally, after each 100 cycles of loading, 565
520 of bimalleolar ankle fractures in which there is an the lag screws significantly exceeded the amount 566
521 anterior colliculus avulsion of the medial malleo- of compression force maintained by the tricorti- 567
522 lus. Tornetta reported on 27 patients with bimal- cal screw. No differences were seen between the 568
523 leolar fractures who underwent external rotation 3.5- and 4.5-mm lag screws [78]. 569
524 stress radiographs intraoperatively after medial Ultimately, although cadaveric studies have 570
525 malleolar fixation and found that 7 (26%) had suggested that four cortices provide more rigid 571
526 MCS widening even after medial fixation. He fixation, screws with purchase in three cortices 572
527 explained that this represents an injury to the del- have been shown to more closely replicate tibio- 573
574 talar biomechanics [66] (Fig. 6.7a). Additionally, to justify removal along with the additional cost 598
575 tricortical screws have decreased risk of screw and increased risk to the patient would suggest 599
576 breakage albeit at the cost of an increased rate of that routine removal should be avoided [85]. 600
577 screw loosening [57, 75, 79]. There is no current
578 evidence to suggest a clinically appreciable dif- Suture-Button Constructs 601
579 ference between these two methods of screw fix- While screw fixation is still considered the gold 602
580 ation [76]. standard, there are a number of theoretical advan- 603
581 In terms of screw removal, there has been a tages of suture-button fixation (Fig. 6.8). 604
582 longstanding debate in the literature. Although These have been theorized to allow physio- 605
583 some recommend removal of quadricortical logic motion at the syndesmosis while maintain- 606
584 screws to prevent screw breakage [79, 80], there ing reduction. Further, there is less risk of 607
585 is no consensus on when this should be performed symptomatic hardware and need for implant 608
586 and there have been reports of diastasis at screw removal. 609
587 removal [46]. Finally, these constructs have been sug- 610
588 Additionally, studies have suggested similar gested to safely allow earlier ankle range of 611
589 or better outcomes when the screw is retained motion as the reduction can be held with pro- 612
590 [81] and therefore, there is growing consensus gression of motion without the concern for 613
591 that screw removal should be reserved for screws implant failure (i.e., screw breakage) and recur- 614
592 that are symptomatic (i.e., painful prominence) rent diastasis [46]. 615
593 [66, 82–84]. The argument that these constructs might be 616
594 A recent systematic review by Dingemans superior because they do not require routine 617
595 et al. concluded that although there is insufficient removal is weakened by the growing evidence 618
596 evidence overall to draw definitive conclusions against routine screw removal. However, it has 619
597 regarding routine removal, the lack of evidence been suggested that these constructs might allow 620
earlier weight-bearing. This is due to concern 621
that early stress on a syndesmotic screw might 622
lead to breakage prior to ligamentous healing. 623
Conversely, less rigid constructs such as the 624
TightRope (Arthrex, Naples, FL) are purported to 625
be sturdy enough to withstand physiologic load- 626
ing that occurs with weight-bearing and normal 627
ankle motion [86]. 628
Teramoto et al. performed a cadaveric study 629
on six ankles comparing single suture-button 630
fixation, double suture-button fixation, anatomic 631
suture-button fixation (from posterior fibula to 632
anterolateral distal tibia), and screw fixation. The 633
authors evaluated the amount of diastasis with 634
various stresses on the ankle, including anterior 635
traction, medial traction, and external rotation. 636
With single suture-button fixation the diastasis 637
increased significantly with all forces, whereas 638
with double fixation the diastasis increased sig- 639
nificantly with medially directed force and with 640
external rotation but not with anterior traction. 641
They found that with anatomic suture-button 642
Fig. 6.8 Intraoperative fluoroscopic antero-posterior placement, there were no significant differences 643
view of a double suture-button fixation compared to ankles tested prior to syndesmotic 644
68 P. D’Hooghe
645 disruption. The screw fixation proved to be the 2 Nm and “various other activities” generally 693
646 most rigid fixation, with significantly decreased create stresses less than 20 Nm [89]. 694
647 diastasis compared to suture-button results [87]. One issue that arises with regard to the use of 695
648 However, the clinical implications of that a suture button is how to determine the amount of 696
649 amount of motion are not currently known. Naqvi force to put on the construct while securing the 697
650 et al. reported retrospectively on 49 patients with syndesmosis. Additionally, there has been debate 698
651 suture-button syndesmotic fixation. Patients with regarding which position the foot should be in at 699
652 syndesmotic injuries associated with ankle the time of final tightening. A recent cadaveric 700
653 fractures underwent single suture-button fixation study revealed that with the use of suture-button 701
654 and those with Maisonneuve injury underwent syndesmotic fixation, there was consistent over- 702
655 double suture-button fixation. The authors compression compared to the intact state, with 703
656 reported a mean time to weight-bearing of significant volume reduction and medial dis- 704
657 7.7 ± 1.1 weeks (range 5–10) and a mean return placement of the fibula [50]. 705
658 to normal activities at 11.2 ± 1.8 weeks. They Overcompression, however, is not unique to 706
659 reported that the original technique of tying the suture-button constructs as it has been reported to 707
660 knot over the lateral aspect of the fibular button occur with forceps reduction and screw fixation 708
661 resulted in a significantly higher rate of wound as well [90]. 709
662 complications compared to their reported modi- However, the clinical impact of overcompres- 710
663 fied technique of creating a subperiosteal recess sion of the syndesmosis is not known and it has 711
664 in the posterior fibula in which they buried the been shown that this compression does not appear 712
665 knot. They reported satisfactory results at 2 years to affect ankle dorsiflexion/plantarflexion. 713
666 postoperatively [86]. Further, it has been shown that the position of the 714
667 A recent prospective randomized trial com- foot (i.e., plantarflexion, neutral, or dorsiflexion) 715
668 paring screw fixation with a single 3.5-mm screw during the time of compression and fixation has 716
669 (n = 22) vs. suture-button fixation (n = 22) of the no significant effect on postoperative ankle 717
670 syndesmosis revealed no difference in quality or motion [90–92]. 718
671 maintenance of reduction between the two as Another recent cadaveric study compared a 719
672 seen on postoperative imaging. Additionally, single screw to either a single suture-button con- 720
673 there was no difference at 2-year follow-up in the struct or a divergent double-suture button con- 721
674 incidence of ankle joint osteoarthrosis [88]. struct [93]. The authors found that while all 722
675 In 2013, Ebramzadeh et al. compared two fixation techniques provided significant torsional 723
676 suture-button devices (ZipTight [Biomet] and stability, no technique provided the rotational sta- 724
677 TightRope [Arthrex]) along with a 3.5-mm quad- bility and native anatomic relationships provided 725
678 ricortical screw fixation in a cadaveric, failure-to- by the intact ligaments. 726
679 load model. In 12 of 20 specimens, failure Further, the screw provided the most rigid 727
680 occurred via a fibula fracture. The screw con- restraint to anterior-posterior translation of the 728
681 struct was found to provide a significantly higher fibula with the highest amount of translation seen 729
682 torsional strength than the ZipTight (30.1 vs. in the single suture-button group [94]. 730
683 22.2 Nm) but the difference seen between the Although multiple studies have addressed bio- 731
684 screw and the TightRope was not significant. mechanical stability, Laflamme et al. reported on 732
685 The authors reported that there were no sig- functional scores in addition to radiographic out- 733
686 nificant differences between the two suture- comes of patients randomized to either static fix- 734
687 button constructs. Ultimately, they suggested that ation with a single 3.5-mm quadricortical screw 735
688 the torsional fixation strengths of all three con- (n = 36) or dynamic fixation with a single 736
689 structs were above the physiologic loads that TightRope (n = 34). 737
690 would “likely” be experienced during the healing Dynamic fixation resulted in improved 738
691 process, citing that level ground walking gener- Olerud-Molander functional scores at 3, 6, and 739
692 ally creates syndesmotic torsional stresses below 12 months (significant at 12 months). AOFAS 740
741 scores were significantly better in the TightRope cal outcomes as trans-syndesmotic screw fixation 788
742 group at 3 months only. There were four cases of [97]. This is typically performed through a pos- 789
743 lost reduction in the screw group compared to terolateral approach with the patient in a prone 790
744 zero in the TightRope group. position [98]. 791
Syndesmotic injuries are increasingly com- 792
745 Anatomic Repair of Syndesmotic mon in both competitive and recreational ath- 793
746 Ligaments letes. Although screw fixation has been shown to 794
747 There has been recent support for anatomic repair provide greater stability than newer suture-button 795
748 of the syndesmosis. constructs, the benefit of the earlier motion 796
749 Schottel et al. in 2016 reported from a cadav- allowed by these constructs is not completely 797
750 eric model that anatomic repair using suture understood. 798
751 anchors for the deltoid ligament and PITFL was Although both of these techniques have the 799
752 not significantly inferior to screw fixation in ability to overcompress the syndesmosis, it is 800
753 terms of external rotational stability [95]. unclear what effect this has on healing and ankle 801
754 Zhan et al. reported that patients who had aug- motion. Additionally, direct anatomic repair of 802
755 mented anatomic repair of the AITFL with a 5.0- syndesmotic ligaments with or without augmen- 803
756 mm anchor placed into tibia and tied to the fibular tation has shown promising results in terms of 804
757 plate had better functional outcomes and earlier anatomic restoration of the joint with acceptable 805
758 return to work than patients with screw fixation. strength. At present, more work is needed to 806
759 Additionally, there were significantly fewer understand the long-term impact of newer treat- 807
760 cases of malreduction in the repair group (19.2% ments and the utility of more aggressive rehabili- 808
761 vs. 7.4%). The repair group had significantly tation techniques. 809
762 higher overall range of motion, although they had
763 significantly decreased plantarflexion compared
764 to the screw group [68]. 6.8 New Ideas: “Syndhoo” [41] 810
765 A recent topic of debate is in relation to fixa-
766 tion of the posterior malleolus and the role that it There are no standardized criteria for the diagno- 811
767 plays in syndesmotic reconstruction and stabili- sis and management of syndesmotic injuries, cre- 812
768 zation. Even small posterior fragments in trimal- ating great ambiguity regarding optimal 813
769 leolar fractures can represent complete avulsion treatment. Future challenges are to identify clini- 814
770 of the PITFL. Therefore, the previous teaching cal syndesmotic instability without the need of 815
771 that posterior malleolar fractures that constitute invasive arthroscopic procedures, especially in 816
772 less than 20% of the joint surface do not require subtle (grade IIb) instabilities [41]. 817
773 fixation has been called into question. A grade II isolated syndesmotic injury is 818
774 Posterior malleolar fixation has been found to defined as a lesion to the antero-inferior tibiofibu- 819
775 further stabilize the syndesmosis and decrease lar ligament and the interosseous ligament of the 820
776 the risk of post-traumatic arthritis [53]. ankle with involvement of the deltoid ligament 821
777 A cadaveric study by Gardner et al. found that on magnetic resonance scanning (MRI). 822
778 in specimens with unstable syndesmoses, fixa- We tested 15 registered athletes between the 823
779 tion of a posterior malleolus fracture restored age of 18 and 36 years, who presented with a 824
780 70% of preinjury stiffness compared to only 40% grade II isolated syndesmotic injury (confirmed 825
781 with screw fixation [96]. on MRI) between 1 January 2015 and 1 May 826
782 A prospective clinical study of 31 patients (9 2017. All 15 athletes were independently tested 827
783 who underwent posterior malleolus fixation and by an experienced physiotherapist with the “synd- 828
784 14 who underwent screw fixation of their syndes- hoo” device that we developed. They all had a 829
785 motic injury) revealed that fixation of a posterior grade II isolated syndesmotic injury with clinical 830
786 malleolus fracture with the PITFL attached and radiological signs of potential instability and 831
787 resulted in at least equivalent stability and clini- therefore all were indicated for arthroscopy [37]. 832
70 P. D’Hooghe
833 For every “syndhoo”-tested athlete, an arthros- The board can be put in neutral position, 20° 852
834 copy was performed by the same experienced of plantar flexion and 20° of dorsiflexion 853
835 ankle surgeon at our Center between January (Fig. 6.9c, d). 854
836 2017 and September 2017. During arthroscopy, The knee is stabilized through a patellar strap 855
837 the syndesmosis was considered positive (unsta- and the patient is tested in sitting position 856
838 ble) if a 4.5-mm arthroscopic shaver could be (Fig. 6.9b). With a dynamometer, the foot is pas- 857
839 pushed through the distal syndesmosis, 1 cm sively externally rotated with the hinge posi- 858
840 proximal from the tibiotalar joint. The physio- tioned over the heel (Fig. 6.9e, f). 859
841 therapist and surgeon were blinded to the other When the patient experiences clinical appre- 860
842 one’s results. All patients were tested and treated hension at a force <87 N, the “syndhoo” test is 861
843 between 1 and 4 weeks from the initial injury. considered positive. 862
844 The principle of this “syndhoo” device is to If the apprehension occurs during a force 863
845 dynamically evaluate the distal tibiofibular stabil- 87–100 N, the syndhoo test is considered 864
846 ity during external rotation of the ankle as an equivocal. 865
847 extension to the available clinical tests. Cadaveric When no apprehension occurs or the appre- 866
848 testing has shown that the distal syndesmosis is hension occurs with a force >100 N, the “synd- 867
849 unstable when a force of 87–100 N is applied. hoo” test is considered negative. 868
850 The foot is positioned and fixed on the syndhoo Statistically, Cohen’s kappa (κ) has been used 869
851 board that rotates over the heel (Fig. 6.9a, b). to determine the inter-rater agreement between 870
a b
Fig. 6.9 (a) Image of the “syndhoo” device (front side). Image of the syndhoo device from the side with the foot
(b) Image of the “syndhoo” device from the side with the placed on the rotating board in 20° of dorsiflexion. (e)
foot placed on the rotating board in neutral position. (c) Image close up of the dynamometer, placed at the medial
Image of the syndhoo device from the side with the foot foot side of the rotating board. (f) Overview image of the
placed on the rotating board in 20° of plantar flexion. (d) dynamometer, linked to the rotating board
c d
e f
Fig. 6.9 (continued)

72 P. D’Hooghe
871 the arthroscopy method (as a reference) and the agreement between the examination described 916
872 three “syndhoo” methods (dorsiflexion, neutral, here and MR quantification of syndesmotic 917
873 plantar flexion). injury which we hope will better depict the cut- 918
874 Based on the guidelines from Altman, and point for a positive test. 919
875 adapted from Landis and Koch, Cohen’s kappa We have incorporated these finding in this 920
876 (κ) is interpreted as poor agreement if less than chapter on novel techniques since we have found 921
877 0.20, fair agreement if between 0.20 and 0.40, this “syndhoo” device very helpful as part of the 922
878 moderate agreement if between 0.40 and 0.60, available noninvasive options in the clinical diag- 923
879 good agreement if between 0.60 and 0.80, and nosis of syndesmotic instability [41]. 924
880 very good agreement if between 0.80 and 1.00.
6.9 Return to Play 925

881 6.8.1 “Syndoo” Testing Results
Athletes who sustain a syndesmotic ankle sprain 926
882 “Syndhoo” dorsiflexion: When pushing manually typically should go through much longer recov- 927
883 the dynamometer in external rotation (with the ery periods than those who sustain a lateral ankle 928
884 board in 20° of dorsiflexion), the test is consid- sprain [9]. Return to play (RTP) in grade I injuries 929
885 ered positive if the athlete feels apprehension at a is usually at 6–8 weeks post-injury, but is vari- 930
886 force <87 Newton (N). able. Professional athletes with stable isolated 931
887 “Syndhoo” neutral: When pushing manually grade II syndesmotic injuries are reported to RTP 932
888 the dynamometer in external rotation (with the at a mean of 45 days, compared with 64 days for 933
889 board in neutral position), the test is considered those with unstable grade II injuries [99]. Also, 934
890 positive if the athlete feels apprehension at a athletes with injury to both the AITFL and deltoid 935
891 force <87 Newton (N). ligament took longer to RTP than those with an 936
892 “Syndhoo” plantar flexion: When pushing AITFL injury alone and IOL injury on MRI and 937
893 manually the dynamometer in external rotation PITFL injury on MRI were both independently 938
894 (with the board in 20° of plantar flexion), the test associated with a delay in RTP [99]. In the case of 939
895 is considered positive if the athlete feels appre- surgically treated grade III injuries, the expected 940
896 hension at a force <87 Newton (N). time frame to RTP is between 10 and 14 weeks 941
897 There was very good agreement between [9, 100] although RTP as early as 6 weeks has 942
898 arthroscopy and syndhoo dorsiflexion diagnosis been described in case series [101]. RTP in syn- 943
899 (κ = 1, p < 0.001) but no significant agreement desmotic injury is permitted when able to single- 944
900 was found between arthroscopy, and “syndhoo” leg hop for 30 s without significant pain [5]. To 945
901 neutral and “syndhoo” plantar flexion (p = 0.053 our knowledge, there are no specific studies on 946
902 and p = 0.99, respectively). prevention of syndesmotic re-injury. Although it 947
903 Traditionally, individuals with clinical and/or might be assumed that neuromuscular bracing 948
904 radiological suspicion of syndesmotic instability and bracing or taping is beneficial, injury mecha- 949
905 warrant an examination under anesthesia and/or nisms differ and further investigation is required 950
906 diagnostic arthroscopy to confirm and treat. to increase our understanding of syndesmosis 951
907 However, the invasive process of this has inherent injuries and improve treatment and prevention of 952
908 risks to the patient. The described noninvasive this significant injury [9, 28, 40]. 953
909 “syndhoo” device in this chapter can be a valu-
910 able tool in the evaluation of isolated syndes-
911 motic ankle instability. 6.10 Conclusion 954
912 Further studies on the correlation of this non-
913 invasive test with clinical examination, imaging, Syndesmosis injuries are increasingly common in 955
914 and arthroscopic findings are needed. Ongoing both competitive and recreational athletes. Recent 956
915 work at our institution is seeking to establish the advances in the diagnosis and management enable 957
958 early detection of these injuries that can avoid evo- 12. Williams GN, Allen EJ. Rehabilitation of syn- 1012
desmotic (high) ankle sprains. Sports Health. 1013
959 lution to chronic debilitating ankle conditions. 2010;2:460–70. 1014
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1000 9. Williams GN, Jones MH, Amendola A. Syndesmotic 25. Bassett FH 3rd, et al. Talar impingement by the 1060
1001 ankle sprains in athletes. Am J Sports Med. anteroinferior tibiofibular ligament. A cause of 1061
1002 2007;35:1197–207. chronic pain in the ankle after inversion sprain. J 1062
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1005 tion of the ligamentous structures, methods of fixa- tal tibiofibular syndesmosis: an evidence-based 1065
1006 tion, and radiographic assessment. J Bone Joint Surg approach to acute and chronic lesions. Foot Ankle 1066
1007 Am. 1995;77:847–56. Clin. 2008;13(4):611–33.. vii-viii 1067
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1009 SJ, Alitz CJ, et al. Risk factors for syndesmotic and “low” to “high” athletic ankle sprains: a comprehen- 1069
1010 medial ankle sprain: role of sex, sport, and level of sive review. Oper Tech Orthop. 2018;28(2):54–60. 1070
1011 competition. Am J Sports Med. 2011;39:992–8. https://doi.org/10.1053/j.oto.2018.01.002. 1071
74 P. D’Hooghe
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1076 professional footballers in the UEFA Elite Club MRI findings with disability in syndesmotic sprains 1135
1077 Injury Study. Br J Sports Med. 2017;21:bjsports- of NFL players. Foot Ankle Int. 2012;33(5):371–8. 1136
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1079 bjsports-2017-097710. M, Bolhuis HW. Which ankle fractures require 1138
1080 29. Fritschy D. An unusual ankle injury in top skiers. syndesmotic stabilization? J Foot Ankle Surg. 1139
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1085 Sports Med. 2005;33(2):183–7. 2016;7(11):718. 1144
1086 31. Wright RW, Barile RJ, Surprenant DA, et al. Ankle 47. Femino JE, Vaseenon T, Phistkul P, et al. Varus 1145
1087 syndesmosis sprains in national hockey league play- external rotation stress test for radiographic detec- 1146
1088 ers. Am J Sports Med. 2004;32(8):1941–5. tion of deep deltoid ligament disruption with and 1147
1089 32. Kaplan LD, Jost PW, Honkamp N, et al. Incidence without syndesmotic disruption. Foot Ankle Int. 1148
1090 and variance of foot and ankle injuries in elite college 2013;34(2):251–60. 1149
1091 football players. Am J Orthop. 2011;40(1):40–4. 48. Dikos GD, Heisler J, Choplin RH, Weber TG. 1150
1092 33. Hunt KJ, George E, Harris AH, et al. Epidemiology Normal tibiofibular relationships at the syndes- 1151
1093 of syndesmosis injuries in intercollegiate football: mosis on axial CT imaging. J Orthop Trauma. 1152
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1096 from 2004-2005 to 2008-2009. Clin J Sport Med. between radiological assessment of acute ankle 1155
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1125 Clin Res Foot Ankle. 2018;6(1):252–9. https://doi. Syndesmosis sprains of the ankle. The influence 1184
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1129 desmosis injury: a systematic review. Br J Sports leolar fractures need a positioning screw? Injury. 1188
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1191 based approach to treatment of acute traumatic management of syndesmosis injury: a National US 1250
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1202 Amendola A. Ankle ligament lesions. In: The ankle 4.5-millimeter stainless steel screws. Foot Ankle Int. 1261
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1204 62. Schepers T. Acute distal tibiofibular syndesmo- 76. Beumer A, Campo MM, Niesing R, Day J, 1263
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1 Subtalar Joint Instability
7
2 Vincenzo Candela, Umile Giuseppe Longo,
3 Giuseppe Salvatore, Alessandra Berton,
4 Nicola Maffulli, and Vincenzo Denaro
5 7.1 Anatomy which connects the anterior margin of the susten- 24

taculum tali of the calcaneus to the plantar sur- 25
6 The subtalar joint (STJ), also known as the talo- face of the navicular, also called “spring 26
7 calcaneal joint, is an important and complex joint ligament”), and the calcaneo-navicular portion 27
8 in the hindfoot that allows articulation of the of the bifurcated ligament (also called “Y 28
9 talus and calcaneus. It consists of three articular shaped” ligament, a strong band which origi- 29
10 facets between the inferior surface of the talus nates from the anterior surface of the calcaneus 30
11 and the dorsal surface of the calcaneus (Fig. 7.1). and splits anteriorly into the calcaneo-cuboid 31
12 STJ is formed by two articular components: the portion, which lies in the horizontal plane and 32
13 anterior talocalcaneal articulation and the poste- attaches to the dorsal aspect of the cuboid, and 33
14 rior talocalcaneal articulation [1]. the calcaneo-navicular portion, which lies in the 34
15 The anterior talocalcaneal articulation is vertical plane and attaches to the lateral aspect of 35
16 formed by the anterior and middle facets of ante- the navicular) [2]. 36
17 rior one-third of the calcaneum that articulate The posterior talocalcaneal articulation is 37
18 with the head of the talus and the proximal navic- formed by the posterior calcaneal facet on the 38
19 ular surface. The joints are connected by a fibrous inferior surface of the talus and the posterior 39
20 capsule, the talonavicular ligament (a fibrous facet on the superior surface of the calcaneus and 40
21 band which connects the neck of the talus to the makes up the largest articulation between the 41
22 dorsal surface of the navicular), the plantar talus and calcaneus. The joint is surrounded by a 42
23 calcaneo-navicular ligament (a broad thick band fibrous capsule and synovial membrane that 43
attach at the edges of the articular surface. 44
However orthopedic surgeons consider the talo- 45
V. Candela · U. G. Longo (*) · G. Salvatore
A. Berton · V. Denaro calcaneal joint and the talocalcaneonavicular 46
Department of Orthopaedic and Trauma Surgery, joint to be one functional unit [2]. 47
Campus Bio-Medico University, Rome, Italy The subtalar joint essentially is a uniaxial joint 48
e-mail: g.longo@unicampus.it
at which the calcaneus rotates from dorsolateral 49
N. Maffulli to medioplantar. The axis of motion passes 50
Faculty of Medicine and Surgery, Department of
obliquely from a posterior, plantar, and lateral 51
Musculoskeletal Disorders, University of Salerno,
Salerno, Italy position to an anterior, dorsal, and medial posi- 52
tion. STJ range of motion (ROM) is approxi- 53
Centre for Sports and Exercise Medicine, Barts and
The London School of Medicine and Dentistry, mately from 25 to 30° of inversion/supination to 54
Mile End Hospital, London, England 5 to 10° eversion/pronation [3–5]. However the 55
© ISAKOS 2019 77
https://doi.org/10.1007/978-3-662-58704-1_7
78 V. Candela et al.
Fig. 7.1 Inferior
Corpus Posterior talar Sulcus
surface of the talus and
calcanei articular facet calcanei
the dorsal surface of the Middle talar
calcaneus articular facet
Anterior talar
articular facet
Medial Anterior
Posterior calcaneal calcaneal Navicular
calcaneal Talar articular articular articular
articular facet sulcus facet facet facet
Flexor hallucis
longus sulcus
56 STJ motions are linked to the ankle joint motions ITCL lies posterior to the anterior band. ITCL 68
57 and to the midtarsal joint motions. Subtalar liga- attaches to the sinus tarsi anterior to the superior 69
58 ments can be divided into intrinsic ligaments posterior articular facet of the calcaneus and 70
59 (interosseous talocalcaneal ligament—ITCL, inserts into the sinus tali just anterior to the pos- 71
60 cervical ligament—CL, lateral, posterior, and terior inferior articular facet of the talus [2]. It is 72
61 medial talocalcaneal ligament) and extrinsic liga- the primary restraint of the subtalar joint and can 73
62 ments (calcaneo-fibular ligament—CFL and the be classified according to its shape in band type, 74
63 tibio-calcaneal fascicle of the deltoid ligament). fan type, and multiple type [6]. The ITCL can be 75
64 The ITCL is a dense, broad, and flat bilaminar compared with the cruciate ligaments of the knee 76
65 bundle that descends obliquely and laterally from for its stabilizing and proprioceptive function [7]. 77
66 the sulcus tali to the calcaneal sulcus and runs The CL is located along the antero-lateral por- 78
67 through the sinus tarsi. The posterior band of tion of the STJ and is the strongest ligament con- 79
7 Subtalar Joint Instability 79
80 necting the talus and the calcaneus [8]. It is STI could be a consequence of acute subtalar 125
81 attached to the upper surface of the calcaneus and injury or dislocation; however chronic tear or insuf- 126
82 passes superiorly and medially to a tubercle on ficiency of interosseous talocalcaneal ligament 127
83 the inferior and lateral aspect of the neck of the (ITCL), cervical ligament (CL), and calcaneo- 128
84 talus [2]. The primary function of the CL is to fibular ligament (CFL) have been reported as the 129
85 resist excessive STJ supination whereas the ITCL most frequent etiologies of STI [12]. 130
86 remains taut during pronation. Acute injury of ST joint is common in basket- 131
87 The lateral talocalcaneal ligament arises from ball and volleyball players and it is seen when the 132
88 the lateral tubercle of the talus, runs obliquely player comes to an abrupt stop [13]. 133
89 inferiorly and posteriorly, and attaches to the lat- Acute subtalar dislocation is a relatively 134
90 eral surface of the calcaneus [2]. uncommon injury that occurs frequently in the 135
91 The posterior talocalcaneal ligament arises from third decade of life in male patients after motor 136
92 the lateral tubercle of the talus and inserts on the vehicle accidents [14, 15]. Frequently the subta- 137
93 proximal and medial portion of the calcaneus [2]. lar dislocation is closed; however, between 10 138
94 The medial talocalcaneal ligament connects and 40% of all cases, high-energy injuries may 139
95 the medial tubercle of the talus with the posterior lead to open subtalar dislocation. Medial disloca- 140
96 and medial aspect of the calcaneus [2]. tions are the most common, followed by lateral 141
97 The calcaneo-fibular ligament is a narrow, and posterior. 142
98 rounded cord, running from the tip of the lateral Acute subtalar dislocation is caused by forced 143
99 malleolus of the fibula downward and slightly inversion combined with the ankle in dorsiflexion 144
100 backward to a tubercle on the lateral surface of or the neutral sagittal position. The CFL is the 145
101 the calcaneus. It restricts the hyperinversion of first to be damaged, followed by the lateral talo- 146
102 the subtalar joint. calcaneal ligament, the cervical ligament, and 147
103 The tibio-calcaneal fascicle of the deltoid liga- finally the ITCL. Dislocation of subtalar joint is 148
104 ment arises from the medial malleolus, descends often associated with fractures of the fifth meta- 149
105 almost perpendicularly, and inserts into the whole tarsal, the talus, or the malleoli. However isolated 150
106 length of the sustentaculum tali of the calcaneus. subtalar dislocation is common in patients with 151
107 The extensor retinaculum significantly con- aplasia of the ankle ligaments or the calcaneus 152
108 tributes to stability of the ankle and subtalar joint. facets, hypoplasia of the malleolus, recurrent 153
109 Weindel et al. demonstrated in a biomechanical ankle sprains, post-traumatic ligamentous insuf- 154
110 cadaver study that dissection of the inferior ficiency, and atrophy of the peroneal muscles 155
111 extensor retinaculum results in a significant [16]. Broca distinguished three types of subtalar 156
112 increase in eversion and inversion [9]. dislocation: (1) the medial dislocation; (2) the 157
lateral dislocation; and (3) the posterior disloca- 158
tion. Direction of the rest foot in relation to the 159
113 7.2 Pathophysiology talus was the determinant element to classify dis- 160
location as medial, lateral, or posterior [17]. 161
114 Subtalar instability (STI) is a chronic functional Malaigne and Burger described an additional 162
115 talocalcaneal instability characterized by a com- type of subtalar dislocation, the anterior disloca- 163
116 bination of anterior movement, medialization, tion [17]. After an acute dislocation, conservative 164
117 and varus tilt of the calcaneus [10]. treatment with closed reduction under general 165
118 Subtalar instability is a problem because it can anesthesia and an ankle brace for 3–6 weeks, fol- 166
119 lead to severe flatfoot with growing pain and quick lowed by physical therapy, is recommended. 167
120 fatigue while walking and running. It can lead to However the interposition of posterior tibialis 168
121 many orthopedic problems affecting ankle, knee, tendon after the rupture of the flexor retinaculum 169
122 hip joint, and lower back and result in clinical pre- or the interposition of the extensor retinaculum 170
123 sentations like anterior or posterior tibial tendi- makes the dislocation not reducible. In this case 171
124 nopathy, plantar fasciitis, and forefoot pain [11]. an operative treatment is required [4]. 172
173 Chronic tear or insufficiency of ligaments could the joint surfaces for osteochondral defects and 218
174 be a consequence of recurrent ankle sprains [18]. identifying peroneal tendon injury. With MRI, a 219
175 Subtalar instability is frequently accompanied partial or complete tear of components of the 220
176 by ankle instability. On the other hand, lateral ligaments contributing to subtalar stability may 221
177 ankle instability may be combined with subtalar be diagnosed as well as an acute involvement of 222
178 joint involvement in up to 25% of the cases [10]. the subtalar joint by bone marrow edema in 223
T2-weighted sequence. 224
Arthrography of the ankle and STJ can also be 225
179 7.3 Diagnosis used for the evaluation of ruptured ligaments and 226
associated pathologic condition. Sugimoto et al 227
180 Clinical symptoms of ankle and subtalar instabil- [23] attributed to arthrography a sensitivity of 228
181 ity are very similar and therefore a correct diag- 92% and a specificity of 87% for the diagnosis of 229
182 nosis is not easy. A feeling of uncertainty during CFL rupture in patients with recurrent ankle 230
183 walk on uneven ground is a common finding. instability. 231
184 Other symptoms include recurrent swelling,
185 painful stiffness of the subtalar joint, and diffuse
186 pain in the hindfoot and onto the sinus tarsi. 7.4 Treatment 232
187 In the acute phase lateral ecchymoses, swell-
188 ing, and tenderness in the area of the sinus tarsi The treatment of acute STJ injury consists of 233
189 can be found. In contrast to chronic ankle insta- wearing an ankle–foot orthosis within the shoe 234
190 bility female patients with STJ instability may for 5–6 weeks [24]. In chronic injury nonopera- 235
191 prefer high-top shoes [18]. tive treatment is essential and involves physical 236
192 The instability of the subtalar joint has been therapy directed at the soft tissue envelope and 237
193 assessed clinically by a manual inversion stress dynamic stabilizers, taping, proprioceptive train- 238
194 test. An increased amount of inversion is revealed ing, stretching of the Achilles tendon, and lateral 239
195 stressing the hindfoot. However, after acute wedging of the shoe or insole up to 0.5 mm for 240
196 injury it may be problematic to recognize an 12–16 week [18]. If conservative treatment is 241
197 increased amount of calcaneal inversion com- unsuccessful, operative treatment may be an 242
198 pared with the intact side due to pain-induced option to restore stability and function to the 243
199 limitations [19]. joint. However, normal subtalar joint kinematics 244
200 Radiographic examination of STJ instability are not restored by tenodesis ligament recon- 245
201 involves stress Broden views [20]. To perform struction [25, 26]. Techniques for surgical recon- 246
202 the stress Broden view, the examiner internally struction generally are divided into anatomical 247
203 rotates the foot, the beam is centered on the talo- and nonanatomical reconstruction, such us ten- 248
204 navicular joint, and the tube is angled from 30 don transfer procedures. 249
205 cephalad. This positioning allows the surgeon to Broström first introduced a direct anatomic 250
206 view different portions of the posterior facet of repair of the ruptured ATFL and CFL, with 251
207 the STJ. Separation of the posterior facet of the good long-term results and functional recovery 252
208 calcaneus and talus greater than 7 mm may indi- (Fig. 7.2) [27]. The Gould modification of the 253
209 cate chronic subtalar instability [20]. Brostrom procedure associated the direct repair 254
210 CT scan may be helpful. Some investigators of the lateral ligaments with extensor retinacu- 255
211 have recommended its use because of the inac- lum reinforcement (Fig. 7.3) [27]. Brostrom 256
212 curacies of stress radiographs [21, 22]. CT allows Evans procedure adds to Brostrom repair the 257
213 an accurate analysis of any type of osseous defor- transfer of the anterior third of the peroneus 258
214 mity or osteoarthritis. brevis tendon to provide supplemental lateral 259
215 MR imaging has been shown to have signifi- static restraint [28], but it increased stiffness 260
216 cant role in the detection of injured structures and had poor long-term patient satisfaction 261
217 [22]. Moreover, MRI can be useful in evaluating [29]. Moreover it has been suggested that the 262
Anterior lalofibular Evans procedure is ineffective for SJI [30]. 263

ligament However, especially for STJ instability, teno- 264
desing procedures may be considered advanta- 265
geous because of the reduction of hindfoot 266
Extensor
retinaculum
motion. For this reason Chrisman-Snook proce- 267
Lateral dure has become the procedure of choice for 268
malleolus patients with isolated STJ instability [24]. The 269
Chrisman-Snook tenodesis consists in the use 270
of a split peroneus brevis tendon: the proximal 271
Peroneal
part of the tendon is passed through the fibula in 272
tendons
an anterior to posterior direction and finally the 273
Calcaneofibul
tendon is fixed to the calcaneus near the original 274
ligament
insertion of the CFL. Other procedures 275
addressed in the literature include ITCL recon- 276
struction, ligamentous reconstruction using the 277
entire peroneus brevis tendon to recreate the 278
ATFL and CFL, and triligamentous reconstruc- 279
tion procedures to address the ruptured ATFL, 280
Fig. 7.2 Brostrom procedure

CFL, ITCL, and cervical ligament [31]. Kato 281
performed an ITCL reconstruction with a par- 282
tial Achilles tendon graft with good functional 283
results and a very low rate of postoperative 284
complications [32]. Pisani used the anterior half 285
of the peroneus brevis tendon for reconstruction 286
of ITCL with an open surgical technique [33]. 287
Lateral Liu described an arthroscopic approach with a 288
malleolus gracilis tendon from the ipsilateral knee as a 289
graft with controversial results [34]. 290
Surgery is a successful solution for patients 291
with STJ instability; however, hindfoot malalign- 292
Extensor ment can contribute to subtalar joint instability 293
retinaculum and dysfunction and can be a cause of surgery’s 294
failure [35]. 295
7.5 Surgical Technique 296

of Brostrom-Gould 297
Procedure 298
Brostrom procedure is performed with the patient 299

placed in the lateral decubitus position. The bor- 300
ders of the fibular malleolus and the location of the 301
anterior talo-fibular and calcaneo-fibular liga- 302
ments are identified. The skin incision is inferiorly 303
Peroneal Calcaneofibular to the tip of the fibula ending just posterior to the 304
tendons ligament lateral malleolus and extends across the body of 305
the ATFL and CFL. Careful dissection is critical to 306
Fig. 7.3 Gould modification of the Brostrom procedure avoid damage to dorsal cutaneous and sural nerves. 307
308 After the identification of the intra-capsular ATFL 7.7 Conclusion 354
309 the ligament is incised and the midportion
310 removed. Dissection is then directed toward the Subtalar joint pain and instability is a common 355
311 distal portion of the fibula. The peroneal sheath is problem. The estimated number of unknown 356
312 incised, peroneal tendons are retracted, and CFL is cases with chronic subtalar instability might be 357
313 identified. The lax portion of the ligament is substantially higher than the number of patients 358
314 removed and the remaining portions saturated where we actually recognize this diagnosis. A 359
315 with a nonabsorbable suture. The foot is dorsi- high degree of suspicion is necessary for the cor- 360
316 flexed and evefied and the ATFL ligament is satu- rect diagnosis. Moreover weight-bearing X-rays 361
317 rated. Finally the extensor retinaculum is identified including Broden views, CT scan, MR imaging, 362
318 and its lateral border is brought superficial to the and arthrography could be helpful. The treatment 363
319 ATFL repair and sutured to the fibular periosteum. of acute injuries is conservative and has good 364
320 The subcutaneous tissue and skin are then closed. outcomes. The situation is less clear for operative 365
321 The patient is maintained in a non-weight-bearing approaches although tenodesing procedures had 366
322 orthosis. After about 1 month the ankle is pro- showed good clinical outcomes. There is a defini- 367
323 tected with an air stirrup brace, and range of tive need for prospective and controlled studies to 368
324 motion exercises are begun [36, 37]. get a more reliable answer regarding subtalar 369
joint pathology. 370
325 7.6 Surgical Technique

326 of Chrisman-Snook References 371
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1 Lisfranc Complex Injuries
8
2 Samuel O. Ewalefo, Stephanie M. Jones,
3 Lorraine Boakye, Arthur R. McDowell,
4 Scott Nimmons, Jorge L. Rocha, Humza Shaik,
5 and MaCalus V. Hogan
6 8.1 Introduction potentially career-ending for the athlete, as they 30

often result in significant long-term morbidity 31
7 Lisfranc or tarsometatarsal (TMT) joint complex such as post-traumatic osteoarthritis, anatomic 32
8 injuries involve disruption of one or more of the deformity, and functional disability [1, 3, 8, 9]. 33
9 osseous or ligamentous stabilizers of the trans- Early diagnosis and appropriate management of a 34
10 verse arch of the midfoot [1, 2]. The TMT joint Lisfranc injury is therefore essential [2]. While 35
11 complex encompasses the bases of the first non-operative management is a feasible option 36
12 through fifth metatarsals and their respective for stable injuries, surgical treatment is typically 37
13 articulations with the three cuneiform bones and recommended for unstable injuries [8, 9]. 38
14 the cuboid bone [3]. The Lisfranc joint is stabi- The objective of this chapter is to discuss the 39
15 lized by dorsal, interosseous, and plantar liga- current treatment options for Lisfranc injuries. 40
16 ments that tether the lateral border of the medial However, the literature regarding operative man- 41
17 cuneiform to the medial border of the second agement of Lisfranc injuries is in need of more 42
18 metatarsal base. These three ligaments are col- high-quality, randomized controlled trials before 43
19 lectively known as the “Lisfranc ligament” [3, 4]. any definitive recommendations regarding opti- 44
20 Injuries to the Lisfranc or TMT joint complex mal surgical techniques can be made. 45
21 are generally rare and almost 20% are missed or
22 misdiagnosed on initial imaging [3, 5, 6]. Lisfranc
23 injuries often occur as a result of axial loading of 8.2 Clinical Evaluation 46
24 the plantarflexed foot and may involve any of the
25 joints in the TMT complex [3, 7]. Injuries may Prior to intervention, a surgeon should obtain a 47
26 occur via high- and low-energy mechanisms [3, detailed history, with special emphasis placed on 48
27 8]. However, low-energy mechanisms constitute the mechanism of injury [10]. Lisfranc injuries 49
28 a significant number of Lisfranc injuries seen in can occur in acute traumatic settings from both 50
29 the athlete. Injuries to the Lisfranc joint are high- and low-energy mechanisms. In athletes, 51
Lisfranc injuries often present with subtle signs 52
following a low-velocity mechanism [8]. The 53
S. O. Ewalefo · S. M. Jones · L. Boakye position of the foot and the direction of force 54
A. R. McDowell · S. Nimmons · J. L. Rocha applied at the time of injury are key aspects of the 55
H. Shaik · M. V. Hogan (*)
AU1 Department of Orthopaedic Surgery, University of
history. Injuries classically occur with axial load- 56
Pittsburgh, Pittsburgh, PA, USA ing of the foot in a hyper-plantarflexed position 57

e-mail: hoganmv@upmc.edu [3, 8]. 58
© ISAKOS 2019 85
https://doi.org/10.1007/978-3-662-58704-1_8
86 S. O. Ewalefo et al.
59 Medial plantar ecchymosis of the midfoot is a and lateral views of the foot [5, 10]. It is recom- 78
60 hallmark of Lisfranc injury [8, 10]. Other addi- mended that radiographs include imaging of the 79
61 tional findings include midfoot edema and tender- ankle, as concomitant injuries may be missed [11]. 80
62 ness to palpation. Passive flexion of the metatarsal On radiographic imaging of a Lisfranc injury, 81
63 (MT) heads as well as passive abduction-adduction there will be intra-articular displacement through- 82
64 through the forefoot may demonstrate instability out the TMT joints, the intercuneiform joints, 83
65 within the TMT joint. Special tests such as prona- and/or the naviculo-cuneiform joint which is dis- 84
66 tion-abduction of the forefoot and the TMT com- tinct from an uninjured radiograph [10] (Fig. 8.1). 85
67 pression test may elicit pain in the injured region Any displacement of more than 2 mm in any 86
68 of the midfoot [9]. Examination should always plane around the TMT joint should raise suspi- 87
69 include a thorough neurovascular assessment as cion for a Lisfranc injury [8]. The “fleck sign” 88
70 dislocation of the second metatarsal can compro- indicates an avulsion of the second metatarsal 89
71 mise blood flow through the dorsalis pedis artery. base into the interval between the first and second 90
72 Additionally, diffuse swelling may lead to com- metatarsals. This radiographic sign is pathogno- 91
73 partment syndrome [3, 8, 10]. monic of a Lisfranc injury [3, 9, 10] (Fig. 8.2). 92
Additionally, the lateral radiograph may reveal 93
either dorsal or plantar displacement of the 94
74 8.3 Radiographic Evaluation affected joints as well as an overall flattening of 95
the medial column [3]. 96
75 Weight-bearing radiographs of both the injured Stress radiographs may be necessary in 97
76 and uninjured foot should be obtained in addition patients with indeterminate weight-bearing 98
77 to the standard non-weight-bearing AP, oblique, images. Advanced imaging is useful when there 99
a b
Fig. 8.1 Normal radiographic findings of the Lisfranc form. (b) Oblique: Alignment of the medial border of
joint. (a) AP: Alignment of the medial border of the fourth metatarsal with the medial border of the cuboid
second MT with the medial border of the middle cunei- bone
8 Lisfranc Complex Injuries 87
100 is a high index of suspicion for a Lisfranc injury 8.4 Lisfranc Injury Classification 112
101 in the setting of inconclusive plain radiographs or
102 in patients who are unable to perform weight- There are a variety of classification systems for 113
103 bearing imaging [5, 12, 13]. CT scan may iden- Lisfranc injuries, although none have demon- 114
104 tify occult fractures, assess intra-articular strated significant efficacy in determining opti- 115
105 extension of fractures, and detect subtle sublux- mal management or predicting outcomes. 116
106 ation of pertinent joints [13]. MRI may be useful In 1909, Quenu and Kuss were the first to use 117
107 in the evaluation of the extent of soft tissue dam- standardized terminology to describe Lisfranc 118
108 age associated with purely ligamentous Lisfranc injuries using a system based on mechanism of 119
109 injuries [12]. Advanced imaging may also pro- injury and the direction of the metatarsal disloca- 120
110 vide additional benefit in preoperative planning tion [3, 12]. The terminology was later modified 121
111 for severely comminuted osseous injuries [8]. in 1982 by Hardcastle et al. who observed that 122
the level of joint displacement seemed to have a 123
greater influence on prognosis than mechanism 124
of injury [3, 5, 11, 14]. In 1986, Myerson et al. 125
used the scaffold of the earlier classifications to 126
develop a system based on the columnar structure 127
of the foot. The medial column consists of the 128
first TMT and medial naviculo-cuneiform joints. 129
The middle column comprises the articulations 130
between the second and third TMT joints as well 131
as the articulations between the middle and lat- 132
eral cuneiforms and the navicular. The lateral col- 133
umn encompasses the articulations between the 134
fourth and fifth metatarsals and the cuboid bone 135
[3, 10, 14]. The Myerson Classification empha- 136
sizes the strong prognostic implications of 137
column-specific midfoot motion and is currently 138
the most commonly used system [3]. However, 139
the current classification systems often only 140
describe the high-energy or traumatic subset of 141
Lisfranc injuries [7]. Thus, more recently in 142
2002, Nunley and Vertullo developed a classifica- 143
tion system to specifically describe the more 144
subtle, low-energy Lisfranc injuries occurring in 145
Fig. 8.2 The “fleck” sign athletes [3, 7, 8, 15] (Table 8.1). 146
Table 8.1 Lisfranc injury classifications t1.1
Quenu and Kuss (1909) Hardcastle (1982) Myerson (1986) Nunley and Vertulloa (2002) t1.2
Homolateral All MTs displaced A Complete A Total I Negative radiographs t1.3
in the same displacement incongruity Increased uptake on bone scan t1.4
direction of all MTs t1.5
Isolated Displacement of B Displacement of B Partial II 1–5 mm diastasis between first t1.6
only one or two one or more MTs incongruity and second MTs t1.7
MTs B1: Medial No loss of midfoot arch height t1.8
B2: Lateral t1.9
Divergent MTs displaced in C Divergent C Divergent III >5 mm diastasis t1.10
different directions C1: Partial Loss of midfoot arch height t1.11
C2: Total t1.12
Classification criteria are based on comparison with the uninjured contralateral foot
a
t1.13
147 While classification systems effectively stan- injuries, whether osseous or ligamentous, can be 166
148 dardize terminology and provide a method to managed non-operatively for the duration of the 167
149 communicate injury patterns, many surgeons use treatment protocol [8–10]. Other indications and 168
150 clinical signs of instability in lieu of structured contraindications for non-operative treatment of 169
151 classifications to guide their medical decision- Lisfranc injuries are described in (Table 8.2). If 170
152 making. Clinically, Lisfranc injuries may be clas- there is mild displacement, a closed reduction 171
153 sified based on stability: unstable injuries present should be achieved using axial traction and direct 172
154 with mild to marked displacement (>2 mm) and manipulation of the metatarsal bases. 173
155 typically require surgery while stable injuries with Percutaneous Kirschner wire (K-wire) fixation 174
156 no or minimal displacement (>2 mm) are variably may be performed to provide stability to the 175
157 amenable to non-operative management [8]. reduction of simple Lisfranc injuries [5]. When 176
used, K-wires should be directed obliquely across 177
the metatarsal base and into the adjacent tarsal 178
158 8.5 Non-operative Treatment bone. Due to the oblique placement, loss of cor- 179
rection and migration of the metatarsal heads 180
159 All Lisfranc injuries in the acute setting should may be better avoided [16]. 181
160 be managed following the standard PRICE-M The non-operative treatment timeline should 182
161 approach: protection with immobilization, rest be individualized for each patient (Table 8.3). 183
162 with weight-bearing restrictions, ice, compres- Cast immobilization is indicated once there is 184
163 sion, elevation, and medications for analgesia. significant reduction in soft tissue swelling 185
164 Following confirmation with either stress [15]. Patients should be evaluated every 2 weeks 186
165 radiographs, CT scan, or MRI, stable Lisfranc with weight-bearing plain radiographs to assess 187
Table 8.2 Indications and contraindications of management for Lisfranc injury t2.1
Indications Contraindications t2.2

Non-operative Stable ligamentous injury Unstable Lisfranc injuries t2.3
management No static or dynamic displacement TMT joint misalignment t2.4
Stable osseous injury First and second metatarsal diastasis >2 mm t2.5
None to minimal displacement Latent instability in athletes t2.6
Latent instability in nonathletes t2.7
Pes cavus deformity t2.8
Operative Emergent injuriesa Poor surgical candidates t2.9
management Open fracture-dislocation Poor wound healing t2.10
Vascular compromise Significant soft tissue injury t2.11
Acute neuropathy Vascular insufficiency t2.12
Compartment syndrome Medical comorbidities t2.13
Unstable ligamentous injuryd Socioeconomic factors t2.14
Unstable osseous injury Psychiatric illness t2.15
Irreducible fracture-dislocationa Nonambulatory patients t2.16
Static malalignment t2.17
Latent malalignment t2.18
Intercuneiform displacement >2 mm t2.19
Displacement between medial cuneiform t2.20
and second MT >2 mm t2.21
Latent instability in athletes t2.22
Comminuted fracturesb t2.23
Athletes t2.24
Pes planus deformityb t2.25
Absolute indication
a
t2.26
Relative indication
b
t2.27
Table 8.3 Lisfranc injury treatment timeline t3.1
Time Non-operative management a

Operative management t3.2
Acute injury PRICE-M protocolb PRICE-M protocol t3.3
Non-weight-bearing Non-weight-bearing t3.4
Immobilization Immobilization t3.5
CAM boot CAM boot t3.6
Short-leg cast Short-leg cast t3.7
After reduction of edema Delay surgery for 1–2 weeks after reduction of edemac t3.8
0–2 weeks Weight-bearing radiographs Operative intervention performed t3.9
If stable Immediate postoperative period t3.10
Immobilization Plaster splint t3.12
Short-leg cast t3.13
If unstable t3.14
Refer for orthopedic evaluation t3.15
2–6 weeks Weight-bearing radiographs Removal of sutures t3.16
Immobilization Immobilization t3.18
Short-leg cast Short-leg cast t3.19
CAM boot t3.20
6–8 weeks Weight-bearing radiographs Heel-weight-bearingd t3.21
Non-weight or heel-weight-bearing Immobilization t3.22
Immobilization Short-leg cast t3.23
Short-leg cast CAM boot t3.24
8–10 weeks CAM boot Removal of K-wires in the lateral column [1] t3.25
Partial weight-bearingd t3.26
Immobilization t3.27
Short-leg cast t3.28
CAM boot t3.29
10–12 weeks Weight-bearing radiographs Weight-bearing radiographs t3.30
Partial weight-bearing Progressive weight-bearing as tolerated t3.31
Stiff-sole shoe CAM boot t3.32
Semi-rigid arch support orthotic Semi-rigid arch support orthotic t3.33
12–16 weeks Weight-bearing radiographs Weight-bearing radiographs t3.34
Full weight-bearing Athletes <200 lb t3.35
Stiff-sole shoe Full weight-bearing t3.36
Semi-rigid arch support orthotic Stiff-sole shoe t3.37
Gradual return to sport Semi-rigid arch support orthotic t3.38
Athletes >200 lb t3.39
Progressive weight-bearing as tolerated t3.40
CAM Boot t3.41
Semi-rigid arch support orthotic t3.42
24 weeks Full return to sport Athletes <200 lb t3.43
Semi-rigid arch support orthotic Full return to sport t3.44
Athletes >200 lb t3.46
Full weight-bearing t3.47
Stiff-sole shoe t3.48
a
Return/persistence of pain or tenderness to palpation should immediately prompt phase regression and secondary t3.50
evaluation with advanced imaging. t3.51
b
PRICE-M stands for protection (immobilization), rest (weight-bearing restriction), ice, elevation, medication t3.52
(analgesia) t3.53
c
Non-emergent Lisfranc injuries t3.54
d
Dependent upon patient weight and fixation construct t3.55
188 alignment and stability of the Lisfranc joint. At 8.7 Non-operative Outcomes 232
189 6–8 weeks post-injury, patients may be transi-
190 tioned into a low profile Controlled Ankle Outcomes following non-operative management 233
191 Movement (CAM) boot or short-leg cast. If of Lisfranc injuries vary based on the severity of 234
192 used, K-wires may also be removed at this time. injury. Injuries involving a mild degree of TMT 235
193 However, the patient will continue non-weight- displacement tend to have fair outcomes. 236
194 bearing or heel-weight-bearing restrictions until However, this may not be the case in athletes. 237
195 week 8 or 10. After 10 or 12 weeks, patients Curtis et al. report treatment failure and inferior 238
196 may be weaned from the CAM boot or short-leg results following non-operative management in 239
197 cast into a stiff-sole shoe with well-molded arch athletes with minimal Lisfranc instability [9]. 240
198 support. Over the course of 2 week, patients Closed reduction and casting is reliably unsuc- 241
199 will transition to partial weight-bearing [8]. cessful in the majority of moderate to severe 242
200 Patients may continue to increase weight-bear- cases [1, 4, 11, 17]. Furthermore, due to articular 243
201 ing intensity every 2 weeks. Full weight-bear- damage sustained at the time of injury, many 244
202 ing is not recommended prior to 12 weeks patients develop painful, symptomatic midfoot 245
203 post-injury. Physical therapy may be prescribed arthritis and may require fusion of the TMT joint 246
204 to assist with strengthening and gait training [4, 13]. 247
205 [3]. Return of pain or tenderness to palpation at Although the most invasive nonsurgical 248
206 any time during treatment should prompt phase option, closed reduction and percutaneous pin- 249
207 regression and secondary evaluation with imag- ning with K-wire has also been conceded as inef- 250
208 ing [12]. Recovery from a Lisfranc injury may fective for unstable Lisfranc injuries due to the 251
209 take up to 4 months. Life-long use of a semi- high rate of treatment failure [18, 19]. K-wire 252
210 rigid arch support is often recommended [3]. fixation is recognized as inferior in achieving 253
rigid reconstruction of the Lisfranc joint when 254
compared to cortical screw fixation [2]. 255
211 8.6 Non-operative
212 Complications
8.8 Operative Treatment 256
213 Complications of non-operative management are
214 attributed to difficulty in obtaining adequate Absolute indications for operative management 257
215 reduction and relative instability of non-operative of a TMT joint complex injury include open inju- 258
216 methods in achieving immobilization of the TMT ries, acute vascular compromise, neurologic 259
217 joint. Closed reduction is often obstructed by damage, compartment syndrome, and unstable 260
218 bony fragments and soft tissue between the frac- fracture-dislocations [8]. Other indications and 261
219 tured or dislocated structures [16]. Casting pro- contraindications for surgical management of 262
220 vides poor immobilization of the disrupted Lisfranc injuries are described in Table 8.2. 263
221 Lisfranc joint when the integrity of the capsular Acute, unstable Lisfranc injuries with mini- 264
222 and ligamentous structures is compromised [1]. mal displacement may be treated electively with 265
223 Due to failure to maintain reduction and subse- surgery in the outpatient setting [8]. Surgery is 266
224 quent irritation due to increased motion at the often delayed for at least 2 weeks to allow for 267
225 affected joint, non-operative management has resolution of the associated edema and healing of 268
226 been associated with symptomatic degeneration the damaged soft tissue envelope [3, 10, 19]. 269
227 and reflex sympathetic dystrophy syndrome. Acute, unstable Lisfranc injuries with moderate 270
228 K-wire fixation has been associated with loss of to severe displacement should be treated surgi- 271
229 reduction due to proximal migration of the meta- cally as soon as clinically possible. Immediate 272
230 tarsals as well as osteolysis and infection along surgical intervention with external fixation or 273
231 the pin tract [5, 16]. ORIF is particularly warranted if the acute injury 274
275 is open or accompanied by neurovascular com- often utilized during the operation. A tourniquet 298
276 promise or compartment syndrome [19]. Chronic cuff may be placed on the thigh or calf and 299
277 unstable or severely comminuted Lisfranc inju- inflated or deflated intraoperatively as neces- 300
278 ries may require primary TMT arthrodesis. sary. The preference at our institution is to place 301
279 The primary goal of operative management is a sterile tourniquet on the ankle using a 4-inch 302
280 to restore stability and biomechanical function to non-latex elastic bandage. The foot may be 303
281 the midfoot. As such, maintenance of the anatomic placed on a sterile radiolucent triangle or a 304
282 relationships between the bony and soft tissue bump to allow for further manipulation intraop- 305
283 structures that stabilize the TMT joint complex eratively. Our preference is to use a sterile bump 306
284 should be prioritized intraoperatively in order to under the ipsilateral ankle. 307
285 promote optimal postoperative outcomes. General anesthesia or regional anesthesia 308
using a spinal, popliteal fossa, or ankle block 309
may be employed. The authors prefer general 310
286 8.8.1 Preoperative Planning anesthesia in conjunction with an ankle block. A 311
local anesthetic (1% lidocaine with 0.25% 312
287 The patient is positioned supine on a flat Jackson Marcaine) may be injected into the surgical inci- 313
288 table with a soft bump placed underneath the sions either preoperatively or postoperatively to 314
289 ipsilateral hip. The bump provides internal rota- provide additional analgesia. 315
290 tion to the lower extremity, which allows the Fluoroscopy is used to identify Lisfranc joint 316
291 foot to remain in optimal, neutral alignment instability, confirm reduction of the TMT joint 317
292 throughout the procedure. All bony prominences fracture-dislocation, guide hardware trajectory, 318
293 are well padded and the contralateral limb is and assess the adequacy of anatomic fixation. 319
294 secured to the table. The entire length of the Various types and combinations of hardware 320
295 ipsilateral limb should be draped out to allow have been employed for fixation of unstable 321
296 manipulation of the lower extremity during sur- Lisfranc injuries (Table 8.4). The authors prefer 322
297 gery. A tourniquet for the lower extremity is to use K-wires, standard AO screws, and dorsal 323
Table 8.4 Hardware for operative fixation of Lisfranc injuries t4.1
Hardware Indications Advantages Disadvantages t4.2

Kirchner (K) wires Fourth TMT joint Preserves natural motion of High rates failure when t4.3
Fifth TMT joint the lateral column used alone t4.4
Standard AO screws Lisfranc joint Strong Iatrogenic cartilage t4.5
Intercuneiform Rigid damage t4.6
Medial column Hardware failure t4.7
Middle column Removal of hardware t4.8
Bio-absorbable Lisfranc joint Strong Iatrogenic cartilage t4.9
polylactide screws Intercuneiform Rigid damage t4.10
Medial column No removal of hardware Hardware failure t4.11
Middle column t4.12
Extra-articular dorsal ORIF Strong Plantar gapping t4.13
plate Intra-articular cartilage Rigid Hardware irritation t4.14
Multiple unstable TMT joints Preserves cartilage Longer operating time t4.15
Adjunct to screw fixation Non-union t4.16
Primary arthrodesis Mal-union t4.17
Severely comminuted fractures t4.18
Significantly damaged t4.19
intra-articular cartilage t4.20
External fixation Open injuries Strong Infection t4.21
Significant edema Rigid Delayed treatment t4.22
Temporary stabilization t4.23
Table 8.5 Surgical techniques for Lisfranc injuries t5.1
Method Hardware Indications Contraindications t5.2

Closed reduction, K-wire Stable closed injuries Unstable injuries t5.3
percutaneous fixation Low energy trauma Open injuries t5.4
Closed reduction, External fixator Stable closed injuries Unstable injuries t5.5
external fixation High energy trauma Open injuries t5.6
Significant edema t5.7
Open reduction, External fixator Open injuries Stable injuries t5.8
external fixation High energy trauma t5.9
Compartment syndrome t5.10
Open reduction, K-wires Unstable injuries Stable injuries t5.11
internal fixation Standard AO screws Moderate to severe displacement (>2 mm) Reducible with splint t5.12
Extra-articular dorsal Moderate to severe angulation (>15°) Significant edema t5.13
plate Athletes t5.14
Bio-absorbable Low energy trauma t5.15
polylactide screws Failed closed reduction and percutaneous t5.16
Combination fixation t5.17
Primary arthrodesis K-wires Medial column injuries Lateral column injuries t5.18
Extra-articular dorsal >50% articular cartilage damage t5.19
plate Severely comminuted fractures t5.20
Standard AO screws High energy trauma t5.21
Combination Unstable, purely ligamentous t5.22
Failed ORIF t5.23
324 extra-articular plates. However, the type and fusion across all TMT joints of the foot [18]. 348
325 combination of hardware used varies based on However, some argue that loss of motion due to 349
326 the individual injury pattern as well as patient- fusion across the medial, middle, and lateral col- 350
327 specific demographic factors. umns of the midfoot would result in a biomechan- 351
ical deficit [1]. An in vitro study of midfoot 352
biomechanics demonstrated that the three col- 353
328 8.8.2 Operative Techniques umns of the midfoot vary with respect to inherent 354
motion at each articulation. On average, the lat- 355
329 ORIF and primary arthrodesis are the most widely eral column demonstrates approximately 11.1° of 356
330 used techniques of operative management for motion during supination-pronation while the 357
331 Lisfranc injuries [17]. ORIF and primary arthrod- medial and middle columns only demonstrate 358
332 esis reliably return stability to the Lisfranc joint; 1.5° and 2.6°, respectively [21]. As such, partial 359
333 however, it is debated which surgical technique arthrodesis is a hybrid fixation-fusion method 360
334 optimally restores anatomic function to the mid- that attempts to address the column-specific bio- 361
335 foot [2]. The indications and contraindications of mechanical differences of the midfoot [2, 18]. 362
336 ORIF versus arthrodesis are detailed in Table 8.5. Partial arthrodesis may be defined as fusion of the 363
337 Primary ORIF is the currently accepted tech- medial and middle columns while the lateral col- 364
338 nique for the management of displaced, unstable umn is either provisionally fixed or left free [18]. 365
339 Lisfranc injuries and is often indicated for treat-
340 ment of athletes with low-energy injuries, regard- 8.8.2.1 Open Reduction and Internal 366
341 less of severity [1, 20]. TMT arthrodesis has been Fixation 367
342 traditionally viewed as a salvage procedure fol-
343 lowing failure of ORIF [18, 20]. Yet, for various Surgical Approach 368
344 reasons, there has been an increasing trend in The choice of incision for Lisfranc ORIF is 369
345 arthrodesis as the primary method of fixation [1]. guided by the injury pattern and required expo- 370
346 Arthrodesis may be categorized as either com- sure (Table 8.6). The authors prefer a dual- 371
347 plete or partial. Complete arthrodesis consists of incision approach, as it allows access to the 372
Table 8.6 Surgical approaches to Lisfranc injuries t6.1
Incision Landmark Approach Exposure Dangers t6.2

Dorsomediala Second MT Medial to EHL 1st TMT Dorsal medial cutaneous nerve t6.3
First MT interval (branch of superficial peroneal t6.4
nerve) t6.5
Between EHL and First TMT t6.6
EHB Second TMT t6.7
Lisfranc ligament t6.8
Between EHB and Second TMT joint Dorsalis pedis artery t6.9
second EDL tendon Third TMT joint Deep peroneal nerve t6.10
Superficial to dorsalis Lisfranc ligament t6.11
pedis artery and DPN t6.12
Dorsolateral Fourth MT Between EDL and Third TMT joint Superficial peroneal nerve t6.13
Third MT interval EDB Fourth TMT joint branches t6.14
Fifth TMT joint t6.15
Medial Medial border of Tibialis anterior tendon First TMT joint Dorsal medial cutaneous nerve t6.16
first TMT joint insertion NCJ joint (branch of superficial peroneal t6.17
Lisfranc screw nerve) t6.18
Intercuneiform Tibialis anterior tendon t6.19
screw t6.20
Medial plating of t6.21
first TMT t6.22
NCJ Naviculo-cuneiform joint, DPN Deep peroneal nerve t6.23
Can be extended proximally to access the naviculo-cuneiform joint
a
t6.24
373 medial, middle, and lateral columns of the foot A dorsolateral incision can be made to provide 399
374 [14, 18]. access to the third, fourth, and fifth TMT joints, 400
375 In the dorsomedial approach to the midfoot, a as necessary [1]. For Lisfranc injuries resulting in 401
376 15-blade is used to make a 4–5 cm longitudinal lateral column instability, our authors use a dor- 402
377 incision between the first and second TMT joints solateral incision that is parallel over the fourth 403
378 on the dorsomedial aspect of the foot [1, 19]. metatarsal. During incision and dissection, it is 404
379 Skin hooks or sens are used to apply gentle trac- important to maintain the integrity of a wide skin 405
380 tion on the epidermis during dissection. Great bridge between the dorsomedial and dorsolateral 406
381 care should be taken at the distal most aspect of incisions in order to avoid necrosis of inter- 407
382 the incision in order to preserve the integrity of arching tissue [18]. After blunt dissection, inci- 408
383 the medial branch of the dorsal medial cutaneous sion of the inferior extensor retinaculum reveals 409
384 nerve. Following skin exposure, the inferior the underlying extensor digitorum communis 410
385 extensor retinaculum is incised. The exposure (EDC) tendon and the medial margin of the 411
386 continues in the plane between the extensor hal- extensor digitorum brevis (EDB) muscle. The 412
387 lucis longus (EHL) and extensor hallucis brevis EDC and EDB tendons are retracted laterally to 413
388 (EHB). The EHL tendon sheath is incised dor- expose the third TMT joint capsule. Full- 414
389 sally, while the EHL tendon is retracted laterally, thickness subperiosteal flaps are developed in a 415
390 and the exposed floor of the EHL tendon sheath similar fashion as the dorsomedial incision, with 416
391 is incised. A medial full-thickness flap is created medial extension toward the lateral aspect of the 417
392 by extending this incision to the medial margin of second TMT joint and lateral extension toward 418
393 the first TMT joint. A lateral full-thickness flap is the medial aspect of the fourth TMT joint. 419
394 created in a subperiosteal dissection toward the Lastly, a medial incision can be made along 420
395 lateral margin of the second TMT joint. The lat- the medial utility line to assist with reduction and 421
396 eral full-thickness flap may be used to protect the screw placement across the Lisfranc joint. If indi- 422
397 adjacent neurovascular bundle throughout the cated, fixation of the intercuneiform joints, the 423
398 procedure. first TMT joint, and the naviculo-cuneiform joint 424
425 can also be performed through this incision. or a dorsal extra-articular plate may be used for 470
426 Using a 15-blade, a 3-cm longitudinal incision is definitive stabilization of the first TMT joint [1, 471
427 made on the medial border of the first MT base. 9, 19]. The first trans-articular screw is placed 472
428 Dissection is performed along the fiber lines of retrograde, starting at the dorsal crest of the first 473
429 the tibialis anterior tendon down to the level of MT metadiaphysis and aimed plantarly toward 474
430 the insertion. the medial naviculo-cuneiform joint. The retro- 475
grade screw should be countersunk to avoid vio- 476
431 Intraoperative Assessment lation of the cortex and hardware prominence. A 477
432 Once appropriate exposure has been obtained, second trans-articular screw is then placed in an 478
433 the fracture-dislocation is debrided of hematoma antegrade manner. Starting at the dorsal edge of 479
434 and irrigated to allow for further assessment of the medial cuneiform along the Chopart joint, the 480
435 articular damage and to ensure an anatomic antegrade screw is aimed toward the plantar 481
436 reduction. If more than 50% of the medial and aspect of the first metatarsal metadiaphysis. If an 482
437 middle column joints show evidence of chondral extra-articular plate is used, it is positioned and 483
438 damage, primary midfoot arthrodesis may be fixed in the same manner as the trans-articular 484
439 used instead of ORIF. There is significant debate screws [1]. 485
440 regarding primary arthrodesis of the lateral col- Attention is then turned to fixation of the 486
441 umn given the functional advantages of its inher- Lisfranc joint. A pointed reduction clamp is used 487
442 ent mobility. to span the joint, with one tine placed on the 488
medial aspect of the medial cuneiform and the 489
443 Reduction other tine placed on the lateral border of the sec- 490
444 Depending on the specific injury pattern of the ond MT [1]. Special care should be taken to 491
445 TMT joint complex, several reduction techniques ensure that there is no dorsal or plantar mal- 492
446 may be employed. The first MT joint is generally reduction. It has been observed that plantar dis- 493
447 reduced with a supination-external rotation placement of greater than 2 mm may lead to 494
448 maneuver relative to the proximal bones of the transfer metatarsalgia. Next, anatomic reduction 495
449 foot. Distinct crests on the dorsal aspects of the is confirmed with fluoroscopy. A K-wire is passed 496
450 first MT and the medial cuneiform should be along the anticipated path of the fixation, begin- 497
451 aligned as closely as possible. Alignment of these ning at the medial cortical shelf of the medial 498
452 dorsal landmarks can guide accurate reduction of cuneiform and angling through the proximal 499
453 the joint. metaphysis of second MT. A common error is to 500
454 A K-wire is passed along the intended path of aim too plantarly when performing this step. The 501
455 the trans-articular screw or extra-articular plate, second MT serves as the “keystone” in the 502
456 across the first MT and the medial cuneiform or “roman arch” structure of the midfoot; as such, 503
457 across the second MT and the medial cuneiform, to the K-wire should be aimed slightly more dor- 504
458 provide provisional fixation. Temporary reduction sally [2]. A trans-articular screw or an extra- 505
459 was confirmed via intraoperative fluoroscopy [1]. articular plate is placed along the trajectory of the 506
provisional fixation. 507
460 Fixation The second TMT is provisionally reduced and 508
461 Once anatomic reduction has been achieved, a stabilized with a K-wire. Definitive fixation of 509
462 variety of options exist for definitive fixation of the second TMT joint is achieved using a trans- 510
463 Lisfranc injuries. In athletes and patients partici- articular screw or an extra-articular plate [19]. If 511
464 pating in high impact activities, our authors pref- necessary, the third TMT is secured in a similar 512
465 erence is to use either a traditional technique with fashion to that of the second TMT. 513
466 trans-articular screws or a joint-sparing approach If the intercuneiform joints are involved in the 514
467 with dorsal extra-articular plates. injury complex, these are also reduced and fixed 515
468 Final fixation is performed in a medial to lat- to ensure complete stabilization of the Lisfranc 516
469 eral orientation [1, 2, 19]. Trans-articular screws joint. A trans-articular screw is passed through 517
518 the cuneiforms and is oriented parallel to the first. The floor of the EHL tendon sheath and the 532
519 Chopart joint [1, 9]. As the intermetatarsal liga- associated subperiosteal flaps are repaired with 533
520 ments are often intact between the third, fourth, deep absorbable suture, 2-0 or 3-0 vicryl. 534
521 and fifth metatarsals, reduction may be obtained Through the dorsolateral incision, the subperios- 535
522 indirectly, which allows for percutaneous fixation teal flaps and the inferior extensor retinaculum 536
523 of these joints [19]. At the conclusion of the pro- are repaired using the same deep absorbable 537
524 cedure, final fluoroscopic images are obtained. suture, 2-0 or 3-0 vicryl. A layered superficial 538
525 Radiographs should demonstrate anatomic closure of both incisions is performed next. The 539
526 reduction of the articular surfaces and appropri- subcutaneous tissue is closed using 2-0 or 3-0 540
527 ate placement of the hardware (Figs. 8.3 and 8.4). absorbable vicryl suture. The skin is closed 541
superficially with 3-0 monofilament suture, 542
monocryl, via a vertical mattress or simple inter- 543
528 Wound Closure rupted stitch. If an intercuneiform screw was 544
529 Wounds are copiously irrigated and suction is placed, a simple superficial closure of the medial 545
530 used to achieve further visualization of the opera- incision with 3-0 monocryl or 3-0 nylon may be 546
531 tive field. The dorsomedial incision is closed adequate. 547
a b
Fig. 8.3 AP (a) and oblique (b) plain films following open reduction and internal fixation of the Lisfranc joint using
trans-articular screws
a b
Fig. 8.4 AP (a) and oblique (b) plain films following open reduction and internal fixation of the Lisfranc joint using a
combined technique with trans-articular screws and a dorsal extra-articular plate
548 8.8.2.2 Primary Arthrodesis more than 50% of the articular surface demon- 565
strates evidence of chondral damage, primary 566
549 Surgical Approach midfoot arthrodesis is indicated. Articular carti- 567
550 The surgical approach for primary arthrodesis is lage is removed from the affected joints via con- 568
551 similarly guided by the injury pattern and trolled movements with a rongeur, osteotome, or 569
552 required exposure. A dual-incision approach is curved curette [1]. Special care must be taken to 570
553 also commonly used for primary arthrodesis in ensure that the subchondral plate is not violated. 571
554 order to access the medial, middle, and lateral The exposed subchondral bone can be further 572
555 columns of the foot. perforated in a controlled punctate fashion to 573
556 The dorsomedial, dorsolateral, and medial allow for cancellous bleeding, which is thought 574
557 aspects of the midfoot are incised using the same to promote a higher likelihood of fusion. Bone 575
558 techniques as described above for ORIF [1]. graft from the calcaneus may also be used to pro- 576
mote successful fusion [6, 18]. 577
559 Intraoperative Assessment
560 Once appropriate exposure has been obtained, Reduction 578
561 the fracture-dislocation is debrided and irrigated Depending on the injury pattern and number of 579
562 to allow for further assessment of articular dam- joints involved, several reduction techniques may 580
563 age. Use of a small laminate spreader may allow be used. The same reductions techniques as those 581
564 for better visualization of the involved joint. If for ORIF may be used during primary arthrodesis. 582
583 Alignment should be confirmed using fluoroscopy metatarsal into the keystone position. As in ORIF, 604
584 [6]. A K-wire should be passed along the intended special care should be taken to ensure that there 605
585 path of the screw to provide provisional fixation. is no dorsal or plantar malalignment. Anatomic 606
reduction should be confirmed with fluoroscopy. 607
586 Fixation A trans-articular screw or an extra-articular plate 608
587 Once anatomic reduction has been achieved, a is placed from the medial cuneiform to the base 609
588 variety of options exist for definitive fixation of of the second metatarsal [1]. 610
589 Lisfranc injuries. Fixation is commonly achieved If complete arthrodesis is desired, additional 611
590 using a solid screw construct across multiple trans-articular screws or extra-articular plates 612
591 midfoot joints. However, dorsal extra-articular may be placed across the remainder of the TMT 613
592 plates may also be used for fusion. Stabilization joint. If partial arthrodesis is desired, percutane- 614
593 of the medial column is the recommended first ous fixation of the lateral column may be 615
594 step in fixation as it provides a foundation for achieved using K-wires. However, depending on 616
595 subsequent fixation of the lesser metatarsals. the injury pattern, the third-fourth, and fourth- 617
596 Fixation of the medial column is traditionally fifth intermetatarsal ligaments may be intact and 618
597 achieved via placement of a trans-articular screw reduction of the lateral may have been achieved 619
598 from the medial cuneiform to the first metatarsal indirectly after fixation of the medial and middle 620
599 via lag technique or via a dorsal extra-articular columns. In that case, the lateral column may be 621
600 plate positioned in the same manner. left free [18] (Fig. 8.5). Final fluoroscopic images 622
601 Attention is then turned to fixation of the sec- should demonstrate anatomic reduction of the 623
602 ond metatarsal. A pointed reduction clamp is articular surfaces and appropriate placement of 624
603 used to ensure anatomic reduction of the second all hardware. 625
a b
Fig. 8.5 AP (a) and oblique (b) plain films follwing partial arthrodesis of the Lisfranc joint
626 Wound Closure 8.9 Postoperative Complications 671

627 Wounds are copiously irrigated and suctioned for
628 further visualization of the operative field prior to The most common complication following oper- 672
629 closure. The dorsomedial, dorsolateral, and ative management of Lisfranc injuries is post- 673
630 medial incisions are closed using 2-0 vicryl for traumatic arthritis, regardless of surgical 674
631 the deep closure and 3-0 nylon for superficial clo- technique [17]. In a prospective, randomized 675
632 sure in the same fashion as detailed above for study, Mulier et al. reported that 94% of patients 676
633 ORIF. demonstrated degenerative changes at an average 677
follow-up of 30.1 months. However, surgeons 678
debate whether iatrogenic disruption of the artic- 679
634 8.8.3 Postoperative Management ular surface compounds the pre-existing cartilage 680
damage sustained at the time of injury [3]. Further 681
635 The postoperative timeline is individualized for studies are needed to assess the extent of intraop- 682
636 each patient (Table 8.3). Typically, sterile dress- erative damage during Lisfranc fixation and 683
637 ings and a well-padded, bulky posterior short- whether it contributes to the severity of subse- 684
638 leg splint are applied in the operating room [19]. quent osteoarthritis [4, 18, 19]. 685
639 Sutures and splint are removed 2 weeks postop- Osteoarthritis is significantly associated with 686
640 eratively. The patient is transitioned into a CAM injuries that have not been anatomically reduced at 687
641 boot or short-leg cast. If K-wires were used, they the time of fixation [5, 16, 17]. Adib et al. found 688
642 are removed around 6 weeks postoperatively that only 35% of patients with anatomic reduction 689
643 [18, 19]. Progressive weight-bearing occurs in a developed osteoarthritis while 80% of those who 690
644 step-wise manner after 6 weeks. Full weight- with nonanatomic reduction developed degenera- 691
645 bearing is not permitted until 10–12 weeks post- tive changes [17]. However, patients with purely 692
646 operatively, at which point weight-bearing ligamentous Lisfranc injuries demonstrate a higher 693
647 radiographs can be performed. When appropri- prevalence of osteoarthritis (40%) compared to 694
648 ate, weight- bearing images should confirm combined osseous-ligamentous injuries (18%), 695
649 maintenance of reduction and appropriate bone despite achieving anatomic reduction [19]. 696
650 healing [1, 3]. ORIF has also been associated with hardware 697
651 Removal of hardware in the postoperative failure, missed concomitant injuries, deep vein 698
652 period is highly debated. There is currently no thrombosis, and superficial wound infection as 699
653 consensus regarding timing, necessity, and role compared to arthrodesis [17]. Persistent pain, 700
654 that hardware removal plays in overall patient midfoot deformity, and symptomatic hardware 701
655 outcomes [1]. Some surgeons believe that corti- have also been frequently reported [20, 22]. 702
656 cal screws involved in medial column fixation Primary arthrodesis has also been linked to a 703
657 should remain implanted indefinitely [19]. greater incidence of pseudoarthrosis, delayed 704
658 Alternatively, other surgeons advocate for routine union, and non-union as compared to ORIF [1, 705
659 removal of any and all hardware at 18 weeks to 6 17, 18]. Ly et al. reported specific instances of 706
660 months following the procedure [13, 18–20]. delayed union and non-union requiring a bone 707
661 Under the rationale that removal of hardware stimulator and revision arthrodesis with bone 708
662 potentially restores the natural motion of the graft, respectively [20]. 709
663 midfoot, it has been suggested that athletes may
664 benefit from removal of hardware while nonath-
665 letes may not [1, 8]. Furthermore, hardware 8.10 Postoperative Outcomes 710
666 removal among athletes may be influenced by
667 individual weight, such that those >200 pounds Outcomes following Lisfranc injuries are influ- 711
668 should undergo removal of hardware after enced by a variety of factors such as injury pat- 712
669 24 weeks while those <200 pounds may undergo tern, patient-specific demographic factors, 713
670 hardware removal at 12–16 weeks [7, 8]. diagnostic accuracy, and appropriate manage- 714
715 ment. High-energy traumatic mechanisms and hardware, whether due to patient dissatisfaction 763
716 concomitant injuries demonstrate worse out- or surgeon preference. Kuo et al. reported that 764
717 comes compared to low-energy mechanisms and 50% of patients underwent subsequent arthrode- 765
718 isolated injuries [13]. Delayed diagnosis and pro- sis at an average time of 12 months from initial 766
719 longed time to treatment is associated with per- ORIF due to persistent pain associated with post- 767
720 sistent pain, functional disability, progressive traumatic arthritis [19]. Ly et al. reported that 768
721 post-traumatic osteoarthritis, and need for sal- 30% of Lisfranc ORIF patients underwent a sec- 769
722 vage arthrodesis [6]. ond surgery for removal of prominent or painful 770
723 Outcomes following postoperative manage- hardware at an average of 6.75 months postoper- 771
724 ment also vary based on the surgical technique atively [20]. In a systematic review of the litera- 772
725 employed. Following ORIF, fixation of the ture, Sheibani-Rad et al. reported an overall 773
726 affected Lisfranc joint in anatomic reduction is higher rate of reoperation among patients after 774
727 an essential factor in determining long-term ORIF (75–79%) compared to arthrodesis (17– 775
728 prognosis [19]. Increased average width between 20%). However, many of the studies included in 776
729 the first and second metatarsal base after ORIF the systematic review describe scheduled removal 777
730 has been associated with worse outcomes among of hardware at specified time intervals following 778
731 patients with severe Lisfranc injuries [18]. As the index procedures; and thus, it is possible that 779
732 such, maintenance of accurate reduction is of the higher rates of operation may be simply due 780
733 equal importance, regardless of the severity of to study design [17]. Further studies are needed 781
734 injury [2, 11]. Fortunately, anatomic reduction of in order to provide evidence-based recommenda- 782
735 the Lisfranc joint following rigid fixation appears tions regarding the specific implications of hard- 783
736 to be well maintained over the long term. Henning ware removal on patient outcomes following 784
737 et al. reported that 100% of patients who under- ORIF. 785
738 went Lisfranc ORIF maintained anatomic reduc- Like ORIF, arthrodesis has also demonstrated 786
739 tion at 2-years follow-up [1]. When anatomic favorable outcomes. In a study conducted by 787
740 reduction of the midfoot is both achieved and Henning et al., 94% of patients who underwent 788
741 maintained, normal dynamic walking patterns primary arthrodesis of the Lisfranc joint main- 789
742 may be restored in the injured foot [22]. tained anatomic reduction and achieved solid 790
743 Restoration of adequate midfoot function fol- fusion at 2-year follow-up [1]. Due to the high 791
744 lowing ORIF has been frequently demonstrated. rates of success and nature of the technique, 792
745 In a study of patients with radiographically con- arthrodesis rarely requires additional surgery for 793
746 firmed anatomic reduction, there was a mean hardware removal or revision [1, 20]. 794
747 American Orthopaedic Foot and Ankle Score Primary arthrodesis appears to have particu- 795
748 (AOFAS) of 78.3 at 42.6 months follow-up [13]. larly favorable functional outcomes with respect 796
749 Similarly, Kuo et al. found positive postoperative to operative management of purely ligamentous 797
750 outcomes, reporting a mean midfoot AOFAS of Lisfranc injuries. Ly et al. report significantly 798
751 77 and a mean Musculoskeletal Function higher mean midfoot AOFAS at 2-year follow-up 799
752 Assessment (MFA) Score of 19 at an average among patients with purely ligamentous Lisfranc 800
753 follow-up of 52 months [19]. Patient-reported injuries who underwent primary arthrodesis com- 801
754 outcomes following ORIF of Lisfranc injuries pared to those who underwent ORIF, 88 and 68.6, 802
755 also demonstrate positive results. Arntz et al. respectively [20]. Purely ligamentous Lisfranc 803
756 document that greater than 90% of patients report injuries have also shown favorable patient- 804
757 excellent or satisfactory outcomes following reported outcomes following primary arthrode- 805
758 ORIF of the Lisfranc joint using a standard AO sis. Patients with ligamentous injuries reported a 806
759 technique [3, 17]. return to 92% of their pre-injury level at 2 years 807
760 While ORIF of Lisfranc injuries generally following primary arthrodesis. At 2 years, 808
761 demonstrates favorable outcomes, the technique patients also reported an average Visual Analog 809
762 often requires second surgery for removal of Pain Scale (VAPS) score of 1.2 compared to an 810
811 average VAPS score of 4.2 among open reduction function within the midfoot. While anatomic 856
812 patients [20]. reduction is highly recognized as an essential fac- 857
813 Both ORIF and arthrodesis are reasonable pri- tor in promoting positive outcomes, there is cur- 858
814 mary surgical interventions for Lisfranc injuries, rently no consensus regarding the ideal operative 859
815 and it appears that most patients may experience method for the treatment of Lisfranc injuries. 860
816 positive outcomes regardless of the surgical tech-
817 nique employed [17]. Mulier et al. demonstrated
818 no significant difference in pain, foot function, References 861
819 and cosmesis among patients who underwent

1. Henning JA, Jones CB, Sietsema DL, Bohay DR, 862
820 either ORIF or partial arthrodesis in which only
Anderson JG. Open reduction internal fixation versus 863
821 the first through third TMT joints were fused primary arthrodesis for Lisfranc injuries: a prospective 864
822 while the fourth and fifth TMT joints were left randomized study. Foot Ankle Int. 2009;30(10):913– 865
823 free [18]. In a more recent study, Henning et al. 22. https://doi.org/10.3113/FAI.2009.0913. 866
2. Lee CA, Birkedal JP, Dickerson EA, Vieta PA, Webb LX, 867
824 similarly found no statistical difference in Short
Teasdall RD. Stabilization of Lisfranc joint injuries: a 868
825 Musculoskeletal Function Assessment (SMFA) biomechanical study. Foot Ankle Int. 2004;25(5):365– 869
826 scores, Short Form Survey 36 (SF-36) scores, 70. https://doi.org/10.1177/107110070402500515. 870
827 and satisfaction rates between primary ORIF and 3. Watson TS, Shurnas PS, Denker J. Treatment of 871
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828 primary arthrodesis patients at an average follow-
Orthop Surg. 2010;18(12):718–728. https://upload. 873
829 up of 53 months [1]. orthobullets.com/journalclub/free_pdf/21119138.pdf. 874
Accessed 29 Sept 2018. 875
4. Jeffreys TE. Lisfranc’s fracture-dislocation: a clini- 876
cal and experimental study of tarso-metatarsal dis-
830 8.11 Conclusion locations and fracture-dislocations. J Bone Jt Surg
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1963;45B(3):546–551. https://online.boneand- 879
831 Injury to the Lisfranc joint is rare and commonly joint.org.uk/doi/pdf/10.1302/0301-620x.45b3.546. 880
832 missed or misdiagnosed. These injuries may Accessed 26 Sept 2018. 881
5. Buzzard BM, Briggs PJ. Surgical management of 882
833 cause significant damage to the midfoot resulting
acute tarsometatarsal fracture dislocation in the adult. 883
834 in disabling morbidity. Thus, timely identifica- Clin Orthop Relat Res. 1998;353:125–33. https://doi. 884
835 tion and appropriate treatment of Lisfranc inju- org/10.1097/00003086-199808000-00014. 885
836 ries are important. Stable Lisfranc injuries with 6. Komenda GA, Myerson MS, Biddinger KR. Results of 886
arthrodesis of the tarsometatarsal joints after traumatic 887
837 minimal displacement are amenable to a trial of
injury. J Bone Jt Surg. 1996;78-A(11):1665–76. 888
838 non-operative management. However, non- 7. Nunley JA, Vertullo CJ. Classification, investigation, 889
839 operative management in the competitive athlete and management of midfoot sprains. Am J Sports 890
840 is recommended with caution, as there is a higher Med. 2002;30(6):871–8. https://doi.org/10.1177/036 891
35465020300061901. 892
841 likelihood of treatment failure. Unstable injuries
8. Lattermann C, Goldstein JL, Wukich DK, Lee S, 893
842 with moderate to severe displacement require Bach BR. Practical management of Lisfranc injuries 894
843 prompt surgical management in both the athlete in athletes. Clin J Sport Med 2007;17(4):311–315. 895
844 and nonathlete. Although ORIF has been accepted https://insights.ovid.com/pubmed?pmid=17620787. 896
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845 as the standard for operative management, pri-
9. Curtis MJ, Myerson M, Szura B. Tarsometatarsal 898
846 mary arthrodesis has become an increasingly joint injuries in the athlete. Am J Sports Med 1993; 899
847 favorable option among surgeons. Arthrodesis 21(4):497–502. http://journals.sagepub.com/doi/ 900
848 appears to have a unique application in that stud- pdf/10.1177/036354659302100403. Accessed 1 Oct 901
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849 ies cite superior outcomes in purely ligamentous
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850 Lisfranc injuries as compared to ORIF. However, locations. Clin Orthop Relat Res. 2011;469(7):2078– 904
851 both surgical techniques are reasonably contro- 80. https://doi.org/10.1007/s11999-010-1586-z. 905
852 versial in nature. ORIF has been associated with 11. Hardcastle PH, Reschauer R, Kutscha-Lissberg E, 906
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853 high rates of reoperation due to planned removal
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854 of hardware, and primary arthrodesis has been online.boneandjoint.org.uk/doi/pdf/10.1302/0301- 909
855 associated with a loss of natural biomechanical 620x.64b3.7096403. Accessed 1 Oct 2018. 910
911 12. Llopis E, Carrascoso J, Iriarte I, De M, Serrano P, Cerezal fractures. Orthopedics. 2012;35(6):868–73. https:// 939
912 L. Lisfranc injury imaging and surgical management. doi.org/10.3928/01477447-20120525-26. 940
913 Semin Musculoskelet Radiol. 2016;20(2):139–53. 18. Mulier T, Reynders P, Dereymaeker G, Broos P. Severe 941
914 https://doi.org/10.1055/s-0036-1581119. Lisfrancs injuries: primary arthrodesis or ORIF? Foot 942
915 13. Rajapakse B, Edwards A, Hong T. A single surgeon’s Ankle Int 2002;23(10):902–905. http://journals.sage- 943
916 experience of treatment of Lisfranc joint injuries. Int pub.com/doi/pdf/10.1177/107110070202301003. 944
917 J Care Inj. 2006;37:914–21. https://doi.org/10.1016/j. Accessed 26 Sept 2018. 945
918 injury.2005.12.003. 19. Kuo R, Tejwani N, DiGiovanni C, et al. Outcome 946
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922 the literature. Int Orthop. 2010;34:1083–91. https:// 20. Coetzee JC, Ly TV. Treatment of primarily ligamentous 950
923 doi.org/10.1007/s00264-010-1101-x. Lisfranc joint injuries: primary arthrodesis compared 951
924 15. Crates JM, Barber FA, Sanders EJ. Subtle Lisfranc with open reduction and internal fixation: surgical 952
925 subluxation: results of operative and nonoperative technique. J Bone Jt Surg. 2007;89-A(Suppl. 2, Part 953
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927 doi.org/10.1053/j.jfas.2014.07.015. 21. Ouzounian TJ, Shereff MJ, Sherman Oaks Md, York 955
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938 DiGiovanni C. Arthrodesis versus ORIF for Lisfranc
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Part II 1
Cartilage 2
1
2
Cartilage Techniques
for Osteochondral Lesions
9
3 of the Talus
4 Eoghan T. Hurley, Yoshiharu Shimozono,
5 and John G. Kennedy
6 9.1 Introduction microfracture [4]. Replacement procedures 25

include autologous osteochondral transplantation 26
7 Osteochondral lesions of the talus (OLT) are a (AOT) and osteochondral allograft transplanta- 27
8 common ankle pathology and have been shown tion [5]. Autologous chondrocyte implantation 28
9 to occur in over 65% of chronic ankle sprains and (ACI), matrix-induced autologous chondrocyte 29
10 75% of ankle fractures [1, 2]. OLT can be a implantation (MACI), autologous matrix-induced 30
11 significant source of pain and disability and chondrogenesis (AMIC), and scaffolds as 31
12 may have a potential to progress to arthritis. adjuncts to surgery have become popular in 32
13 Conservative management, including physiother- recent years, but further studies are required to 33
14 apy, injections, and a period of non-weight- substantiate their widespread use [6]. Biological 34
15 bearing, may relieve symptoms in the short term, adjuncts, including platelet-rich plasma (PRP) 35
16 but they often recur due to inadequate healing of and concentrated bone marrow aspirate (CBMA), 36
17 the lesion and require surgical treatment. have been shown to have promising evidence and 37
18 The surgical management of OLT is largely may be utilized alongside surgery to improve 38
19 dependent on the size of the lesion, the occur- healing potential [7]. 39
20 rence of cysts, and whether the patient has failed Despite the advances in the treatment of 40
21 previous surgeries. Surgery can be broadly OLT in the last few years, no gold standard 41
22 divided into reparative and replacement proce- treatment exists and surgical treatment should 42
23 dures [3]. Reparative procedures include bone be individualized to the patient in order to opti- 43
24 marrow stimulation procedures (BMS) such as mize outcomes [8]. 44
E. T. Hurley
Hospital for Special Surgery, New York, NY, USA 9.2 Microfracture 45
Royal College of Surgeons in Ireland, Dublin, Ireland
Y. Shimozono 9.2.1 Indications 46
Hospital for Special Surgery, New York, NY, USA
NYU Langone Health, New York, NY, USA Microfracture is a reparative technique, where the 47
subchondral bone in the defects is perforated with 48
J. G. Kennedy (*)
NYU Langone Health, New York, NY, USA awls to release the mesenchymal stem cells and 49
e-mail: John.Kennedy@nyulangone.org growth factors from bone marrow, leading to the 50
© ISAKOS 2019 105

https://doi.org/10.1007/978-3-662-58704-1_9
106 E. T. Hurley et al.
51 formation of fibrous cartilage repair tissue.

52 Microfracture is indicated for smaller lesion
53 which is typically less than 150 mm2 in area or
54 15 mm in diameter [9, 10]. However, a recent sys-
55 tematic review by Ramponi et al. demonstrated
56 that microfracture may be optimal for lesions
57 smaller than 107.4 mm2 in area and/or 10.2 mm in
58 diameter [11]. Ankle stability, joint alignment,
59 lesion size, the presence of a cyst, previous carti-
60 lage repair procedure, and uncontained lesion are
61 all prognostic factors when performing microfrac-
62 ture [9, 10]. There are several disadvantages with
63 microfracture, including the quality of fibrocarti-
64 lage which is inferior to native hyaline cartilage,
65 permanent damage to the subchondral bone, and Fig. 9.1 Arthroscopic image of the microfracture awl
66 deterioration of the fibrocartilage over time [12]. penetrating the subchondral bone plate
in good to excellent clinical outcomes [8, 13]. In 93

67 9.2.2 Technique regard to return to play sports following micro- 94
fracture, Hurley et al. found in a systematic review 95
68 Microfracture is typically performed arthroscopi- that 86.8% of patients returned to sport at previ- 96
69 cally using anteromedial and anterolateral porous levels, with a mean return at 4.5 months [14]. 97
70 tals. After inspection of the ankle joint, the OLT Despite successful outcomes in the short to 98
71 is prepared prior by debriding all unstable carti- mid-term, there is a concern about deterioration 99
72 lage by shaving or curettage until there is a stable of the fibrocartilage repair tissue over time, which 100
73 rim of articular cartilage. The calcified cartilage may potentially affect the clinical outcomes in 101
74 layer of bone should be removed; however, care the longer term [12, 15, 16]. Ferkel et al. found 102
75 should be taken not to disrupt the subchondral deterioration of clinical scores in up to 35% of 103
76 bone excessively. patients within 5 years following BMS [12]. Lee 104
77 Once the defect site is prepared, an awl <1 mm et al. found that only 30% of patients who under- 105
78 is used to perforate the subchondral bone. A went BMS showed lesion integration at second 106
79 smaller awl may result in less damage to the sub- look arthroscopy at 12 months postoperatively 107
80 chondral bone and may be preferable. [17]. In addition, van Bergen et al. reported that 108
81 Additionally, the distance between the awl aper- one-third of patients progressed ankle arthritis by 109
82 tures should be 3–4 mm apart to minimize dam- one grade on plain radiographs at a mean follow- 110
83 age to the subchondral bone (Fig. 9.1). After the up of 141 months [18]. 111
84 holes have been created, the tourniquet should be Recent studies have focused greater attention 112
85 turned off to assess for bleeding and fat droplet on the subchondral bone, which provides signifi- 113
86 extrusion. Biological adjuvants, including PRP cant joint loading [15, 19]. Seow et al. found in a 114
87 or CBMA, may be added, which may improve systematic review that there was permanent alter- 115
88 fibrocartilage repair tissue. ation of the subchondral bone following BMS in 116
preclinical studies [15]. This subchondral bone 117
alteration will reduce its mechanical support and 118
89 9.2.3 Outcomes may contribute to fibrocartilage deterioration. 119
Therefore, techniques minimizing damage to the 120
90 Microfracture has been shown to result in favor- subchondral bone will be important for cartilage 121
91 able short-term outcomes in several systematic longevity. In a translation animal model Orth 122
92 reviews, with typically >85% of patients resulting et al. found that the use of small-diameter awls 123
9 Cartilage Techniques for Osteochondral Lesions of the Talus 107
124 offers better articular cartilage repair than large-

125 diameter awls on histological exam [20].
126 Gianakos et al. evaluated different microfracture
127 awl sizes in a cadaver talus model, and found that
128 smaller awl sizes may help diminish the amount
129 of subchondral bone microarchitectural distur-
130 bances [21]. Additionally, biologics may play a
131 role in reducing the deterioration of the fibrocar-
132 tilage, although the long-term evidence on this is
133 still limited.
134 9.2.4 Particulated Juvenile

135 Cartilage Allograft
136 PCA (DeNovo NT; Zimmer Biomet, Inc.) is a

137 scaffold containing juvenile chondrocytes and Fig. 9.2 PCA application into the defect, mixed with
CBMA or PRP
138 particulated juvenile cartilage, typically har-
139 vested from donors less than 3 years old. PCA is
140 theoretically advantageous as an adjunct to
141 microfracture, as their high metabolic activity
142 level and differential gene expression may have
143 the potential to reproduce more hyaline cartilage
144 than adult chondrocytes (Fig. 9.2).
145 The supporting evidence for PCA is limited;
146 however several in vitro studies have found PCA
147 has a superior chondrogenic potential to adult
148 cartilage [19]. These studies showed improve-
149 ment in histological, biochemical, and biome-
150 chanical analyses, but not in gene expression
151 [19]. Karnovsky et al. performed a retrospective
152 comparative study of the results of patients
153 treated with microfracture and PCA, and those
154 treated with microfracture alone, at a mean fol-
155 low-up of 30 months [22]. The authors found Fig. 9.3 MCA application into the defect, mixed with
CBMA or PRP
156 both groups still showed fibrocartilaginous
157 growth that did not appear normal on MRI, and
158 there was no difference in functional outcomes factors. MCA is theoretically advantageous as an 166
159 between the two groups. The current role of PCA adjunct to microfracture, by inciting the migra- 167
160 remains unclear, and further long-term high-level tion of stem cells to the defect site of the defect, 168
161 studies are needed. while MCAs facilitate chondrogenesis by acting 169
as a tissue network promoting cell interaction 170
(Fig. 9.3). 171
162 9.2.5 Micronized Cartilage Allograft The evidence supporting MCA is still limited, 172
although the results of early literature appear 173
163 MCA (BioCartilage; Arthrex, Inc) contains an promising. Fortier et al. found that alongside 174
164 allogeneic extracellular matrix, including type II microfracture, MCA with PRP improved the 175
165 collagen, proteoglycans, and cartilaginous growth quality of cartilage repair tissue compared to 176
177 microfracture alone in an equine model [23].

178 Desai et al. reported on the results of nine patients
179 treated with microfracture and MCA at a mean
180 follow-up of 12 months [24]. Seven patients had
181 excellent outcomes, and two patients reported
182 good outcomes, although no quantitative out-
183 come measures were noted. However, no com-
184 parative studies comparing MCA with
185 microfracture to microfracture alone have been
186 reported. Therefore, long-term high-level studies
187 are warranted to justify its current widespread
188 use [19].
189 9.3 Autologous Osteochondral

190 Transplantation
191 9.3.1 Indications
192 AOT is a cartilage replacement technique where Fig. 9.4 A medial malleolar osteotomy utilized to ade-
193 a graft is harvested from the host, and transferred quately visualize the lesion
194 into a prepared site at the defect in the talus. As
195 AOT replaces the local subchondral bone, it may visualize the lesion (Fig. 9.4). A Chevron osteot- 218
196 result in the restoration of the native biological omy is preferred for this approach as it provides 219
197 environment leading to improved functional out- appropriate alignment, stability, a large surface 220
198 comes and survivorship over BMS. It is typically area for healing, and greater visualization [5]. 221
199 indicated in primary cystic lesions, lesions >10 or However, an anteromedial lesion may only 222
200 100 mm2, and revision procedures following a require a standard arthrotomy for visualization. 223
201 failed primary procedure [11, 25–27]. A recent Anterolateral lesions may be exposed via stan- 224
202 systematic review by Ramponi et al. found that dard arthrotomy of the ankle joint, although if it 225
203 AOT is indicated in lesions greater than is in a central or posterior position an anterolat- 226
204 107.4 mm2 in area and/or 10.2 mm in diameter eral tibial osteotomy may be required. After the 227
205 [25]. Lesion containment, the requirement greater lesion is visualized, a trephine is utilized to 228
206 than two grafts, previous BMS, and body mass remove the damaged cartilage and underlying 229
207 index can be prognostic factors when performing bone at the recipient site. A depth of 12–15 mm is 230
208 an AOT [25, 28–30]. There are several disadvan- the optimal depth to drill the lesion site. 231
209 tages to AOT, including donor site morbidity, the Multiple donor sites exist for graft harvesting; 232
210 possible need for an osteotomy to approach the however, our preferred technique is to harvest 233
211 lesions, and differences in cartilage biology/ from a non-weight-bearing portion of the ipsilat- 234
212 mechanics between the host and graft tissues. eral femoral condyle. This site is utilized as it is 235
technically undemanding to access and the varia- 236
tion in topography closely matches the talar 237
213 9.3.2 Technique dome. It also has a large surface area, allowing 238
for at least three grafts to be harvested without 239
214 The OLT may be accessed by a medial or lateral compromising the patellofemoral articulation. 240
215 osteotomy depending on the location of the Additionally, the superior aspect of the lateral 241
216 lesion. In the case of a medial OLT, a medial mal- femoral condyle experiences less pressure than 242
217 leolar osteotomy may be utilized to adequately other articular surfaces. There is a low incidence 243
Fig. 9.6 The osteochondral graft transplant being placed

into the created recipient site
Fig. 9.5 Application of PRP or CBMA into the defect

site comes at mid-term follow-up [33]. Fraser et al. 266
found that in athletes, 90% of professional athletes 267
and 87% of recreational athletes were able to fully 268
244 of donor site complications, typically less than return to pre-injury activity levels at a mean of 269
245 5% in large series [5, 31–33]. Larger lesions may 24 months follow-up [36]. However, Paul et al. 270
246 require two grafts, which should be “nested” next showed patients engaging in high-impact and con- 271
247 to each other to reduce risk of fibrocartilage for- tact sports required partial modification of sport- 272
248 mation and synovial fluid inflow between the ing activities and a reduced level of participation 273
249 grafts [5, 34]. [29]. Additionally, several studies have shown 274
250 Prior to graft implantation, biological adju- improved radiological outcomes following AOT, 275
251 vants, including PRP or CBMA, are added, which with a low incidence of joint space narrowing [33]. 276
252 may facilitate biological integration of graft and There is still lack of evidence regarding the long- 277
253 host interface (Fig. 9.5). The AOT plug is then term outcomes of AOT for OLT. 278
254 transferred to the prepared recipient site. Complications remain a concern with AOT; 279
255 Congruency of the implanted graft is essential as Shimozono et al. found in a systematic review 280
256 the final graft position should be as flush as pos- that 10.6% of patients had complications, with 281
257 sible to match the surrounding cartilage, and care the most common being donor site morbidity 282
258 should be taken during surgery to achieve an [33]. Yoon et al. found that while 9% patients had 283
259 articular surface as closely as possible to the early donor site morbidity all of these resolved at 284
260 native talus (Fig. 9.6) [35]. 48 months follow-up, and Fraser et al. found an 285
early donor site morbidity of 12.5% but this 286
decreased to 5% at a mean of 41-month follow- 287
261 9.3.3 Outcomes up [27, 37]. Shimozono et al. found that the over- 288
all rate of reoperations was 6.2%; however, only 289
262 The clinical outcomes following AOT have been 1% of patients were considered a clinical failure 290
263 shown to be excellent in multiple studies, and a at mid-term follow-up [33]. The osteotomy may 291
264 recent systematic review by Shimozono et al. be a concern for some surgeons; however, studies 292
265 found 87% of patients had good to excellent out- have found minimal morbidity when performing 293
294 an osteotomy to access the talar dome [17, 38]. 9.4.2 Technique 337
295 Lamb et al. found that in 62 patients a chevron-
296 type medial malleolar osteotomy provided satis- The recipient site for osteochondral allograft 338
297 factory healing on T2 mapping MRI and only transplantation may be accessed and prepared in 339
298 four patients reported some pain postoperatively a similar manner to AOT. However, bulk allograft 340
299 [39]. Additionally, postoperative cysts have been may require an anterior approach in the majority 341
300 shown to occur in up to 65% of patients follow- of cases. Additionally, bulk allograft may require 342
301 ing AOT, although the clinical significance of this more extensive preoperative imaging utilizing 343
302 remains unclear. Savage-Elliott et al. found that 3D-CT planning to accurately determine the siz- 344
303 clinical influence of postoperative cyst formation ing of the graft needed. 345
304 was not significant in the short term [40]. Finally, AOT can be harvested from either cadaveric 346
305 the congruency of the graft is paramount to knees or ankles, and there is no consensus over 347
306 restore contact mechanics in the ankle [35]. Fansa which is the optimal site. Cadaveric talus may be 348
307 et al. found that implantation of the osteochon- preferable as the cartilage biology, tissue mechan- 349
308 dral graft in the most congruent position possible ics, and topography may more closely match the 350
309 restored the force, mean pressure, and peak pres- recipient site. Fresh nonfrozen allografts less 351
310 sure on the medial region of the talus comparable than 28 days old may be preferable to maintain 352
311 to intact levels [35]. chondrocyte viability, as less than 70% chondro- 353
cyte viability is associated with poor outcomes 354
and osteochondral allograft transplantation loses 355
312 9.4 Osteochondral Allograft approximately 30% viability at 28 days [43, 44]. 356
313 Transplantation Prior to graft, biological adjuvants, including 357
PRP or CBMA, can be utilized, as Oladeji et al. 358
314 9.4.1 Indications have found that utilizing CBMA in allograft 359
improves radiographic integration [45]. The 360
315 Osteochondral allograft transplantation is a carti- osteochondral allograft transplantation should be 361
316 lage replacement technique similar to AOT in placed in a manner as congruent as possible to 362
317 which the graft is harvested from a cadaver. There AOT, in order to as closely match the local bio- 363
318 are two types of osteochondral allograft: bulk mechanics and of the local joint. Additionally, 364
319 type and cylindrical plug type. Bulk allograft is bulk allograft requires screw fixation in order to 365
320 generally considered as a salvage surgery if pre- secure the graft, and in this instance a headless 366
321 vious surgeries fail, but can be performed as a screw is preferable. 367
322 first-line procedure for excessive large lesions
323 whose successful outcomes cannot be expected
324 by other procedures. Osteochondral allograft 9.4.3 Outcomes 368
325 transplantation using cylindrical plug has similar
326 indications to AOT, but is usually indicated in Studies have found mixed clinical outcomes fol- 369
327 preference to AOT in knee osteoarthritis, history lowing osteochondral allograft transplantation 370
328 of knee infection, and patients concerned with for OLT. The results of osteochondral allograft 371
329 donor site morbidity in the knee. Patient counsel- transplantation differ whether it is bulk or 372
330 ing is important in deciding on autograft or cylindrical plug allograft, as bulk allograft may 373
331 allograft, and the pros/cons must be discussed experience poorer outcomes due to larger size of 374
332 with the patient. There are several disadvantages the lesions treated. VanTienderen et al. found in a 375
333 to allograft, including potential higher failure systematic review of 91 OLTs treated with bulk 376
334 rate, increased cost, disease transmission, and allograft that at a mean of 45 months follow-up 377
335 differences in immunology/cartilage biology the average AOFAS score improved from 48 to 378
336 between the host and cadaveric tissues [41, 42]. 80 and the mean VAS score improved from 7.1 to 379
380 2.7 [42]. Raikin et al. found in 15 patients treated expanded in vitro. ACI is then placed into a 423
381 with bulk allograft at a mean of 54 months that prepared site at the defect in the talus and cov- 424
382 the mean VAS score improved from 8.5 to 3.3 ered in an autologous periosteal membrane. The 425
383 and the mean AOFAS score improved from 38 to aim of this procedure is to regenerate damaged 426
384 83, with 11 patients reporting good/excellent cartilage with hyaline-like tissue. ACI is indi- 427
385 results [46]. However, two patients required con- cated in larger lesions or revision procedures fol- 428
386 version to arthrodesis [46]. On plain radiographs, lowing a failed primary procedure. There are 429
387 some evidence of collapse or resorption of the several disadvantages to ACI, including two 430
388 graft was found in 67% of patients [46]. steps to the procedure, cost, and potential failure 431
389 El-Rashidy et al. showed using cylindrical plug rates. 432
390 allograft in the treatment of OLT significantly
391 improved clinical outcomes at a mean follow-up
392 of 3 years, although there was a 10.4% failure 9.5.2 Technique 433
393 rate over this time [47]. Ahmad et al. found simi-
394 lar clinical outcomes following cylindrical plug ACI is a two-step procedure, whereby in the first 434
395 allograft and autograft for OLT at 35.2 months step chondrocytes are harvested from the ankle, 435
396 [48]. However, 18.8% of patients in allograft the osteochondral fragment itself, or the ipsilat- 436
397 group required revision surgery due to non-union eral knee [49]. These cells are then expanded and 437
398 at the graft/host integration site. cultured in vitro for 2–3 weeks. 438
399 Complications including failure and reopera- Once the cells are prepared, the patient returns 439
400 tions remain a concern with osteochondral for the second step where the chondrocytes are 440
401 allograft transplantation. VanTienderen et al. implanted, either arthroscopically or via an open 441
402 found in their systematic review that 13.2% of incision. The OLT recipient site is first prepared, 442
403 patients were considered clinical failures and where it is debrided to the subchondral bone and 443
404 25% required reoperation [42]. The cause of the any cysts present are removed. In larger subchon- 444
405 early failure is likely a combination of chondral dral cystic defects, a “sandwich” technique can 445
406 wear, chondral fissuring, and cyst formation in be utilized. This is where after cyst debridement, 446
407 the graft’s subchondral bone, due to poor graft/ the autologous bone graft obtained is placed into 447
408 host bone incorporation. Additionally, differ- the defect creating a smaller defect, followed by 448
409 ences in the cellular biology between the graft/ placement of a periosteal patch. The periosteal 449
410 host and the chondrocyte viability may be a cause patch is taken from the distal or proximal tibia 450
411 for the higher failure rates. Neovascularization and is made 1–2 mm larger than the defect to 451
412 may also play a role in the failure of allograft, as account for shrinkage. The patch is then secured 452
413 Neri et al. found that only 10 out of 15 osteo- over the defect, cambium side down, with sutures 453
414 chondral allografts showed gene expression and fibrin glue. 454
415 matching the recipient, indicating blood supply
416 between the graft/host interface [41].
9.5.3 Outcomes 455
417 9.5 Autologous Chondrocyte ACI has been shown to result in good clinical 456
418 Implantation outcomes, and a recent systematic review by 457
Niemeyer et al. found a clinical success rate of 458
419 9.5.1 Indications 89.9% in 213 patients at a mean follow-up of 459
32 months [6]. Giannini et al. reported on the 460
420 ACI is a two-step cartilage reparative technique clinical and MRI outcomes of ten patients fol- 461
421 where autologous chondrocytes are harvested lowing ACI for OLT at 10-year follow-up [50]. 462
422 from a non-weight-bearing area and culture The authors showed in patients with a mean 463
464 lesion size of 3.1 cm2 treated with ACI at a mean 9.6.2 Autologous Matrix-Induced 506
465 follow-up of 119 months that the AOFAS score Chondrogenesis 507
466 improved from 37.9 preoperatively to 92.7 post-
467 operatively with well-modeled restoration of the Autologous matrix-induced chondrogenesis 508
468 articular surface on MRI. Additionally, Giannini (AMIC) is where a porcine collagen I/III matrix 509
469 et al. found that in 46 patients at a mean follow- is utilized at the site of the defect following 510
470 up of 87.2 months there were only three failures microfracture and is a one-step procedure. The 511
471 [51]. Battaglia et al. evaluated 20 patients follow- supporting theory is that this porcine collagen 512
472 ing ACI at a mean follow-up of 5 years and found matrix supports the growth of cartilage following 513
473 that, on MRI evaluation, all patients showed a T2 microfracture. 514
474 mapping value consistent with normal hyaline The literature on AMIC is limited to a few 515
475 cartilage [52]. small case series, but the results seem promising. 516
476 ACI has a low rate of complications specific to Valderrabano et al. reported in a series of 26 517
477 the procedure, and most complications are those patients that 84% of patients had normal/near 518
478 associated with ankle arthroscopy or osteotomy, normal signal intensity of the repair tissue com- 519
479 particularly non-union, scar tissue formation and pared with the native cartilage on MRI [55]. 520
480 nerve damage as this is a two-stage procedure. However, Wiewiorski et al. observed a significant 521
481 However, there is a concern of periosteal hyper- difference in T1 relaxation times between AMIC 522
482 trophy due to overgrowth of the repair tissue, repair tissue and the surrounding cartilage, sug- 523
483 which may require debridement. gesting lower glycosaminoglycan content in the 524
repair tissue [56]. 525
484 9.6 Scaffolds

9.6.3 B
one Marrow-Derived Cell 526
485 9.6.1 Matrix-Induced Autologous Transplantation 527
486 Chondrocyte Implantation
Bone marrow-derived cell transplantation 528
487 Matrix-induced autologous chondrocyte implan- (BMDCT) is a combination of CBMA and scaf- 529
488 tation (MACI) is where a biodegradable polymer fold material and is a one-step procedure. 530
489 scaffolds embedded with chondrocytes is uti- BMDCT is theoretically beneficial as the mesen- 531
490 lized as a scaffold. MACI is a third generation chymal stem cells and the growth factors in 532
491 version of ACI and a two-step procedure. CBMA support the scaffold in chondrogenesis, 533
492 However, it is advantageous as it is a self-adher- to develop hyaline-like cartilage at the site of the 534
493 ent scaffold, and avoids complications related to defect. 535
494 the graft harvest. Similar to AMIC, the clinical evidence sup- 536
495 Aurich et al. reported on the results of 19 porting the use of BMDCT is limited albeit 537
496 patients treated with MACI and observed promising. Vannini et al. reported on 140 ath- 538
497 improvement of the AOFAS score from 58.6 to letes treated with BMDCT at a mean of 539
498 80.4 at a final follow-up of 24 months [53]. 48 months follow-up and found the overall mean 540
499 Additionally, they found 81% of patients AOFAS score improved from 58.7 to 90.9 [57]. 541
500 returned to play sports after MACI for OLT, The authors also showed that 72.8% of athletes 542
501 including 56% returning to their pre-injury level. were able to return to pre-injury level of sports. 543
502 Similarly, Magnan et al. showed improvement in Buda et al. evaluated 80 patients treated with 544
503 the mean AOFAS score from 36.9 to 83.9 in 36 ACI or BMDCT at 48 months follow-up [58]. 545
504 patients, with 18 returning to sport within There was no significant difference in clinical 546
505 2 months [54]. outcomes, but the rate of return to sports was 547
548 slightly higher with BMDCT, although the dif- pain-related scores of BMS in the treatment of 590
549 ference was not statistically significant. OLT compared to a placebo control [62]. 591
550 However, this shows that BMDCT may be a Additionally, Gormeli et al. and Mei-Dan et al. 592
551 viable alternative to ACI, with the advantage of both found that PRP improved the clinical out- 593
552 being a one-stage procedure. comes and pain scores of patients with ankle 594
osteoarthritis compared to hyaluronic acid in the 595
short term [63, 64]. 596
553 9.7 Biologics
554 9.7.1 Platelet-Rich Plasma 9.7.2 C

oncentrated Bone Marrow 597
Aspirate 598
555 PRP may be considered as adjuncts to surgical
556 therapies in the treatment of OLT to improve the CBMA may be considered as adjuncts to surgical 599
557 local healing potential. PRP is an autologous therapies in the treatment of OLT to improve the 600
558 blood product that contains at least twice the con- local healing potential in a similar manner to 601
559 centration of platelets above the baseline value, PRP. CBMA is an autologous blood product har- 602
560 or >1.1 × 106 platelets/μl. PRP contains an vested from the long bones, typically the iliac 603
561 increased number of growth factors and bioactive crest or the tibia. CBMA contains a similar 604
562 cytokines, including transforming growth factor, growth factor and cytokine profile compared to 605
563 vascular endothelial growth factor, fibroblast PRP, with the addition of interleukin 1 receptor 606
564 growth factor, and platelet-derived growth factor antagonist protein in CBMA, which is a potent 607
565 [59]. PRP is harvested by drawing venous blood anti-inflammatory agent [65]. CBMA may be 608
566 from a peripheral site, and then is put in a prepa- harvested in either the office or in the operating 609
567 ration kit where it is spun to formulate PRP. This room. However, as CBMA harvest can be painful 610
568 may be performed in either the office or in the and may be difficult to perform in the office, we 611
569 operating room. typically only harvest this in the operating room. 612
570 There is strong basic science evidence to sup- Fortier et al. have shown that CBMA improves 613
571 port the use of PRP in cartilage repair. Smyth both the histological and radiological outcomes 614
572 et al. performed a systematic review and found in the repair of cartilage defects in an equine 615
573 that 18 of 21 (85.7%) basic science literature microfracture model, compared to a control with- 616
574 studies reported positive effects of PRP on carti- out CBMA [66]. Fortier et al. found increased fill 617
575 lage repair, establishing a proof of concept [7]. of defect and improved integration of repair tis- 618
576 Smyth et al. also showed that the application of sue with surrounding cartilage [66]. In addition, 619
577 PRP at the time of AOT implantation in a rabbit Saw et al. found in a goat model that CBMA and 620
578 model improved the integration of the osteochon- hyaluronic acid (HA) improved defect coverage 621
579 dral graft at the cartilage interface and decreased and repair tissue following BMS compared to 622
580 graft degeneration [60]. Similarly, Boayke et al. HA alone [67]. 623
581 found using PRP alongside AOT in a rabbit Hannon et al. found patients who underwent 624
582 model that there was increased TGF-β1 expres- BMS with CBMA in the treatment of OLT had 625
583 sion at the graft/host interface compared to comparably good mid-term clinical outcomes, but 626
584 saline-treated controls, and thus PRP may play a improved MOCART scores compared to BMS 627
585 chondrogenic role [61]. alone [68]. While the clinical evidence is limited in 628
586 Several randomized controlled trials have the use of CBMA in the treatment of OLTs, Chahla 629
587 shown a benefit of PRP in the treatment of OLT et al. performed a systematic review and showed 630
588 and ankle osteoarthritis. Guney found PRP at the CBMA was a promising treatment in the treatment 631
589 time of surgery improved the AOFAS scores and of osteochondral defects in the knee [69]. 632
633 9.8 Summary/Conclusion 9. Choi WJ, Choi GW, Kim JS, Lee JW. Prognostic 682
significance of the containment and location of 683
osteochondral lesions of the talus independent 684
634 The surgical management of OLT remains con- adverse outcomes associated with uncontained 685
635 troversial. Based on the current available clinical lesions of the talar shoulder. Am J Sports Med. 686
636 evidence, both reparative and replacement proce- 2013;41(1):126–33. 687
10. Choi WJ, Park KK, Kim BS, Lee JW. Osteochondral 688
637 dures have a role in the surgical treatment of OLT lesion of the talus: is there a critical defect size for poor 689
638 and have been shown to result in good clinical outcome? Am J Sports Med. 2009;37(10):1974–80. 690
639 outcomes. MACI, which is a next-generation 11. Ramponi L, Yasui Y, Murawski CD, Ferkel RD,
691
640 technique of ACI, has become increasingly uti- DiGiovanni CW, Kerkhoffs GMMJ, Calder JDF, 692
Takao M, Vannini F, Choi WJ, Lee JW, Stone J, 693
641 lized in recent years. Additionally, biological Kennedy JG. Lesion size is a predictor of clinical out- 694
642 adjuncts and scaffolds have increasingly gathered comes after bone marrow stimulation for osteochon- 695
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644 However, further high-level studies are still Sports Med. 2016;45(7):1698–705. 697
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883 I. Are ankle chondrocytes from damaged fragments Deland JT, Kennedy JG. The effect of platelet-rich 941
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885 Cartil. 2010;18(8):1067–76. tion an in vivo rabbit mode. J Bone Joint Surg Am. 943
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888 lesions of the talus by open-field autologous chon- Hannon CP, Fortier LA, Kennedy JG. Platelet-rich 946
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1
2
Tissue Engineering
for the Cartilage Repair
10
3 of the Ankle
4 Alberto Gobbi, Stefan Nehrer, Markus Neubauer,

5 and Katarzyna Herman
6 10.1 Introduction lesions (OCLs) of the talus; nevertheless a gold 27

standard is yet to be established [2]. A systematic 28
7 The cartilage in the ankle is a highly specialized review by Verhagen et al. has shown that nonsur- 29
8 tissue, known to be unique both in biology and gical treatment of OLCs of the talus seems to be 30
9 anatomy, thinner than in the knee, but with a successful in only 45% of the cases and for that 31
10 higher cell density, metabolic activity and more reason it is not advised [3]. Microfracture has 32
11 resistance to chronic inflammation [1]. For these been considered a primary line of treatment in the 33
12 reasons the ankle joint is, although often involved majority of lesions, and even though short-term 34
13 in sports injuries, less prone to osteoarthritic pro- results have been promising, some long-term 35
14 gression than other joints, and many osteochon- follow-up studies have shown fair and poor 36
15 dral lesions remain clinically silent. However, results from 47.7% up to 54% [4, 5]. What is 37
16 larger osteochondral lesions and osteochondritis more, in our randomized study comparing micro- 38
17 dissecans of the talus can rapidly develop unsta- fracture, chondroplasty and osteochondral auto- 39
18 ble joint fragments, cyst formation and deteriora- graft transplantation, we have seen an incomplete 40
19 tion of the subchondral bone leading to healing on a control MRI 12 months after micro- 41
20 deformation and collapse of the talus. Young, fracture [6]. Ferkel et al. reported that the promis- 42
21 active people constitute the majority of the ing clinical outcome after microfracture 43
22 patients developing postresidual pain after either deteriorated in 35% of the treated patients over a 44
23 acute sprain or repetitive trauma that is why it is period of 5 years [7]. The primary reason of long- 45
24 crucial that the chosen treatment method has term failure may be the poor biomechanics and 46
25 good long-term functional outcomes. There are biological quality of subsequently forming 47
26 many treatment possibilities for osteochondral fibrous cartilage, rich in type I collagen. The 48
autologous chondrocyte implantation (ACI) was 49
the next step in the development of osteochondral 50
A. Gobbi (*) · K. Herman
Orthopaedic Arthroscopic Surgery International lesion treatment, and it has demonstrated good 51
(OASI), Bioresearch Foundation Gobbi NPO, clinical outcomes [8–10]. However, the proce- 52
Milan, Italy dure has been considered demanding and required 53
e-mail: gobbi@cartilagedoctor.it
two surgeries. Evolution of tissue engineering 54
S. Nehrer · M. Neubauer and biomaterial science provided a substrate for 55
Department for Health Sciences, Medicine and
the development of different scaffolds for carti- 56
Research Center for Regenerative Medicine,
Center for Health Sciences and Medicine, lage repair. Firstly, used with chondrocytes that 57
Danube University Krems, Krems, Austria were seeded onto the matrix, still that did not 58
© ISAKOS 2019 119

https://doi.org/10.1007/978-3-662-58704-1_10
120 A. Gobbi et al.
59 eliminate the need for chondrocyte harvest and of collagen I and III and is a bilayer matrix that has 105
60 cultivation. Subsequently, a need for a “biologi- been used in first-generation ACI and in combina- 106
61 cal solution to a biological problem” idea has led tion with microfracture providing a good outcome 107
62 to the use of bone marrow aspirate concentrate [18, 19]. A scaffold used in treatment of OCL that 108
63 (BMAC) and a hyaluronic acid-based scaffold varies in structure from collagen- and hyaluronan- 109
64 (HA) in a one-step procedure [11]. based scaffolds mimics the trilateral morphology 110
of the osteochondral unit. The superficial layer is 111
made of type I collagen, while the lower layer 112
65 10.2 Scaffolds for Tissue consists mainly of magnesium-enriched hydroxy- 113
66 Engineering apatite. Although presenting clinical improvement 114
in the treatment of OCL in the talus, it has shown 115
67 Scaffolds are designed to host and support the limited tissue regeneration [20, 21]. 116
68 cells used for cartilage regeneration. Materials
69 used in matrices development are either naturally
70 occurring (i.e. hyaluronan, collagen, chitosan) or 10.3 B
one Marrow in Cartilage 117
71 synthetic (i.e. polystyrene, polylactic acid) [12]. Repair 118
72 The physical structure and the macro- and micro-
73 architecture also vary, and liquid scaffolds entrap Using BMAC for cartilage regeneration is a valu- 119
74 the cells, whereas a multilayered fibre or mesh able technique, offering a chance to avoid two sur- 120
75 supports implanted cells allowing their adherence geries and expensive chondrocyte cultivation. 121
76 [13, 14]. There are crucial criteria that character- BMAC has proven to be a good material for cell- 122
77 ize a good scaffold [14]. Firstly, the material must based therapy in cartilage regeneration with a 123
78 be biocompatible, and the scaffold itself and the potential to differentiate into osteogenic and chon- 124
79 breakdown products should not create an immune drogenic cells [22–24]. Moreover, many studies 125
80 response. Secondly, the sufficient porosity of the and publications have proven that BMAC has the 126
81 material is important, so that it allows the cells ability to restore healthy and functional tissues 127
82 ingrowth. Finally, the mechanical resistance to even in cases of high-grade articular cartilage 128
83 shear forces acting in the joint and scaffold stabil- injury [11, 25–27]. The bone marrow aspirate 129
84 ity are of great importance. Among the natural (BMA) is usually harvested from an ipsilateral 130
85 and synthetic materials that have been investi- iliac crest prior to the main procedure. A sharp tro- 131
86 gated, only a few have been used in ankle lesions. car with an aspiration needle is placed in the bone 132
87 The hyaluronan-based scaffolds are entirely between the cortices, about 3–5 cm deep. An aver- 133
88 based on the benzylic ester of hyaluronic acid, age total aspiration volume of 60 mL is harvested, 134
89 which is a natural glycosaminoglycan, widely dis- using a standard syringe. Frequently used centrif- 135
90 tributed in connective tissues. Because of its ugation systems include the “RegenKit Extracell 136
91 molecular structure and multifunctional activity, it BMC” (Regen Lab, Le Mont-sur-Lausanne, 137
92 has proven to be an ideal material for tissue engi- Switzerland), “Arthrex Angel®”(Arthrex, Naples, 138
93 neering. The network of 15–20-μm-thick fibres United States), “Harvest Technologies system” 139
94 forms a scaffold that provides a good support that (Plymouth, MA) or the “Cobe 2991 Cell 140
95 allows contact of seeded cells, subsequent cluster Processor” (Terumo BCT, Paris, France) [28]. 141
96 formation and extracellular matrix deposition. The aspirate is then prepared and centrifuged 142
97 Good clinical results have been achieved in a two- to obtain a concentrated product. The rationale 143
98 step procedure using the matrix-induced autolo- behind the process is to increase the proportion of 144
99 gous chondrocyte implantation technique and the mesenchymal stem/progenitor cells (MSCs) in 145
100 use of a hyaluronic acid-based scaffold [15–17], plain BMA, which is in between 0.001 and 0.01% 146
101 as well as in a one-step procedure with the use of of the nucleated cells [29]. The process of cen- 147
102 BMAC (Hyalofast, Anika Therapeutics Inc., trifugation not only results in a higher proportion 148
103 Massachusetts, USA) [11]. Another type of scaf- of MSCs but also higher concentration of plate- 149
104 fold used in treatment of OCL of the talus consists lets and disrupts cell components increasing free 150
10 Tissue Engineering for the Cartilage Repair of the Ankle 121
151 growth factors that might be predominantly rele- reconstruction [31]. Defects that are deeper than 180
152 vant for the regenerative processes. The average 5 mm are considered indicated for cancellous bone 181
153 processing time takes around 15 min, but a newly filling as has been stated in the latest published 182
154 introduced bone marrow retrieval system recommendations of a consensus group [32]. For 183
155 (Marrow Cellution®) may reduce time and cost of chondral defects without bony defect, the same 184
156 the procedure and avoid regulation problems group also recommended the use of a biomaterial 185
157 regarding cell manipulation by centrifugation. to facilitate cartilage tissue formation and support 186
158 Combination of gradual aspiration through a sys- fill of the defect, especially in defect sizes bigger 187
159 tem of lateral holes reduces the peripheral blood than 10 mm in diameter. The treatment options are 188
160 harvest, which results in an aspirate consisting a the application of a biomaterial, mostly hyaluro- 189
161 greater amount of fibroblast-like colony-forming nan-based scaffold, filled with bone marrow aspi- 190
162 units (CFU-f) without the centrifugation step. rate concentrate (BMAC) preferable without 191
microfracture. The bone marrow harvested from 192
the iliac crest is a source of cells that provide a 193
163 10.4 S
caffold and Stem Cell biological regenerative potential in the defect 194
164 Surgical Technique without disturbing the subchondral bone. However, 195
a thorough debridement of the defect and removal 196
165 The first and crucial decision in the surgical treat- of any unstable fragments in the cartilage or bone 197
166 ment of OCL of the talus is if the defect is acces- is mandatory for a successful outcome. The surgi- 198
167 sible through an anterior approach or a medial cal application technique requires bone marrow 199
168 malleolar osteotomy is needed in case of the aspiration followed by its concentration, as well as 200
169 medial talar dome OCL. Lesions on the lateral side the seeding of the scaffold and the implantation 201
170 are usually more accessible in plantar flexion and procedure. Trials investigating BMAC in combi- 202
171 only in rare cases require a fibular osteotomy, nation with scaffolds used this approach for type II 203
172 which is a technically challenging procedure. chronic talus cartilage lesions of >1.5 cm2 [22, 33]. 204
173 Figure 10.1 shows basic surgical procedures to Firstly, bone marrow is harvested and centri- 205
174 access chondral lesions of the talus [30]. The fuged to obtain a concentrated product 206
175 second decision is if an osseous reconstruction is (Fig. 10.2a). We advocate the use of batroxobin 207
176 necessary in addition to the cartilage repair proce- enzyme (Plateltex Act, Plateltex SRO, Bratislava, 208
177 dure. In that case, cancellous bone can be har- Slovakia), to activate BMAC and to produce a 209
178 vested from the tibia or from the iliac crest with a sticky clot material (Fig. 10.2b) that makes the 210
179 coring drill instrument to provide a stable bony application into the defect easier. A standard 211
a b c
Fig. 10.1 Surgical procedures to access osteochondral lesions of the talus (a) delaminated piece of cartilage, (b)
debrided defect and (c) malleolar osteotomy and suturing
122 A. Gobbi et al.
212 ankle arthroscopic procedure is performed, and edges are visible and measured. According to the 215
213 the lesion site is visualized (Fig. 10.3a), debrided measurements, a scaffold is cut to fit into the 216
214 until healthy bone (Fig. 10.3b) and clear cartilage defect side. For a 2 × 2 cm hyaluronan scaffold, 217
a b c
Fig. 10.2 Preparation of the HA-BMAC. (a) Harvesting after activation with batroxobin enzyme forms a sticky
bone marrow from the ipsilateral iliac crest using a sharp clot (c) hyaluronic acid-based (HA) scaffold combined
trocar (b) bone marrow aspirate concentrate (BMAC) with BMAC clot ready for implantation
a b
c d
Fig. 10.3 Arthroscopic procedure with the use of debridement with a curette, (c) placement of the
HA-BMAC osteochondral lesion of the talus. (a) HA-BMAC into the lesion and (d) adding fibrin glue to
Identification of the lesion on the talar dome, (b) lesion secure the scaffold
10 Tissue Engineering for the Cartilage Repair of the Ankle 123
218 approximately 2–3 mL of BMAC is needed to References 261

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249 trial, the AOFAS score decreased at 36 and articular cartilage defects: current status and pros- 302
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360 treatment in osteochondral lesions of the talus: autolo-
1
2
New and Emerging Techniques
in Cartilage Repair: Matrix-
11
3 Induced Autologous Chondrocyte
4 Implantation (MACI)
5 Jonathan J. Berkowitz and Richard D. Ferkel
6 Autologous chondrocyte implantation (ACI) was More recently, modifications have been made 31
7 originally developed based on the work of Smith, to the original technique to try to reduce its asso- 32
8 who cultured chondrocytes ex vivo [1]. Grande ciated pitfalls. Matrix-induced autologous chon- 33
9 et al. treated full-thickness cartilage defects with drocyte implantation (MACI) obviates the need 34
10 expanded chondrocytes and showed viable chon- for periosteal patch harvest by using a biodegrad- 35
11 drocytes and hyaline-like repair tissue on histol- able scaffold to retain chondrocytes and theoreti- 36
12 ogy [2]. Initially successful in treating cally reduce leakage [6]. Periosteal donor site 37
13 osteochondral defects (OCD) in the knee [3], ACI morbidity and postoperative patch hypertrophy 38
14 has subsequently been adopted for treatment of can thus be avoided. The cultured chondrocytes 39
15 osteochondral lesions of the talus (OLT). are dispersed on a porcine collagen type I/III 40
16 ACI is a two-stage procedure in which healthy scaffold which is then implanted onto the osteo- 41
17 chondrocytes are harvested arthroscopically from chondral lesion. This procedure will be further 42
18 nonessential areas such as the loose osteochon- discussed in detail later in this chapter. 43
19 dral fragment, the periphery of the OLT, or the Currently, MACI is approved by the Food and 44
20 ipsilateral knee intercondylar notch. The authors Drug Administration for use in the knee. 45
21 prefer to use the ipsilateral intercondylar notch Contraindications include a history of hypersen- 46
22 due to decreased cartilage-forming capacity of the sitivity to aminoglycosides or porcine material, 47
23 excised osteochondral fragment [4] and concern malalignment that would increase stress on the 48
24 for creating a new OLT by biopsy of the talus [5]. graft, advanced osteoarthritis, history of inflam- 49
25 The harvested chondrocytes are sent to a commer- matory arthritis, and uncorrected blood coagula- 50
26 cial laboratory to be cultured and expanded into tion disorders. 51
27 millions of cells. In the second stage, the isolated There are still no large comparative blinded 52
28 and expanded chondrocytes are implanted into the studies of MACI for OLTs, and the evidence for 53
29 prepared OLT under a harvested periosteal patch its use is currently limited to level IV case series. 54
30 that is sealed with 6-0 sutures and fibrin glue.
J. J. Berkowitz 11.1 Patient Selection 55

Los Angeles Orthopaedic Institute,
Sherman Oaks, CA, USA
Patients with OLTs who have failed extensive 56
R. D. Ferkel (*) nonsurgical management including physical ther- 57
Southern California Orthopedic Institute, Department
apy, bracing, casting, and nonsteroidal anti- 58
of Orthopaedic Surgery, UCLA Center for Health
Sciences, Van Nuys, CA, USA inflammatory medication should be considered 59
© ISAKOS 2019 125

https://doi.org/10.1007/978-3-662-58704-1_11
126 J. J. Berkowitz and R. D. Ferkel
a b
Fig. 11.1 Preoperative CT of a left ankle with a cystic Sagittal view showing the cystic osteochondral lesion in
osteochondral lesion. (a) Coronal view demonstrating approximately the middle of the medial talus
medial location of the cystic osteochondral lesions. (b)
60 for a cartilage transplant. MACI should be consid-

61 ered for an OLT between 1.07 and 4 cm2. MACI is 11.3 Equipment 87
62 also indicated for patients who have failed mar-
63 row stimulation procedures. Additionally, if the For the first phase, supine ankle arthroscopy is 88
64 lesion is deeper than 6 mm, bone graft augment- performed through anteromedial, anterolateral, 89
65 ing of the lesion should be considered [7]. Worse and posterolateral portals using 30 and 70° 90
66 outcomes have been reported when the lesion is 2.7 mm arthroscopes with noninvasive soft tis- 91
67 more than 7 mm in depth, and this should be kept sue distraction [9]. A 1.9 mm 30° arthroscope 92
68 in mind when indicating patients with these may be used for tight joints. For the cartilage 93
69 lesions for MACI [8]. Unipolar lesions involving harvest in the knee, ring curettes and arthroscopic 94
70 only the talus are preferred. graspers are used, as well as a cannula for graft 95
harvest. 96
71 11.2 Imaging
11.4 Positioning 97
72 Preoperative imaging should include standard
73 weight-bearing anteroposterior, mortise, and lat- In the first phase, the ankle arthroscopy is per- 98
74 eral plain films. Stress radiographs with Telos formed in the supine position. All padding should 99
75 device should be performed if ligamentous injury be removed from the leg of the table and the non- 100
76 is suspected. operative leg should be padded independently, 101
77 Magnetic resonance imaging (MRI) should be allowing for clearance between the operative 102
78 routinely performed. It is useful to evaluate the ankle and the table. The knee and hip are both 103
79 articular cartilage, subchondral bone, and periar- flexed at around 45° and held in place with a 104
80 ticular soft tissues. Ferkel Thigh Holder (Smith & Nephew). The 105
81 Computed tomography (CT) with 3D recon- ankle is distracted with a sterile soft tissue dis- 106
82 structions is helpful for localizing and accurately tractor (Guhl Non-Invasive Ankle Distractor, 107
83 measuring the size of the lesion, especially if Smith & Nephew). 108
84 there are associated cysts. CT images represent In the second phase, when the open procedure 109
85 the true size of the lesion, absent the obscuring is done, the ankle is positioned based on the sur- 110
86 bone edema often seen on MRI (Fig. 11.1a, b). gical approach to the lesion. 111
11 New and Emerging Techniques in Cartilage Repair: Matrix-Induced Autologous Chondrocyte… 127
112 11.5 Surgical Procedure
113 The first phase of the procedure includes a diag-

114 nostic ankle arthroscopy using previously
115 described techniques to evaluate the lesion and
116 confirm that MACI treatment is appropriate.
117 Debridement of non-involved parts of the ankle
118 can then be performed, but the lesion should be
119 left alone until the second stage. At the same
120 time, the cartilage biopsy is removed from the
121 ipsilateral knee intercondylar notch. From stan-
122 dard knee arthroscopy portals, cartilage is har-
123 vested from the lateral aspect of the intercondylar Fig. 11.2 Predrilling the medial malleolus for a medial
124 notch by a sharp ring curette (a 200–300 mg malleolar osteotomy, utilizing a hook plate for reduction
after insertion of the MACI graft
125 sample is necessary). Care is taken to avoid
126 detaching the cartilage completely so that it does
127 not float free in the knee joint. A tissue grasper is
128 then used to remove the cartilage piece with a
129 gentle twisting motion and removed out a can-
130 nula to prevent its entrapment in the anterior soft
131 tissue. The tissue is then stored in packaging pro-
132 vided by and as instructed by the Vericel
133 Corporation (Vericel, Cambridge, Massachusetts).
134 The second phase of the procedure is the
135 implantation phase. This is typically performed
136 at a minimum of 6–12 weeks after the cells have
137 been cultured and placed onto the membrane. In
138 most cases, the implant is available for 5 years
139 after biopsy. Implantation can be performed by
140 open surgery or occasionally by arthroscopically.
141 The size and location of the lesion will often dic- Fig. 11.3 Fluoroscopic X-ray demonstrating inserting
142 tate which approach is optimal. Arthroscopic guide pins in the correct planes. The saw tip is then placed
143 results have so far been promising, with multiple on the guide pins to assist with the appropriate location of
the medial malleolar osteotomy
144 studies showing good short- and medium-term
145 results [6, 10, 11].
drilled for two 4.0 mm cancellous lag screws or a 154
medial malleolar hook plate (Fig. 11.2). Then, 155
146 11.5.1 Traditional Open Surgery under fluoroscopy, a guide pin is used as a cutting 156
guide for the saw to assist in making the osteot- 157
147 A tourniquet is placed to ensure the surgical field omy in exactly the correct plane (Fig. 11.3). 158
148 remains bloodless. The location of the lesion Imaging should confirm that the saw will exit lat- 159
149 determines the positioning of the patient. Medial eral to the extent of the OLT so that the entire 160
150 lesions are positioned supine and a bump is lesion can be accessed. 161
151 placed under the contralateral hip. A medial mal- If the lesion is lateral, it can be accessed by 162
152 leolar osteotomy is performed to gain access to predrilling the fibula for two interfragmentary 163
153 the lesion. First, the medial malleolus is pre- lag screws and then making an oblique fibular 164
Fig. 11.4 After excising the osteochondral lesion, the

Fig. 11.5 The MACI graft is self-adherent but some-
defect is measured with a ruler to get the exact dimensions
times a few stitches are used to further secure it to the
for preparation of the MACI graft
osteochondral lesion bed. Pictured is the graft in the
medial talar dome of a left ankle prior to fibrin glue
165 osteotomy. Releasing the anterior talofibular lig- insertion
166 ament and the anterior capsule allows for the
167 fibula to be rotated posteriorly. A cuff of tissue is secured with compression across the medial mal- 197
168 left on the fibula for latter Brostrom-type repair leolar osteotomy (Fig. 11.6a, b). Lateral osteoto- 198
169 of the lateral ligaments. mies can be fixed with a neutralization one-third 199
170 After adequate exposure is obtained, the OLT tubular plate after placing the interfragmentary 200
171 can then be debrided to stable vertical margins. A lag screws. The incisions are then closed with 3-0 201
172 15 blade can be used to obtain sharp vertical bor- Vicryl sutures, followed by 4-0 nylon vertical 202
173 ders. The subchondral bone must be left intact in mattress sutures. The leg is then placed in a well- 203
174 order to prevent osseous bleeding. After deflating padded short-leg cast that is subsequently split 204
175 the tourniquet, the lesion is dried with thrombin- with the cast saw in the recovery room. 205
176 soaked pledgets. The lesion is then measured to
177 determine the exact size of the defect (Fig. 11.4).
178 A sterile suture foil package is then pressed into 11.6 Arthroscopic Technique 206
179 the defect to form a template. The MACI mem-
180 brane is then cut to match this template. After Due to the less technically demanding nature of 207
181 further drying with thrombin, the membrane is the MACI procedure, it is reasonable to perform 208
182 then placed onto the lesion and pressed gently entirely arthroscopically, thereby avoiding the 209
183 into place, ensuring that the cell side is facing morbidity of an osteotomy. The all arthroscopic 210
184 down into the lesion (Fig. 11.5). Fibrin glue is second stage procedure is performed with the 211
185 then applied to the membrane, sealing it in place. same setup and through the same portals as the 212
186 After the fibrin has been set (5–7 min), range of first stage. After debridement of any loose carti- 213
187 motion testing should then be performed to lage fragments and synovitis, debridement of 214
188 ensure that the MACI graft is stable. 6-0 Vicryl the lesion should occur at this time, using 215
189 sutures can be applied for additional security, but arthroscopic different-angled curettes to obtain 216
190 are rarely needed because the membrane is stable vertical borders. The lesion is then accu- 217
191 self-adherent. rately measured and the MACI graft cut to size. 218
192 The osteotomy is then reduced and repaired. Next, the arthroscopic fluid flow is stopped and 219
193 An additional transverse screw at the proximal all fluid is drained from the ankle joint. 220
194 portion of the medial malleolar osteotomy is used Thrombin-soaked pledgets are inserted from the 221
195 for additional fixation due to the oblique nature portal closest to the lesion and used to dry the 222
196 of the osteotomy. If a hook plate is utilized, it is lesion. 223
a b
Fig. 11.6 Reduction of the medial malleolar osteotomy. medial malleolar osteotomy. (b) Lateral radiograph dem-
(a) AP X-ray demonstrating the appropriate location of onstrates the plate located in the medial of the distal tibia
the hook plate and screws to reduce and compress the and medial malleolus
224 Arthroscopic forceps or a specialized cannula p hysical therapist is necessary and on the gen- 251
225 delivery system can be used to deliver the matrix eral concepts to follow [14]. 252
226 into the ankle joint [12]. A probe and a freer ele- The rehabilitation process can be divided into 253
227 vator can then be used to place the matrix onto four phases [15]: 254
228 the lesion and precisely fit it into the lesion.
229 Fibrin glue should then be placed over the matrix 1. Phase 1
is the “healing phase,” surgery to 255
230 with a commercially available applicator. Once week 6. 256
231 the fibrin is set (5–7 min), the ankle is then taken 2. Phase 2
is the “transitional phase,” weeks 257
232 through extension and flexion to ensure that 6–12. 258
233 matrix is stable. All instruments should then be 3. Phase 3
is the “remodeling phase,” weeks 259
234 removed and the portals closed with 4-0 nylon 12–32. 260
235 vertical mattress sutures. 4. Phase 4
is the “maturation phase,” weeks 261
32–52. 262
236 11.7 Postoperative Protocol The following protocol is for first-generation 263
ACI, but for newer techniques, quicker advance- 264
237 The importance of a comprehensive protocol for ment can be considered because they don’t rely 265
238 postoperative care and rehabilitation cannot be on periosteal patch graft containment. 266
239 overstated. The physician, patient, and physical Phase 1: Surgery to Week 6 267
240 therapist must work as a team and be in close Cast and sutures are removed at 2 weeks post- 268
241 contact during the process. The goals are to pro- surgery. A compression stocking is applied, and 269
242 mote effective healing of the surgical site and the patient is placed in a controlled ankle motion 270
243 cartilage graft and to then return the patient to a (CAM) walking boot. They are allowed to start 271
244 high level of function. There is a paucity of good partial weight bearing up to 30 lb. Range of 272
245 evidence in the literature, so much of the infor- motion exercises are initiated at week 2 and focus 273
246 mation is based off of animal models as well as on the sagittal plane. At 4 weeks stationary bike 274
247 accepted information of cartilage physiology with no resistance is begun. Weight bearing is 275
248 [13]. It is also reasonable to extrapolate infor- increased toward full weight bearing in a CAM 276
249 mation from ACI/MACI in the knee. Most boot at week 6, and osteotomy healing must be 277
250 authors agree that supervision by a skilled checked. They are transitioned to a lace-up 278
279 figure-
of-eight brace and supportive athletic 11.8 Results 327
280 shoes when the osteotomy is healed. Formal
281 physical therapy is then initiated. Phase 1 is Previously, we have reported on our results of ACI 328
282 designed to recover full range of motion while of the talus [11, 18]. Outside the United States, 329
283 protecting the healing graft. Motion and light Schneider and Karaikudi did MACI on 20 patients, 330
284 compressive forces are needed for healthy chon- with a mean follow-up of 21 months. The mean 331
285 drocytes [16]. size of the lesions was 233 mm2. The AOFAS 332
286 Phase 2: Weeks 6–12 scores improved from 60 to 87, but there were two 333
287 The musculature around the ankle is strength- failures and six patients with no improvement in 334
288 ened under close direction of the physical thera- pain [6]. Magnan et al. treated 30 patients with 335
289 pist. Resistance can be added to the stationary MACI, with a mean OLT size of 236 m2. The 336
290 bicycle, and proprioceptive exercises are begun. AOFAS score improved from 37 to 84, with a fol- 337
291 Isometric followed by eccentric strengthening low-up of 45 months. However, only 50% of the 338
292 exercises are included in this phase. The basis patients returned to their previous sporting activity 339
293 for this increase in resistance is that the [19]. More recently, Kreulen et al. reported on 340
294 implanted chondrocytes are maturing and can 7-year follow-up of nine patients who had failed 341
295 undergo increased compressive loading. An previous arthroscopic treatment for an osteochon- 342
296 increase in strength and proprioception are dral lesion of the talus. The average OLT size was 343
297 needed in order to progress to more demanding 129 mm2. The AOFAS score went from 62 to 78, 344
298 activities. and the SF-36 score showed significant improve- 345
299 Phase 3: Weeks 12–32 ments in physical functioning, lack of bodily pain, 346
300 Patients can now increase their activity level and social functioning, compared with preopera- 347
301 and strengthening. Both walking speed and dura- tive data [20]. Brittberg et al. studied MACI versus 348
302 tion can be increased, as long as their pain and microfracture of the knee in a prospective random- 349
303 swelling allows. No jogging or running is ized trial and published results in 2014 and 2018 in 350
304 allowed. Strengthening exercises in weight- the same group. At an average follow-up of 351
305 bearing positions are started. This phase serves to 5 years, the symptomatic knee cartilage defects 352
306 increase strength and endurance while maintain- 3 cm2 or greater treated with MACI were signifi- 353
307 ing range of motion, which are needed for sports- cantly improved over microfracture [21, 22]. 354
308 specific training. The graft is still maturing in this
309 phase, and 30 min of weight-bearing exercise
310 without pain and swelling is necessary in order to 11.9 Complications 355
311 graduate to phase 4.
312 Phase 4: Weeks 32–52 Infection, bleeding, wound breakdown, neurovas- 356
313 Cross-training and return-to-sport activities cular injury, and continued symptoms are possible 357
314 are begun. By 8 months, the graft should toler- in any foot and ankle surgery. Graft and patch 358
315 ate high-impact activities. The therapist can hypertrophy are specific complications of ACI, but 359
316 supervise an increase in intensity and duration, are decreased in second- and third-generation ACI 360
317 with symptoms such as pain and swelling guid- techniques such as MACI [23]. If an osteotomy is 361
318 ing progression. Due to extended periods of performed, nonunion and hardware-related pain 362
319 immobilization and slow progression in the are possible complications. 363
320 prior phases, the patient may be generally Pearls: 364
321 deconditioned, and generous rest periods
322 between sessions should be standard. 1. If performing an osteotomy, ensure that direct 365
323 Unrestricted activity can begin 12 months after perpendicular access to the entirety of the 366
324 surgery, bearing in mind that the graft continues lesion is maintained. The osteotomy site 367
325 to mature and remodel for up to 2 years from the should exit the plafond lateral to a medial 368
326 time of surgery [17]. OLT and medial to a lateral OLT. 369
370 2. A thorough debridement of all diseased tissue 12. Giannini S, Buda R, Ruffilli A, et al. Arthroscopic 415
autologous chondrocyte implantation in the ankle 416
371 from the lesion is necessary, and stable verti- joint. Knee Surg Sports Traumatol Arthrosc. 417
372 cal walls should be obtained. 2014;22:1311–9. 418
373 3. Concomitant ankle malalignment or instabil- 13. Hambly K, Bobic V, Wondrasch B, Van Assche D, 419
374 ity must be corrected. Marlovits S. Autologous chondrocyte implantation 420
postoperative care and rehabilitation: science and 421
375 4. Be prepared to perform an open procedure practice. Am J Sports Med. 2006;34(6):1020–38. 422
376 with or without an osteotomy in the event that 14. Larsen NJ, Sullivan M, Ferkel RD. Autologous
423
377 the lesion proves to not be amenable to chondrocyte implantation for treatment of osteo- 424
378 arthroscopic MACI graft placement. chondral lesions of the talus. Oper Tech Orthop. 425
2014;24(3):195–209. 426
15. Antkowiak T, Ferkel R, Sullivan M, Kreulen C, Giza 427
E, Whitlow S. Rehabilitation after cartilage recon- 428
struction. In: van Dijk CN, Kennedy JG, editors. Talar 429
379 References osteochondral defects. Berlin, Germany: Springer; 430
2014. p. 135–44. 431
380 1. Smith A. Survival of frozen chondrocytes iso- 16.
Brittberg M, Peterson L, Sjogren-Jansson E, 432
381 lated from cartilage of adult mammals. Nature. Tallheden T, Lindahl A. Articular cartilage engineer- 433
382 1965;205:782–4. ing with autologous chondrocyte transplantation. A 434
383 2. Grande DA, Pitman MI, Peterson L, Menche D, Klein review of recent developments. J Bone Joint Surg Am. 435
384 M. The repair of experimentally produced defects in 2003;85-A(Suppl 3):109–15. 436
385 rabbit articular cartilage by autologous chondrocyte 17. Giannini S, Buda R, Vannini F, Di Caprio F, Grigolo 437
386 transplantation. J Orthop Res. 1989;7(2):208–18. B. Arthroscopic autologous chondrocyte implantation 438
387 3. Peterson L, Vasiliadis HS, Brittberg M, Lindahl in osteochondral lesions of the talus: surgical technique 439
388 A. Autologous chondrocyte implantation: a long-term and results. Am J Sports Med. 2008;36(5):873–80. 440
389 follow-up. Am J Sports Med. 2010;38(6):1117–24. 18. Kwak SK, Kern BS, Ferkel RD, et al. Autologous 441
390 4. Candrian C, Miot S, Wolf F, et al. Are ankle chon- chondrocyte implantation of the ankle: 2 to 10-year 442
391 drocytes from damaged fragments a suitable cell results. Am J Sports Med. 2014;42:2156–64. 443
392 source for cartilage repair? Osteoarthr Cartil. 19. Magnan B, Somalia E, Bondi M, et al. Three-
444
393 2010;18(8):1067–76. dimensional matrix-induced autologous chondrocyte 445
394 5. Wodicka R, Ferkel E, Ferkel R. Osteochondral lesions implantation for osteochondral lesions of the talus: 446
395 of the ankle. Foot Ankle Int. 2016;37(9):1023–34. midterm results. Adv Orthop. 2012;2012:942174. 447
396 6. Schneider TE, Karaikudi S. Matrix-induced autolo- 20. Kreulen C, Giza E, Walton J, Sullivan M. Seven year 448
397 gous chondrocyte implantation (MACI) grafting for follow-up of matrix-induced autologous transplan- 449
398 osteochondral lesions of the talus. Foot Ankle Int. tation in talus articular defects. Foot Ankle Spec. 450
399 2009;30(9):810–4. 2018;11:133–7. 451
400 7. Petersen L, Brittberg M, Lindahl A. Autologous chon- 21. Brittberg M, Recker D, Ilgenfritz J, Saris DBF. Matrix- 452
401 drocyte transplantation of the ankle. Foot Ankle Clin. applied characterized autologous cultured chondro- 453
402 2003;8:291–303. cytes versus microfracture: five-year follow-up of 454
403 8. Choi WJ, Park KK, Kim BS, Lee JW. Osteochondral a prospective randomized trial. Am J Sports Med. 455
404 lesion of the talus: is there a critical defect size for 2018;46:1343–51. 456
405 poor outcome? Am J Sports Med. 2009;37(10): 22. Saris D, Price A, Widuchowski W, et al. Matrix-
457
406 1974–80. applied characterized autologous cultured chondro- 458
407 9. Ferkel RD. Foot and ankle arthroscopy. 2nd ed. cytes versus microfracture: two-year follow-up of 459
408 Philadelphia: Wolters Kluwer; 2017. a prospective randomized trial. Am J Sports Med. 460
409 10. Giza E, Sullivan M, Ocel D, et al. Matrix-induced 2014;42:1384–94. 461
410 autologous chondrocyte implantation of talus articu- 23. Gomoll AH, Probst C, Farr J, Cole BJ, Minas T. Use 462
411 lar defects. Foot Ankle Int. 2010;31(9):747–53. of a type I/III bilayer collagen membrane decreases 463
412 11. Nam EK, Ferkel RD, Applegate GR. Autologous
reoperation rates for symptomatic hypertrophy after 464
413 chondrocyte implantation of the ankle: a 2 to 5 year autologous chondrocyte implantation. Am J Sports 465
414 follow-up. Am J Sports Med. 2009;37:274–84. Med. 2009;37(Suppl 1):20S–3S. 466
1 Osteochondral Lesions of the Talus
12
2 P. A. D. van Dijk and C. N. van Dijk
3 12.1 Introduction incidence of these lesions in patients with acute 14

lateral ankle ligament ruptures varies around 15
4 Intra-articular ankle pathologies are a relatively 5–7% [2–4]. Typically, talar OCL lead to swell- 16
5 common source of ankle disability, most often ing, pain, functional impairment, and disability. 17
6 associated with osteochondral lesions (OCL) of While most traumatic cartilage lesions have a 18
7 the talus [1]. Historically, numerous terms have good prognosis and patients will become asymp- 19
8 been used to describe what is known being tomatic eventually, traumatic osteochondral 20
9 referred to as OCL, including osteochondritis lesions have a poor healing tendency. 21
10 dissecans, transchondral talus fracture, and osteo- Despite constant improvement in the treat- 22
11 chondral talus fracture. ment of symptomatic OCL, proper selection of 23
12 OCL consist of both pathology to the sub- the most suitable treatment remains a challenge. 24
13 chondral bone and its overlying cartilage. The In order to optimize management, adequate 25
knowledge of the clinical presentation and appro- 26
priate diagnostics of OCL is essential. This chap- 27
P. A. D. van Dijk (*) ter gives an overview of the pathophysiology and 28
Department of General Surgery, OLVG - west,
classification, patient history, clinical examina- 29
Amsterdam, The Netherlands
tion, and diagnostics of OCL of the talus. 30
Academic Center for Evidence Based Sports
Moreover, it provides a step-by-step description 31
Medicine (ACES), Amsterdam, The Netherlands
of anterior ankle arthroscopy technique in treat- 32
Amsterdam Collaboration for Health and Safety in
ing these lesions. 33
Sports (ACHSS), Amsterdam, The Netherlands
C. N. van Dijk
Department of Orthopedic Surgery,
Amsterdam University Medical Centers, 12.2 Classification of Talar 34
Amsterdam, The Netherlands Osteochondral Defects 35

Medicine (ACES), Amsterdam, The Netherlands Several classifications for OCL have been 36
Amsterdam Collaboration for Health and Safety in described in literature, with the first classification 37
Sports (ACHSS), Amsterdam, The Netherlands being from Berndt and Harty [5]. Years later, 38
FIFA Medical Center of Excellence, Madrid, Spain Ferkel and Sgaglione proposed a classification 39
bases on CT findings [6]. Anderson described an 40
FIFA Medical Center of Excellence, Porto, Portugal
e-mail: c.niekvandijk@anklecare.org; MRI-based classification and Cheng and Ferkel 41
c.n.vandijk@amc.uva.nl proposed an arthroscopy-based classification [7, 42
© ISAKOS 2019 133

https://doi.org/10.1007/978-3-662-58704-1_12
43 8]. In a more recent consensus statement, the resorptive stimulus. In situations with net bone 85
44 ISAKOS consensus group concluded that there is loss, there is ongoing bone formation adjacent 86
45 only limited need for these classification systems, to bone resorption [20]. This bone resorption 87
46 and proposed a therapy-based classification: due to hydrostatic pressure leads to subchondral 88
cysts surrounded by a newly formed calcified 89
47 1. Asymptomatic lesions or low symptomatic
zone [21]. 90
48 lesions: conservative treatment. Numeral theories have been proposed as a 91
49 2. Symptomatic lesions up to 15 mm: debride- cause of OCL pain, including synovial pain, ele- 92
50 ment and drilling/microfracturing/bone mar- vated joint pressure, elevated interosseous 93
51 row stimulation. (venous) pressure, and bone pain: 94
52 3. Symptomatic lesions larger then 15 mm:

53 fixation. • Synovial pain would imply tenderness on 95
54 4. Cystic lesions in tibial roof or large talar
palpation of the inflamed and thickened 96
55 cystic lesions: retrograde drilling and bone synovium. During physical examination, 97
56 transplantation. the synovium is relatively easily accessible 98
57 5. Failed primary treatment: osteochondral
on both the anteromedial and anterolateral 99
58 transplant, hemicap or calcaneal osteotomy. joint line. Patients with a symptomatical 100
OCL, however, usually present with absence 101
59 In patients with category 4 or 5 OCL, debride- of recognizable tenderness on palpation of 102
60 ment and bone marrow stimulation can also be the synovium, implicating that the synovium 103
61 considered [9–11]. is not the main cause of pain in these 104
patients [22]. 105
• In order for articular pressure to cause pain, 106
62 12.3 Pathophysiology of Pain the joint must be filled with synovial fluid. In 107
63 Related to Talar patients with a talar OCL, there can be some 108
64 Osteochondral Lesions ankle effusion but this is not sufficient to give 109
a relevant rise in intra-articular pressure. 110
65 Both traumatic and nontraumatic talar OCL exist. These patients normally demonstrate remark- 111
66 Lateral lesions are associated with trauma in 98% ably low levels of effusion. Therefore, ele- 112
67 of cases; in medial lesions this is only 70% [12]. vated joint pressure is not a plausible cause of 113
68 The nontraumatic etiology concerns idiopathic pain. 114
69 OCL, associated with ischemia, necrosis, and • Several authors studied the relationship 115
70 genetical predisposition. In this matter, OCL of between painful osteoarthritis and intraosse- 116
71 the talus have been described in identical twins ous venous pressure. Their research suggested 117
72 and siblings [13–15]. In 10–25% of patients, the that blockage of flow in the periarticular veins 118
73 lesion is found bilateral with most OCL being can lead to high interosseous venous pressure, 119
74 asymptomatic [16, 17]. After a traumatic event, with osteotomy or cortical fenestration result- 120
75 however, they can become symptomatic. ing in a remarkable reduction in interosseous 121
76 Traumatic lesions may develop after repeti- pressure [23, 24]. 122
77 tive loading of the damaged articular cartilage • It has been determined that nerve fibers are 123
78 surface, leading to local cellular degeneration or widely distributed in bone tissue. The nerves 124
79 death by the disruption of collagen fibril ultra- in the bone marrow, for example, show appar- 125
80 structure and thickening of the subchondral ent regional distribution with different densi- 126
81 bone [18]. In animal experiments, van der Vis ties. They are often associated with blood 127
82 et al. have shown that oscillating fluid pressure vessels and show a beaded appearance [25, 128
83 can lead to osteolysis [19]. Fluid pressure- 26]. Local fluid pressure is a powerful stimulus 129
84 induced bone resorption is a powerful bone- for the nerve endings in the bone marrow. 130
12 Osteochondral Lesions of the Talus 135
131 Interstitial water is expressed from the carti- clear history of ankle trauma, weakness and 174
132 lage matrix as it is compressed, leading to instability of the ankle, and swelling and stiffness 175
133 stimulation of the nerves. of the ankle joint [31–34]. 176
134 • Cartilage consists of cells (chondrocytes), col-
135 lagen (arcade structure), and water. The water
136 content of human articular cartilage is deter- 12.5 Additional Diagnostics 177
137 mined to be 79% [27]. Under dynamic load
138 (0.1 s), the deformation of talar cartilage has In general, routine radiographs of the ankle con- 178
139 been determined to reduce 20% of its thick- sist of an AP and lateral radiographs. The X-ray 179
140 ness, releasing water into the joint space. may show an area of detached bone, surrounded 180
141 Under static load (30 min), up to 55% of the by radiolucency. In most cases, however, the 181
142 thickness of the cartilage will be reduced [27]. damage is too small to be visualized on initial 182
143 In case the subchondral bone plate is dam- radiographs [31, 32, 35]. By repeating radio- 183
144 aged, (released) water can penetrate into the graphics in a later stage, the abnormality some- 184
145 richly innervated subcortical spongiosa [28]. times becomes apparent. With conventional 185
146 In this way, loading of the damaged talar car- radiographs having only moderate sensitivity, 186
147 tilage by the distal tibia will result in local additional imaging is recommended in diagnos- 187
148 fluid pressure towards the subchondral bone ing talar OCL [30]. 188
149 plate. If the subchondral bone plate is dam- A heel-rise view with the ankle in a plan- 189
150 aged, fluid can enter the underlying bone, tarflexed position may reveal a posteromedial or 190
151 leading to bone resorption and eventually cyst posterolateral defect. For further diagnostic eval- 191
152 formation [29]. uation, a CT scan and MRI have demonstrated a 192
similar level of accuracy (p = 0.33) [36]. For pre- 193
153 Extensive review of the literature revealed that operative planning, however, a CT scan has the 194
154 pain associated with talar OCL does not arise advantages of detection and characterization of 195
155 from the cartilage lesion itself. It is most proba- the bony lesion. Based on the findings of a study 196
156 bly caused by repetitive high fluid pressure dur- by van Bergen et al, a recent international con- 197
157 ing dynamic loading such as walking, resulting in sensus statement suggested that the preferred CT 198
158 stimulus of the highly innervated subchondral settings are helical or spiral CT with ultrahigh- 199
159 bone underneath the cartilage lesion [22, 28]. resolution axial slices with an increment of 200
0.3 mm and a thickness of 0.6 mm, and a coronal 201
and sagittal reformation of both 1 mm [30, 35]. 202
160 12.4 P
atient History and Clinical The consensus panel advised CT scan for preop- 203
161 Examination erative planning [30]. 204
162 In the acute situation, diagnosis of talar OCL is

163 often delayed because of a relatively low index of 12.6 Treatment 205
164 suspicion. In chronic cases, careful patient his-
165 tory and clinical examination is the key to proper There are various published surgical techniques 206
166 diagnosis of an OCL of the talus. On examina- for the treatment of symptomatic OCL. These are 207
167 tion, these patients can show surprisingly little based on one of the following three principles: 208
168 abnormality. In most cases, there is a normal
169 range of motion with the absence of recognizable 1. Debridement and bone marrow stimulation
209
170 pain on palpation or swelling during physical (microfracturing, abrasion arthroplasty, 210
171 examination. Deep ankle pain during or after drilling) 211
172 activity is the most important sign indicating an 2. Securing a lesion to the talar dome (retrograde 212
173 OCL of the talus [30]. Other findings include a drilling, fragment fixation) 213
214 3. Preservation of hyaline cartilage (osteochon- treated by means of anterior arthroscopy by 261
215 dral autografts, allografts, autologous chon- bringing the foot in hyperplantarflexion. It should 262
216 drocyte implantation) be noted, however, that skills and experience are 263
required [45]. Posterior lesions in the most poste- 264
217 The effectiveness of the different principles rior quarter of the talar dome, which cannot be 265
218 varies greatly in literature and no superior treat- reached by hyperplantarflexion, can be treated by 266
219 ment strategy is yet defined. Several systematic means of a two-portal endoscopic hindfoot 267
220 reviews of the literature have been published approach. 268
221 [37–41], with the two most recent systematic
222 reviews concluding that there is no superior treat-
223 ment in treating both primary and secondary 12.7 A
nterior Ankle Arthroscopy: 269
224 OCL of the talus [42, 43]. Worldwide, bone mar- A Step-by-Step Description 270
225 row stimulation is most often used in the treat- of the Procedure 271
226 ment of primary lesions, because it is highly
227 effective, it is relatively inexpensive compared to From anterior to posterior, the talar dome can be 272
228 other (implantation) techniques, it has low mor- divided into four equal parts. When the OCL is 273
229 bidity, it provides a quick recovery, and it pro- located in one of the three anterior parts of the 274
230 vides early return to sports [43]. talar dome, it can be treated by a routine anterior 275
231 The choice of the management strategy when ankle arthroscopy. In cases the lesion is located in 276
232 treating a talar OCL depends mostly on the dura- the most posterior quarter of the talar dome, the 277
233 tion of complaints, size of the lesion, and whether defect should be approached by a posterior ankle 278
234 we deal with a primary or secondary OCL. In arthroscopy or by means of a medial malleolar 279
235 general, asymptomatic or low symptomatic osteotomy [46]. For anterior ankle arthroscopy 280
236 lesions are treated conservatively with rest, ice, technique, two portals are created: 281
237 temporarily reduced weight bearing, and, in case
238 of giving way, an orthosis.
239 For mechanically unstable lesions, fixation is 12.7.1 Anteromedial Portal 282
240 preferred in (semi) acute situations in which the
241 fragment is 15 mm or larger. In adolescents, The anteromedial portal is made first since it is 283
242 refixation of a lesion must always be considered easy to access, especially when the ankle is in a 284
243 even in fragments that are smaller than 15 mm. dorsiflexed position. In this position, the point 285
244 Large talar cystic lesions can be treated by retro- of entry is easily reproducible and the risk of 286
245 grade drilling and filling the defect with a bone neurovascular damage is minimal. The portal is 287
246 graft. In case of failed primary treatment, an placed just medial to the anterior tibial tendon 288
247 osteochondral transplant can be considered. The at the level of the joint line. At this level, a 289
248 technique of osteochondral transplant should be depression (soft spot) can be palpated with the 290
249 reserved for secondary cases with a malleolar ankle in hyperdorsiflexion. In the horizontal 291
250 osteotomy often being needed in order to ade- plane, the depression is located between the 292
251 quately gain access to the lesion. anterior tibial rim and the talus. In the vertical 293
252 The type of surgical treatment influences the position, the anterior tibial tendon is the land- 294
253 perioperative exposure. Most primary lesions can mark. The anterior tibial tendon should be pal- 295
254 be treated by ankle arthroscopy. For posterome- pated in the dorsiflexed position. Note that in 296
255 dial lesions in a stable ankle some authors recom- this dorsiflexed position, the tendon moves 1 cm 297
256 mend the use of either malleolar osteotomy, lateral. The location of the anteromedial portal 298
257 “grooving” of the anteromedial distal tibia, or can now be marked on the skin just medial from 299
258 drilling through the medial malleolus [12, 17, the anterior tibial tendon. Care must be taken 300
259 44]. In the experience of the senior author of this not to injure the saphenous vein and nerve 301
260 chapter, however, 90–95% of all OCL can be transversing the ankle joint along the anterior 302
303 edge of the medial malleolus. By moving the anterolateral portal can be placed slightly above 348
304 ankle joint from the plantarflexed position to the the level of the ankle joint and as close to the 349
305 dorsiflexed position, the talus can be felt to peroneal tertius tendon as possible. For the treat- 350
306 move in relation to the distal tibia. The palpat- ment of lateral pathology, the anterolateral portal 351
307 ing finger gets locked into the soft spot in the is placed at the level of the joint line and more 352
308 hyperdorsiflexed position. A small longitudinal laterally. After a small skin incision has been 353
309 incision is made through the skin only, just made, the subcutaneous layer and capsule are 354
310 medial from the anterior tibial tendon. Blunt divided bluntly with a mosquito clamp. Most 355
311 dissection is performed with a mosquito clamp important is to apply a nick and spread 356
312 through the subcutaneous layer and through the technique. 357
313 capsule into the ankle joint. With the ankle in
314 forced dorsiflexed position, cartilage damage is
315 avoided. In this forced dorsiflexed position, the 12.7.3 Surgical Procedure 358
316 arthroscope shaft with the blunt trocar is intro-
317 duced. When the trocar is felt to contact the Routinely, the procedure is performed without 359
318 underlying bony joint line, the shaft with the distraction. The standard anteromedial and 360
319 blunt trocar is gently pushed further into the anterolateral portals are created as described 361
320 anterior working area in front of the ankle joint above. In case of a medial OCL, the 4 mm arthro- 362
321 towards the lateral side. The anterior compart- scope is moved over to the anterolateral portal 363
322 ment is irrigated and inspected. and the instruments are introduced through the 364
anteromedial portal. For an anterolateral lesion, 365
the arthroscope remains in the anteromedial por- 366
323 12.7.2 Anterolateral Portal tal and the instruments are introduced through 367
the anterolateral portal. In case of osteophytes, 368
324 Next, the anterolateral portal is made. It is placed these are removed first. Synovitis is removed 369
325 just lateral to the tendon of the peroneus tertius or with the ankle in plantar flexion, after which the 370
326 slightly proximal to the joint line and is made OCL can be identified. 371
327 under direct vision by introducing a spinal nee- Not only can the lesion be palpated with a 372
328 dle. In the horizontal plane, it is situated at the probe, but it should also be possible to visualize 373
329 level of the joint line or slightly proximal to it. In at least the most anterior part of the lesion. It can 374
330 the vertical plane, it is located lateral to the com- be helpful to distract the joint by means of a soft- 375
331 mon extensor tendons and the peroneus tertius tissue distractor [47]. 376
332 tendon. Care must be taken to avoid damage to After removal of the fragment, a 3.5 or 4.5 mm 377
333 the subcutaneous superficial peroneal nerve, synovator is now introduced into the lesion. After 378
334 which can often be palpated or visualized by it has been debrided, the arthroscope is moved 379
335 placing the foot in forced hyperplantarflexion over to the portal opposite the defect to check the 380
336 and supination. The intermediate dorsal cutane- completeness of the debridement. It is important 381
337 ous branch of the superficial peroneal nerve to remove all dead bone and overlying, unsup- 382
338 crosses the anterior aspect of the ankle joint ported, unstable cartilage. Every step in the 383
339 superficial to the common extensor tendons. debridement procedure should be checked by 384
340 Damage to this branch can be avoided by staying regularly switching portals in order to perform a 385
341 just lateral to the extensor tendons. Once the lat- precise and complete debridement, with removal 386
342 eral branch is identified, its position can be of all loose fragments. Introduction of the instru- 387
343 marked with a marking pen on the skin. ments and the arthroscope is performed with the 388
344 It should be noted that the location of the ankle in the fully dorsiflexed position, thus pre- 389
345 anterolateral portal might vary depending on the venting iatrogenic cartilage damage. After full 390
346 location of the lesion in the ankle joint. For the debridement, the sclerotic zone is perforated with 391
347 treatment of anteromedial ankle pathology, the a microfracturing technique. 392
393 12.8 Rehabilitation 4. Bosien WR, Staples OS, Russell SW. Residual dis- 434
ability following acute ankle sprains. J Bone Joint 435
Surg Am. 1955;37-A(6):1237–43. 436
394 After arthroscopic debridement and drilling, 5. Berndt AL, Harty M. Transchondral fractures (osteo- 437
395 patients are encouraged to make active plan- chondritis dissecans) of the talus. J Bone Joint Surg 438
396 tarflexed and dorsiflexed ankle movements. Am. 1959;41-A:988–1020. 439
6. Sgaglione NA, et al. Arthroscopic-assisted anterior 440
397 Partial weight bearing is allowed of up to 6 weeks, cruciate ligament reconstruction with the semitendi- 441
398 and full weight bearing after 6 weeks. Running nosus tendon: comparison of results with and without 442
399 on even ground is permitted after 12 weeks. Full braided polypropylene augmentation. Arthroscopy. 443
400 return to sporting activities is advised at 5 months 1992;8(1):65–77. 444
7. Cheng JC, Ferkel RD. The role of arthroscopy in 445
401 after surgery. ankle and subtalar degenerative joint disease. Clin 446
Orthop Relat Res. 1998;349:65–72. 447
8. Anderson IF, et al. Osteochondral fractures of 448
402 12.9 Pearls and Pitfalls the dome of the talus. J Bone Joint Surg Am. 449
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9. Reilingh ML, et al. Measuring hindfoot alignment 451
403 • Pain associated with talar OCL is caused by radiographically: the long axial view is more reli- 452
404 repetitive high fluid pressure during dynamic able than the hindfoot alignment view. Skelet Radiol. 453
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417 whether it is a primary or secondary lesion. 14. Woods K, Harris I. Osteochondritis dissecans of
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1
2
Lift, Drill, Fill, and Fix (LDFF):
A New Arthroscopic Treatment
13
3 for Talar Osteochondral Defects
4 Jari Dahmen, J. Nienke Altink, Mikel L. Reilingh,

5 and Gino M. M. J. Kerkhoffs
6 13.1 Introduction (BMS) procedure can be carried out. However, 22

this surgical intervention may solely be reserved 23
7 An osteochondral defect (OCD) of the talus is an for defects that are less than 107.4 mm2 in area 24
8 injury to the articular cartilage of the talus and its [10]. Moreover, a number of studies showed that 25
9 underlying subchondral bone. Although a number the clinical efficacy of BMS deteriorates over 26
10 of studies described vascular and genetic etiolo- time, most probably due to the fact that osteoar- 27
11 gies of the particular injury, the lesions are most thritis of the ankle joint is being observed at long- 28
12 frequently caused by traumatic events, such as term follow-up [11, 12]. The osteoarthritis can be 29
13 ankle fractures and sprains [1–4]. The injury can caused by a depressed subchondral bone plate, 30
14 rigorously affect daily activities of patients lead- which is frequently present at midterm [13–15]. 31
15 ing to a deterioration of the quality of life [5]. The Furthermore, the procedure does not aim at mir- 32
16 treatment protocol is usually initiated by a conser- roring the natural congruency of the ankle joint, 33
17 vative protocol by means of shared decision-mak- being an alternative or combined explanation of 34
18 ing (SDM) [6–9]. However, in case of persistence the declining clinical efficacy [16–18]. For larger 35
19 of symptoms, one can opt for one of the many and secondary defects, more aggressive surgical 36
20 existing surgical procedures. For the primary and treatment options are probably necessary in order 37
21 smaller defects, a bone marrow stimulation to relieve the patient’s symptoms. Even though a 38
recent systematic review by Lambers et al. [19] 39
J. Dahmen · J. N. Altink · M. L. Reilingh stated that the authors could not identify a best 40
Gino M. M. J. Kerkhoffs (*) surgical strategy for these type of lesions, 41
Amsterdam UMC, University of Amsterdam, osteo(chondral) transplantation procedures and 42
chondrocyte implantation procedures seem to be 43
Amsterdam Movement Sciences, Meibergdreef 9,
Amsterdam, The Netherlands effective strategies for secondary defects. 44
As an alternative to performing bone marrow 45
Academic Center for Evidence based Sports
medicine (ACES), Amsterdam, The Netherlands procedures, cartilage implantations, and 46
osteo(chondral) transplantations, one could exe- 47
Amsterdam Collaboration for Health and Safety in
Sports (ACHSS), International Olympic Committee cute a fixation procedure for large primary defects 48
(IOC) Research Center Amsterdam UMC, as well. A fixation procedure would theoretically 49
Amsterdam, The Netherlands preserve the cartilage of the affected region of the 50
e-mail: j.dahmen@amsterdamumc.nl;
talar dome, prevent the degradation of the sub- 51
j.n.altink@amsterdamumc.nl;
m.l.reilingh@amsterdamumc.nl; chondral bone, and restore the natural congru- 52
g.m.kerkhoffs@amsterdamumc.nl ency of the joint and it would be possible to treat 53
© ISAKOS 2019 141

https://doi.org/10.1007/978-3-662-58704-1_13
142 J. Dahmen et al.
54 large defects with this surgical intervention. In dome could be a consequence of traumatic 99
55 this chapter we present a novel promising events, but also medial lesions of the talar dome 100
56 arthroscopic internal fixation technique, known were prone to be secondary to traumatic events, 101
57 as the Lift, Drill, Fill, and Fix (LDFF) technique. thereby posing that generally speaking the etiol- 102
58 Furthermore, we describe the historical perspec- ogy of the majority of the talar osteochondral 103
59 tive of talar osteochondral defects. defects is posttraumatic. Currently, different 104
descriptions for talar osteochondral defects are 105
being utilized: osteochondral defects, osteochon- 106
60 13.2 Historical Perspective dral lesions, osteochondritis dissecans, tran- 107
schondral talar fractures, osteochondral talar 108
61 The treatment of talar osteochondral defect was fractures, talar dome fractures, and flake fractures 109
62 most probably initiated in 1743, when Hunter of the talus. Since the influential publication in 110
63 [20] mentioned the following: “From Hippocrates 1959, a great number of different surgical tech- 111
64 down to the present age, ulcerated cartilage is a niques have been developed and subsequently 112
65 troublesome disease; when destroyed, it is not published in the literature ever since. 113
66 recovered.” In 1856, Monro [21] reported on the
67 presence of cartilaginous loose bodies in the
68 ankle joint, and it was the year of 1870 when 13.3 Arthroscopic LDFF: 114
69 Paget described these lesions in the knee joint Indications, 115
70 [22]. However, when it comes to the first descrip- Contraindications, 116
71 tion of something similar to “osteochondral and Preoperative Planning 117
72 defects,” it was the German surgeon Franz König
73 who was the first to utilize the term “osteochon- The indication for an arthroscopic lift, drill, fill, 118
74 dritis dissecans” when referring to loose bodies and fix procedure is a large (anterior-posterior or 119
75 originating from the articular surfaces of differ- medial-lateral diameter >10 mm on computed 120
76 ent joints [23]. The German reasoned that the tomography (CT) scan) primary, acute, or chronic 121
77 underlying etiology of these corpora libera was osteochondral defect of the talus [28]. Additionally, 122
78 of necrotic nature, thereby accompanying some the patient needs to have undergone and subse- 123
79 type of inflammation. Actually, the first descrip- quently failed a conservative protocol for a mini- 124
80 tion of the term osteochondritis dissecans in the mum of 6 months. It should be mentioned that a 125
81 ankle was executed by Kappis, who found great symptomatic displaced fragment in all patients or 126
82 similarities of osteochondral defects in the knee a non-displaced fragment in a skeletally mature 127
83 to the ones recognized in the ankle joint [24]. A patient can be fixed as soon as possible; this, so 128
84 decade thereafter, in the year of 1932 it was that one minimizes potential intra-articular dam- 129
85 Rendu [25] who published on the etiology and age and one maximizes the healing potential [28]. 130
86 the treatment of an intra-articular fracture of the Contraindications for the procedure are loose 131
87 talus. The terminology and the knowledge behind chondral lesions, ankle osteoarthritis grade II or 132
88 the etiology and therefore indirectly the treat- III, advanced osteoporosis, infectious pathology, 133
89 ment of talar osteochondral defects took a turn, and malignancy [28]. There is no contraindication 134
90 when in 1953 Rödén et al. [26] indicated that concerning a particular age of the patient as no 135
91 talar OCDs located on the lateral side of the talar violation of the growth plate takes place during 136
92 dome were secondary to trauma. This finding the arthroscopic LDFF procedure. As preopera- 137
93 suggested that the definition of osteochondritis tive planning for assessment of the talar OCD 138
94 dissecans seemed to be a misnomer as rather the location, the size, the morphology, and the degree 139
95 primary underlying mechanism of etiology was of displacement of an osteochondral fragment, a 140
96 of a traumatic nature. In 1959, the famous article preoperative CT scan in maximum plantar flexion 141
97 by Berndt and Harty [27] was published. They is advisable to assess the right accessibility of the 142
98 indicated that not solely lateral lesions of the talar talar OCD [29–31]. 143
13 Lift, Drill, Fill, and Fix (LDFF): A New Arthroscopic Treatment for Talar Osteochondral Defects 143
144 13.4 Surgical Technique: surgeon can use a noninvasive soft-tissue distrac- 162
145 Arthroscopic Lift, Drill, Fill, tion device. The surgeon then pays attention to 163
146 and Fix (LDFF) Procedure creating the commonly used anteromedial and 164
anterolateral arthroscopic portals. When these 165
147 The arthroscopic fixation procedure has a number have been created, the ankle joint can be visual- 166
148 of surgical steps that will be outlined hereafter: ized. In order to create a proper facilitation of 167
149 lift, drill, fill, and fix (LDFF) [32]. The operation access to the ankle joint, the distal tibial rim is 168
150 is carried out as an outpatient procedure either removed. Subsequently, by means of a probe the 169
151 under general or spinal anesthesia and the patient precise location of the osteochondral defect on 170
152 is positioned in a supine position with slight ele- the talar dome can be assessed. The first step of 171
153 vation of the ipsilateral buttock by placing a sup- the LDFF procedure is the lifting step. In order to 172
154 port at the contralateral side of the patient’s pelvis. prepare for the first step of the LDFF technique, a 173
155 In order for the surgeon to be able to plantar- or beaver knife is used to create a sharp osteochon- 174
156 dorsiflex the injured ankle by leaning against the dral flap (Fig. 13.1a, b). It should be mentioned 175
157 foot sole, the heel of the affected foot is posi- that the orthopedic surgeon should pay great 176
158 tioned on the end of the operating table. By means attention to leaving the posterior side of the flap 177
159 of this special position, the surgeon can use the purely intact. This flap should be left intact and 178
160 operating table as a lever in case maximum plan- may then be used as a lever which facilitates an 179
161 tar flexion is necessary. When this is required, the anterior lift by means of a chisel (lift) (Fig. 13.1c). 180
a b c d
e f g h
Fig. 13.1 Arthroscopic images of the lift, drill, fill, and dral fragment at its posterior side. (e) A 4 mm chisel is
fix (LDFF) procedure, a medial osteochondral lesion of utilized to harvest cancellous bone from the distal tibial
the left talus. (a) The surgeon palpates the diseased carti- metaphysis. (f) Thereafter, the harvested cancellous bone
lage with a probe in order to identify the precise location is transported into the osteochondral defect by an
of the talar osteochondral defect; this step can be per- arthroscopic grasper (fill). (g) In order to prepare one of
formed when the ankle is held in plantar flexion. (b) The the last steps of the procedure (fix), a cannulated system is
orthopedic surgeon creates an osteochondral flap by uti- utilized to perform predrilling and tapping of a compres-
lizing a beaver knife. (c) The flap is lifted by a chisel (lift). sion screw. (h) An absorbable screw 1–2 mm recessed
(d) The drilling step consists of drilling the bone flake of relative to the surrounding hyaline cartilage is placed. Due
the fragment with a Kirschner wire and a shaver blade; to the diameter and the compression strength, one prefers
this so that one promotes revascularization of the sub- the non-cannulated screw (figure reproduced with permis-
chondral bone. It needs to be mentioned that one has to be sion from Reilingh et al. [33])
careful not to loosen the iatrogenically created osteochon-
period of immobilization, the ankle is placed in a 212

short-leg walking cast in a neutral flexion and 213
neutral hindfoot position—having full weight 214
bearing allowed. One removes the cast at 8 weeks 215
postoperatively. A referral to a physiotherapist 216
for functional physiotherapy is performed in 217
order to help the patient concerning functional 218
recovery and range of motion (dorsiflexion and 219
plantar flexion) exercises. This, so that the patient 220
can progress to full weight bearing in a time 221
frame of about 2 weeks. The important aim of the 222
whole medical team is to supply a well-designed 223
Fig. 13.1 (continued) personalized after-treatment protocol in which it 224
is key to focus on balance, proprioception, and 225
181 The step hereafter is the second step, namely the ankle functionality. By these means, one can 226
182 drilling step. During this step, one aims at the pro- progress to a normal ambulation pattern and 227
183 motion of revascularization. The surgeon debrides achieve full strength as well as propriocepsis. 228
184 the osteosclerotic area of the bed and osteochon- Depending on the patient, running abilities, and 229
185 dral fragment (Fig. 13.1d). It is important that the personal wishes, as well as sport-specific train- 230
186 surgeon pays clear attention to debriding and ing, the team can subsequently prepare the patient 231
187 puncturing any subchondral cysts that may be for a timing of return to sports. It is advised to 232
188 present in selected cases. The subsequent penulti- personalize after treatment after the 3-month 233
189 mate step of the LDFF procedure is the step dur- period based on the clinical exam and the CT 234
190 ing which the debrided and drilled defect will be scan of the patient. In general, the patient should 235
191 filled with bone (fill). Cancellous bone is har- be advised to prevent performing any type of 236
192 vested from the distal tibial metaphysis by means activities that consist of peak mechanical forces 237
193 of a chisel, after which these harvested bony around the ankle (walking on toes, running, etc.) 238
194 flakes are transported into the defects by means of until after 6 months postoperatively. After these 239
195 a grasper (Fig. 13.1e, f). The last step of the LDFF 6 months, the team can gradually start the prepa- 240
196 procedure (fix) consists of fixating the fragment ration of return to sports, such as football, run- 241
197 that has been created during the first step of the ning, and other high-impact sports. 242
198 LDFF. A clinically important condition prior to
199 initiating the fixation procedure itself is that the
200 surgeon needs to have achieved a correctly aligned 13.6 Arthroscopic LDFF: Results 243
201 osteochondral fragment. For the fixation proce-
202 dure itself, Bio-Compression (Arthrex Inc., In 2016, the first results of the arthroscopic LDFF 244
203 Naples, USA) or metal screw(s) can be used procedure were published. This publication con- 245
204 (Fig. 13.1g, h). Additional bioabsorbable dart(s) sisted of a patient group of seven patients whose 246
205 or pin(s) can be utilized to prevent rotation. clinical and radiological results were analyzed at 247
short term (mean follow-up 12 months, SD 0.6) 248
[32]. The mean preoperative size of the defects 249
206 13.5 Arthroscopic Osteochondral was 15.7 mm (SD 3.0) in the anteroposterior 250
207 Fragment Fixation: direction, 9.6 mm (SD 3.2) in the mediolateral 251
208 Postoperative Management direction, and 6.7 mm (SD 1.4) in the craniocau- 252
dal direction. In each and every patient, the LDFF 253
209 A short-leg, non-weight-bearing cast is applied at procedure resulted in significant improvements 254
210 the operation theatre for a period of 4 weeks postin both American Orthopedic Foot and Ankle 255
211 operatively. When having completed this 4-week Society score (AOFAS) and the numeric rating 256
a b
Fig. 13.2 Preoperative and 1-year postoperative computed tomography scans of a patient treated with an arthroscopic
lift, drill, fill, and fix (LDFF) procedure. (a) Preoperative coronal CT scan. (b) 1-year postoperative coronal CT scan
257 scales (NRS) of pain at rest and during walking significantly improved. However, no significant 280
258 [34]. Additionally, all patients reported that they differences were to be found between the 281
259 were satisfied about the procedure, and that they arthroscopic LDFF procedure and the 282
260 would be willing to undergo the surgery once arthroscopic BMS procedure preoperatively as 283
261 again. Twelve months postoperatively, 71% of well as 1 year postoperatively concerning the 284
262 the patients showed remodeling and progressive functional results being measured by the AOFAS 285
263 bone ingrowth when assessed on CT scan and the NRS. As opposed to the clinical results, 286
264 (Fig. 13.2a, b). there was a significant difference (p = 0.02) with 287
265 More recently, in 2017, a prospective com- regard to healing of the subchondral bone plate 288
266 parative case series was published by Reilingh between both arthroscopic treatment groups. 289
267 et al. [35] and appeared in the KSSTA journal. From the 14 patients that had undergone the 290
268 This study evaluated the clinical and radiological arthroscopic BMS procedure, 11 patients were 291
269 results between arthroscopic LDFF and observed to have a depressed subchondral bone 292
270 arthroscopic BMS in primary fixable talar OCDs plate. Three of the fourteen actually contained a 293
271 at 1-year follow-up. Both the LDFF group and flush subchondral bone plate. On the contrary, 10 294
272 the BMS group consisted of 14 patients each. out of 14 patients in the arthroscopic LDFF group 295
273 After the arthroscopic LDFF procedure, the had a flush subchondral bone plate, and 4 had a 296
274 AOFAS (preoperative score, 66 (SD 10.1), post- depressed subchondral bone plate. Union of the 297
275 operative score 89 (SD 17.0), (p = 0.004)) and the osteochondral fragment was found in nine 298
276 NRS pain at rest (preoperative score 2.1 (SD 1.8), patients after arthroscopic LDFF. 299
277 postoperative score 0.9 (SD 1.3), (p = 0.043)) as In November 2017, 75 international experts in 300
278 well as when running (preoperative score 7.4 (SD cartilage repair of the ankle representing 25 coun- 301
279 1.9), postoperative score 2.5 (SD 3.1) (p = 0.004)) tries and 1 territory were convened and participated 302
303 in a process based on the Delphi method of achiev- 3. Hintermann B, Regazzoni P, Lampert C, Stutz G, 346
Gachter A. Arthroscopic findings in acute fractures of 347
304 ing consensus at the International Consensus the ankle. J Bone Joint Surg. 2000;82(3):345–51. 348
305 Meeting on Cartilage Repair of the Ankle in 4. Saxena A, Eakin C. Articular talar injuries in athletes: 349
306 Pittsburgh. One of the working groups concerned results of microfracture and autogenous bone graft. 350
307 the treatment of osteochondral defects of the ankle Am J Sports Med. 2007;35(10):1680–7. 351
5. D’Ambrosi R, Maccario C, Serra N, Ursino C, Usuelli 352
308 by internal fixation [28]. The statements derived FG. Relationship between symptomatic osteochon- 353
309 from the whole process indicated that a bone mar- dral lesions of the talus and quality of life, body mass 354
310 row stimulation procedure can be performed in the index, age, size and anatomic location. Foot Ankle 355
311 case of surgical treatment failure by internal fixa- Surg. 2017;24(4):365–72. 356
6. Seo SG, Kim JS, Seo DK, Kim YK, Lee SH, Lee 357
312 tion in lesions smaller than 15 mm in diameter. HS. Osteochondral lesions of the talus. Acta Orthop. 358
313 However, the authors concluded that there is no 2018:1–6. 359
314 indication to perform fixation after a prior bone 7. Elias I, Jung JW, Raikin SM, Schweitzer MW, Carrino 360
315 marrow stimulation procedure. Furthermore, it JA, Morrison WB. Osteochondral lesions of the talus: 361
change in MRI findings over time in talar lesions 362
316 was stated by the consensus group that fixation without operative intervention and implications for 363
317 techniques for osteochondral defects of the ankle staging systems. Foot Ankle Int. 2006;27(3):157–66. 364
318 are likely to facilitate healing of the cartilage and/ 8. Bauer M, Jonsson K, Linden B. Osteochondritis dis- 365
319 or subchondral bone. Therefore, satisfactory clini- secans of the ankle. A 20-year follow-up study. J Bone 366
Joint Surg. 1987;69(1):93–6. 367
320 cal results can be expected when the right type of 9. Klammer G, Maquieira GJ, Spahn S, Vigfusson V, 368
321 lesion is chosen for arthroscopic fixation. Zanetti M, Espinosa N. Natural history of nonopera- 369
tively treated osteochondral lesions of the talus. Foot 370
Ankle Int. 2014;36(1):24–31. 371
10. Ramponi L, Yasui Y, Murawski CD, Ferkel RD, 372
322 13.7 Conclusion DiGiovanni CW, Kerkhoffs GM, et al. Lesion size is a 373
predictor of clinical outcomes after bone marrow stim- 374
323 Despite these clinical and radiological results ulation for osteochondral lesions of the talus: a system- 375
324 demonstrating that the arthroscopic “Lift, Drill, atic review. Am J Sports Med. 2016;45(7):1698–705. 376
11. Ferkel RD, Zanotti RM, Komenda GA, Sgaglione 377
325 Fill, and Fix” procedure for primary large and NA, Cheng MS, Applegate GR, et al. Arthroscopic 378
326 fixable talar osteochondral defects is a highly treatment of chronic osteochondral lesions of 379
327 clinically promising surgical intervention, longer the talus: long-term results. Am J Sports Med. 380
328 follow-up times are certainly required. A greater 2008;36(9):1750–62. 381
12. van Bergen CJA, Kox LS, Maas M, Sierevelt IN, 382
329 cohort of patients needs to be included for a Kerkhoffs GMMJ, van Dijk CN. Arthroscopic treat- 383
330 larger statistical power, and it is highly important ment of osteochondral defects of the talus: outcomes 384
331 to assess the outcomes of the arthroscopic LDFF at eight to twenty years of follow-up. J Bone Joint 385
332 procedure in a prospective comparative random- Surg Am. 2013;95(6):519–25. 386
13. Reilingh ML, van Bergen CJ, Blankevoort L, Gerards 387
333 ized manner. Furthermore, it is of clinical impor- RM, van Eekeren IC, Kerkhoffs GM, et al. Computed 388
334 tance that in case of clinical failure after an tomography analysis of osteochondral defects of 389
335 arthroscopic LDFF procedure, alternative surgi- the talus after arthroscopic debridement and micro- 390
336 cal interventions (i.e., BMS and osteo(chondral) fracture. Knee Surg Sports Traumatol Arthrosc. 391
2016;24(4):1286–92. 392
337 transplantations) are still possible. 14. Seow D, Yasui Y, Hutchinson ID, Hurley ET,
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442 Am. 1959;41:988–1020.
1
2
One-Stage Treatment
for Osteochondral Lesion
14
3 of the Talus
4 Bogusław Sadlik, Alberto Gobbi, Karol Pałka,

5 and Katarzyna Herman
6 14.1 Cartilage Restoration erative joint injury. Given that the ankle joint is 26
7 Considering Ankle Joint the most dynamic human weight-bearing joint, it 27
8 Congruency is crucial that there is proper matching of adja- 28
cent articular surfaces over the full range of 29
9 In order for weight-bearing joints to remain func- motion. 30
10 tional and avoid premature failure, the articula- The ankle is characterized by higher congru- 31
11 tion should meet several criteria that are ence than the knee with thinner cartilage, and this 32
12 consistent with mechanical laws. From a mechan- is why it requires much more precision in chon- 33
13 ical point of view, two weight-bearing surfaces dral surface reconstruction. Surgical treatment of 34
14 that are moving relatively to each other should osteochondral lesions of the talar dome (OLT) 35
15 articulate over the functional range with the aims to restore layers of the defect using biologi- 36
16 smallest frictional forces possible in order to cal material that undergoes further remodeling 37
17 minimize trauma to the opposing surfaces and and integration with the surrounding tissue. The 38
18 avoid overheating. The second important crite- purpose of the reconstruction is to effectively rec- 39
19 rion is the optimization of joint contact surface reate the shape of the talar dome in every loca- 40
20 area. Although a smaller surface area of articulation, especially on the medial edge, where the 41
21 tion may allow for a reduction in frictional forces, majority of traumatic lesions are located [1]. 42
22 a larger surface area will decrease pressure and Considering the mechanical and geometric 43
23 peak loads on the weight-bearing surfaces; these components of joint function, restoration of the 44
24 are important factors to minimize the destructive articular cartilage surface after chondral injury is 45
25 mechanical forces that lead to progressive degen- not complicated if subchondral bone remains 46
intact and anatomically unaltered. In cases of 47
B. Sadlik (*) subchondral osteophytes, restoration of anatomic 48
Biological Joint Reconstruction Department, surface geometry is accomplished with a shaver 49
St. Luke’s Hospital, Bielsko-Biała, Poland or burr that can be used to mill the subchondral 50
A. Gobbi · K. Herman bony protuberance. In cases of large osteochon- 51
Orthopaedic Arthroscopic Surgery International dral defects involving deep areas of subchondral 52
(OASI), Bioresearch Foundation Gobbi NPO,
Milan, Italy bone deficiency, careful reconstitution of the 53
bone deficit is needed. Special attention must be 54
K. Pałka
Biological Joint Reconstruction Department, paid to restore the natural subchondral surface 55
St. Luke’s Hospital, Bielsko-Biała, Poland geometry, necessary for optimal adjacent carti- 56
Medical University of Silesia, Katowice, Poland lage regeneration. 57
© ISAKOS 2019 149

https://doi.org/10.1007/978-3-662-58704-1_14
150 B. Sadlik et al.
58 Until now the most commonly used single- compared to autologous chondrocyte proce- 104
59 stage treatment for large osteochondral lesions of dures. Bone layer of the defect is usually 105
60 the talar dome was OAT with a graft harvested restored by a calcaneus bone plug taken from 106
61 from the knee [2–5]. Unfortunately, that tech- iliac crest or bone chips compacted into the 107
62 nique may cause symptoms related to donor site defect before covering its surface with a chon- 108
63 morbidity in the knee after osteochondral auto- drogenic matrix [10–12]. 109
64 graft harvesting [6]. Moreover, the osteochondral
65 graft harvested from the knee rarely restores the
66 talar surface properly, especially in terms of its 14.2 Single-Stage Surgical 110
67 curvature and the joint congruence. Some authors Treatment of the 111
68 have reported incomplete integration of the OAT Osteochondral Lesion 112
69 graft with surrounding tissues as well as bone
70 plug necrosis [7]. Recent advances in arthroscopic instrumentation 113
71 Biological scaffolds are frequently used to have enabled the provision of minimally invasive 114
72 restore chondral tissue and can be implanted as procedures to treat chondral and osteochondral 115
73 cell-free or cell-embedded scaffolds. Second- or injury by a one-stage, single- or dual-layer, cell- 116
74 third-generation autologous chondrocyte implan- based reconstruction techniques [13]. These 117
75 tation procedures have been developed to provide developments in instrumentation and biomateri- 118
76 cartilage restoration in treatment of significant als have greatly reduced the need for aggressive, 119
77 chondral injury. In cases of cartilage injury that open procedures in the treatment of chondral and 120
78 are associated with significant subchondral bone osteochondral defects. 121
79 loss, a dual-layer restoration procedure may be One of the examples of new one-stage proce- 122
80 used, originally described by Peterson in 2003 as dures is the arthroscopically assisted approach 123
81 a “sandwich” technique. in surgical repair of osteochondral lesions of the 124
82 Of the available techniques described, the talus using biological inlay osteochondral recon- 125
83 dual-layer, cell-based technique has the great- struction (BIOR) (Fig. 14.1) [14]. In our opin- 126
84 est potential to restore articular congruity. This ion, successful repair of the deeper osteochondral 127
85 is achieved through the surgical contouring of lesions of the talar dome requires a separate res- 128
86 the restored osteochondral surface to match the toration of the bone layer and chondral layer. 129
87 native radius of curvature and the postoperative Filling of the lesion should be adapted to the 130
88 plastic adjustments that inherently occur as shape of the curvature of the talar dome in the 131
89 result of the forces from the opposing articular same way as a dentist molds a tooth filling. The 132
90 surface. Additionally, progress in biomaterial bone plug filling of the defect should be formed 133
91 engineering has allowed for development of and suitably concentrated, to carry the joint pre- 134
92 three-dimensional scaffolds that are more mal- load without the risk of subchondral layer col- 135
93 leable and therefore more stable within chon- lapse. Due to the limited accessibility to the 136
94 dral defects, as opposed to periosteal tissue that articular surface of the talar bone, BIOR implan- 137
95 was used by Petersen in the original method. tation can be made only through three minimally 138
96 Another important advancement in cell-based invasive portals. The classic approach through a 139
97 cartilage repair is the elimination of the two- medial malleolar osteotomy is advised in cases 140
98 stage ACI procedure. The use of autologous of larger lesions situated in the talar dome cen- 141
99 bone marrow aspirate concentrate in conjunc- ter. Due to a narrow joint space and deep loca- 142
100 tion with biological scaffolds, as described by tion of the lesion, this arthroscopy assisted and 143
101 Gobbi [8, 9], has been introduced widely into minimally invasive approach may only be per- 144
102 clinical practice and is performed as a one- formed with the help of a skillful assistant 145
103 stage procedure at considerably reduced cost surgeon. 146
14 One-Stage Treatment for Osteochondral Lesion of the Talus 151
a b Ar
Sh
Ch
Ar
AM
c
Im
OD
d
Ar
Sp
Fig. 14.1 Minimally invasive anteromedial approach to chips. Biological Inlay Osteochondral Reconstruction
the talar dome with an arthroscope visual assistance for step by step: (a) osteochondral defect removal using chon-
osteochondral defect biological inlay reconstruction drectome or curette; (b) refreshing sclerotic bone plate on
(BIOR): AM, anteromedial approach; Ar arthroscope, Ch the bottom and walls of the defect; (c) bone chips inlay
chondrectome, F force manually applied by an assistant, implantation using barrel implantation device; (d) bone
OD osteochondral defect, Sp heel support point, Sh chips inlay covered with matrix immersed with BMAC
“burr”-type shaver, Im barrel implantation device for bone
147 14.3 Approaches to the Talar 14.3.1 Anteromedial Approach 158

148 Osteochondral Lesion
The anteromedial approach that requires skin 159
149 An arthroscopic approach is useful in the cases of incision from 3 to 4 cm long directly above the 160
150 shallow osteochondral or chondral lesions treated joint line, medially to the tibialis anterior tendon, 161
151 by defect debridement and bone marrow stimula- is the most often used technique for addressing 162
152 tion technique. In favorable conditions, an lesions localized on the anterior and central sur- 163
153 arthroscopic matrix implantation might be face of the medial talar dome. The patient is posi- 164
154 achievable, although a minimally invasive open tioned supine, as for standard ankle arthroscopy. 165
155 technique is much easier for that purpose. Up to 50% of the medial talar dome surface can 166
156 Osteochondral reconstruction of a deep lesion be visualized arthroscopically after synovium 167
157 needs to be performed with an open approach. removal and excessive plantar flexion of the foot. 168
Fig. 14.3 Anterolateral approach to the ankle joint. Ar

arthroscope, R retractor, P3 peroneus tertius tendon, SP
superficial peroneal nerve
form the implantation. Special attention must be 182

paid to not damage the intermediate dorsal cuta- 183
neous nerve, which should remain intact either on 184
Fig. 14.2 Anteromedial arthroscopic approach to the the lateral or medial side of the incision (Fig. 14.3). 185
ankle joint. Ar arthroscope, R retractor, Ta tibialis anterior
tendon
169 Treatment of the lesion and implantation in such 14.3.3 Posterolateral Approach 186
170 a narrow space is possible with the assistance of
171 an arthroscope, controlled by an assistant, while If the defect is located in the lateral part, it is 187
172 the work of the second assistant should be accessible from an incision located on the pos- 188
173 focused on maneuvering the foot (Fig. 14.2). terolateral side of the joint, near a lateral border 189
of the Achilles tendon. The incision is made at 190
the level of a standard posterolateral portal; the 191
174 14.3.2 Anterolateral Approach cut should be extended by 1.5 cm proximally and 192
1.5 cm distally. The patient is placed on their 193
175 In the case of a lesion localized in the anterolat- side, and the operated limb is turned upward with 194
176 eral part of the talus, an analogous technique may knee bent to 90°. This position relaxes the tension 195
177 be applied from the anterolateral approach. It is of the calf muscles and allows the Achilles ten- 196
178 performed on the anterior edge of the lateral mal- don to be pulled toward the medial side. The dor- 197
179 leolus with the retraction of the third tendon of the sal flexion of the foot held by the assistant makes 198
180 sagittal muscle in the medial direction. Also in it possible to visualize 20% of the surface of pos- 199
181 this situation, two assistants are required to per- terolateral edge of the talus. Also here, the use of 200
and what is more important the rehabilitation 226

protocol should be individually modified. In our 227
opinion, the best way to properly control the 228
osteochondral graft maturation is periodically 229
checking of the graft status. In our center, after 230
undergoing osteochondral regeneration proce- 231
dures, patients are followed up with a monitoring 232
MRI protocol, 6 weeks then 6 and 12 months 233
postoperatively. Depending on the bone and sub- 234
chondral lamina quality, patients are allowed 235
more or less physical activity. Slow maturation 236
process of the graft indicates a modified pharma- 237
cotherapy or/and physiotherapy. 238
Fig. 14.4 Posterolateral approach to the ankle joint. Ach The rehabilitation protocol after biologic sur- 239
Achilles tendon, Ar arthroscope, R retractor, Sur Sural nerve gical treatment of osteochondral injury is based 240
on the size and location of the osteochondral 241
201 an arthroscope to visualize the operating field is defect and the contact angle (CA). CA is the 242
202 necessary (Fig. 14.4). angle of the reconstructed articular surface that 243
stays in contact with the opposite articular sur- 244
face during ankle movement. This crucial infor- 245
203 14.3.4 Standard Approach Through mation allows the physiotherapist to determine a 246
204 the Medial Malleolus safe ROM in exercise progression. 247
205 Osteotomy In the authors’ experience, the individual 248
rehabilitation strategy should be planned care- 249
206 Approach to the lesion located in the fully, taking into consideration these three key 250
207 posteromedial-
central part is possible only issues: 251
208 through the osteotomy of the medial malleolus,
209 which is the most common and well-known • Restricted joint motion in the initial phase of 252
210 approach, used and described by many authors graft integration (first 7–10 days), in order to 253
211 [1, 3, 5]. allow graft integration and the formation of a 254
fibrous hematoma on its interface, and then 255
progressively increasing joint motion up to 256
212 14.4 Postoperative Management full range, applying passive mobilization with 257
213 and MRI Monitoring the joint distraction. 258
• MRI graft maturation monitoring at 3 or 259
214 Deep osteochondral defects of the talus are more 6 weeks and then 6 and 12 months after the 260
215 often seen at the outpatient clinic than chondral surgery. 261
216 ones, which require only bone marrow stimula- • Orthopedic equipment should be individual- 262
217 tion technique or chondral scaffold implantation. ized, depending on the size, location, and CA 263
218 Deep osteochondral defects are much more of the osteochondral reconstruction. 264
219 demanding and should be treated with surgical
220 techniques considering reconstruction of both In all cases, the rehabilitation process should 265
221 bone and chondral layers of the defect. Expected be modified depending on the joint status as 266
222 time of graft remodeling and healing is longer swelling, adhesion, additional procedures or 267
223 when compared with treatment of a chondral injures, as well as MRI assessment. 268
224 defect. Thus the type of surgical reconstruction In the first 7–10 days, we recommend limited 269
225 method implies specific postoperative treatment joint motion, in order to encourage successful 270
271 integration of the repair tissue and the formation The one-step cell-based cartilage technique of 316
272 of a fibrous hematoma. After this period, range of HA-BMAC has been used at our institutions with 317
273 motion exercises should be undertaken in con- success using both open and arthroscopic meth- 318
274 junction with joint distraction. Partial weight- ods to treat cartilage defects of various dimen- 319
275 bearing should begin 4 or 5 weeks after surgery, sions and also multi-compartmental knee 320
276 with expected unrestricted weight-bearing by cartilage injury. The arthroscopic BIOR tech- 321
277 weeks 6, 7, or 8, depending on MRI assessment nique combines HA-BMAC cartilage repair with 322
278 at week 6. It is important for a physiotherapist to a malleable bony inlay to provide a bilayer autol- 323
279 understand that a predefined ROM is necessary to ogous reconstruction of the osteochondral unit, 324
280 restore the anatomic curvature of the talus. To with minimal morbidity. 325
281 optimize postoperative monitoring of the healing The biological inlay osteochondral recon- 326
282 process and formation of repair tissue, it is rec- struction technique of osteochondral repair has 327
283 ommended that patients undergo MRI at 6 and the capability to treat a wide range of lesion sizes, 328
284 12 weeks after surgery. At 3 months, patients with various depths of subchondral bone loss. In 329
285 progress to straight-line running, with an empha- addition, lesions of irregular shape may be 330
286 sis on strength, endurance, and aerobic training. repaired without sacrificing healthy adjacent tis- 331
287 Sport-specific training typically begins at sue, as opposed to reconstruction procedures that 332
288 8 months, with expected return to competition by involve circular-shaped osteochondral grafting. 333
289 10 months postoperatively. Furthermore, while osteochondral autograft or 334
290 Most of the rehabilitation centers use standard allograft procedures require graft implantation 335
291 postoperative rehabilitation protocols after ankle from a near-90° approach, the BIOR technique 336
292 osteochondral lesion surgical treatment. may be used to restore the natural anatomic radius 337
293 Management can be various, depending on lesion of articulating surface curvature, from a wide 338
294 size and localization, comorbidities, and patient variety of angles. This single-stage, dual-layer, 339
295 age. The late postoperative management, consid- cell-based cartilage repair procedure with bony 340
296 ering various physical activities of the patients, inlay is a versatile technique that has an attractive 341
297 should be administered with functional tests and cost profile and may be used in minimally inva- 342
298 graft maturation rate in MRI. Various graft matu- sive fashion for a variety of joint cartilage injuries 343
299 ration dynamics in MRI assessment can be seen that involve subchondral bone deficiency. 344
300 (Figs. 14.5, 14.6, 14.7). There is noticeably Biological materials, such as bone autograft, 345
301 slower graft rebuilding rate in older patients. The bone marrow concentrate, fibrin glue, and col- 346
302 biological osteochondral reconstructions of the lagen matrix have been used in orthopedic sur- 347
303 talar dome seem to be slower in maturation com- gery for many years. The presented modified 348
304 paring to the knee. There is no universal postop- surgical “sandwich” technique allows the talar 349
305 erative protocol after osteochondral convexity to be precisely recreated to match the 350
306 reconstruction, due to the fact that biological anatomic radius of curvature of the articular 351
307 healing of the graft is not well defined and uncon- surface. Furthermore, the reconstruction is per- 352
308 trolled in vivo. formed as a one-step procedure. In the 4-year 353
follow-up of our 22 patients, none of the cohort 354
required revision surgery. Except for one 355
309 14.5 Summary patient, all were satisfied with the outcome. 356
Postoperative MRI examinations typically dem- 357
310 The treatment of cartilage injury associated with onstrated good quality repair tissue. A notable 358
311 significant subchondral bone loss with the drawback of this surgical technique was a need 359
312 arthroscopic BIOR technique enables reconstruc- to perform a medial malleolar osteotomy in a 360
313 tion of damaged osteochondral tissue and resto- substantial number of cases (10 of 22 patients), 361
314 ration of the natural anatomic contour of the which theoretically may increase procedure 362
315 articular surface, in a minimally invasive fashion. morbidity. 363
Fig. 14.5 An example of slow remodeling of the biologi- proton density (PD) with or without fat saturation (FS)
cal inlay of medial talus. MRI evaluation of the left ankle (m-SPIRE, 3.0 Tesla digital scanner) and sagittal and cor-
of a 48-year-old female regarding the stepwise remodel- onal scans shape of the talar dome properly formed
ing of the subchondral lamina and chondral surface: (a) (3 months postoperatively); (c) still proper shape of the
osteochondral defect grade III of the medial aspect of the talar dome, subchondral lamina not visible yet (12 months
talar dome, preoperatively; (b) biological osteochondral postoperatively); (d) subchondral lamina and chondral
inlay (asterisk indicates donor site of a spongiosa bone layer visible (24 months postoperatively); PD (proton
graft), 3 months postoperatively; (c) 6 months postopera- density) with or without fat saturation (m-SPIRE, 3.0
tively, a border of subchondral lamina and chondral sur- Tesla digital scanner); sagittal and coronal scans
face are clearly visible, bone edema slightly decreased;
Fig. 14.6 Natural history of OLT: (a) the first MRI at the several pseudocysts appeared in the region of talar edema.
beginning of the ankle pain (2 years before surgery), only MRI 2 months after OLT reconstruction with BIOR tech-
chondral lesion and subchondral bone edema can be seen on nique; (c) talar dome curvature and structure were restored;
the medial boulder of the talus; (b) MRI scans 2 months PD (proton density) with or without fat saturation (m-SPIRE,
before surgery, chondral lesion and edema extended, and 3.0 Tesla digital scanner) and sagittal and coronal scans
364 Currently, all surgical techniques for recon- treatments of osteochondral lesions should be to 374
365 struction of large osteochondral lesions of the develop minimally invasive, or even arthroscopic, 375
366 talus require an approach that provides perpen- techniques that are appropriate for routine use. 376
367 dicular access to the articular surface, thereby Such techniques would enable the restoration of 377
368 allowing the implantation of bone blocks, osteo- anatomic articular congruence within the ankle 378
369 chondral grafts, or synthetic scaffolds. Moreover, joint, while minimizing postoperative morbidity. 379
370 there is less tolerance of articular incongruity in It should be specifically focused on the develop- 380
371 the ankle joint compared to the knee, and so sur- ment of a technique that avoids the malleolar 381
372 gical techniques to treat articular injury are more osteotomy, which remains a disadvantage of cur- 382
373 demanding. In our opinion, the focus of future rent regenerative surgical methods. 383
Fig. 14.7 A 45 year old

female treated for OCD a
of the talus - BIOR
procedure was
performed through
miniarthrotomy from
antero-medial approach,
additionally ATFL and
CFL reconstruction was
done. MRI scans show
the lesion preoperatively
(a), and a slow
maturation process of b
the graft: 1 month
postoperative (b), 3
months postoperative (c)
and 18 months
postoperative (d)
4. Kodama N, Honjo M, Maki J, Hukuda 397

384 References S. Osteochondritis dissecans of the talus treated with 398
the mosaicplasty technique: a case report. J Foot 399
385 1. Robinson DE, Winson IG, Harries WJ, Kelly Ankle Surg. 2004;43(3):195–8. 400
386 AJ. Arthroscopic treatment of osteochondral lesions 5. Gobbi A, Francisco RA, Lubowitz JH, Allegra F, 401
387 of the talus. J Bone Joint Surg (Br). 2003;85-B(7):989. Canata G. Osteochondral lesions of the talus: random- 402
388 2. Hangody L, Füles P. Autologous osteochondral mosa- ized controlled trial comparing chondroplasty, micro- 403
389 icplasty for the treatment of full-thickness defects fracture, and osteochondral autograft transplantation. 404
390 of weight-bearing joints. J Bone Joint Surg Am. Arthroscopy. 2006;22(10):1085–92. 405
391 2003;85-A(Suppl 2):25. 6. Emre TY, Ege T, Çift HT, Demircioğlu DT, Seyhan B, 406
392 3. Valderrabano V, Leumann A, Rasch H, Egelhof T, Uzun M. Open mosaicplasty in osteochondral lesions 407
393 Hintermann B, Pagenstert G. Knee-to-ankle mosa- of the talus: a prospective study. J Foot Ankle Surg. 408
394 icplasty for the treatment of osteochondral lesions 2012;51(5):556–60. 409
395 of the ankle joint. Am J Sports Med. 2009;37(1 7. Nakagawa Y, Suzuki T, Matsusue Y, Kuroki H, 410
396 suppl):105S–11S. Mizuno Y, Nakamura T. Bony lesion recurrence after 411
412 mosaicplasty for osteochondritis dissecans of the chondrocyte implantation versus one-step bone 431
413 talus. Arthroscopy. 2005;21(5):630-e1. marrow derived cells transplantation. Int Orthop. 432
414 8. Gobbi A, Chaurasia S, Karnatzikos G, Nakamura 2015;39(5):893–900. 433
415 N. Matrix-induced autologous chondrocyte implanta- 12. Sadlik B, Kolodziej L, Blasiak A, Szymczak M,
434
416 tion versus multipotent stem cells for the treatment of Warchal B. Biological reconstruction of large osteo- 435
417 large patellofemoral chondral lesions a nonrandom- chondral lesions of the talar dome with a modified 436
418 ized prospective trial. Cartilage. 2015;6(2):82–91. “sandwich” technique—midterm results. Foot Ankle 437
419 9. Gobbi A, Karnatzikos G, Sankineani SR. One-step Surg. 2016;23(4):290–5. 438
420 surgery with multipotent stem cells for the treatment 13. Whyte GP, Gobbi A, Sadlik B. Dry arthroscopic
439
421 of large full-thickness chondral defects of the knee. single-stage cartilage repair of the knee using a 440
422 Am J Sports Med. 2014;42(3):648–57. hyaluronic acid-based scaffold with activated bone 441
423 10. Valderrabano V, Miska M, Leumann A, Wiewiorski marrow- derived mesenchymal stem cells. Arthrosc 442
424 M. Reconstruction of osteochondral lesions of the Tech. 2016;5(4):e913–8. 443
425 talus with autologous spongiosa grafts and autologous 14. Sadlik B, et al. Surgical repair of osteochondral lesions 444
426 matrix-induced chondrogenesis. Am J Sports Med. of the talus using biologic inlay osteochondral recon- 445
427 2013;41(3):519–27. struction: clinical outcomes after treatment using a 446
428 11. Buda R, Vannini F, Castagnini F, Cavallo M, Ruffilli medial malleolar osteotomy approach compared to an 447
429 A, Ramponi L, et al. Regenerative treatment in arthroscopically-assisted approach. Foot Ankle Surg. 448
430 osteochondral lesions of the talus: autologous 2018. https://doi.org/10.1016/j.fas.2018.02.010. 449
Part III 1
Bone and Joint Injuries 2

1 Ankle Fractures
15
2 Shinji Isomoto, Kazuya Sugimoto,
3 and Yasuhito Tanaka
4 15.1 Diagnosis
5 Dislocation fractures are easily diagnosed by

6 plain radiographs. After reduction, medial clear
7 space and widening of the distal tibiofibular joint
8 should be checked. These findings indicate rup-
9 ture of the deltoid ligament and the distal tibio-
10 fibular ligaments (Fig. 15.1). For this evaluation,
11 comparison with the opposite ankle is recom-
12 mended. Tibiofibular injuries are often concomi-
13 tant with proximal fibular fractures. If a fibular
14 fracture is not shown on the ankle radiographs,
15 the radiographs should be checked for a proximal
16 fibular fracture.
17 Computed tomography provides more infor-
18 mation about sagittal dislocation of the tibiofibu-
19 lar joint, rotation of the distal fibula, dislocation
20 of intra-articular fragments, and free bodies in
21 the joint, etc. (Fig. 15.2).
Fig. 15.1 Plain radiograph of the ankle with a fibular
fracture, syndesmosis, and deltoid ligament injury. The
medial clear space (arrow head) and widening of the distal
tibiofibular joint (arrow) are shown
S. Isomoto · K. Sugimoto
Department of Orthopedic Surgery, Nara Prefecture
General Medical Center, Nara, Japan
Y. Tanaka (*)
Department of Orthopedic Surgery, Nara Medical
University, Nara, Japan
e-mail: yatanaka@naramed-u.ac.jp
© ISAKOS 2019 161

https://doi.org/10.1007/978-3-662-58704-1_15
162 S. Isomoto et al.
15.3.2 Arthroscopy 39
Distraction is not used. Anteromedial and antero- 40

lateral portals are used. Ligament injuries, frac- 41
ture, dislocation, and instability are evaluated [1, 42
2]. Chondral damage, osteochondral damage, and 43
free bodies are identified and evaluated. Free bod- 44
ies are removed. Chondral defects without bleed- 45
ing are treated with bone marrow stimulation by 46
the microfracture technique (Fig. 15.3) [3]. 47
15.3.3 Open Reduction and Internal 48

Fixation of the Fibula 49
The lateral approach is commonly used. If access 50

to the posterior malleolus is required, the pos- 51
Fig. 15.2 Computed tomography of the distal tibiofibu- terolateral approach is used. In the lateral 52
lar joint. Sagittal dislocation of the tibiofibular joint is approach, a longitudinal lateral incision is made. 53
shown At the proximal part of the incision, the superfi- 54
cial peroneal nerve lies anteriorly. It should be 55
22 15.2 Primary Care identified and protected. Fractures are reduced 56
and fixed with a plate and screws (Fig. 15.4). In a 57
23 After manual reduction, the ankle is fixed by a comminuted fracture, care is taken to avoid mal- 58
24 cast or splint. Open fractures or unstable frac- reduction with shortening and external rotation. 59
25 tures are fixed by external fixation, and skin dam-
26 age, neurovascular injuries, and compartment
27 syndrome are evaluated. Because such damage 15.3.4 Open Reduction and Internal 60
28 worsens over time, care must be taken over the Fixation of the Posterior 61
29 following days. If skin damage or swelling is Malleolus 62
30 severe, early surgery has a high risk of complica-
31 tions. Surgery should be performed after swelling Open reduction and internal fixation of the poste- 63
32 is decreased. rior malleolus are needed if the gap or step off of 64
the articular surface is large [4]. The posterolat- 65
eral approach is used [5]. A skin incision is made 66
33 15.3 Surgical Procedure between the posterolateral border of the fibula 67
and the medial border of the Achilles tendon. The 68
34 15.3.1 Patient Position distal part of the incision is curved to the tip of 69
the fibula to expose the fibular fracture. The sural 70
35 The lateral decubitus position is used. If treat- nerve is identified and protected. The peroneal 71
36 ment for the medial malleolus or deltoid ligament tendons are retracted laterally. In most cases, the 72
37 is needed, the patient’s position is changed to the posterolateral fragment of the tibia is exposed 73
38 supine position. after the flexor hallucis longus is retracted medi- 74
15 Ankle Fractures 163
a b c
Fig. 15.3 Chondral lesion of the talus. The chondral lesion without bleeding (a) is penetrated by a pick (b). The bone
marrow from the subchondral bone is shown (c)
Fig. 15.4 Plate fixation of the fibular fracture
75 ally. The fracture line is identified and reduced

76 directly. The periosteum and the attachment of
77 the posterior tibiofibular ligament are preserved.
78 The fragment is fixed with cannulated cancellous
79 screws. The first screw is inserted beneath the Fig. 15.5 Fluoroscopy of the ankle after fixation of the
80 tibial plafond. One or two screws are added fibular fracture. Syndesmosis widening and the medial
81 according to the size of the fragment. A plate is clear space remain, and instability of the tibiofibular joint
is evident on the external rotation stress test
82 used if the fragment of the posterior malleolus is
83 large enough.
injuries. Syndesmosis screws should be removed 91
before weight-bearing or training to avoid break- 92
84 15.3.5 Syndesmosis Fixation age of the screws. Widening of the syndesmosis 93
sometimes happens after removal of the screws. 94
85 Syndesmosis instability is checked by fluoroscopy Recently, suture buttons have been used for syn- 95
86 after fixation of the fibular fracture (Fig. 15.5). To desmosis injuries with good results [6]. Suture 96
87 identify instability, adequate external rotation buttons have a lower rate of hardware breakage 97
88 stress is applied. If instability is evident, syndes- than syndesmosis screws, so athletes can return to 98
89 mosis fixation is needed. Syndesmosis screws sports activities with suture buttons. In this chap- 99
90 have been commonly used to fix syndesmosis ter, fixation with a suture button is shown. 100
164 S. Isomoto et al.
101 If the tibiofibular joint is severely dislocated, supine position. An ankle dislocation fracture in 121
102 it is reduced with a clamp. A guide wire is inserted athletes is commonly accompanied by deltoid 122
103 from the posterolateral fibula to the anterolateral ligament rupture. Suture for the deltoid ligament 123
104 tibia. In a distal fibular fracture, a guide wire is rupture is controversial [7, 8]. The medial clear 124
105 inserted through one of the holes of the distal space of the medial gutter is closed after the syn- 125
106 fibular plate (Fig. 15.6a). When there is no frac- desmosis is fixed appropriately. In cases where a 126
107 ture of the fibula, or the proximal fibular fracture medial clear space or talar tilt remains, the del- 127
108 is not fixed, two sets of suture buttons are used. toid ligament is sutured [9, 10]. 128
109 Drilling is performed by a cannulated drill bit A medial longitudinal incision through the tip of 129
110 from the fibula to the tibia (Fig. 15.6b). The suture the medial malleolus is used. The superficial deltoid 130
111 button is inserted, and the medial button is seated ligament is exposed. A longitudinal incision of the 131
112 on the medial cortex of the tibia. The wire is tight- superficial deltoid ligament is made to expose the 132
113 ened, and the lateral button is seated on the lateral deep deltoid ligament. The rupture of the deep del- 133
114 cortex of the fibula or plate. The wire is tightened toid ligament is identified and sutured (Fig. 15.7). In 134
115 until there is sufficient tension (Fig. 15.6c). avulsion of the deltoid ligament from the medial 135
malleolus, a suture anchor is used. The superficial 136
layer is sutured after the deep layer is repaired. 137
116 15.3.6 Suture of the Deltoid
117 Ligament or Fixation 15.3.6.1 Final Assessment 138
118 of a Medial Malleolar Fracture After suture of the deltoid ligament, reduction 139
and instability are checked by fluoroscopy. The 140
119 Surgery for the deltoid ligament or a medial mal- syndesmosis suture wire is tightened again if 141
120 leolar fracture is performed with the patient in the needed (Fig. 15.8). 142
a b c
Fig. 15.6 Syndesmosis fixation with a suture button. (a) inserted, and the medial button is seated on the medial
The guide wire is inserted in one of the holes of the fibular cortex of the tibia. The wire is tightened, and the lateral
plate. (b) Drilling is performed by a cannulated drill bit button is seated on the fibular plate
from the fibula to the tibia. (c) The suture button is
a b
Fig. 15.7 Suture of the deltoid ligament. (a) Suture of the deep layer. (b) After suture of the deltoid ligament
15 Ankle Fractures 165
a b
Fig. 15.8 Postoperative anteroposterior radiograph (a) and lateral radiograph (b)
143 15.4 Postoperative Treatment 4. De Vries JS, Wijgman AJ, Sierevelt IN, Schaap 162
GR. Long-term results of ankle fractures with a 163
posterior malleolar fragment. J Foot Ankle Surg. 164
144 The ankle is fixed in a cast for 3 weeks. Dorsi- 2005;44:211–117. 165
145 plantar flexion exercise and partial weight bear- 5. Abdelgawad AA, Kadous A, Kanlic E. Postero- 166
146 ing are started 3 weeks after the operation with a lateral approach for treatment of posterior mal- 167
leolus fracture of the ankle. J Foot Ankle Surg. 168
147 semirigid brace. Inversion-eversion exercise and 2011;50:607–11. 169
148 full weight-bearing are started 6 weeks after the 6. Inge SY, Pull Ter Gunne AF, Aarts CAM, Bemelman 170
149 operation, and physical training is started after M. A systematic review on dynamic versus static dis- 171
150 bone union. tal tibiofibular fixation. Injury. 2016;47:2627–34. 172
7. Johnson DP, Hill J. Fracture-dislocation of the 173
ankle with rupture of the deltoid ligament. Injury. 174
1988;19:59–61. 175
151 References 8. Stromsoe K, Hoqevold HE, Skjeldal S, Alho A. The 176
repair of a ruptured deltoid ligament is not nec- 177
152 1. Hintermann B, Regazzoni P, Lampert C, Stutz G, essary in ankle fracture. J Bone Joint Surg (Br). 178
153 Gachter A. Arthroscopic findings in acute fractures of 1995;77:920–1. 179
154 the ankle. J Bone Joint Surg (Br). 2000;82:345–51. 9. Lӧtscher P, Lang TH, Zeicky L, Hintermann B, Knupp 180
155 2. Chen XZ, Chen Y, Lui CG, Yang H, Xu XD, Lin P. M. Osteoligamentous injuries of the medial ankle. Eur 181
156 Arthroscopy-assisted surgery for acute ankle fractures: J Trauma Emerg Surg. 2015;41:615–21. 182
157 a systematic review. Arthroscopy. 2015;31:2224–31. 10. Yu GR Zhang MZ, Aiyer A, Tang X, Xie M, Zeng LR, 183
158 3. Takao M, Uchio Y, Naito K, Fukazawa I, Kakimaru T, Zhao YG, Li B, Yang YF. Repair of the acute deltoid 184
159 Ochi M. Diagnosis and treatment of combined intra- ligament complex rupture associated with ankle frac- 185
160 articular disorders in acute distal fibular fractures. J ture: a multicenter clinical study. J Foot Ankle Surg. 186
161 Trauma. 2004;57:1303–7. 2015;54:198–202. 187
1
2
Ankle Fractures and Return
to Sports in Athletes: “Does
16
3 Arthroscopy Add Value
4 to the Treatment?”
5 Pieter D’Hooghe, Fadi Bouri, Akis Eleftheriou,

6 Thomas P. A. Baltes, and Khalid Alkhelaifi
7 16.1 Introduction • Limited surgical exposure and soft-tissue 27

trauma 28
8 The ankle is one of the most commonly injured • Video-assisted fracture reduction 29
9 joints in sports—ankle injuries constitute 12–23% • Direct visualization of the joint articulation 30
10 of all injuries recorded during FIFA competitions. • Evaluation of ligamentous injuries and associ- 31
11 Although the incidence of ankle fractures in ath- ated intra-articular pathology (e.g., osteo- 32
12 letes is low, accounting for less than 3% of all chondral injuries) 33
13 ankle injuries [1, 2], the severity of this injury
14 warrants meticulous treatment [1]. Throughout As ankle fractures constitute a major time-loss 34
15 the past decades open reduction and internal fixa- injury in athletes, treatment should address the 35
16 tion (ORIF) has established itself as standard of demand for early and safe return to sports. Due to 36
17 care for unstable ankle fractures. However, ORIF the minimal soft-tissue trauma associated with 37
18 is associated with substantial surgical exposure arthroscopic fracture treatment, it can facilitate 38
19 and inherent complications, such as infection and early rehabilitation and may lead to improved 39
20 skin necrosis. With the aim to minimize complica- return to sport [2]. In addition, the use of arthros- 40
21 tions and further improve outcomes, arthroscopic copy can aid in the diagnosis and treatment of 41
22 reduction and internal fixation (ARIF) and arthros- concomitant pathology that is often found in 42
23 copy-assisted open reduction internal fixation acute ankle fractures. 43
24 (AORIF) were introduced [3]. Potential benefits of using arthroscopy for 44
25 Potential advantages of arthroscopic treatment ankle fractures in athletes include the following: 45
26 of ankle fractures include [4]:
• Concomitant treatment of cartilage lesions, 46
P. D’Hooghe (*) · F. Bouri · T. P. A. Baltes which are observed in up to 63% of ankle frac- 47
K. Alkhelaifi tures [2]. 48
Department of Orthopaedic Surgery, Aspetar • Stability of the syndesmosis can be assessed 49
Orthopaedic and Sports Medicine Hospital,
Doha, Qatar (e.g., drive-through sign). 50
e-mail: Pieter.Dhooghe@aspetar.com; • Accurate tibial plafond reduction for complex 51
Fadi.Bouri@aspetar.com; Thomas.Baltes@aspetar.com; intra-articular ankle fractures can best be 52
Khalid.Alkhelaifi@aspetar.com achieved through arthroscopy. 53
A. Eleftheriou • The minimally invasive nature of arthroscopy 54
Hippocrateon Private Hospital, Nicosia, Cyprus
can facilitate early rehabilitation. 55
e-mail: akis@dreleftheriou.com
© ISAKOS 2019 167

https://doi.org/10.1007/978-3-662-58704-1_16
168 P. D’Hooghe et al.
56 Although arthroscopic surgery for posttrau- combined with a demand for rapid return to sport 97
57 matic pathology has been shown to have signifi- among athletes, has caused a surge in arthroscopic 98
58 cant benefits, the evidence on its use in the techniques for the treatment of various indica- 99
59 treatment of ankle fractures is scarce. The aim of tions (Figs. 16.1 and 16.2). 100
60 this chapter is to offer an evidence-based over- A recent review on the indications of ARIF 101
61 view of the current literature regarding the indi- in ankle fractures concluded that the use of 102
62 cations for using arthroscopy in the treatment of
63 acute ankle fractures and its associated injuries in
64 athletes.
65 16.2 Materials
66 A Medline search using the keywords “ankle

67 fracture, arthroscopy, and athlete” yielded a total
68 of 55 articles, describing the surgical technique
69 or the outcomes of arthroscopic reduction and
70 internal fixation (ARIF) or arthroscopy-assisted
71 open reduction internal fixation (AORIF) of vari-
72 ous types of ankle fractures. Six of these papers
73 focused on ARIF in elite athletes [2, 5–9].
74 Ligamentous injuries, except for syndesmosis
75 injury, are not discussed in this chapter.
76 Current indications for ARIF/AORIF in sport-
77 related ankle fracture management include:
78 • Malleolar fracture Fig. 16.1 The surge in arthroscopic techniques for ankle
79 • Intra-articular fracture pathology has led to the development of different
arthroscopic portals that can be chosen to treat the various
80 • (Osteo-)chondral injury (described) indications (image copyright: Pieter
81 • Syndesmosis injury D’Hooghe)
82 • Talar body/neck fracture
83 • Talar process fractures
84 16.3 ARIF (Arthroscopic-Assisted

85 Reduction and Internal
86 Fixation)
87 Arthroscopic-assisted reduction and internal fix-

88 ation of ankle fractures was first introduced in
89 1989 and has since gained acceptance [2]. The
90 use of arthroscopy in the treatment of ankle frac-
91 tures presents surgeons with the ability to directly
92 visualize the articular surface and assess the pres- Fig. 16.2 The use of arthroscopy in the treatment of
93 ence of associated pathology (e.g., osteochondral ankle fractures presents surgeons with the ability to
directly visualize the articular surface and assess the pres-
94 lesions), all with minimal surgical exposure. The ence of associated pathology (e.g., osteochondral lesions),
95 increased understanding of the pathophysiology all with minimal surgical exposure (image copyright:
96 of ankle fractures and its associated injuries, Pieter D’Hooghe)
16 Ankle Fractures and Return to Sports in Athletes: “Does Arthroscopy Add Value to the Treatment?” 169
a b
Fig. 16.3 (a) Intraoperative anterior arthroscopic view of fracture after intra-articular reduction (image copyright:
a distal tibial fracture with intra-articular extension. (b) Pieter D’Hooghe)
Intraoperative anterior arthroscopic view of a distal tibial
103 arthroscopy can be advantageous in the time, soft-tissue swelling, and surgeon-dependent 128
104 treatment of [4]: ability to successfully utilize arthroscopic tech- 129
niques have been stated [2]. Despite these concerns, 130
105 • Acute ankle fracture dislocations only one case report describing an acute anterior 131
106 • High-energy ankle fractures requiring reduction compartment syndrome following ankle arthros- 132
107 • Suspected loose bodies and chondral lesions copy in the treatment of a Maisonneuve fracture in 133
a football player has been published [15]. 134
108 The use of arthroscopic reduction and internal Relative contraindications for arthroscopy in 135
109 fixation (ARIF) has been described for a wide the treatment of ankle fractures include [4]: 136
110 variety of fractures, including fractures of the
111 talus and talar processes, the distal tibia, and frac- • Low-energy fracture mechanism 137
112 tures of the medial and lateral malleolus [10–13]. • Open fractures 138
113 Furthermore, using arthroscopic techniques, • Degloving injuries with severe soft-tissue 139
114 symptomatic fractures of the medial and lateral compromise 140
115 posterior process of the talus can be fixed or
116 excised [14]. For most of these indications a clas-
117 sic two-portal anterior/posterior arthroscopic 16.4 Indications for Combined 141
118 technique is utilized (Fig. 16.3a, b) [2, 5, 6]. Ankle Arthroscopy in Acute 142
119 In addition to fracture fixation, arthroscopy Athlete Ankle Fractures 143
120 may facilitate immediate treatment of concomi-
121 tant ligamentous injuries, tendon pathology, and 16.4.1 Malleolar Fractures 144
122 osteochondral lesions, potentially enabling early
123 rehabilitation and faster return to sports [5]. Malleolar fractures are generally evaluated by 145
124 No absolute contraindications for using arthros- physical examination and radiographs—they are 146
125 copy in the treatment of acute ankle fractures and then classified according to either the AO or the 147
126 its associated injuries have been formulated. Weber classification systems. In case of disloca- 148
127 However, concerns regarding increased surgical tion, immediate reduction is mandatory to p revent 149
150 skin necrosis and possible nerve damage. The Stufkens et al. analyzed the long-term out- 171
151 treatment strategy is chosen based on: come after surgical treatment of malleolar frac- 172
tures and noted that over 10% of patients 173
152 • Mechanism of injury eventually go on to develop ankle arthrosis [16]. 174
153 • Classification/injury severity The evidence regarding optimal treatment strate- 175
154 • Associated soft-tissue damage gies, and in particular regarding the return to 176
sports, for these types of fracture is scarce. 177
155 Weber A fractures are usually treated conserva- ARIF is shown to be effective in discovering 178
156 tively, while Weber B and C fractures frequently undetected osteochondral defects in the ankle 179
157 require surgery. Specific attention should be given and enabling the surgeon to evaluate the quality 180
158 to the intraoperative evaluation of syndesmotic of anatomical reduction [3, 5, 17, 22–26]. Up to 181
159 joint stability, as up to 66% of Weber B and C 60–75% of ankle fractures (that require surgical 182
160 ankle fractures have some degree of syndesmotic fixation) have demonstrated evidence of articular 183
161 ligamentous injury [5, 16–22]. A recent retrospec- cartilage damage—previously undiagnosed prior 184
162 tive review by Chan et al. on a series of 254 ankle to surgery [16]. Such injuries are mostly carti- 185
163 fracture patients showed associated syndesmosis laginous in nature and therefore not radiographi- 186
164 disruption in 52% of Weber B fractures, 92% of cally visible (Fig. 16.4a–c). 187
165 Weber C fractures, and 20% of isolated medial These lesions usually occur at locations not 188
166 malleolus fractures [23]. The most frequently accessible through traditional fracture surgery 189
167 encountered complications of open reduction and incisions. Therefore, simultaneous arthroscopic 190
168 internal fixation of these fractures are formation of assessment and management of these lesions are 191
169 wound hematoma and wound necrosis with a post- required to improve the rate and quality of recov- 192
170 operative infection rate of around 2%. ery after fracture surgery. Since radiographs are 193
a b c
Fig. 16.4 (a) Anteroposterior (AP) X-ray of an elite ath- articular excursion. (c) After arthroscopic-assisted percu-
lete with a centro-lateral distal tibial stress fracture with taneous reduction and fixation with control over the
intra-articular excursion. (b) Coronal T2 MRI image of anatomical reduction and articular cartilage status (image
the centro-lateral distal tibial stress fracture with intra- copyright: Pieter D’Hooghe)
194 commonly used as the preferred diagnostic tool in that was smooth and congruous. They noted that 239
195 acute ankle fractures, the very low sensitivity of the fracture line was filled with fibrocartilage- 240
196 plain radiography leads to underdiagnosis of like tissue and concluded that this technique had 241
197 osteochondral lesions [5, 16, 17, 27–29]. In a pro- provided satisfactory results [15]. Various other 242
198 spective randomized trial comparing arthroscopic- case reports reporting similar outcomes have 243
199 assisted with traditional non- assisted lateral been published since [2]. 244
200 malleolar fracture fixation, Takao et al. showed a In a recent study by Feng et al. [31], a series of 245
201 very high rate of secondary pathology. This was 19 patients with a Chaput-Tillaux fracture (treated 246
202 mostly chondral damage and syndesmotic injury with ARIF) were retrospectively followed up after 247
203 [17]. At an average follow-up of 40 months, there a mean of 19.0 months [2]. Good to excellent 248
204 was a small but significantly greater AOFAS out- results were reported in all patients. The Visual 249
205 come score in the arthroscopically assisted group Analogue Scores for pain scores improved from a 250
206 compared to the traditional group [17]. mean preoperative 8.1 (±0.8 SD) to a postopera- 251
tive 0.1 (±0.3 SD), at 6-month follow-up. Further 252
more, the AOFAS score improved from a mean 253
207 16.4.2 Intra-articular Fractures 52.8 (±6.4) preoperatively to a mean 91.7 (±4.3) 254
at final follow-up. 255
208 Intra-articular fractures like triplane and Chaput- The use of arthroscopy for isolated malleolar 256
209 Tillaux fractures clearly benefit from an or distal tibial stress fractures with an intra- 257
210 arthroscopic-assisted approach as fracture site articular fracture line extension can be equally 258
211 clearance and intra-articular realignment can be beneficial, as in Chaput-Tillaux fractures com- 259
212 visualized intraoperatively with minimal surgical plete cartilage assessment can be performed with 260
213 exposure. Some authors claim that the treatment of arthroscopy without the need for large exposures. 261
214 triplane fracture should be performed in two steps. Any step-off into the joint line, comminution, or 262
215 The first step is closed reduction under fluoroscopic depressed fragment can be recognized and 263
216 view. If the displacement is less than 2 mm after realigned (Fig. 16.5a–d). 264
217 closed reduction, it is regarded acceptable and con- Percutaneous temporary K-wires can be used 265
218 servative treatment with a short-leg cast is recom- to manipulate and aid in fracture reduction before 266
219 mended. If the displacement is more than 2 mm definitive osteosynthesis is performed [32, 33] 267
220 after closed reduction, open reduction and internal (Fig. 16.6a–d). 268
221 fixation should be performed [30]. However, a However, the technique can be technically 269
222 long-term follow-up study of triplane fractures demanding and no quality comparative studies 270
223 found that in patients treated conservatively, despite are available [5, 25]. 271
224 there being less than 2 mm of displacement after
225 closed reduction, complications such as decreased
226 ankle mobility, early osteoarthritis, and pain were 16.4.3 Osteochondral Lesions 272
227 present at 5-year follow-up [30].
228 In a case report by Imade et al. they applied Although open reduction and internal fixation of 273
229 ankle arthroscopy for the treatment of an ankle ankle fractures leads to good result in most 274
230 triplane fracture for the first time [15]. The use of patients, poor functional outcome is observed in 275
231 arthroscopy allowed for a minimally invasive a subset of patients. It has been hypothesized that 276
232 treatment strategy and accurate anatomical these lesser results can be attributed to undiag- 277
233 reduction. The patient was able to walk without nosed osteochondral lesions, present in up to 278
234 discomfort 2 months after surgery and was able 63% of the patients [18, 26]. 279
235 to fully participate in athletic activities with no Acute osteochondral defects associated with 280
236 pain at 3 months postoperatively. A second-look ankle fractures are commonly amenable to 281
237 arthroscopy at 1-year follow up showed an arthroscopic treatment. Arthroscopic diagnosis of 282
238 articular surface over the previous fracture area the defect location, defect size, and condition of 283
a b c d
Fig. 16.5 (a) Coronal CT image of a medial malleolar AP X-ray after arthroscopic-assisted percutaneous frac-
stress fracture in the ankle of an elite athlete. Note the ture reduction and fixation. (d) Postoperative lateral X-ray
talar varus deformity alignment. (b) Axial CT image of a after arthroscopic-assisted percutaneous fracture reduc-
medial malleolar stress fracture in the ankle of an elite tion and fixation (image copyright: Pieter D’Hooghe)
athlete. Note the anterior small fragment. (c) Postoperative
a b c d
Fig. 16.6 (a) AP X-ray of a Weber B distal fibular frac- image of the intra-articular ankle fracture. (d) AP X-ray
ture in an athlete. (b) Lateral X-ray reveals the combined image after arthroscopic-assisted fracture reduction and
bony anterior syndesmotic fracture. (c) Coronal 3D CT fixation (image copyright: Pieter D’Hooghe)
284 the osteochondral fragment can guide the selec- treatment of athletes with a chronic osteochon- 295
285 tion of appropriate treatment [2, 17, 18, 28]. dral defect of the talus [39, 40], ARIF in the acute 296
286 Based upon the talar dome/tibial plafond osteo- setting can provide cartilage biopsies for cell cul- 297
287 chondral defect size, bone marrow stimulation ture and cartilage implantation in a later stage 298
288 techniques (e.g., drilling, abrasion, or microfrac- (ACI). The same treatment strategy is applicable 299
289 ture) or transplantation techniques (autograft/ for the less common tibial plafond osteochondral 300
290 allograft) can be used instantaneously [34–38]. lesions [32]. 301
291 Furthermore, as cartilage-regenerative proce- Currently there is sufficient evidence that 302
292 dures (autologous chondrocyte implantation arthroscopy can be successfully employed in the 303
293 [ACI], matrix-induced autologous chondrocyte treatment of fracture-associated intra-articular 304
294 implantation [MACI]) gain popularity in the injuries. However, despite the obvious potential 305
306 of arthroscopy, evidence comparing functional instability of 3% after screw removal [23]. Finally, 351
307 outcome and complication rates of ARIF to ORIF damage to the medial area of the talocrural joint, 352
308 is lacking [41]. which is an indirect finding commonly associated 353
with syndesmotic injury, can be visualized using 354
the arthroscope. 355
309 16.4.4 Syndesmosis
310 Fracture-related injury to the syndesmosis is 16.4.5 Talar Body and Neck Fractures 356
311 observed in 47–66% of patients and is associated
312 with the development of chronic ankle com- Fractures of the talar neck and body (Fig. 16.7a–e) 357
313 plaints [19]. Intraoperative stress views are more are rare injuries that can cause significant mor- 358
314 reliable—when compared to plain radiographs— bidity and complications. 359
315 at detecting definitive instability [20]. For the athlete, these injuries can have a del- 360
316 Nevertheless, borderline instability or partial eterious effect on their long-term functional out- 361
317 injury to the syndesmotic complex without insta- come. Treatment efforts are aimed at the quality 362
318 bility is difficult to detect. Magnetic resonance of fracture reduction and the preservation of talar 363
319 imaging (MRI) has been shown to provide accu- blood supply. Arthroscopic-assisted surgery has 364
320 rate information when documenting a syndes- been shown to be of value in both aspects but the 365
321 motic injury, but has a significant false-positive technique is demanding, prolongs operative 366
322 rate, whereas arthroscopic assessment has been time, and increases soft-tissue swelling. 367
323 shown to be more sensitive and specific and an However, case reports and small case series pro- 368
324 accurate guide for anatomical reduction of the vide some evidence to recommend this technique 369
325 syndesmosis because it provides 3-dimensional [16, 47–49]. The underlying principle in manag- 370
326 assessment and reduces the chance of having ing a talar fracture is to achieve an anatomical 371
327 malreduction [2, 5, 20, 21, 23, 42]. reduction and stable fixation with minimal dis- 372
328 In addition, arthroscopy can debride the extra- turbance to the soft tissue—for the abovemen- 373
329 syndesmotic fibers of the most commonly rup- tioned reasons [47, 48]. Skin necrosis, infection, 374
330 tured anteroinferior tibiofibular ligament that malunion, and posttraumatic arthritis are well- 375
331 may otherwise produce chronic pain due to ante- recognized complications of talar fractures, and 376
332 rior impingement [43–45]. Good to excellent management should be designed to minimize 377
333 results have been reported in a few studies where these. Subairy et al. have shown that arthroscopic- 378
334 arthroscopic assessment (with fixation) and/or assisted surgical stabilization of these fractures 379
335 debridement were used to manage such injuries is advantageous and reduces the time to union 380
336 [17, 18, 27, 29]. Arthroscopic evaluation may [48]. Stress fractures are the most common over- 381
337 also detect sagittal and rotational ankle instabil- use bony injuries in sports but stress fractures of 382
338 ity, which may not always be visualized on intra- the talar body are extremely rare and have only 383
339 operative stress radiography [2, 46]. rarely been reported [6, 10, 50]. More com- 384
340 Arthroscopy is also useful in detecting the mon—but still rare—are stress fractures of the 385
341 relationship between malleolar fractures and syn- talar neck or lateral talar process [6, 11, 12]. Due 386
342 desmotic injury [2, 23] where they found a statis- to their minor displacement, most stress frac- 387
343 tical significance association between Weber B tures of the talar body are treated nonsurgically 388
344 fractures and syndesmotic injuries but no statisti- [6, 10, 13]. Stress fractures in sports are the 389
345 cal significant association between posterior mal- result of excessive, repetitive cyclic loads trau- 390
346 leolus fracture and syndesmotic injury [23]. matizing bones with normal form and structure 391
347 Another important role of arthroscopy can be to [51]. Predisposing factors may be both intrinsic 392
348 monitor residual syndesmosis instability after and extrinsic and include malalignment, lack of 393
349 removal of the syndesmotic screw where they flexibility, increase in training, training of exces- 394
350 found a low number of residual syndesmosis sive volume and intensity, hard or soft activity 395
a b c
d e
Fig. 16.7 (a) Sagittal CT image of an athlete with sudden servative treatment. (d) Axial T2 MRI image of the
ankle pain after a preseason training camp. (b) Sagittal T1 progressive diastasis of the talar body stress fracture dur-
MRI image of a talar body stress fracture. Note the ing conservative treatment. (e) Lateral X-ray of the
Hawkins sign. (c) Coronal T2 MRI image of the progres- arthroscopic-assisted talar body fracture compression
sive diastasis of the talar body stress fracture during con- screw fixation (image copyright: Pieter D’Hooghe)
396 surfaces, inappropriate shoes, and inadequate novel action. In athletes, significant pathogenetic 404
397 coaching [6, 10]. Additional factors to be consid- movements predisposing to a talar stress fracture 405
398 ered include age, ethnicity, gender, fitness, skill can be identified in repetitive, restricted axial 406
399 level, and menstrual history [6, 52]. Mechanical loading while sprinting, kicking a ball, or land- 407
400 factors that may lead to a stress fatigue fracture ing after heading. The load that has to be 408
401 remain unclear but may result from repeated absorbed during these actions (the extremes in 409
402 loading or repetitive prolonged muscular action plantar/dorsiflexion of the foot while kicking the 410
403 on bone not yet conditioned to such heavy and ball and other traumatic actions) should be 411
412 c onsidered as an important pathogenetic factor (Fig. 16.7a–e). No other articles were found 460
413 in repetitive strain injuries. Moreover, when that combine arthroscopy with talar stress frac- 461
414 playing toward the end of a match or tournament, ture fixation management. 462
415 coordination is less precise as athletes are often
416 fatigued [6, 52].
417 The diagnosis of a stress fracture is based on 16.4.6 Talar Process Fractures 463
418 clinical suspicion, a detailed history, and a physi-
419 cal examination, followed by appropriate imag- 16.4.6.1 Lateral Tubercle Fractures 464
420 ing investigations. The role of conventional and Os Trigonum Complex 465
421 radiography is important, although initial find- Posterior impingement in the ankle refers to a 466
422 ings are often minimal or absent (Fig. 16.7a). The mechanical conflict on the posterior side of the 467
423 earliest sign—often delayed until after the onset ankle. In athletes, it accounts for about 4% of all 468
424 of symptoms—may be a lucent linear image ankle injuries and can present either acutely or 469
425 (more often a sclerotic band, periosteal reaction, chronically [2]. Posterior ankle impingement 470
426 or callus formation) seen on X-ray [6, 10, 13]. syndrome is a clinical pain syndrome reflecting 471
427 MRI has a high sensitivity for the detection of the most common cause of posterior ankle pain. 472
428 stress fractures (Fig. 16.7b). In addition, MRI It can be provoked by a forced hyperplantar 473
429 signs are evident several weeks before radio- flexion movement of the ankle [14, 17, 57, 58]. 474
430 graphic signs appear. In the event of bony posterior impingement of 475
431 Conservative treatment is preferred if there the ankle, plantar flexion induces a conflict 476
432 is no (or only minor) displacement at the frac- between the posterior malleolus of the distal 477
433 ture site. There is only limited literature on tibia and the posterosuperior calcaneal bone. A 478
434 adequate healing times for stress fractures of hypertrophic posterior talar process or an os tri- 479
435 the talar body but overall stress fractures are gonum is present in almost 7% of the sports 480
436 known for their prolonged time to heal [6, 53]. population [2]. Not every apparent posterior 481
437 Generally, treatment of stress fractures is bone—caused by acute or repetitive overload 482
438 immobilization for 4–8 weeks [10, 50, 52, 53]. (micro)trauma—induces posterior ankle pain 483
439 Avascular necrosis remains a relatively high and is not necessarily associated with the poste- 484
440 risk—given the suboptimal talar vascular sta- rior ankle impingement syndrome. 485
441 tus—even after an adequate immobilization Acute forced hyperplantar flexion movement 486
442 period [53, 54]. Hawkins classified (non-stress) of the ankle can induce a bony conflict in the pos- 487
443 fractures of the talus in an attempt to predict terior ankle joint as is frequently seen in sports 488
444 the risk of avascular necrosis [55]. A Hawkins like football and ballet. The mechanism of injury 489
445 type 1 fracture has a good prognosis as the risk is a repetitive forced plantar flexion or an acute 490
446 of avascular necrosis is less than 15% [56]. If blocked kicking action. Compression of the os 491
447 significant diastasis/displacement (Hawkins trigonum between the distal tibia and calcaneal 492
448 type 2) occurs, the risk of avascular necrosis bone can also cause this lesion, thus potentially 493
449 rises to 50%, and surgical repositioning and leading to displacement of an os trigonum or 494
450 fixation is indicated [56] (Fig. 16.7c–e). If ade- fracture of the processus posterior tali or distal 495
451 quate measures—with rapid intervention to tibia (Fig. 16.8). 496
452 reposition the displaced fracture—are taken, it Over the last three decades, posterior arthros- 497
453 is possible to achieve a positive outcome with- copy of the ankle joint has become a standardized 498
454 out ongoing problems [6] (Fig. 16.7e). procedure, with numerous indications for treat- 499
455 d’Hooghe et al. described the management of ing posterior (intra-articular) ankle pathology. 500
456 progressive talar body stress fractures in pro- Lack of direct access and nature and deep loca- 501
457 fessional football players through posterior tion of its hindfoot structures are reasons why 502
458 arthroscopy-assisted compression screw fixa- posterior ankle problems still pose a diagnostic 503
459 tion with excellent healing results [6] and therapeutic challenge today. 504
505 The two-portal endoscopic technique by van more rapid rehabilitation time make this tech- 518
506 Dijk et al. allows for excellent access to the poste- nique a beneficial technique in athletes [56–59]. 519
507 rior ankle compartment and also to the surround-
508 ing extra-articular posterior ankle structures [57]. 16.4.6.2 Medial Tubercle Fractures 520
509 This technique, using modified classic Fractures of the medial tubercle are rare but can 521
510 arthroscopic tools and skills, has introduced a occur due to [2]: 522
511 broad spectrum of new indications in posterior
512 ankle pathology [57–59]. The most influential • Avulsion of the posterior tibiotalar ligament 523
513 indication to perform posterior ankle arthroscopy • Dorsiflexion and eversion (Cedell fracture) 524
514 remains the treatment of os trigonum. This is an • Direct compression of the process as above 525
515 attractive alternative to open surgery for experi- • Impingement of the sustentaculum tali in 526
516 enced arthroscopic surgeons. Improved functional supination 527
517 outcomes after surgery, lower morbidity, and
In contrast to lateral tubercle injuries, pain and 528
swelling are usually present between the Achilles 529
tendon and the medial malleolus. However, there 530
may be limited pain on walking or movement of 531
the ankle. It is difficult to visualize fractures of the 532
medial tubercle on plain AP and lateral radio- 533
graphs, and it has been suggested that the addition 534
of two oblique views at 45° and 70° of external 535
rotation may significantly aid in the detection prior 536
to resorting to a CT or MRI [2] (Fig. 16.9a, b). 537
These fractures can be approached through 538
the posterior arthroscopic technique—their 539
Fig. 16.8 Lateral X-ray of an os trigonum in an athlete’s extent can be visualized and the necessary treat- 540
ankle (image copyright: Pieter D’Hooghe) ment can be performed in a one-stage procedure. 541
a b
Fig. 16.9 (a) Sagittal CT image of a Cedell fracture in an athlete’s ankle. (b) Axial CT image of a Cedell fracture in an
athlete’s ankle (image copyright: Pieter D’Hooghe)
542 16.4.6.3 E ntire Posterior Process 16.5 Rehabilitation 579

543 Fractures
544 These injuries are usually fractures of the lat- Rehabilitation is an essential aspect in the manage- 580
545 eral or posterior process and comprise some of ment of the athlete ankle fracture. The aim of 581
546 the most commonly missed fractures in acute arthroscopy is to improve functional outcome and 582
547 ankle injuries. Routine AP and lateral radio- reduce morbidity and shorten rehabilitation time. 583
548 graphs do not often show acute fractures and Therefore, it is commonly used as a valuable tool in 584
549 may be incorrectly interpreted. CT scan sports-related ankle injuries. Initial elevation after 585
550 remains the mainstay of diagnosis, but there injury or operation, as well as early range of motion 586
551 also needs to be a high index of suspicion by exercises as soon as safely possible, is encouraged 587
552 the assessing physician [2, 5]. Lateral process in the early postoperative phase [2] (Table 16.1). 588
553 fractures in sports often present with signs During the healing process of operatively treated 589
554 and symptoms of a simple ankle sprain. ankle fractures, adequate follow-up is advised, as 590
555 Undiagnosed and untreated fractures often lead chronic ankle pain may occur. Chronic pain after 591
556 to persistent lateral ankle pain and late subtalar fracture consolidation may arise as a result of soft- 592
557 joint arthritis. Outcomes are suboptimal when tissue impingement, bony impingement, or loose 593
558 diagnosis and treatment are delayed for more bodies. Arthroscopy has been shown to improve the 594
559 than 2 weeks [5, 60]. Type 1 fractures benefit outcome of chronic pain after fracture surgery. As 595
560 from stable fixation usually via an open surgi- demonstrated by Kim et al., pain scores improved 596
561 cal technique. Type 3 fractures respond well to when hardware removal after ORIF of ankle frac- 597
562 conservative treatment. Type 2 fractures, how- tures was combined with arthroscopy, compared to 598
563 ever, appear to respond best to early removal of hardware removal alone [61]. 599
564 the fracture fragments as opposed to delayed
565 surgery. Removal of these fracture fragments
566 by arthroscopy would reduce the surrounding 16.6 G
eneral Outcomes and Time 600
567 soft-tissue dissection and potentially accelerate to Return to Competition 601
568 return to normal activity. However, at present, (Table 16.1) 602
569 there is no study available that supports this
570 theory. Further studies are therefore necessary Outcomes from the general population cannot be 603
571 in this area. Posterior process fractures usually directly extrapolated to athletes, who usually 604
572 occur as a result of forced plantar flexion inju- receive better and more intense rehabilitation. 605
573 ries and are even less common than lateral pro- Their safe and prompt return to a highly demand- 606
574 cess fractures. Most of these injuries are ing level of activity is paramount. Evidence on 607
575 initially treated with conservative management, outcomes on the rare fractures around the ankle 608
576 but a small number of cases with significant (i.e., process and talar fractures) in sports is 609
577 comminution may be appropriately treated by scarce as discussed earlier. Some evidence on the 610
578 early arthroscopic debridement [5]. more common malleolar type fractures has been 611
Table 16.1 Time (in weeks) athletes required the use of rehabilitative devices and time when athletes were able to t1.1
resume activities [2] t1.2
Classification N Crutches Boot Brace Daily living Practice Competition t1.3

Lateral malleolus fracture 6 1.3 ± 0.5 3.0 ± 0.9 4.3 ± 3.8 1.2 ± 0.8 5.0 ± 0.9 6.8 ± 2.4 t1.4
Medial malleolus fracture 2 2.0 ± 1.4 2.0 ± 1.4 7.0 ± 1.4 2.0 ± 0.0 12.0 ± 5.7 17.0 ± 9.9 t1.5
Bimalleolar fracture 10 3.7 ± 1.6 3.7 ± 2.0 4.2. ± 2.2 1.0 ± 0.5 10.9 ± 4.0 12.7 ± 4.0 t1.6
Syndesmosis disruption injury 4 3.3 ± 1.0 2.3 ± 1.3 6.8 ± 6.1 0.8 ± 0.5 13.5 ± 2.5 15.8 ± 1.7 t1.7
Salter-Harris-type fracture 4 2.0 ± 0.8 3.5 ± 1.7 9.0 ± 1.2 1.0 ± 0.0 6.3 ± 1.3 8.5 ± 1.0 t1.8
Pilon fracture 1 4.0 2.0 2.0 1.0 8.0 16.0 t1.9
612 documented and allows for conclusions to be Studies specifically looking at ankle fractures 660
613 made [2]. It has to be noted that a number of stud- in elite athletes are limited [2, 8, 9, 63], but 661
614 ies reporting time-loss ankle injuries provide lim- appear to demonstrate that a successful return to 662
615 ited information. These studies often group ankle high-level competition can be expected. A study 663
616 injuries together, with the severity of injury often by Dunley et al. on three professional American 664
617 being defined by the time to return to sport (rather football players showed that all three returned to 665
618 than the type of injury) [2]. their pre-injury level [9]. Walsh et al. reported 666
619 Surgical treatment may allow a more rapid similar findings in a study on the surgical treat- 667
620 recovery, with earlier weight bearing and func- ment of ankle fractures in three American foot- 668
621 tional rehabilitation providing a speedier return ball players and one soccer player [63]. Another 669
622 to normal daily living and work. However, a study by Oztekin et al. looked at the time-loss 670
623 recent systematic review by Donken et al. looked from play in ankle injuries of Turkish profes- 671
624 at surgical versus conservative intervention for sional football players. In this study, all patients 672
625 treating ankle fractures in adults [62]. They con- that were surgically treated for their ankle frac- 673
626 cluded that there is insufficient evidence to deter- ture were able to return to their previous level of 674
627 mine which type of treatment provided better play [64]. A layoff of 150 days in this study was 675
628 long-term outcomes. The review only identified reported for two football players (one with a 676
629 four controlled trials (292 adults with displaced Maisonneuve fracture and one with a lateral mal- 677
630 ankle fractures) from the general population. leolar fracture with deltoid rupture), while a 678
631 Also, there were significant variations and limita- patient that was treated for a lateral malleolus 679
632 tions in the types of patients, the surgical and pseudarthrosis took 200 days. Another study by 680
633 rehabilitation protocols applied, the outcomes Porter documented the management, rehabilita- 681
634 reported, and the duration of follow-up. Another tion, and outcomes in 27 athletes with ankle frac- 682
635 study by Colvin et al. looked at the functional tures that underwent ORIF (including repair of 683
636 ability of 243 patients who underwent operative any injured ligaments). The indication for sur- 684
637 fixation of unstable ankle fractures to return to gery was either displacement of ≥3 mm or if the 685
638 “vigorous activity” and sport [7]. athlete was “especially enthusiastic” for an early 686
639 In their study, young and healthy male patients return to sports [8]. The most common sport inju- 687
640 were more likely to return to sport. At 1-year ries were in American football (ten athletes) and 688
641 follow-up—although 88% of recreational ath- baseball (three athletes), but two athletes involved 689
642 letes were able to return to sport—only 11.6% of in soccer were also included. At an average fol- 690
643 competitive athletes were able to do so. low-up of 2.4 years (12 months to 3.7 years), all 691
644 Specifically, those with bimalleolar fractures athletes reported an average 96.4% functional 692
645 were more likely to return to sport, compared rating compared to their pre-injury level, with 12 693
646 with those with unimalleolar fractures. However, athletes rating their ankle as 100%. Early reha- 694
647 this retrospective study analyzed self-reported bilitation and ambulation were encouraged, 695
648 outcomes from a general trauma population only which included the use of an ankle Cryo/Cuff™, 696
649 [7]. Nevertheless, it has been suggested that sur- with athletes encouraged to weight bear in a 697
650 gical management (by open reduction and inter- walking boot within a week postoperatively. 698
651 nal fixation of unstable ankle fractures) in athletes The ability of athletes to be weaned off their 699
652 may provide a number of advantages. Firstly, it rehabilitative devices and the time required to 700
653 would avoid the issues of secondary fracture dis- reach activity goals are shown in Table 16.1 [8]. 701
654 placement which delay recovery. Secondly, it Those athletes with isolated Weber A and B lat- 702
655 would ensure anatomic fracture reduction and eral malleolar fractures were able to return to 703
656 articular surface restoration. Finally, it allows for sport within the shortest time. In this study, return 704
657 early range-of-movement exercises and early to full activity was seen as early as 4 weeks. Two 705
658 weight bearing (within 1–2 weeks of fixation) out of the six athletes did not rate their ankle 706
659 and a more rapid recovery and return to sport [8]. 100% in either flexibility or decreased stability 707
708 issues. Two athletes in this study (with isolated stability and can assist in the accurate reduction 753
709 medial malleolar fractures) required deltoid liga- of displaced (tibial plafond, malleolar, and talar) 754
710 ment repair at the same time. These athletes took fractures. Arthroscopic techniques allow for a 755
711 longer to return to competition, with one patient more rapid rehabilitation, with fewer complica- 756
712 taking 24 weeks to return to motocross racing. tions, than conventional techniques in athletes. 757
713 Athletes with bimalleolar fractures required
714 12.7 ± 4.0 weeks to return to competition, while
715 athletes with syndesmotic injury and pilon frac- References 758
716 tures took slightly longer. The authors did not

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management of fractures about the ankle. J Am Acad 764
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725 that documents arthroscopic-assisted ankle frac- 2013;18(2):185–94. 770
726 ture fixation and its value in return to elite sports 6. d’Hooghe P, Wiegerinck JI, Tol JL, Landreau P. A 771
727 resumption, compared to a control group (with- 22-year-old professional soccer player with atraumatic 772
728 out arthroscopy). Further work is required to ankle pain. Br J Sports Med. 2015;49(24):1589–90, 773
1602-3 774
729 objectively describe the potentially added value 7. Colvin AC, et al. Return to sports following opera- 775
730 of arthroscopy in this return-to-sport tively treated ankle fractures. Foot Ankle Int. 776
731 perspective. 2009;30(4):292–6. 777
8. Porter DA, et al. Functional outcome after operative 778
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spective case series. Foot Ankle Int. 2008;29(9):887–94. 780
732 16.7 Conclusion 9. Donley BG, et al. Pronation-external rotation ankle 781
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735 Optimal management for the elite athlete has to Skelet Radiol. 2005;34(7):389–94. 786
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737 high level of activity. The evidence for current process of the talus in a runner. A case report. J Bone 788
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738 best practice in athlete-related ankle fractures 12. Motto SG. Stress fracture of the lateral process of the 790
739 remains limited. A thorough history, examina- talus – a case report. Br J Sports Med. 1993;27(4):275–6. 791
740 tion, and adequate imaging are essential to cor- 13. Kaeding CC, Yu JR, Wright R, Amendola A, Spindler 792
741 rectly diagnose injuries and decide upon the KP. Management and return to play of stress fractures. 793
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742 optimal treatment plan. Early rehabilitation 14. Glazebrook MA, Ganapathy V, Bridge MA, Stone 795
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744 months depending on the fracture severity. arthroscopy. Arthroscopy. 2009;25(12):1478–90. 797
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1
2
Arthroscopic Treatment
of Anterior Ankle Impingement
17
3 Thomas Bauer
4 17.1 Introduction and talar neck [10]. However, whereas anterome- 28

dial ankle impingement syndrome usually involves 29
5 Ankle impingements are painful syndromes due to tibial and talar osteophytes, ALAIS is usually due 30
6 hyperplasic synovitis and fibrotic soft tissues only to soft tissue interposition. The first report of 31
7 being caught between the ankle and hindfoot bony ALAIS, written in 1950 by Wollin, describes joint 32
8 surfaces during ankle motion. Basically anterior invasion by a mass of connective tissue originating 33
9 ankle impingements occur after injuries or supina- from the anterior talo-fibular ligament (ATFL) [11]. 34
10 tion trauma and can be localized either on the In 1991, Ferkel and Scranton provided further 35
11 anteromedial or the antero-lateral part of the ankle details on the pathophysiology of ALAIS [1]. The 36
12 joint. Diagnosis of ankle impingement is clinical: inciting event is an ankle sprain with injury to the 37
13 palpation associated to passive mobilization of the ATFL. If ligament healing is incomplete, repeated 38
14 ankle reproduces the localized pain recognized by ankle movements result in synovitis, followed by 39
15 the patient. Local injection is an important step not fibrosis with the development of a soft tissue mass, 40
16 only to confirm the diagnosis but also to definitely whose interposition in the joint space causes pain at 41
17 remove painful symptoms in some cases. the talo-fibular groove. Thus, pain due to ALAIS is 42
extremely common and perhaps even inevitable 43
after an ankle sprain, as the ATFL healing process is 44
18 17.2 Distinction Between accompanied with local inflammation. However, 45
19 Anteromedial and Antero- the pain is expected to resolve within a few weeks 46
20 lateral Ankle Impingement after complete ATFL healing. 47
21 Syndrome (ALAIS) ALAIS is closely linked to ATFL injury and, in 48
some patients, to chronic ankle instability. Rota 49
22 Antero-lateral ankle impingement syndrome tional micro-instability of the ankle is challenging 50
23 (ALAIS) manifests as anterior ankle pain at the to document. Pain may be the only manifestation, 51
24 talo-fibular groove. A distinction is classically made with no objective evidence of laxity, and the pre- 52
25 based on whether the impingement is due to bone sentation is then identical to that of ALAIS. 53
26 or soft tissue [1–9]. Bony impingement is caused by
27 osteophytes originating at the anterior tibial margin
17.3 Diagnostic Strategy 54
T. Bauer (*)
Orthopedic Department, Ambroise Paré University
Diagnosis of an anterior ankle impingement is 55
Hospital, West Paris University, clinical, and distinction is made with the localiza- 56
Boulogne-Billancourt, France tion of the pain at palpation: an anteromedial pain 57
© ISAKOS 2019 183

https://doi.org/10.1007/978-3-662-58704-1_17
184 T. Bauer
58 with osteophytes is an anteromedial ankle

59 impingement and a bony impingement, whereas
60 an antero-lateral pain without osteophyte at pal-
61 pation is an antero-lateral soft tissue ankle
62 impingement. The diagnosis of ALAIS rests on
63 clinical findings. ALAIS should be considered in
64 patients with persistent pain 6 months after
65 appropriate treatment of an inversion ankle injury
66 [12]. The reported frequency of ALAIS after
67 ankle sprains is 1–2% but is no doubt consider-
68 ably underestimated [12–14].
69 The clinical manifestations of ALAIS [1, 5, 15,
70 16] include range-of-motion limitation, a swell-
Fig. 17.2 X-rays lateral ankle view: anterior bony
71 ing in the antero-lateral groove, and a locking sen- impingement
72 sation or snapping during dorsiflexion and
73 eversion of the foot. The best diagnostic test is the
74 Molloy test, which is 94.8% sensitive and 88% Anteroposterior and lateral radiographs of the 80
75 specific for ALAIS [17]. The examiner places the ankle rule out bony impingement (Fig. 17.2) and 81
76 foot in forced dorsiflexion while applying pres- osteochondroma and may provide suggestive evi- 82
77 sure to the antero-lateral groove (Fig. 17.1). The dence of an osteochondral lesion [18]. Ultraso 83
78 test is positive if this maneuver replicates the nography documents the soft tissue impingement. 84
79 usual pain. A heterogeneous mass larger than 7 mm in diam- 85
eter is visible at the antero-lateral corner of the 86
ankle [19, 20]. The mass is hypervascular by 87
Doppler ultrasonography. Performing the Molloy 88
test during ultrasonography confirms the soft tis- 89
sue impingement, with a mass bulging in the 90
antero-lateral groove during ankle dorsiflexion, 91
but fails to add to the physical examination (77% 92
sensitivity and 55% specificity) [19]. Importantly, 93
ultrasonography serves to guide the corticosteroid 94
injection, which is crucial to both the diagnosis 95
and the treatment of ALAIS [20, 21]. Computed 96
tomography (CT) arthrography has 97% sensitiv- 97
ity and 71% specificity for ALAIS. Nodules may 98
be visible in the antero-lateral groove, and the joint 99
capsule contour may appear uneven. However, CT 100
arthrography has little impact on therapeutic deci- 101
sion-making [22]. Magnetic resonance imaging 102
(MRI) contributes little to the diagnosis of 103
ALAIS. Sensitivity has ranged from 39 to 100% 104
and specificity from 50 to 100% [23–28]. MR 105
arthrography performs better, however, with 96% 106
sensitivity and 97% specificity [29]. 107
Liu et al. defined six clinical criteria for the 108
diagnosis of ALAIS [4]: persistent antero-lateral 109
Fig. 17.1 Molloy test: the examiner applies pressure to
the antero-lateral groove while moving the ankle into pain after a sprain of the lateral collateral liga- 110
forced dorsiflexion ments, antero-lateral effusion and swelling, 111
17 Arthroscopic Treatment of Anterior Ankle Impingement 185
112 recurrent tibio-talar pain after exercising, antero- ankle impingement syndrome (Fig. 17.4a, b). In 157
113 lateral pain during dorsiflexion with eversion, case of malleolar osteophytes (at the tip and ante- 158
114 pain during single-leg squats, and absence of lat- rior margin of the medial malleolus), after resec- 159
115 eral laxity. Patients with at least five of these cri- tion of the osteophyte, a large resection of the 160
116 teria were diagnosed with ALAIS [4]. These anterior surface and tip of the medial malleolus is 161
117 criteria require the elimination of ankle instability made in order to decrease the volume of the 162
118 based on the absence of objective lateral laxity. medial malleolus and avoid anteromedial rem- 163
119 They do not consider rotational micro-instability, nant impingement in dorsiflexion and inversion. 164
120 which is difficult to establish clinically. The six In patients with ALAIS, arthroscopy may 165
121 criteria may be met in patients with true rota- show several abnormalities, which are often pres- 166
122 tional micro-instability who have no symptoms ent in combination: focal or extensive inflamma- 167
123 other than those of ALAIS. The physical exami- tion of the synovial membrane, which has a 168
124 nation alone has 94% sensitivity and 75% speci- pinkish-purple hue; one or more bands of scar 169
125 ficity for the diagnosis of ALAIS [4, 30]. tissue, in some cases with a meniscoid appear- 170
ance at the level of the distal band of the antero- 171
inferior tibio-fibular ligament; osteophytes 172
126 17.4 Arthroscopic Treatment arising from the anterior margin of the distal tibia 173
and neck of the talus, best seen with the ankle in 174
127 Anterior ankle impingement surgical treatment is forced dorsiflexion; ossifications at the anterior 175
128 performed as an arthroscopic procedure. The edge and tip of the lateral malleolus; and osteo- 176
129 standard patient installation for anterior ankle chondral loose bodies in the anterior talo-fibular 177
130 arthroscopy is used, without joint distraction. groove. 178
131 Two portals are created, one anteromedial and the The resection is started at the distal band of 179
132 other antero-lateral. The arthroscope is 4.0 mm in the anteroinferior tibio-fibular ligament in order 180
133 diameter. The instruments (hook probe, 4.0-mm to visualize this major anatomical landmark. The 181
134 power shaver, power scalpel) are introduced synovectomy is then extended to the antero- 182
135 through an antero-lateral portal created under lateral corner of the ankle and, subsequently, to 183
136 direct visual guidance after insertion of a needle. the anterior tibio-talar compartment and antero- 184
137 The anterior part of the joint is cleared with the lateral groove. 185
138 ankle in forced dorsiflexion until the anterior tib- At the antero-lateral groove, the resection of 186
139 ial margin, talar neck, and both malleoli are visi- synovial membrane and fibrous tissue should be 187
140 ble. The fibrous and inflammatory tissue is stopped at the upper edge of the ATFL, which 188
141 removed completely, to make the bony landmarks should be identified routinely. At this point, the 189
142 and any osteophytes clearly visible. risk is excessive extension of the synovectomy, 190
143 In patients with anteromedial bony impinge- with partial or complete resection of the ATFL, 191
144 ment, an anterior synovectomy is first performed which would worsen any pre-existing instability 192
145 and then a complete resection of the tibial and and, even more importantly, result in persistent 193
146 talar osteophytes after complete visualization. pain from ALAIS. 194
147 Osteophyte resection is begun at the level of the After starting the synovectomy, the crucial step 195
148 origin of the bone spur (anterior tibial margin or in the arthroscopy procedure is a visual assess- 196
149 talar neck) with a progression from its insertion ment of the antero-lateral groove with detection 197
150 to the articular surface: thus for a tibial osteo- of any ATFL lesions. Following the anteroinferior 198
151 phyte the resection is performed from proximal to tibio-fibular ligament in the medial-to-lateral 199
152 distal, and for a talar osteophyte, the resection is direction leads to the ATFL, where any lesions 200
153 performed from distal to proximal (Fig. 17.3a–c). can be assessed visually and with the probe [31, 201
154 With this technique a complete and flat resection 32]. Distension of the ligament plane should be 202
155 of the osteophyte can be achieved without resid- sought, as well as detachment from the malleolus 203
156 ual bone spur that can lead to a recurrent anterior (by inserting the hook between the anterior mal- 204
186 T. Bauer
a b c
Fig. 17.3 (a–c) Arthroscopic technique of anterior ankle osteophyte resection from its implantation in the direction of
the articular surface to achieve a complete resection
a b
Fig. 17.4 (a, b) Bad technique of osteophyte resection (beginning at the joint line) with risk of residual osteophyte
205 leolar edge and the ATFL), talar avulsion, and a good or excellent outcomes [3, 5, 9, 35–37]. 224
206 tear in the body of the ligament (which is less Compared to open surgical treatment of ALAIS, 225
207 common). The quality of the residual ATFL the time to recovery is halved with arthroscopic 226
208 should be assessed as thinned, discontinuous and treatment, and the time to sports resumption is 227
209 irregular, or thick and strong [32]. Appropriate decreased by about 1 month [35]. An important 228
210 repair of any ATFL lesions seems reasonable [33]. distinction is between isolated anterior impinge- 229
ment, in which a good outcome can be expected, 230
and impingement due to osteophytes occurring as 231
211 17.5 Outcomes of Surgical an early manifestation of tibio-talar cartilage 232
212 Treatment: Literature Review degeneration, which has a more reserved progno- 233
sis. Tol et al. and van Dijk [27, 35] reported that 234
213 In early studies of arthroscopic methods for treat- the proportion of patients with good or excellent 235
214 ing ALAIS, outcomes were good or excellent in outcomes after arthroscopic treatment for ante- 236
215 over 60% of cases, with a complication rate rang- rior osteophytes was 82% when the joint space 237
216 ing from 10 to 15% (nerve injury, superficial was intact compared to only 50% in the event of 238
217 surgical-site infection) [4]. In more recent stud- joint space narrowing. In the medium or long 239
218 ies, the rate of good or excellent outcomes was term, however, no progression of the cartilage 240
219 67–100%, and complications were considerably lesions occurs after arthroscopic treatment for 241
220 less common than with open surgery and in early ALAIS, and about two-thirds of patients remain 242
221 studies of arthroscopic treatment [3, 5, 8, 34, 35]. satisfied or very satisfied for many years despite 243
222 Anterior bony impingement involving osteo- experiencing functional impairments [35]. 244
223 phytes had the best prognosis, with over 80% of Furthermore, although the osteophytes recur 245
246 within a few years after the arthroscopic proce- festations of ALAIS. No anterior or lateral laxity 291
247 dure, most patients remain free of symptoms, is found upon physical examination or imaging 292
248 indicating that the ankle pain is not caused by the studies. Use of the term “functional instability” to 293
249 osteophytes but, instead, by pinching of the syno- designate this presentation, as opposed to “mechan- 294
250 vial membrane and synovitis [35]. A multicenter ical instability” (with objective laxity), in the 295
251 study reported in 2007 identified three predictors English-language literature adds to the confusion. 296
252 of arthroscopic treatment failure in patients with In a study by Takao et al. of 14 patients with func- 297
253 ALAIS [36]: older age (mean age at surgery was tional instability, arthroscopy consistently showed 298
254 46 years in patients with poor outcomes and lesions of the ATFL (partial fibrosis, n = 9; total 299
255 34 years in those with good or excellent out- fibrosis, n = 3; and detachment, n = 2) [39]. More 300
256 comes), longer trauma-to-surgery time (mean recently, Vega et al. reported findings in 38 301
257 was 33 months in the group with poor outcomes patients with ALAIS and functional instability 302
258 and 20 months in the group with good or excel- who underwent arthroscopic surgery [40]. Only 303
259 lent outcomes), and cartilage damage (grade 2 half the patients had evidence of synovitis. 304
260 lesions were present in 50% of patients with poor However, proximal detachment and fibrosis of the 305
261 outcomes compared to only 18% of those with ATFL were noted in 60% and 50% of patients, 306
262 good or excellent outcomes). respectively. These recent data confirm the very 307
263 Arthroscopic treatment of ALAIS is extremely high prevalence of ATFL lesions in patients with 308
264 effective in relieving the anterior ankle pain, ALAIS. Most of the studies reporting outcomes in 309
265 allowing a return to previous activities, providing patients treated for ALAIS did not consider micro- 310
266 a good subjective outcome, and improving range instability, which is a recent concept. Thus, for 311
267 of motion. Mobility can be maximized by exten- many years, ALAIS was described under the 312
268 sive capsule and ligament release combined with assumption that the absence of objective laxity 313
269 extensive resection of any anterior osteophytes ruled out ankle instability. Although outcomes of 314
270 [37]. The low complication rate is among the anterior ankle impingement overall are generally 315
271 main advantages of arthroscopic treatment. described as good, the data are less clear for 316
272 Proper arthroscopic technique must be followed ALAIS. Most importantly, although the symp- 317
273 to avoid injury to nerves and tendons. toms of ALAIS originate in ATFL lesions, the 318
274 In a recent systematic review of arthroscopic treatment and outcome of these are only very 319
275 treatment for anterior ankle impingement syn- rarely discussed in the literature [1]. This underes- 320
276 drome, outcomes did not differ significantly timation of the close intertwining between ATFL 321
277 between antero-lateral and anteromedial lesions and ALAIS is probably ascribable to the 322
278 impingement, bony and soft tissue impingement, definition of ALAIS, which excludes ankle insta- 323
279 or impingement with versus without concomitant bility, and to the techniques used early in the 324
280 lesions [38]. The main published studies pooled development of anterior ankle arthroscopy (trac- 325
281 all types of anterior ankle impingement and thus tion, 2.7-mm arthroscope). 326
282 provided no specific data on ALAIS. Advances in ankle arthroscopy have improved 327
the ability to explore the talo-fibular groove and 328
lateral ligament complex, thus providing new 329
283 17.6 C
oncept of Rotational Ankle insight into the pathophysiology of ALAIS by 330
284 Micro-instability demonstrating the key role for ATFL lesions and 331
shedding light on the concept of rotational micro- 332
285 Rotational ankle micro-instability is defined as instability. A new arthroscopic classification of 333
286 any combination of chronic ankle instability chronic lesions of ATFL in chronic ankle insta- 334
287 symptoms with no objective evidence of forced bility has recently been published showing that 335
288 varus or anterior-drawer laxity. The symptoms for early stages of lesions (stage 1 = ATFL dis- 336
289 may consist of recurrent ankle sprains, weakness tension, stage 2 = ATFL avulsion) it creates a 337
290 of the ankle, ankle pain and instability, and mani- rotational ankle micro-instability with symptoms 338
188 T. Bauer
339 of ALAIS [41, 42]. This new knowledge has 14. Cheung Y, Rosenberg ZS. MRI imaging of ligamen- 393
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342 (as appropriate for the observed lesions) in addi- 1950;32:68–9. 397
343 tion to antero-lateral synovectomy. Prospective 16. Cutsuries AM, Saltrick KR, Wagner J, et al.
398
Arthroscopic arthroplasty of the ankle joint. Clin 399
344 multicenter studies are under way with the goal Podiatr Med Surg. 1994;11:449–67. 400
345 of gaining further knowledge about ALAIS and 17. Molloy S, Solan MC, Bendall SP. Synovial impinge- 401
346 rotational ankle micro-instability and of obtain- ment in the ankle: a new physical sign. J Bone Joint 402
347 ing details on outcomes. Surg (Br). 2003;85:330–3. 403
18. Spiga S, Vinci V, Tack S, Macarini L, Rossi M,
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482
1
2
Posterior Impingement
and Os Trigonum
18
3 Hélder Pereira, Jorge Batista, Duarte Sousa,
4 Sérgio Gomes, J. P. Pereira, and Pedro L. Ripoll
5 18.1 Introduction global assessment of the joint and comprehend 21

patient’s symptoms. 22
6 The posterior ankle impingement (PAI) is a clini- According to Ribbans et al. [6], the first descrip- 23
7 cal syndrome which involves a bony structure or tion of surgical treatment of posterior ankle 24
8 soft tissue that becomes entrapped between the impingement syndrome was related to pathology of 25
9 calcaneus and the posteroinferior aspect of the the flexor hallucis longus (FHL) in dancers [7]. 26
10 tibia (Fig. 18.1). Repetitive microtrauma in plan- Given the hindfoot anatomy, FHL pathology can be 27
11 tar flexion is the most frequent mechanism lead- either a differential diagnosis or the cause of symp- 28
12 ing to PAI syndrome [1, 2]. tomatic posterior ankle impingement (Fig. 18.2). 29
13 Recurrent loading in plantar flexion might The description of os trigonum is attributed to 30
14 lead to inflammatory response, soft tissue and/or both Cloquet and Shepherd who have indepen- 31
15 bony edema, and spur formation, ultimately caus- dently performed anatomic descriptions of this 32
16 ing impingement syndromes [3, 4]. However, structure [8]. Moreover, both initially considered 33
17 major acute trauma can also be the source of that this structure derived from a fracture (for this 34
AU2
18 bony or soft-tissue symptomatic PAI [5]. reason it was called Shepherd’s fracture). The 35
19 One must understand the involved mechanism former finally recognized that this structure was 36
20 of each sports/activity, and always perform a in fact a secondary ossification center of the 37
H. Pereira (*) J. Batista

AU1 I3B’s Research Group - Biomaterials, Biodegradables Clinical Department Club Atletico Boca Juniores,
and Biomimetics, Univ. Minho, Headquarters of the CAJB – Centro Artroscopico,
European Institute of Excellence on Tissue Buenos Aires, Argentina
Engineering and Regenerative Medicine, D. Sousa
Guimarães, Portugal Orthopedic Department of Póvoa de Varzim, Vila do
ICVS/3B’s - PT Government Associated Laboratory, Conde Hospital Centre, Póvoa de Varzim, Portugal
Guimarães, Portugal S. Gomes · J. P. Pereira
Orthopedic Department of Póvoa de Varzim, Vila do International Centre of Sports Traumatology of the
Conde Hospital Centre, Póvoa de Varzim, Portugal Ave, Taipas, Portugal
Ripoll y De Prado Sports Clinic: Murcia-Madrid P. L. Ripoll
FIFA Medical Centre of Excellence, Murcia, Spain Ripoll y De Prado Sports Clinic: Murcia-Madrid
FIFA Medical Centre of Excellence, Murcia, Spain
International Centre of Sports Traumatology of the
Ave, Taipas, Portugal
© ISAKOS 2019 191

https://doi.org/10.1007/978-3-662-58704-1_18
192 H. Pereira et al.
a b
Fig. 18.1 (a) Posterior impingement test, in which the pain from the patient (yellow arrow); (b) 3D CT image in
examiner induces stress in hindfoot combining some plan- plantar flexion demonstrating the impingement of an os
tar flexion (blue arrow) and posterior manual gridding of trigonum between the posterior distal tibia and calca-
the hindfoot aiming to reproduce a recognizable posterior neus—posterior ankle impingement
p osterior talar process [8]. Often this structure is 38

asymptomatic, but after a trauma or repeated 39
loading it might cause pain and functional limita- 40
tion (Figs. 18.3 and 18.4). Together with hyper- 41
trophic posterior talar process, these are probably 42
the most frequent causes of symptomatic PAI [9]. 43
History and clinical examination are the main 44
focuses for the diagnosis of this syndrome. 45
However, imaging might be useful for differen- 46
tial diagnosis or preoperative planning. 47
Conservative treatment (physiotherapy, injec- 48
tions, shoe wear) is usually the first option when 49
dealing with symptomatic PAI [3, 5, 10, 11]. 50
Upon failure of conservative management sur- 51
gical treatment is recommended [3, 5, 10, 11]. 52
Surgery evolved from open to endoscopic pro- 53
Fig. 18.2 Entrapment of the flexor hallucis longus cedures [6]. Since Vand Dijk’s description of the 54
(FHL—red arrow) inside its sheath with hypertrophic soft
tissue (fibrosis—yellow arrow) causing soft-tissue poste-
two-portal endoscopic approach of the hindfoot in 55
rior ankle impingement. The hook probe is used to find the the year 2000, most cases of PAI are treated by 56
opening of FHL tunnel minimally invasive endoscopic approach [2, 9, 12]. 57
18 Posterior Impingement and Os Trigonum 193
a b
Fig. 18.3 (a) Lateral X-ray demonstrating a fracture of between its original and final position); (b) MRI showing
the fibrous connection of an os trigonum (yellow arrow) os trigonum fracture with focal edema in a child (yellow
which became dislocated (red line shows the difference arrow)
a b
Fig. 18.4 (a) MRI with synovitis and inflammatory tissue surrounding an os trigonum (yellow arrow); (b) 3D CT
showing posterior entrapment of os trigonum (yellow arrow)
18.2 Epidemiology, Diagnostic, considered as an acute entity following a trau-

and Mechanisms of Injury matic event (os trigonum or Stieda process frac-
for Posterior Ankle ture or dislocation) [10, 13–15] or chronic,
Impingement (PAI) linked to repetitive microtrauma (which might
also be combined/aggravated by CAI). Chronic
Posterior impingement syndrome is related to a cases can be linked to hypertrophic os trigonum
mechanical conflict of the hindfoot aggravated or posterior talar process as well as related frac-
by hyperplantarflexion [11]. It can be either tures or soft-tissue impingement (e.g., cysts,
58 labral injuries, hypertrophic intermalleolar lig- ary ossification center of the posterolateral talus. 87
59 aments). It is often observed in ballet dancers, In 7–14% of adults it remains as a separate acces- 88
60 footballers, cyclists, swimmers, acrobatic gym- sory bone, which is bilateral in 1.4% of cases [8]. 89
61 nasts, and downhill runners (Fig. 18.5) [5, 8, This structure is usually asymptomatic, but it 90
62 10, 16]. may become painful in individuals participating 91
in sports involving repeated plantar flexion [18]. 92
On the other hand, the incidence of os trigo- 93
63 18.2.1 Epidemiology num syndrome in athletes is highly variable, 94
ranging from 1.7% to 50%. Moreover, it has also 95
64 When considering literature, most descriptions of been stated that between 33% and 50% of ath- 96
65 PAI are connected to dance (around 60% of letes present it bilaterally [19, 20]. It appears that 97
66 reported studies) [6, 8] followed by increasing there are no major differences concerning gender 98
67 interest and research in football [6, 8]. or age [20]. 99
68 Somewhat surprisingly, PAI is one of the most It is less frequent to find PAI in the nonathletic 100
69 frequent causes for players considered unable to population or athletes from sports which require 101
70 train/play related to foot and ankle problems [6, 8]. less frequently ankle plantar flexion. In patients 102
71 However, the true incidence and prevalence of who present with chronic hindfoot pain and do 103
72 this condition are still unknown or at least debat- not participate in activities with repetitive plantar 104
73 able, particularly if all possible causes are con- flexion, it is more likely to find anatomic varia- 105
74 sidered [5, 6]. One study followed 186 ballet tions as cause of PAI and these should be ruled 106
75 dancers during 1-year follow-up and identified a out [5]. 107
76 prevalence of PAI of 6.5% [17].
77 PAI was the cause for 31% of all days lost for
78 sports activity due to foot and ankle conditions, 18.2.2 Diagnosis 108
79 which was higher than lateral ankle ligament
80 injuries and Achilles disorders combined [6]. Once being considered a syndrome, clinical diag- 109
81 Bony-related PAI is apparently two times nosis based on a complete history and careful 110
82 more frequent than soft-tissue etiology [6, 8]. clinical examination is of major relevance. The 111
83 Amongst bony reasons, os trigonum or hypertro- clinical presentation of PAI usually includes deep 112
84 phic Stieda process are the most usual causes [6]. posterior ankle pain caused/aggravated by plan- 113
85 An os trigonum is an accessory bone which tar flexion of the ankle joint, descending stairs or 114
86 follows a developmental variation of the second- uneven ground, or high heels [21]. Patients tend 115
a b c
Fig. 18.5 Mechanisms of repeated microtrauma and demi-pointe (left foot) (b) and football player while kick-
hindfoot overload in plantarflexion (yellow arrows) in ing a ball (c). In red is shown the angles of plantar flexion
gymnasts (a). Ballet dancer en-pointe (right foot) and required for these technical gestures
116 to describe consistent, sharp, dull, and radiating which has shown significant superior diagnostic 164
117 hindfoot pain. Nevertheless, often they cannot accuracy compared with the lateral view in the 165
118 indicate the exact painful location/spot. The pos- detection of os trigonum or other bony causes of 166
119 terior impingement test, in which the examiner PAI. 167
120 induces stress in hindfoot combining some plan- In a study from the Amsterdam School, the 168
121 tar flexion and posterior manual gridding aiming mean sensitivity and specificity of the lateral 169
122 to cause a pain that the patient recognizes as his/ view were 50% and 81%, respectively. For the 170
123 her major complaint (Fig. 18.1), is the most PIM view, these were 78% and 89%, respectively 171
124 important maneuver [1, 2]. A significant amount [21]. 172
125 of false positive for hyperplantarflexion test has CT is considered gold standard having higher 173
126 been empirically reported [1, 2]. sensitivity for bony impingement [10, 14, 15, 22, 174
127 Physical examination should include evalua- 24–26] (particularly small ossicles, loose bodies, 175
128 tion of gait and alignment. A complete neurovas- painful broken osteophytes. or missed fractures 176
129 cular examination as well as assessment of (e.g., Cedell’s fracture) (Fig. 18.6). It is also a 177
130 strength and range of motion (active and passive) valid resource for preoperative planning concern- 178
131 are also required. Hindfoot pain aggravated by ing joint’s bone morphology. 179
132 plantar flexion of the ankle reinforced by a posi- Ultrasound provides dynamic assessment of 180
133 tive posterior impingement test (Fig. 18.1) pro- the hindfoot, besides being operator dependent, 181
134 vides the diagnosis of PAI. A negative test makes and is often more useful in soft-tissue patholo- 182
135 the diagnosis of PAI much more unlikely; how- gies [22]. 183
136 ever, there are no studies reporting on the speci- MRI (Fig. 18.7) for PAI will show edema of 184
137 ficity or sensitivity of the plantar flexion test in bone or surrounding soft tissue (T2 images are the 185
138 the diagnosis of PAI. The examiner must care- most valuable in this setting) [22]. Moreover, it 186
139 fully try to assess the precise location of tender- enables assessment of several anatomic variations 187
140 ness. As example, posteromedial pain over the including accessory muscles, labral pathology, 188
141 posterior tibial tendon suggests posterior tibial synovitis, cysts, capsule, or ligament’s changes 189
142 tendon pathology and not PAI. [16, 27, 28]. 190
143 It is suggested to flex and extend the great toe However, in some cases, imaging might fail in 191
144 (passive and active examination) while palpating providing definitive diagnostic. Currently, the 192
145 the course of the FHL once this might help in the arthro-endoscopic approach enables minimally 193
146 identification of FHL pathology. invasive assessment of the hindfoot while provid- 194
147 A neurologic examination should be per- ing a tool for final treatment [2, 9]. 195
148 formed to exclude tarsal tunnel syndrome, once
149 the pain might also be caused by Valleix’s sign
150 (proximal tingling and plantar paraesthesia when 18.2.3 Mechanisms of Injury 196
151 tibial nerve is percussed posterior to medial
152 malleolus). Mechanisms of injury in PAI can basically be 197
153 In most cases, imaging is used for differential divided as overuse or blunt trauma. 198
154 diagnosis or preoperative planning [3, 22]. It must be considered that, in some move- 199
155 In standard X-rays, standing anteroposterior ments/technical gestures (e.g., kicking a ball), 200
156 (AP), mortise, and lateral views of ankle joint are both the anterior (by direct trauma) and posterior 201
157 routinely used. The lateral view is the most help- (indirect forces with repeated strain on the hind- 202
158 ful to assess the hindfoot (e.g., Stieda process, os foot) ankle compartments are affected [29, 30]. 203
159 trigonum, osteophytes, loose bodies, chondroma- Indirect recurrent loading of both compartments 204
160 tosis, subtalar coalition). However, more recently, can occur in cycling. On the other hand, ballet 205
161 the posterior impingement (PIM) view has shown dancing in pointe/demi-point or gymnastics 206
162 to be more effective [23]. The PIM view is a lat- might load more frequently the hindfoot through 207
163 eral, 25° exo-rotation, oblique view of the ankle, indirect forces (Fig. 18.5). 208
a b
Fig. 18.6 (a) Axial and (b) sagittal CT views of a Cedell’s fracture (fracture of the medial tubercle of the posterior
process of the talus with risk for FHL entrapment)
a b
Fig. 18.7 (a) CT sagittal view in which is visible the talar by an os trigonum (yellow arrow); (b) MRI showing
impression (blue arrow) caused by posterior impingement hypertrophic intermalleolar ligament (red arrow) and
effusion surrounding os trigonum (yellow arrow)
209 PAI can sometimes be found combined with Repetitive microtrauma can be due to spe- 218
210 anterior impingement syndrome, ankle instabil- cific activities and gestures but might also be 219
211 ity, or other joint pathologies. So, differential linked or aggravated by combined chronic 220
212 diagnosis must be considered. Other causes of ankle instability [5] which facilitates repetitive 221
213 posterior ankle pain include Achilles tendon or strains in the posterior ankle compartment. As 222
214 tibialis posterior pathologies, peroneal sheath previously referred, examples of sports-related 223
215 contents, tibial or sural nerve lesions, as well as and gesture-related PAI include kicking the ball 224
216 ankle or subtalar primary joint lesions (from in football, ballet dancing (mainly due to pointe 225
217 osteochondral defects to arthritis) [2, 3, 5, 27]. or demi-pointe positions), cycling, swimming, 226
227 acrobatic gymnasts, amongst others [3, 5, 6, 13, Bony impingement seems to be twice more 271
228 18, 27, 30, 31]. frequent than any causes related to soft tissue [6]. 272
229 The rapid direction and step’s changes in addi-
230 tion to landings from falls, collisions, and jumps
231 present players with high injury risk during 18.3.2 Soft-Tissue Posterior 273
232 sports. These maneuvers, which are key elements Impingement 274
233 of the sport at the top level, produce high loads to
234 the hindfoot, frequently exceeding the mechani- Soft-tissue posterior impingement enrolls cysts 275
235 cal resistance of the ankle joint [32, 33]. (Fig. 18.8), hypertrophy of posterior intermalleo- 276
236 D’Hooghe et al. have shown an increased likeli- lar ligament, “labral injuries” (Fig. 18.9), flexor 277
237 hood for surgical treatment amongst high-level ath- hallucis longus pathology, and anomalous mus- 278
238 letes with combined chronic ankle instability and cles (anatomical variation inducing hindfoot 279
239 posterior impingement related to os trigonum syn- overload/overstuffing) [5, 6, 16]. Amongst the 280
240 drome [19]. This might be due to the demands of causes of soft-tissue-related, hypertrophic or 281
241 this specific sports, combined with the consequences damaged posterior ligaments including the poste- 282
242 of joint instability which is known to affect globally rior intermalleolar ligament (Fig. 18.10) or tibio- 283
243 the biomechanics of the ankle [28, 29, 31, 34, 35]. talar component of the deltoid are sometimes 284
244 Another possible cause of PAI is major trau- difficult to assess by preoperative imaging but 285
245 matic events including higher energy single must be kept in mind [36]. 286
246 trauma (e.g., hindfoot fractures or dislocated os
247 trigonum) [2, 13, 14].
18.3.3 Ankle and Subtalar Joint- 287
Related Posterior 288
248 18.3 T
ypes of Posterior Ankle Impingement 289
249 Impingement (PAI)
The bone morphology of the posterior ankle 290
250 Several conditions have been identified as possi- and/or subtalar joints can cause symptomatic 291
251 ble sources of PAI. PAI. Despite not very frequent, the posterior 292
252 Two major groups of pathologies were identi- tibial plafond slope can be implicated [6]. 293
253 fied as symptomatic PAI requiring surgical treat- Osteophytes or loose bodies, possibly connected 294
254 ment (according to Ribbans et al.): bony PAI to joint degeneration (Fig. 18.11), are another 295
255 (81% of surgeries) and soft-tissue PAI (42%) [6]. source of PAI. Golano et al. have described par- 296
256 However, causes related to joint changes in the ticularly the possible entrapment of the poste- 297
257 ankle and subtalar joints should also be consid- rior intermalleolar ligament (besides being a 298
258 ered [6]. The most frequent cause enrolling soft- soft-tissue impingement, it can also be consid- 299
259 tissue etiology is related to flexor hallucis longus ered as related to joint pathology—for this rea- 300
260 (FHL) pathology [6, 15, 27]. A summary is pro- son this and other causes might appear 301
261 vided in Table 18.1, based on Ribbans et al. [6]. intentionally repeated in Table 18.1) [36]. 302
262 18.3.1 Bony Posterior Impingement 18.4 Principles of Treatment 303

of Posterior Ankle 304
263 The bony structures possibly involved in PAI are Impingement (PAI) 305
264 located in the tibio-calcaneal interval. Such struc-
265 tures include the posterior malleolus, the posterior Either enrolling, bony, or soft-tissue causes over- 306
266 talar process (Stieda process), an os trigonum, the use or direct trauma the principle of treatment is 307
267 posterior subtalar joint structure, and the posterior reducing mechanical impingement and recurrent 308
268 calcaneal tuberosity [3, 5, 10, 26]. Shepherd’s inflammation. The clinical prognosis appears to 309
269 fracture is still considered whenever fracture be better in those presenting with overuse injuries 310
270 occurs of the posterolateral talar process. rather than trauma [1, 19, 20]. 311
AU3 Table 18.1 Classification of possible causes of posterior ankle impingement t1.1
Causes of posterior ankle impingement t1.2

Bony causes Soft tissue Ankle and subtalar joints t1.3
• Hypertrophic posterior talar process • FHL-related pathologies: • Increased slope posterior t1.4
• Os trigonum − Tendinopathy/synovitis tibial plafond t1.5
• Shepherd’s or Cedell’s fractures − Stenosing tenosynovitis • Loose bodies t1.6
• Accessory ossicles − Low ridding belly • Osteophytes t1.7
• Ossification of FHL tunnel − Scars/adhesions • Pseudomeniscus syndrome t1.8
• Sequelae of posterior malleolus fractures − Tears • Synovitis/posttraumatic t1.9
(malunion, avulsions, periosteal thickening) − Nodules thickened capsule t1.10
• Syndesmotic lesions (including avulsions) − Ossicles • Hypertrophic or damaged t1.11
• Chondromatosis • Hypertrophic or damaged posterior ligaments t1.12
posterior ligaments t1.13
• Synovitis/posttraumatic t1.14
thickened capsule t1.15
• Accessory muscles t1.16
− Peroneocalcaneus internus t1.17
− Tibiocalcaneus t1.18
− Peroneus quartus t1.19
• Cysts/ganglions t1.20
a b
Fig. 18.8 (a) MRI showing cyst with fluid causing impingement (yellow arrow); (b) arthroscopic view of the same cyst
(yellow arrow) causing soft-tissue impingement
312 18.4.1 Conservative Treatment even without any evidence supporting it [37]. 320
However, these biologic agents are becoming rec- 321
313 Conservative treatment of PAI includes rest, mod- ognized as promising adjuvants that may have a 322
314 ification of shoe wear, change of activity, ortho- positive impact on tissues and decrease the inflam- 323
315 ses, physiotherapy, anti-inflammatory drugs, and matory responses [15, 37, 38]. 324
316 ultrasound-guided injections [6]. Biologics includ- Ultrasound-guided injections may be useful in 325
317 ing hydrogels (hyaluronic acid), growth factors high-level athletes for transient symptom relief, 326
318 (e.g., platelet-rich plasma), and stem cells (e.g., possibly enabling them to finish the competitive 327
319 concentrated bone marrow aspirate) may be used season [39]. 328
329 Although there is lack of published evidence There is a poor standardization of outcome 342
330 concerning the success rate with conservative reported in literature concerning the different treat- 343
331 treatment [6], a small cohort study reported ment options which impairs definitive conclusions. 344
332 around 60% of success rates following conserva- However, the complication rates [41] are quite low 345
333 tive treatment in PAI [40]. for both open medial and arthro-endoscopic sur- 346
gery [42, 43] (around 4% or less for endoscopy). 347
However, the chance for complications is three 348
334 18.4.2 Surgical Treatment times higher (12%) for open lateral approaches 349
[6]. So, this option must be carefully considered 350
335 Upon failure of conservative measure, surgical and limited in its indications. 351
336 resolution of the mechanical conflict with/with- Earlier return to activities, including all levels 352
337 out removal of inflammatory tissue is required. of sports, has been reported in the arthro- 353
338 According to Ribbons et al., 81% of patients endoscopic group [11, 13, 16, 18, 19, 25, 27, 28, 354
339 required surgical excision when osseous pathol- 35, 44, 45]. However, there is insufficient evi- 355
340 ogy was involved and 42% when soft-tissue dence supporting differences on the long-term 356
341 problems were implicated [6]. outcome of one approach over the other [6, 11, 357
13, 16, 18, 19, 25, 27, 28, 35, 44, 45]. Football 358
players apparently return faster to same level of 359
previous activities when compared to dancers [6, 360
8, 11, 13, 16, 18, 19, 25, 27, 28, 35, 44, 45]. As 361
previously stated, there seems to be an increased 362
likelihood for surgical treatment amongst high- 363
level athletes with combined chronic ankle insta- 364
bility and posterior impingement related to os 365
trigonum syndrome [19]. 366
The two-portal endoscopic approach for the 367
hindfoot described by Van Dijk et al. represented a 368
huge step forward in the surgical treatment of PAI 369
[12]. It enables addressing bony or soft- tissue 370
impingement in a reproducible, safe, and adapt- 371
able method [1, 3, 6, 14, 25, 44–46]. The arthro- 372
scope is placed first in the lateral portal aiming for 373
the first interdigital space. Afterwards, the shaver 374
Fig. 18.9 MRI showing labral lesion (yellow arrow) and is introduced in the medial portal at 90° with the 375
posterior talar process edema (red arrow) arthroscope and it slides along its course until hit- 376
a b c
Fig. 18.10 (a) Arthroscopic view of fibrosis and synovitis; (b) hypertrophic intermalleolar ligament; (c) final look after
endoscopic removal of soft-tissue impingement
a b c
d e f
Fig. 18.11 Ankle and subtalar joint degeneration causing cleaned subtalar joint (e), and cleaning and release of FHL
flexor hallucis longus (FHL) entrapment (a), several sheath (f)
osteophytes and loose bodies (b–d) and final look of the
377 ting on solid bone. The scope is gently and slightly ity is possible within 4–6 weeks for most iso- 399
378 pulled back keeping its orientation and the shaver lated procedures [11]. 400
379 slightly advanced. The shaver is now visible. A The knowledge of hindfoot anatomy [36] is 401
380 few turns of the shaver blade will create an open- essential and the step-by-step technique has been 402
381 ing in Rouviére and Canela ligament. The arthro- described elsewhere [1]. Whenever it is the case, 403
382 scope is afterwards introduced through this effort shall be made to remove the os trigonum in 404
383 opening and the hindfoot and subtalar joint become one piece aiming to avoid leaving small loose 405
384 visible. The next step will be to find the FHL bodies behind (Fig. 18.12). 406
385 which represents the medial border of the safe Sometimes, besides the clinical diagnosis, 407
386 working area (lateral to it). Keep in mind that the imaging fails to provide the etiology of the com- 408
387 neurovascular bundle is medial to the FHL. The plains. This is the case of loose bodies which can 409
388 hindfoot is now available for assessment and treat- move around the hindfoot. In such cases, the 410
389 ment [1]. diagnosis can be made by endoscopic approach 411
390 The arthro-endoscopic approach lowered the with immediate treatment. However, patients 412
391 surgical aggression enabling an outpatient pro- must receive information and agree with the 413
392 cedure for most cases with early weight bearing approach (Fig. 18.13). 414
393 (from day 1 if tolerated) and active range of Taking a look on the future, the good results 415
394 motion [1, 3, 6, 14, 25, 44–46]. Several authors and low complication’s rate of posterior endo- 416
395 highlight the relevance to start active scopic approach have provided a valid source of 417
396 dorsiflexion-plantar flexion exercises as soon as tissue (cells, autograft) from os trigonum or pos- 418
397 possible (from day 1) [2, 5, 9, 43]. Stiches are terior talar process either for transplantation or 419
398 removed around weeks and full return to activ- advanced tissue engineering approaches [47]. 420
a b
c d
Fig. 18.12 (a) Standard two-portal endoscopic view); and (d) arthroscopic view showing the grasper
approach; (b) bony and soft-tissue impingement with holding the os trigonum after its liberation
synovitis; (c) os trigonum removal in one piece (external
18.5 Take-Home Messages plantar flexion of the ankle reinforced by a posi-

tive plantar flexion test provides the diagnosis of
The posterior ankle impingement (PAI) is a clini- PAI. However, global assessment including align-
cal syndrome which involves entrapment of some ment and biomechanics of foot and ankle is
structure between the calcaneus and the postero- mandatory.
inferior aspect of the tibia. It is more frequent to find PAI in athletes
Posterior impingement syndromes are mostly (mainly sports which require frequent ankle plan-
based on clinical diagnosis, with posterior tar flexion) than in the general population.
impingement test playing a role in clinical evalu- PAI is one of the most frequent causes for
ation. History of hindfoot pain aggravated by absence of activity related to foot and ankle for
a b
Fig. 18.13 A case of recurrent hindfoot pain in a football inside flexor hallucis longus tunnel; (b) removal of the
player with sudden onsets of pain in different spots. No loose body and cleaning of some tendon’s damage. The
relevant changes could be identified in preoperative plan- patient became asymptomatic and returned to the pitch at
ning. (a) Endoscopic view where a loose body is seen 4 weeks
421 ballet dancers, footballers, cyclists, swimmers, lateral ankle instability seems to increase the 433
422 acrobatic gymnasts, and downhill runners. need for surgical treatment of PAI. 434
423 Bony impingement appears to be much more Usually, the first treatment approach is conser- 435
424 frequent than soft-tissue causes of PAI. vative treatment. 436
425 Imaging might be helpful in preoperative Arthroscopic/endoscopic approach enables 437
426 planning. high percentage of good results with minimal 438
427 CT has higher sensitivity for bony impinge- complications and fast return to activity for most 439
428 ment (particularly small ossicles or missed frac- causes of PAI. 440
429 tures). MRI and ultrasound can be more helpful The outcome seems to be better in those pre- 441
430 for soft-tissue-related causes. senting overuse injuries when compared to trau- 442
431 Etiology can be overload by repeated micro- matic causes. 443
432 trauma or traumatic events. Combined chronic
Top 10 Evidence-Based References on Arthroscopic Treatment (ICL 17).

1. van Dijk CN, van Bergen C. Advancements Springer. In: Becker R. KG, E. Gelber P.,
AU4 in ankle arthroscopy. J Am Acad Orthop Denti M., Seil R. (eds) ESSKA Instructional
Surg. 2008;16(11):635–46. Course Lecture Book. Springer, Berlin,
2. Ribbans WJ, Ribbans HA, Cruickshank Heidelberg; 2016.
JA, Wood EV. The management of poste- 4. Pereira H, Vuurberg G, Spennacchio P,
rior ankle impingement syndrome in Batista J, D’Hooghe P, Hunt K, Van Dijk
sport: a review. Foot Ankle Surg. 2015; N. Surgical Treatment Paradigms of
21(1):1–10. Ankle Lateral Instability, Osteochondral
3. Haverkamp D, Bech N, de Leeuw P, Defects and Impingement. Adv Exp Med
d’Hooghe P, Kynsburg A, Calder J, Ogut Biol. 2018;1059:85–108.
T, Batista J, Pereira H. Posterior 5. Golano P, Vega J, de Leeuw PA, Mal
Compartment of the Ankle Joint: A Focus agelada F, Manzanares MC, Gotzens V,
van Dijk CN. Anatomy of the ankle liga- JG. Football injuries of the ankle: A review
ments: a pictorial essay. Knee Surg Sports of injury mechanisms, diagnosis and man-
Traumatol Arthrosc. 2016;24(4):944–56. agement. World J Orthop. 2016;7(1):8–19.
6. Frigg A, Maquieira G, Horisberger M. 9. LiMarzi GM, Khan O, Shah Y, Yablon
Painful stress reaction in the posterior sub- CM. Imaging Manifestations of Ankle
talar joint after resection of os trigonum or Impingement Syndromes. Radiol Clin
posterior talar process. Int Orthop. 2017; North Am. 2018;56 (6):893–916.
41(8):1585–92. 10. Correia SI, Silva-Correia J, Pereira H,

7. Nickisch F, Barg A, Saltzman CL, Beals Canadas RF, da Silva Morais A, Frias
TC, Bonasia DE, Phisitkul P, Femino JE, AM, Sousa RA, van Dijk CN, Espregueira-
Amendola A. Postoperative complica- Mendes J, Reis RL, Oliveira JM. Posterior
tions of posterior ankle and hindfoot talar process as a suitable cell source for
arthroscopy. J Bone Joint Surg Am. 2012; treatment of cartilage and osteochondral
94(5):439–46. defects of the talus. Journal of Tissue
8. Walls RJ, Ross KA, Fraser EJ, Hodgkins Engineering and Regenerative Medicine.
CW, Smyth NA, Egan CJ, Calder J, Kennedy 2015. doi:10.1002/term.2092
Fact Box 1: Posterior Impingement • Bony impingement appears to be two times

Epidemiology and Mechanisms of Injury (PAI) more frequent when compared to soft-tis-
• There is low evidence on incidence and sue causes of PAI.
prevalence of PAI. • Usually repeated microtrauma in plantar
• It is more frequent to find PAI in athletes flexion is the most frequent mechanism
than in the general population. (e.g., dancers, footballers).
• PAI is often observed in ballet dancers, • Mechanisms include repetitive overload or
footballers, cyclists, swimmers, acrobatic blunt trauma.
gymnasts, and downhill runners. • Anatomy seems to play a role.
• PAI was the cause for 31% of all days lost • An asymptomatic os trigonum might became
for sports activity due to foot and ankle painful after an ankle sprain—“There is no
conditions, which was higher than lateral such thing as a simple ankle sprain.”
ankle ligament injuries and Achilles disor- • Trauma or “hidden” hindfoot fractures
ders combined. must be ruled out.
Fact Box 2: Diagnosis of Posterior Ankle fractures (e.g., Cedell’s fracture).

Impingement (PAI) • MRI will show edema, of bone or sur-
• PAI is, by definition, a clinical diagnosis. rounding soft tissue (T2 images are the
• Imaging might be helpful in preoperative most valuable in this setting).
planning. • Ultrasound provides dynamic assessment
• CT has higher sensitivity for bony impinge- of the hindfoot, despite being operator
ment (particularly small ossicles or missed dependent.
course lecture book. Springer, Berlin, Heidelberg.

Fact Box 3: Types of Posterior Ankle https://doi.org/10.1007/978-3-662-49114-0_15.
2. van Dijk CN, van Bergen CJ. Advancements
Impingement (PAI)
in ankle arthroscopy. J Am Acad Orthop Surg.
• Bony or soft-tissue causes are possible. 2008;16(11):635–46.
• Os trigonum syndrome, hypertrophic 3. Niek van Dijk C. Anterior and posterior ankle
impingement. Foot Ankle Clin. 2006;11(3):663–83.
posterior talar process, or flexor hallucis https://doi.org/10.1016/j.fcl.2006.06.003.
longus-related pathologies are the most 4. Ross KA, Murawski CD, Smyth NA, Zwiers R,
frequent causes. Wiegerinck JI, van Bergen CJ, Dijk CN, Kennedy
• Some cases combine both. JG. Current concepts review: arthroscopic treat-
ment of anterior ankle impingement. Foot Ankle
• Ankle and subtalar joint pathologies are Surg. 2017;23(1):1–8. https://doi.org/10.1016/j.
also included. fas.2016.01.005.
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ankle impingement syndrome: a systematic four-
stage approach. World J Orthop. 2016;7(10):657–63.
https://doi.org/10.5312/wjo.v7.i10.657.
6. Ribbans WJ, Ribbans HA, Cruickshank JA, Wood
EV. The management of posterior ankle impinge-
Fact Box 4: Treatment Options for Posterior
ment syndrome in sport: a review. Foot Ankle
Ankle Impingement (PAI) Surg. 2015;21(1):1–10. https://doi.org/10.1016/j.
• Conservative treatment is usually the fas.2014.08.006.
initial option for treatment of PAI. 7. Sammarco GJ, Miller EH. Partial rupture of the
flexor hallucis longus tendon in classical ballet
• Arthroscopic approach of bony or soft-
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tissue impingement is the rule upon fail- 1979;61(1):149–50.
ure of conservative treatment. 8. Giannini S, Buda R, Mosca M, Parma A, Di Caprio
• Arthroscopy/endoscopy enables outpa- F. Posterior ankle impingement. Foot Ankle Int.
2013;34(3):459–65. https://doi.org/10.1177/1071100
tient clinical treatment, normally with
713477609.
immediate active range of motion and 9. van Dijk CN, de Leeuw PA, Scholten PE. Hindfoot
weight bearing. Full return to activity is endoscopy for posterior ankle impingement. Surgical
usually achieved between 4 and 6 weeks. technique. J Bone Joint Surg Am. 2009;91(Suppl
2):287–98. https://doi.org/10.2106/JBJS.I.00445.
• It is very important to start active
10. Maquirriain J. Posterior ankle impingement syn-

dorsiflexion-plantar flexion as well as drome. J Am Acad Orthop Surg. 2005;13(6):365–71.
weight bearing in order to prevent stiff- 11. Miyamoto W, Miki S, Kawano H, Takao M. Surgical
ness and provide proprioceptive stimu- outcome of posterior ankle impingement syndrome
with concomitant ankle disorders treated simultane-
lus (prevention of complex regional
ously in patient engaged in athletic activity. J Orthop
pain syndrome). Sci. 2017;22(3):463–7. https://doi.org/10.1016/j.
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scopic approach for diagnosis and treatment of poste-
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586
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1
2
Advanced Techniques
in Arthroscopy of the Foot
19
3 Alastair Younger, Andrea Veljkovic,
4 Michael Symes, and Wafa Al Baluki
5 19.1 Introduction also improve the blood supply around the surgi- 13
cal site to bone. Better cartilage removal may 14
6 Less invasive techniques result in smaller occur in fusions. Cartilage has growth factors 15
7 wounds. This will reduce postoperative swelling preventing new bone formation. 16
8 and pain. This has been shown in ankle arthritis Prior to performing arthroscopic procedures 17
9 to potentially improve outcomes and reduce surgeons should be familiar with and be able to 18
10 length of stay. Other benefits may include perform the open procedures well. The surgical 19
11 reduced narcotic utilization, less wound compli- goals with minimally invasive and arthroscopic 20
12 cations, and less hematoma formation. It may procedures still need to be achieved. 21
A. Younger (*)
Division of Distal Extremities, Department of 19.2 Subtalar Arthroscopy 22
Orthopaedics, University of British Columbia,
Footbridge Clinic for Integrated Orthopaedic Care, 19.2.1 Indications 23
Vancouver, BC, Canada
St. Paul’s Hospital, University of British Columbia, Subtalar arthroscopy is of use in removing carti- 24
lage to perform subtalar, pantalar, and triple 25
Department of Orthopaedics, St-Paul’s Hospital, fusions. Arthroscopy reduces the dissection 26
University Of British Columbia,
involved. A symptomatic os trigonum can be 27
removed through the subtalar joint to avoid the 28
A. Veljkovic
dissection of a posterior approach. Fractures 29
Division of Distal Extremities, Department of
Orthopaedics, University of British Columbia, extending into the subtalar joint involving either 30
Footbridge Clinic for Integrated Orthopaedic Care, the talus or the calcaneus can be percutaneously 31
Vancouver, BC, Canada reduced and transfixed, with arthroscopy being 32
M. Symes used to assist in understanding the fracture pat- 33
St. Paul’s Hospital, University of British Columbia, tern and assessing the reduction once performed. 34
e-mail: admin@drmichaelsymes.com.au
Impingement on the anterior lateral side of the 35
posterior facet can be addressed as part of subta- 36
W. Al Baluki
Department of Orthopaedics, St-Paul’s Hospital,
lar arthroscopy. Subtalar arthroscopy can be 37
University Of British Columbia, performed in conjunction with sinus tarsi 38

Vancouver, BC, Canada debridement and peroneal tendoscopy. 39
© ISAKOS 2019 207

https://doi.org/10.1007/978-3-662-58704-1_19
208 A. Younger et al.
40 19.2.2 Positioning –– The final portal for use in the supine position 84
lies just lateral to the Achilles tendon. The 85
41 The patient is positioned either prone or supine posterior and medial side of the subtalar joint 86
42 depending on surgeon preference and other can be seen and visualized from this approach. 87
43 pathology needing to be addressed.
44 For supine positioning the patient is placed on a
45 beanbag-positioning device. The hip needs to be 19.2.4 Procedure 88
46 internally rotated so that the lateral side of the
47 Achilles tendon can be accessed as a portal. In • Impingement: 89
48 some cases the patient may need to be positioned –– For impingement the sinus tarsi approach 90
49 laterally. A calf or thigh tourniquet is used. is first used. The shaver is used to remove 91
50 Regional, spinal, or general anesthesia can be used the synovium and the interosseous liga- 92
51 and this may change the choice of tourniquet. ment if need be. Once visualized a burr can 93
52 For prone positioning the same anesthetic and be inserted in from the lateral sinus tarsi 94
53 tourniquet alternatives exist. The posterior aspect portal and used to remove the anterior lat- 95
54 of the subtalar joint is easily accessed through eral osteophytes. The direct lateral osteo- 96
55 portals on each side of the Achilles tendon. phytes can also be removed by aiming the 97
56 However anterior ankle arthroscopy or sinus tarsi shaver posterior instead of medial. Once 98
57 debridement is harder to perform in this position. the anterior and lateral side has been 99
debrided the posterior and medial osteo- 100
phytes can be removed by sequentially 101
58 19.2.3 Technique switching to the posterior portals. The 102
scope is therefore moved from the dorsal 103
59 • Equipment: 2.9 scope, 3.5 shaver, 4.5 burr, sinus tarsi portal to the lateral sinus tarsi 104
60 osteotomes, curettes, thigh or calf tourniquet. portal, and to the posterior lateral portals. 105
61 • Portals: –– While the margins of the joint can be 106
62 –– As many portals to access the joint as reached, it is rarely possible to reach an 107
63 needed are performed. osteochondral injury within the joint to 108
64 –– The simplest way to start a subtalar arthros- debride it unless it is small, well contained, 109
65 copy is to start with a sinus tarsi approach. the rest of the joint is in good condition and 110
66 The arthroscope can be inserted dorsally in the lesion is towards the joint edge. 111
67 the sinus tarsi next to the talar neck aimed Sometimes this type of cartilage defect 112
68 down towards the floor of the sinus tarsi. exists after a lateral talar process fracture. 113
69 The shaver is inserted in from a direct lateral • ORIF: 114
70 approach to the floor of the sinus tarsi. The –– Arthroscopy of the subtalar joint can be 115
71 shaver is in a safe position from the skin used to assist reduction in a lateral talar 116
72 nerves, and will be visible from the scope. process fracture, a posterior talar process 117
73 The shaver can then be used to debride the fracture, a medial talar fracture extending 118
74 sinus tarsi and achieve visualization and the into the subtalar joint, or a calcaneal frac- 119
75 contents of the sinus tarsi as well as the ture. The benefit of this approach is that the 120
76 anterior and lateral portion of the subtalar soft-tissue attachments are left in place and 121
77 joint can be seen. The peroneal tendons can the hardware can be correctly placed into 122
78 also often be seen from this portal. the fracture fragment. 123
79 –– The third portal lies just posterior to the sub- –– Anterior lateral process fracture: 124
80 talar joint in the recess behind the fibula, and –– For this fracture the fragments need to be 125
81 above the calcaneus, behind the talus, and large enough to transfix. The soft-tissue 126
82 below the tibia. The lateral and posterior side attachments are left intact and the fracture 127
83 of the joint can be seen from this portal. fragment reduced and held with a K wire. 128
19 Advanced Techniques in Arthroscopy of the Foot 209
129 The reduction is confirmed with arthros- 19.3 Calcaneocuboid Arthroscopy 175
130 copy and fluoroscopy. Sometimes a pelvic
131 reduction forceps is beneficial if placed 19.3.1 Indications 176
132 medially anterior to the FHL tendon to
133 hold the fragment in place. 2 mm or 2.7 mm Synovitis, dorsal chondral injury, acute fracture 177
134 solid screws can be used to maintain fixa- reduction, removal of fracture fragments either 178
135 tion with an appropriate arch to prevent acutely or in symptomatic nonunion of the anterior 179
136 penetration of the joint. calcaneal process, calcaneocuboid fusion in isola- 180
137 –– Posterior fractures and medial process tion or as part of a triple arthrodesis, arthroscopic 181
138 fractures can be visualized in the prone or resection of calcaneonavicular coalition or its vari- 182
139 supine position. These can be reduced ants, ganglion cysts, and CC impingement [1]. 183
140 using either K wires or a pelvic reduction
141 forceps. The screws are then placed with
142 the assistance of the scope from the stable 19.3.2 Positioning 184
143 to the unstable segment.
144 –– For calcaneal fractures the space to enter The patient is placed either in the lateral position 185
145 the subtalar joint exists with the joint with the surgical side superior or in a supine posi- 186
146 depression. The fracture hematoma is tion with the surgical leg internally rotated. A 187
147 removed and the fracture fragments are calf, sterile calf, or thigh tourniquet can be used 188
148 visualized. Once seen the fracture frag- depending on anesthetic choice. 189
149 ments can then be reduced using plantar
150 medial and plantar lateral portals, as well
151 as using traction on the tuberosity segment. 19.3.3 Technique 190
152 Provisional fixation can be achieved using
153 K wires. The fracture reduction can be • Nick spread portal technique is used. 191
154 assessed from the joint margin and by • Instrumentation: 30° 2.7 mm, 2.4 mm, 1.9 mm 192
155 viewing the angle of Gissane. arthroscope for visualization, 2 or 3 mm 193
156 • Arthroscopic fusion: arthroscopic shaver, 4.5 mm burr. 194
157 –– For arthroscopic fusion the above portals • Portals: 195
158 are used to visualize the joint. The cartilage • Three portals can be used to visualize the cal- 196
159 is then sequentially removed. The anterior caneocuboid joint (Fig. 19.1): 197
160 and lateral sinus tarsi approach can initially –– The direct lateral portal is at the level of the 198
161 be used and once the joint is visualized joint line and half way from the dorsal to 199
162 using a shaver a burr can be used to then the plantar side. The sural nerve may be 200
163 start removing cartilage from the posterior close so deep dissection should be blunt. 201
164 facet. Approximately 50% of the cartilage –– The direct dorsal portal is at the joint line 202
165 in the posterior facet can be removed from and lies just next to the lateral side of the 203
166 these two portals, and once cartilage has navicular and talar neck. 204
167 been removed the arthroscope can be –– A dorsal lateral portal is considered the most 205
168 advanced into the joint. All the cartilage important portal located between these two 206
169 should be removed as it may inhibit bone other portals. Fluoroscopy can be used to 207
170 healing. The medial cartilage can only be guide localizing this portal. It is directly 208
171 removed using the posterior portal next to over the space between the TN and CC 209
172 the Achilles tendon. The joint is then held joints. Lateral branch of superficial peroneal 210
173 in a neutral position and screw fixation nerve and the lateral terminal branch of the 211
174 achieved. deep peroneal nerve are at risk [1, 2]. 212
213 19.3.4 Procedure described above. A burr can be placed from 245
the dorsal and lateral side to sequentially 246
214 • Fracture reduction: remove cartilage. The plantar and medial 247
215 –– The arthroscope is placed in the lateral por- cartilage should be removed to ensure solid 248
216 tal and the fracture site visualized. The fusion. Screws can be placed percutane- 249
217 fracture is reduced using K wires and the ously either from the anterior process of 250
218 fracture reduction reviewed. If satisfactory the calcaneus to the cuboid or from the 251
219 then dorsal to plantar screws can be placed. cuboid back. Full thread headless screws 252
220 Accessory portals may be required. are helpful and the trajectory of the screw 253
221 • Dorsal osteophyte removal: needs to be correct to prevent medial pen- 254
222 –– On occasion a dorsal osteophyte can either etration on the cuboid. For isolated calca- 255
223 overhang the calcaneocuboid joint or neocuboid joint fusion three screws are 256
224 impinge. The osteophyte can first be visu- likely needed. 257
225 alized using a shaver from the dorsal portal
226 with the arthroscope placed in the lateral
227 portal. Once visualized the osteophyte is 19.4 Talonavicular Arthroscopy 258
228 then removed under visualization with a
229 burr. Once resected the resection can be 19.4.1 Indications 259
230 checked using the arthroscope and imag-
231 ing. A similar approach is used to remove The talonavicular joint is very congruent and 260
232 fracture fragments that usually lie dorsal tight. It is therefore difficult to perform a pro- 261
233 and proximal to the calcaneocuboid joint. cedure without cartilage removal. Some of the 262
234 • Chondral injury: conditions where arthroscopy can be used 263
235 –– Chondral injuries can occur on the dorsal are fusion, dorsal cheilectomy, and fracture 264
236 side of the calcaneocuboid joint. A curette reduction. 265
237 can be used to debride the cartilage back. The
238 bone margin can also be removed using a
239 burr with removal of the bone back to healthy 19.4.2 Positioning 266
240 cartilage. This is equivalent in principle to a
241 dorsal cheilectomy of a first MTP joint. Patient is positioned supine. The arthroscopy 267
242 • Fusion: tower is placed on the nonsurgical side next to the 268
243 –– Arthroscopic fusion of the calcaneocuboid head of the operating table. Tourniquet can be 269
244 joint can be achieved with the same portals used according to the surgeon preference [1]. 270
Fig. 19.1 Calcaneocuboid
joint arthroscopy: • direct
lateral portal, + direct
dorsal portal, ★ dorsal
lateral portal. Calc
calcaneus, Cu cuboid
bone
Cu
Cal
271 19.4.3 Technique 19.4.4 Procedure 290
272 • Portals: • Fracture reduction: 291

273 • Three portals are usually used for the TN joint –– On occasion a talar head or navicular frac- 292
274 (Figs. 19.2 and 19.3): ture can benefit from an arthroscopic 293
275 –– Dorsal portal to the calcaneocuboid joint approach. The portals are used to visualize 294
276 and also acts as a lateral portal to the TN the fracture fragments to assist in reduc- 295
277 joint. tion. The arthroscopic approach can assist 296
278 –– Plantar medial portal: located at the medial the surgeon with reduction while maintain- 297
279 side of the TN joint, just dorsal to the posing the soft-tissue attachments that might 298
280 terior tibial tendon [1, 2]. otherwise be removed for visualization. 299
281 –– Dorsal-medial: located midway between • Fusion: 300
282 the medial and dorsolateral portals. This –– Talonavicular fusion is a relatively easy 301
283 portal is in close proximity to intermedi- arthroscopic procedure. Once the joint is 302
284 ate cutaneous branch of superficial pero- entered the cartilage can be sequentially 303
285 neal nerve and extensor hallucis longus removed with a burr. Fixation is achieved 304
286 tendon [1, 2]. percutaneously from the medial tubercle 305
287 –– Dorsal lateral portal can be placed at the and from the dorsal lip distal to proximal 306
288 level of the joint line on each side of the into the talar head. 307
289 dorsal neurovascular bundle. • Dorsal osteophyte removal: 308
–– Dorsal osteophytes can be removed using 309
the dorsal medial and dorsal lateral portals. 310
However extreme care must be taken to 311
avoid damage to the deep peroneal nerve 312
and dorsalis pedis artery that lie just super- 313
ficial to the dorsal capsule. 314
T 19.5 Navicular Cuneiform 315

Arthroscopy 316
N
19.5.1 Indications 317
Fusion and fracture reduction. 318

NV
19.5.2 Positioning 319
Supine position. Tourniquet can be applied to 320

either thigh or calf. 321
19.5.3 Technique 322
Fig. 19.2 Talonavicular arthroscopy portals: ★ lateral

• Portals (Figs. 19.4 and 19.5): 323
portal, + dorsal lateral portal, • dorsomedial portal. T –– The navicular cuneiform joint can be 324
talus, N navicular bone, NV dorsal neurovascular bundle approached from the dorsal lateral, lat- 325
Fig. 19.3 Talonavicular
arthroscopy: ★ plantar
medial portal, T Talus, N
navicular bone, TP
tibialis posterior tendon
T
N
TP
Fig. 19.4 Naviculo
cuneiform arthroscopy:
★ the medial portal, N
navicular, M.C medial
cuneiform
N
M.C
326 eral, dorsal medial, and medial sides. The 19.5.4 Procedure 339
327 medial portal is located over the plantar
328 medial corner of the navicular-medial • Fusion: 340
329 cuneiform joint. The dorsal-medial portal –– Using the appropriate portals the joint mar- 341
330 is placed at the junction between the gin is identified. This can be challenging and 342
331 medial and middle cuneiform. The dor- fluoroscopy images may be required. A 343
332 sal-lateral portal is placed at the junction curette can be advanced into the joint to 344
333 of middle and lateral cuneiform joint. The assist in visualization. Once visualized the 345
334 lateral portal is positioned at the lateral cartilage is sequentially removed from all 346
335 corner on the navicular-lateral cuneiform three segments of the joint—the navicular to 347
336 joint. The dorsalis pedis and deep pero- lateral, medial, and intermediate cuneiform 348
337 neal nerve lie centrally dorsally and joints. Once debrided the joint is held in a 349
338 should be avoided. reduced position and cross screws are placed. 350
19.6 TMT Arthroscopy 370
19.6.1 Indications 371
Hypermobility of the first tarsometatarsal (TMT) 372

joint associated with hallux valgus, transfer 373
metatarsalgia, arthritis of the second TMTJ, and 374
posttraumatic arthritis [1]. 375
N
L.C Mi.C Me.C

19.6.2 Positioning 376
Patient is positioned supine with application of 377

thigh tourniquet [1]. 378
19.6.3 Technique 379
First TMT portals: Identify the joint by moving 380

the first metatarsal and locate the motion at the 381
joint. If needed, fluoroscopy can be used to con- 382
firm the portal site. This is done by passing a 383
22-gauge needle to the proposed portal site and 384
confirmed under fluoroscopy. 385
Fig. 19.5 Naviculocuneiform arthroscopy: ★ dorsal-

medial portal, ○ dorsal-lateral portal, • lateral portal, 19.6.4 Portals (Figs. 19.6 and 19.7) 386
Me.C medial cuneiform, Mi.C middle cuneiform, L.C lat-
eral cuneiform, N navicular bone
• Six TMT portals are described. The middle 387
351 Distal to proximal screws are more easily four portals (P1–4) are junction portals that 388
352 placed from each cuneiform. Proximal to can be used to approach the intercuneiform 389
353 distal screws are also placed from the tuber- spaces and spaces between the proximal parts 390
354 cle of the navicular down to the cuneiforms. of metatarsal bones. 391
355 • Fracture care: • Medial portal: located over the plantar medial 392
356 –– On occasion a midfoot injury, subluxation, aspect of the first TMTJ. 393
357 or dislocation involves the navicular cunei- • P1–2 portal: located at the junction point 394
358 form joint. The fracture or dislocation between the medial cuneiform, first metatar- 395
359 makes a space for arthroscope insertion. sal, and second metatarsal bones. The first 396
360 The injury pattern can be determined and TMTJ can be approached using this portal. 397
361 reduction achieved using percutaneous • P2–3 portal: located at the junction point 398
362 techniques. The reduction can be main- between the second metatarsal, intermediate 399
363 tained using either suture bridge constructs cuneiform, and lateral cuneiform bones. This 400
364 or percutaneous screws. is used to approach the second TMT joint. 401
365 –– Once reduced and held the reduction can • P3–4 portal: located at the junction point 402
366 be checked using a periarticular technique. between lateral cuneiform, cuboid, third, 403
367 The joint lining is often stripped and this and fourth metatarsal bones. Third and 404
368 allows visualization of the reduction along- fourth TMT joints can be approached using 405
369 side the joint margin. this portal. 406
407 • P4–5 portal: located between the proximal • Lateral portal: located at the lateral corner of 411
408 articular surfaces of the fourth and fifth meta- the fifth metatarsal-cuboid articulation. This 412
409 tarsal bones. This is used to visualize the portal is used to approach fifth metatarsal- 413
410 fourth and fifth TMT joints. cuboid articulation, the insertion of the pero- 414
neus brevis tendon, and the peroneus tertius 415
tendon [1, 2]. 416
19.6.5 Procedure 417
• First TMT fusion (arthroscopic Lapidus 418

procedure): 419
–– Two portals, plantar medial and dorsome- 420
dial, are utilized for this procedure. The car- 421
tilage is denuded using arthroscopic 422
osteotomes, shaver, or a burr until the sub- 423
chondral bone is exposed. Arthroscopic awl 424
Me.C can be used to perform microfracture. Then, 425
Mi.C
intermetatarsal angle is closed up manually 426
and the first metatarsal is plantarflexed [1]. 427
A temporary K wire can be used to hold the 428
position and fluoroscopy is used to evaluate 429
the alignment. Adjustment is made accord- 430
ingly. For fixation, percutaneous screws are 431
inserted. The usual construct is two ante- 432
grade screws inserted from proximal dorsal 433
to distal plantar direction across the joint 434
and one retrograde-directed screw inserted 435
from the dorsal distal at the metatarsal base 436
Fig. 19.6 TMT arthroscopy: • medial portal, ★ P1–2 por-
to proximal plantar. An additional positional 437
tal, ■ P2–3 portal, Me.C medial cuneiform, Mi.C middle
cuneiform screw can be used. It is inserted from the 438
Fig. 19.7 TMT
arthroscopy: ★ P3–4
portal, • P4–5 portal, +
lateral portal, L.C lateral
cuneiform, C cuboid
L.C
C
439 first metatarsal base to the second metatarsal 6–8]. Traction is not required for this procedure 480
440 base [1]. [3, 6, 9] although some authors had reported 481
441 • TMT joint fusion: applying traction to great toe. This can be in the 482
442 –– Portals are chosen according to the joint form of attaching Chinese finger trap to the great 483
443 being fused. Usually only the medial three toe [4, 7] with traction weight suspended from 484
444 TMTJs are needed to be fused. The corre- the pulley [4, 10]. Others have reported using 485
445 sponding joint spaces can be approached moisten cotton bandage tied with tension loop 486
446 through the proper portal and joint prepara- over first web space. This is attached to distractor 487
447 tion is done. Fusion surface preparation and tension adjusted accordingly [5]. Tourniquet 488
448 technique is similar to arthroscopic Lapidus is not necessary for this procedure [3, 4]. 489
449 procedure. After that, the joint reduction is However, some authors prefer using calf tourni- 490
450 performed in the desired position and percu- quet [2, 5, 6, 8]. Intraoperative fluoroscopy 491
451 taneous screw fixation is done according to should be used to confirm the position of the por- 492
452 the surgeon choice between cannulated and tals in tight joint [3]. 493
453 non-cannulated screws. If bone graft is to be
454 used, it can be packed through the portals
455 with the aid of a small drill sleeve [1]. 19.7.3 Technique 494
Skin incision is made using 11-blade scalpel. 495

456 19.7 First MTP Arthroscopy This is followed with blunt dissection of the sub- 496
cutaneous tissue using a mosquito forceps that is 497
457 19.7.1 Indications used to penetrate the joint capsule. A blunt trocar 498
is then introduced [3, 7]. Some authors reported 499
458 MTP joint arthroscopy is a much easier proce- injecting the MTP joint with 2–3 mL of normal 500
459 dure to perform than other midfoot or hindfoot saline prior to skin incision [2, 4, 5, 10]. 501
460 arthroscopies [3]. Some of the conditions that can
461 be treated arthroscopically are MTP joint fusion
462 for MTP joint arthritis, synovectomy, removal of 19.7.4 Portals and Accessory Portals 502
463 a painful sesamoid bone, partial cheilectomy for (Figs. 19.8 and 19.9) 503
464 hallux rigidus, debridement of an osteochondritis
465 dissecans defect, removal of loose bodies, • Different portal has been described to 504
466 arthroscopic drainage in septic arthritis, and approach the MTP joint. The most common 505
467 assessment of the plantar plate in turf toe injury technique utilized is two-portal approach. In 506
468 [2–6]. Contraindications: There are situations two-portal approach the portals are dorsome- 507
469 where arthroscopy may not be performed like in dial and dorsolateral portals located just 508
470 overlying cellulitis, in sever deformity preventing medial and lateral to the EHL tendon at the 509
471 adequate visualization, or in joint malalignment level of the MTP joint, which is about 0.5 cm 510
472 that necessitates an osteotomy or other corrective on both sides of EHL tendon [2–8, 10]. Both 511
473 procedures. Other contraindications are when portals run close to the dorsomedial and dor- 512
474 plate is required for fixation or in Charcot solateral cutaneous nerves of the great toe. In 513
475 arthropathy because normal anatomy is distorted a cadaveric study by Vaseenon, these portals 514
476 [3, 6, 7]. were about 3.4 mm and 4.0 mm from the dor- 515
solateral and dorsomedial cutaneous nerves, 516
respectively [7]. 517
477 19.7.2 Positioning • Another described technique is three-portal 518
approach. In this technique a third medial por- 519
478 Supine position with a bump in the ipsilateral tal is added [4, 5, 7, 8]. This portal is centered 520
479 hemipelvis to hold the foot in neutral rotation [3, over the medial side at the level of MTP join, 521
522 midway between the dorsal and plantar aspect on the distal metatarsal as shown by Vaseenon 525
523 of the joint. This technique was found to [7]. The medial portal lies about 10 mm medial 526
524 improve the amount of cartilage debridement to the dorsomedial cutaneous nerve and about 527
13 mm from the plantar medial nerve [7]. 528
• Central plantar portal: located over the plantar 529
aspect and established by an inside-out 530
method. From the web portal, trocar is inserted 531
and advanced proximally along the deep sur- 532
face of the intermetatarsal ligament till the tro- 533
car tip touches the plantar aponeurosis. Gently 534
perforate the aponeurosis and advance the tro- 535
car. The plantar portal is made at this point [8]. 536
• Proximal dorsomedial debridement of dorsal 537
osteophytes. 538
• Web portal: located over dorsal side of first 539
web space [8, 9]. If this portal is placed more 540
EHL towards the hallux, it might facilitate subse- 541

quent screw insertion [8]. 542
• Lateral portal: utilized during arthroscopic lat- 543
eral soft-tissue release in hallux valgus correc- 544
tion procedure [4]. Lateral portal: 1 cm lateral to 545
the dorsolateral portal, at the level of MTP joint. 546
• Proximal portal: used in arthroscopic release 547
of the arthrofibrosis and in arthroscopic exci- 548
sion of pathologic medial sesamoid [4]. 549
Fig. 19.8 First MTP joint arthroscopy portals: ★ indi-

• MTP fusion: 551
cates the dorsomedial portal. + indicates the dorsolateral –– Cartilage over the metatarsal head and at the 552
portal. EHL extensor hallucis longus base of proximal phalanx is removed using 553
Fig. 19.9 First MTP

joint arthroscopy
portals: ○ indicates the
medial portal
554 arthroscopic shaver [7]. Instrumentation and ble boarders. The stability of the lesion is 602
555 visualization can alternate between the dor- reassessed using a probe. K wire can then 603
556 somedial and dorsolateral portals until be used to perform microfracture [5, 10]. 604
557 debridement of the joint is achieved. In the
558 three-portal approach, the medial portal is
559 usually used for debridement only [7]. The 19.8 Lesser MTP Arthroscopy 605
560 position of the MTP joint is checked under
561 fluoroscopy. Provisional fixation using K 19.8.1 Indications 606
562 wires can be used to assist in holding the
563 MTP joint in the desirable position for Arthroscopic interventions can be used in treating 607
564 arthrodesis. Fixation is then achieved using lesser toes osteoarthritis, synovitis, chondral lesion, 608
565 percutaneously inserted headless or headed arthrofibrosis, and instability. Corrective proce- 609
566 screws [3, 8]. dures of toe deformity involve excisional arthro- 610
567 • Lateral release in hallux valgus: plasty, arthrodesis of the IP joint, and arthroscopic 611
568 –– The procedure starts with synovectomy if ganglionectomy of recurrent IP ganglion [1]. 612
569 needed. Then, release of lateral suspen-
570 sory ligament is performed using small
571 arthroscopic knife, to visualize the lateral 19.8.2 Positioning (Fig. 19.10) 613
572 sesamoid. Releasing of the lateral cap-
573 sule and the adductor tendon follows Supine position with light manual traction [1, 614
574 this. Care should be taken to avoid injury 11]. Some surgeons prefer to use thigh tourniquet 615
575 to the lateral metatarsophalangeal liga- [1]. Manual traction is used during visualization 616
576 ment [4]. Others have reported utilizing and instrumentation. The surgeon is seated at the 617
577 web portal and central plantar portal to lateral side of the operated foot with the monitor 618
578 perform this release. The plantar portal is at the end of the bed [1]. 619
579 used as viewing portal and the web portal
580 is used as the working portal [8].
581 • Arthroscopic release for arthrofibrosis in hal- 19.8.3 Technique 620
582 lux rigidus:
583 –– J.H Ahn et al. reported on using three por- • To confirm the proper placement of the por- 621
584 tals with proximal portal to perform the tals, 18- or 21-gauge needle is used to mark 622
585 debridement. Through the dorsomedial and the portal site and inject 2–3 mL of normal 623
586 dorsolateral portals, excision of dorsal saline into the joints. Then the portals are 624
587 metatarsal and phalangeal spur is done established using “nick and spread” tech- 625
588 using a burr or a shaver. All loose or delami- nique, that is, using 11-scalpel blade to incise 626
589 nated articular fragments are removed. the skin followed by using mosquito clamp to 627
590 Visualization of medial and lateral gutters, spread subcutaneous tissue and penetrate the 628
591 sesamoids, and plantar plate is performed to capsule [1, 11]. Some reported using pump 629
592 identify any other pathologies. Then MTP system to maintain the normal saline flow and 630
593 joint is maximally dorsiflexed to ensure that achieve joint distraction [11]. 631
594 there is no dorsal impingement [6]. • Instrumentation: 30° 1.9 mm, 2.7 mm 632
595 • OCL debridement: arthroscope. 633
596 –– Using a shaver, synovial debridement is • Portals: 634
597 performed as needed to facilitate visualiza- –– Portals for MTP joint: 635
598 tion. Confirm the location of OCL and ⚬⚬ Dorsal-medial and dorsal-lateral portals 636
599 evaluate the integrity of the underlying placed at or slightly distal to the MTP 637
600 bone using a probe. A curette is used to articular joint line, about 4–5 mm medial 638
601 debride the lesion until getting to more sta- and lateral to the extensor digitorum lon- 639
640 gus tendon [1, 11]. When placing the instrument along the dorsal recess and 656
641 dorsomedial portal over the second MTP point away from the articular surface. 657
642 joint care should be taken to avoid injury The plantar lateral portal: located at the 658
643 to the dorsal digital branch of the deep plantar lateral corner of the joint. 659
644 peroneal nerve. This nerve branch runs in
645 the first intermetatarsal space very close
646 to the medial border of the second MTP 19.8.4 Procedure 660
647 joint [11, 12]. At the level of other MTP
648 joint, the dorsal digital branches of super- • Arthroscopic interposition arthroplasty of sec- 661
649 ficial peroneal nerve are at risk [1]. ond MTP in Freiberg disease: 662
650 –– Portals of proximal IP joint: –– This is performed utilizing the dorsomedial 663
651 ⚬⚬ Dorsomedial and dorsolateral portal made and dorsolateral portal, alternating between 664
652 at the dorsomedial and dorsolateral cor- the two portals as viewing and working 665
653 ners of the IP joint, between the collateral portals. Diagnostic arthroscopy followed 666
654 ligaments and the lateral slips of the ten- by debridement of the damaged cartilage, 667
655 don expansion. Insert the arthroscopic synovectomy, and removal of loose body is 668
performed. A probe is used to measure the 669
distance from one portal to the center of the 670
defect in order to prepare the tendon graft. 671
Harvesting the tendon of the extensor digi- 672
torum brevis follows this. The extensor 673
digitorum brevis tendon is identified along 674
the dorsolateral portal incision, which is 675
the lateral to extensor digitorum longus 676
tendon. Then hemostat is passed around the 677
tendon and tension is applied by lifting the 678
tendon. The tendon is traced proximally 679
and through a small transverse incision the 680
proximal end of the EDB tendon is tran- 681
sected. The tendon is then retrieved through 682
the incision of the dorsolateral portal. The 683
graft is rolled into a ball and sutured with 684
long-stay suture using No. 0 Vicryl. 685
EDL –– The graft is passed through the dorsolateral 686

portal and the stay suture is then passed 687
through the plantar plate while making sure 688
that the suture and then the graft pass over 689
the center of the chondral defect. The stay 690
suture is passed all the way through the 691
plantar skin. The exit point of the suture is 692
dilated via hemostat and the sutures are 693
tied and the tendon graft is stabilized. The 694
insertion of the tendon can be sutured to the 695
dorsal capsule of MTP joint for additional 696
stability of the graft [1]. 697
• Arthroscopic synovectomy: 698
Fig. 19.10 MTP joint arthroscopy ★ indicates the dorso-
medial portal, • indicates the dorsolateral portal. EDL –– It is indicated for pain and swelling control 699
extensor digitorum longus in metabolic, inflammatory arthritis, or 700
701 infections. It is advised to place the portals 19.9.2 Positioning 745

702 slightly further from the extensor tendons.
703 To clean the medial gutter, the dorsolateral In talocalcaneal coalition resection: Patient is posi- 746
704 portal is used to visualize the joint and the tioned supine with hip in flexion, external rotation, 747
705 dorsomedial portal used as instrumentation and abduction and knee in flexion. Tourniquet is 748
706 portal and vice versa for synovectomy of applied to the ipsilateral thigh [13–15]. If the 749
707 the lateral gutter [1]. resection is performed through posterior arthros- 750
708 • Arthroscopic-assisted double-plantar plate copy to hindfoot, patient will be placed prone. 751
709 tenodesis for metatarsophalangeal instability: In calcaneonavicular coalition resection: Patient 752
710 –– Two portals, dorsomedial and dorsolateral, is laid supine with bump under the ipsilateral hip in 753
711 are used to perform this procedure. Any order to position the foot in internal rotation [16]. 754
712 associated intra-articular pathology is
713 treated accordingly.
714 ⚬⚬ The dorsomedial portal is used as the visu- 19.9.3 Technique 755
715 alization portal and dorsolateral portal is
716 used to pass the sutures. This is performed • TC coalition portal insertion: 756
717 while holding the MTP joint in flexion. –– Posterolateral portal: While ankle is in neu- 757
718 The first limb of the sutures is passed tral position, this portal is placed just lat- 758
719 through the lateral part of the plantar plate- eral to the Achilles tendon above imaginary 759
720 fibrous flexor tendon sheath complex and line drawn from the tip of the lateral mal- 760
721 all the way through the plantar skin. A sec- leolus to the Achilles tendon. Some sur- 761
722 ond proximal incision is made over the geons prefer injecting normal saline to 762
723 dorsal aspect of the shaft of metatarsal. subtalar joint prior to skin incision although 763
724 Using a hemostat, a blunt dissection start- this is not our routine practice. Longitudinal 764
725 ing on medial side of the metatarsal shaft skin incision is performed followed by 765
726 and extending to the plantar aspect of the introducing a blunt trocar into the lateral 766
727 distal metatarsal is performed. The suture aspect of the subtalar joint. Arthroscope is 767
728 is retrieved through this proximal incision. then inserted into the lateral recess of the 768
729 A second suture is passed through the subtalar joint. The first landmark to be 769
730 medial part of the plantar plate and identified is flexor hallucis longus (FHL). 770
731 retrieved along the lateral side for the Move the great toe assist for identifying the 771
732 metatarsal shaft through the proximal inci- tendon. Keeping the FHL in view helps 772
733 sion. Then, while holding the ankle in neu- preventing damage to the neurovascular 773
734 tral position, the sutures are secured to the bundle during the procedure [14]. 774
735 extensor digitorum longus tendon at the –– Posteromedial portal: Some authors per- 775
736 proximal dorsal wound. These steps are form this portal by first inserting 18-gauge 776
737 repeated and two figure-of-eight configu- needle into the joint. The needle is visual- 777
738 ration of sutures connecting plantar plate- ized with the arthroscope to ensure its lateral 778
739 flexor tendon sheath complex to extensor position to the FHL. Then skin incision is 779
740 digitorum longus are constructed [1]. performed followed by blunt dissection 780
using mosquito clamp that is introduced into 781
the lateral aspect of the subtalar joint [14]. 782
741 19.9 Excision of Tarsal Coalition • CN coalition portal insertion: 783
–– Location of the portals is identified under 784
742 19.9.1 Indications fluoroscopy (see portal description for 785
location of each portal). 786
743 Resection of talocalcaneal (TC) coalition or –– After skin incision, subcutaneous dissec- 787
744 resection of a calcaneonavicular (CN) coalition. tion with a mosquito clamp is performed in 788
789 the bone. Under fluoroscopic control, the –– Alternative portal: The visualization portal 835
790 mosquito is passed around the coalition at can be placed 0.5 cm anterior to the antero- 836
791 its upper and lesser aspects to create a lateral corner of the calcaneus and the 837
792 working area [15]. working portal at the medial border of the 838
extensor tendons [14]. 839
793 19.9.4 Portals

794 • TC coalition resection:
795 –– Viewing portal: two fingerbreadths poste- • TC coalition resection: 841
796 rior to the vertex of the medial malleolus. –– Hayashi described the resection through pos- 842
797 –– Working portal is created approximately teromedial approach. The viewing and work- 843
798 three fingerbreadths inferior to the vertex ing portals are performed (see description in 844
799 of the medial malleolus [17]. portals). The procedure starts by separating 845
800 –– Others have described posterolateral and the coalition from surrounding soft tissue 846
801 posteromedial portals: using cobb. High perfusion pressure should 847
802 ⚬⚬ Posterolateral portal: a line is drawn from be maintained to prevent soft tissue from 848
803 the tip of the lateral malleolus to the blocking the view. Then using a shaver, con- 849
804 Achilles tendon, parallel to the foot sole. tinue removing any soft tissue attached to the 850
805 The portal is placed above this line, tan- coalition, as this will facilitate the resection of 851
806 gential to the Achilles tendon [13, 14, 18]. the coalition. Care should be taken to keep 852
807 ⚬⚬ Posteromedial portal: placed at the same the instruments facing towards the coalition 853
808 level of posterolateral portal, medial and as neurovascular bundle is on the side oppo- 854
809 tangential to the Achilles tendon [13, site to the coalition. The resection of the 855
810 14, 18]. coalition is continued until normal articular 856
811 • CN coalition: surface can be confirmed. Fluoroscopy can 857
812 –– Visualization portal: Under fluoroscopy an be used to confirm the location of the coali- 858
813 oblique view of the foot is taken and the tion. Bone wax is applied to the resection sur- 859
814 portal is established dorsal to the angle of face once procedure is completed [17]. 860
815 Gissane. Another fluoroscopy image is –– Others have described the resection utilizing 861
816 taken to conform the portal location over posterolateral and posteromedial portals. 862
817 the dorsal aspect of the anterior process of Once the two portals are established, syno- 863
818 the calcaneus at the proximal and lateral vectomy of the subtalar and ankle joint is 864
819 extremity of the coalition [14–16]. performed to achieve optimal visualization 865
820 –– Working portal: located on the distal and of the coalition. Then FHL tendon is identi- 866
821 medial aspect to the coalition at the junc- fied. The subtalar joint line and FHL tendon 867
822 tion of the coalition with the navicular are followed until localizing the TC coali- 868
823 bone. This portal is placed in the space tion. For most of the time the working portal 869
824 between the talonavicular and calcaneocu- will be the posterolateral portal and the 870
825 boid joints. Fluoroscopy is used to localize instruments will be passed through the pos- 871
826 the portal site. This portal is less than 1 cm teromedial portal. In cases of osseous coali- 872
827 dorsal and medial to the superficial pero- tions, visualization of the subtalar joint 873
828 neal nerve [14–16]. might be difficult. The posterior talofibular 874
829 –– Accessory visualization portal: It is estab- ligament (PTFL) is used as a landmark to 875
830 lished to visualize the deep part of the localize the subtalar joint that is located 876
831 anteromedial calcaneal process. It is pre- approximately 5 mm below the talar inser- 877
832 formed under fluoroscopy guidance at the tion of the PTFL. Arthroscopic burr or 878
833 medial side of the extensor hallucis tendons shaver is used to resect the coalition until 879
834 at the level of the talonavicular joint [14]. normal articular surface is encountered and 880
881 always keep the FHL medial to the instru- 19.10.2 Positioning 926
882 ments. Resection is complete when you can
883 visualize healthy cartilage posteriorly, medi- Patient is positioned supine and thigh tourniquet 927
884 ally, and laterally, and good subtalar motion is applied. No distraction is used [19–21]. 928
885 can be elicited clinically. A probe can be
886 inserted between talus and calcaneus, and a
887 gentle levering is performed to verify the 19.10.3 Technique 929
888 opening of the joint. Fluoroscopy image is
889 taken to confirm adequate resection [13, 14]. 18-guage needle can be introduced to confirm the 930
890 • CN coalition: joint level and then 11-guage scalpel blade is 931
891 –– Two portals are placed under fluoroscopy used to perform a skin incision. This is followed 932
892 guidance as described above. After passing by using hemostat to penetrate the capsule. 933
893 the mosquito clamp around the coalition, a Hemostat can be used to break some of the scar 934
894 shaver is introduced to clear up the soft tis- tissue before introducing the trocar. 935
895 sue around the coalition. Minimal release
896 of the extensor digitorum brevis muscle • Portals: standard anteromedial and anterolat- 936
897 should be done just enough to get access to eral ankle arthroscopy portals [19–21]. 937
898 the coalition [16]. Then tissue debridement
899 is performed laterally up to the anterior
900 process of the calcaneus and the calcaneo- 19.10.4 Procedure 938
901 cuboid joint and medially up to the talona-
902 vicular joint. Once complete visualization
• Lateral gutter debridement: 939
903 of the coalition is achieved, resection of the
–– In this technique the anteromedial portal is 940
904 bony bar is performed using a burr. The the visualization portal while the antero- 941
905 landmarks to follow are: lateral portal is used as working portal. 942
906 ⚬⚬ The anterior and dorsal aspect of the Start with clearing the scar tissue anterior 943
907 calcaneus and the calcaneocuboid joint on the lateral gutter. This can be achieved 944
908 laterally using a combination of shaver, arthroscopic 945
909 ⚬⚬ Talar head, the talonavicular joint, and thescissors, and biters and right angled curette 946
910 lateral part of the navicular bone mediallyas necessary. This gives access to visual- 947
911 –– Using the arthroscope, visualize the infe- ize the lateral gutter. Soft tissue in the gut- 948
912 rior side at the talonavicular joint and cal- ter is debrided to clear the space between 949
913 caneocuboid joint to assess if the resection lateral malleolus and lateral edge of the 950
914 is complete. Once resection is completed, talus. A burr is then used to remove any 951
915 the foot is taken into inversion-eversion bony impingement starting laterally on the 952
916 motion to confirm the mobility between fibula. After cleaning the lateral gutter 953
917 navicular bone and the calcaneus [14–16]. arthroscope is taken over the top of the 954
talus to look down into the gutter. Any 955
talar shelf bone if present should be 956
918 19.10 Arthroscopy of Total Ankle cleaned. It is believed that visualization of 957
919 Arthroplasty the peroneal tendons is essential to con- 958
920 for Impingement, Cysts form adequate debridement. Care should 959
921 and Aseptic Loosening be taken to avoid excessive bony resection 960
on the talus or any damage to the metal 961
922 19.10.1 Indications and polyethylene of the TAA implant. 962
This can be achieved by having the shaver 963
923 Bony impingement at medial or lateral gutters in contact with the prosthesis while 964
924 minimum of 90 days, preferably 6 months post- debridement of the joint is performed 965
925 total ankle arthroplasty [19–21]. [19–21]. 966
967 • Medial gutter debridement: 8. Hunt KJ. Hallux metatarsophalangeal (MTP) joint 1004
arthroscopy for hallux rigidus. Foot Ankle Int. 1005
968 –– Arthroscope is introduced through the 2015;36:113–9. 1006
969 anterolateral portal and instruments are 9. Bonasia DE, Phisitkul P, Saltzman CL, Barg A, 1007
970 introduced through the anteromedial portal. Amendola A. Arthroscopic resection of talocalcaneal 1008
971 Similar to lateral gutter debridement the coalitions. Arthroscopy. 2011;27:430–5. 1009
10. Knorr J, Soldado F, Menendez ME, Domenech P, 1010
972 combination of shaver, burr, and curette is Sanchez M, Sales de Gauzy J. Arthroscopic talocal- 1011
973 utilized. Start by cleaning soft tissue anterior caneal coalition resection in children. Arthroscopy. 1012
974 to medial gutter to be able to visualize the 2015;31:2417–23. 1013
975 gutter. Then any soft tissue in the gutter is 11. Hayashi K, Kumai T, Tanaka Y. Endoscopic resec- 1014
tion of a talocalcaneal coalition using a posteromedial 1015
976 removed until the medial malleolus and approach. Arthrosc Tech. 2013;3:e39–43. 1016
977 medial aspect of the talus are seen. A burr is 12. Knorr J, Accadbled F, Abid A, et al. Arthroscopic 1017
978 used to resect any bony prominence on treatment of calcaneonavicular coalition in children. 1018
979 medial malleolus or talus. Some authors Orthop Traumatol Surg Res. 2011;97:565–8. 1019
13. Lui TH. Arthroscopy and endoscopy of the foot and 1020
980 believe that a complete debridement requires ankle: indications for new techniques. Arthroscopy. 1021
981 that the posterior tibial tendon be visualized 2007;23:889–902. 1022
982 in the medial gutter [19–21]. 14. Richardson AB, Deorio JK, Parekh SG. Arthroscopic 1023
debridement: effective treatment for impingement 1024
after total ankle arthroplasty. Curr Rev Musculoskelet 1025
Med. 2012;5:171–5. 1026
983 References 15. Schmid T, Younger A. First metatarsophalangeal joint 1027
degeneration. Arthroscopic Treatment Foot Ankle 1028
984 1. Lui TH. Arthroscopic arthrodesis of the first meta- Clin. 2015;20:413–20. 1029
985 tarsophalangeal joint in hallux valgus deformity. 16. Lui TH, Yuen CP. Small joint arthroscopy in foot and 1030
986 Arthrosc Tech. 2017;6:e1481–7. ankle. Foot Ankle Clin. 2015;20:123–38. 1031
987 2. Lui TH. Arthroscopic interpositional arthroplasty of 17. Nery C, Coughlin MJ, Baumfeld D, et al. Lesser
1032
988 the second metatarsophalangeal joint. Arthrosc Tech. metatarsal phalangeal joint arthroscopy: anatomic 1033
989 2016;5:e1333–8. description and comparative dissection. Arthroscopy. 1034
990 3. Derner R, Naldo J. Small joint arthroscopy of the foot. 2014;30:971–9. 1035
991 Clin Podiatr Med Surg. 2011;28:551–60. 18. Lui TH. First metatarsophalangeal joint arthros-
1036
992 4. Bauer T, Golano P, Hardy P. Endoscopic resection copy in patients with hallux valgus. Arthroscopy. 1037
993 of a calcaneonavicular coalition. Knee Surg Sports 2008;24:1122–9. 1038
994 Traumatol Arthrosc. 2010;18:669–72. 19. Sherman TI, Kern M, Marcel J, Butler A, McGuigan 1039
995 5. Bonasia DE, Phisitkul P, Amendola A. Endoscopic FX. First metatarsophalangeal joint arthroscopy for 1040
996 coalition resection. Foot Ankle Clin. 2015;20:81–91. osteochondral lesions. Arthrosc Tech. 2016;5:e513–8. 1041
997 6. Gross CE, Neumann JA, Godin JA, DeOrio 20. Shirzad K, Viens NA, DeOrio JK. Arthroscopic treat- 1042
998 JK. Technique of arthroscopic treatment of impingement of impingement after total ankle arthroplasty: 1043
999 ment after total ankle arthroplasty. Arthrosc Tech. technique tip. Foot Ankle Int. 2011;32:727–9. 1044
1000 2016;5:e235–9. 21. Vaseenon T, Phisitkul P. Arthroscopic debridement 1045
1001 7. Ahn JH, Choy WS, Lee KW. Arthroscopy of the first for first metatarsophalangeal joint arthrodesis with 1046
1002 metatarsophalangeal joint in 59 consecutive cases. J a 2- versus 3-portal technique: a cadaveric study. 1047
1003 Foot Ankle Surg. 2012;51:161–7. Arthroscopy. 2010;26:1363–7. 1048
1 Ankle Alignment Procedures
20
2 F. Vannini, A. Mazzotti, A. Panciera,
3 B. D. Bulzacki Bogucki, S. Giannini, and C. Faldini
4 20.1 Introduction treatment of tibiotalar posttraumatic outcomes 27

based on the osteoarthritis degree, age, and artic- 28
5 Articular tibiotalar fractures are burdened with ular condition, as shown in Table 20.1. 29
6 many complications that may be distinguished as Malunion is often a complication of ankle 30
7 early and late. joint fractures. This complication is caused by 31
8 Whatever is the type of fracture and related three factors: type of fracture, incomplete reduc- 32
9 complications, the hazard of osteoarthritic evolution, and loss of reduction. Other minor factors 33
10 tion is a common issue with prevalence till 1% of which may contribute to establish a malunion are 34
11 the population [1]. gender, osteoporosis, and age. When a malunion 35
12 In contrast to the osteoarthritis of other joints, occurs in the ankle joint there is a lack of articular 36
13 such as hip and knee, ankle osteoarthritis is, in matching and an alteration of mechanical axis. 37
14 most cases, secondary to trauma outcomes [2, 3]. This happens due to rotational or angular defor- 38
15 As a consequence, keeping in mind the mean age mities which in turn affect weight-bearing distri- 39
16 of distribution of high-energy trauma, ankle arthro- bution playing a role in early and progressive 40
17 sis becomes symptomatic roughly 12 years earlier joint deterioration. 41
18 than compared to other anatomic districts [4]. In order to detect deformities and select the 42
19 Since the pathological anatomy is extremely proper treatment for the ankle joint it is crucial to 43
20 variable, the treatment of the tibiotalar fractures consider some radiographic criteria. 44
21 is often complex resulting in poor outcomes. The anatomic axis of tibia can be found by 45
22 Despite the effort, even if different authors have tracing a line starting from the indentation 46
23 proposed numerous treatment algorithms, today between the two tibial spines proximally and the 47
24 there is still an open debate about the guidelines center of the conjugation cartilage on the tibial 48
25 and ideal treatments of these conditions. In 2007 plafond distally. Another important parameter to 49
26 Giannini described specific indications for the evaluate tibial deformities is the TAS (tibial- 50
ankle surface); this angle is traced by a line pass- 51
ing through tibia’s articular surface which crosses 52
F. Vannini (*) · A. Mazzotti · A. Panciera the mechanical axis of the tibia at the plafond 53
B. D. Bulzacki Bogucki · C. Faldini
center forming, frontally, the angle known as 54
1st Orthopaedic and Traumatologic Clinic,
Istituto Ortopedico Rizzoli, Bologna, Italy TAS (tibial-ankle surface) (Fig. 20.1). This angle 55
e-mail: francesca.vannini@ior.it is open medially and normally ranges between 56
S. Giannini 91° and 93° in the Caucasian population. This 57

Alma Mater Studiorum, Bologna, Italy value describes the slight and physiologic valgus 58
© ISAKOS 2019 223

https://doi.org/10.1007/978-3-662-58704-1_20
224 F. Vannini et al.
Table 20.1 Guidelines according to Giannini t1.1
Stage Age Ankle joint condition Surgical procedure t1.2

2 – Preserved ankle anatomy Arthrodiastasis and t1.3
arthroscopic debridement t1.4
Supra-articular malalignment Supra-malleolar osteotomy t1.5
Intra-articular malalignment Joint reconstruction t1.6
3 < 50 Preserved or restored ankle anatomy <25° of motion in other foot Joint allograft t1.7
joints or arthrodesis refusal Joint prosthesis t1.8
>50 >25° of motion in other foot’s Arthrodesis t1.9
– joints t1.10
– Nonrestorable ankle anatomy, chronic infections, neurological Arthrodesis t1.11
disorders, severe osteoporosis t1.12
59 of the ankle. On the sagittal plane these lines alteration until the development of tibiotalar 90
60 form the angle known as TLS (tibial lateral sur- osteoarthritis. This event sequence results from 91
61 face) (Fig. 20.1), and open anteriorly, and that the altered weight bearing which, as demon- 92
62 normally ranges between 81° and 82°. While strated in many previous studies [8, 9], changes 93
63 evaluating a deformity is essential to consider the location and shape of the contact areas 94
64 another parameter known in literature as CORA between the articular surfaces of tibia and talus, 95
65 (center of rotation and angulation) (Fig. 20.2), leading to deterioration of articular cartilage and 96
66 this is defined as the intersection point between finally premature osteoarthritis. 97
67 the proximal and distal mechanical axis of tibia;
68 the angle between these represents the deformity
69 amount to correct. 20.3 Treatment of Malunion 98
70 Ankle deformity and malunion are often dif- in Adults 99
71 ficult to detect; some authors proposed a classifi-
72 cation of hidden types [5] (Fig. 20.3). In unclear There are many procedures when it comes to 100
73 cases it may be helpful to perform CT scan and malunion surgical treatment, but in literature 101
74 MRI in order to clarify the exact anatomy of the there are mainly two trends: articular salvage sur- 102
75 deformity. gery and articular replacement or blockage sur- 103
gery [6, 10–17]. 104
The rationale of the articular sparing surgery 105
76 20.2 Classification of Malunions is to interrupt or slow down the osteoarthritic pro- 106
gression by realigning every existing deformity 107
77 It’s possible to distinguish malunions in two cat- by reestablishing the correct articular anatomy as 108
78 egories based on age: adult malunions and much as it’s possible. The second approach finds 109
79 growing-age malunions [6]. application whenever the articular degeneration 110
80 Adult’s malunions are divided into more sub- is too advanced to such a degree which makes 111
81 categories based on fracture patterns: impossible any kind of repair efforts, shifting pri- 112
orities to pain treatment mainly and whenever is 113
82 • Supra-malleolar possible to maintain a certain functionality. 114
83 • Malleolar Articular salvage surgery may be divided into 115
84 • Intra-articular distal tibia extra-articular and intra-articular, based on mal- 116
85 • Talar union’s kind [6]. As for any other kind of surgery 117
it is essential to set the right indications and con- 118
86 Their incidence is variable in a range between traindications in order to guarantee the best pos- 119
87 5 and 68% according to literature [6–8]. The sible results (Table 20.2). For these reasons, 120
88 alignment failure secondary to one of these frac- nowadays, the matter is still a subject of debate 121
89 tures is followed by chronic pain and functional [19, 20]. 122
20 Ankle Alignment Procedures 225
Fig. 20.1 (a) Coronal a b

projection of tibial axis,
visualization of TAS
angle. (b) Sagittal
projection of tibial axis,
visualization of TLS
angle
123 Extra-articular salvage surgery is applied to Malunions may be often associated to soft tissue 130
124 malunions classified as supra-malleolar and talar. or articular cartilage lesions: most frequently there 131
125 Intra--articular salvage surgery, on the other are osteochondral lesions and ligamentous laxity of 132
126 hand, is applied in malleolar, articular distal tibial one or more ankle’s compartments. An osteochon- 133
127 fractures, and talar body malunions. The aim of dral lesion is found more often at the medial surface 134
128 this surgical procedure is to restore the proper of the talus dome (up to 80% of reported cases). 135
129 articular matching [21]. Diagnosis in such cases is s uspected when patients 136
refer to symptoms such as pain, swelling, and occa- 137

sional joint blockage with a positive history of ankle 138
trauma. The first choice for an instrumental exami- 139
nation is the standard weight-bearing X-rays in 140
order to visualize the malleolar clamp; often it is 141
necessary to undertake more detailed examinations 142
such as CT scan or MRI scans. Lesion size is crucial 143
to prognosis; that’s why over the years numerous 144
classifications were developed [22, 23]. Ankle liga- 145
mentous laxities, when they occur along with osteo- 146
chondral lesions, are needed to be treated together 147
with malunion. 148
20.4 Extra-Articular Surgery 149
20.4.1 Supra-Malleolar Osteotomies 150
Fig. 20.2 Different localization of CORA angle repre- Speed and Boyd in the 1930s suggested for the 151
sents different orientations of the deformity, therefore
affecting the treatment choice first time in orthopedic surgery a procedure to 152
a b
Fig. 20.3 Hidden nonunion according to Yablon. Figure in Shenton line formed by the outline of tibial plafond and
(a) represents a normal ankle joint whereas figure (b) rep- the outline of fibula’s medial side. (3) The fibula’s apex
resents a hidden nonunion. In particular it should be doesn’t lie in a circle alongside talus lateral joint side. (4)
noted: (1) Lack of symmetry in joint line. (2) Interruption Widening of joint line medially
Table 20.2 Tibiotalar reconstruction guidelines according to Mulhern [18] t2.1
Indications Contraindications t2.2

• Asymmetric ankle osteoarthritis with varus/ Absolute: t2.3
valgus deformity and >50% preserved • End-stage ankle osteoarthritis with <50% preserved t2.4
tibiotalar joint surface tibiotalar joint surface t2.5
• Isolated medial/lateral osteochondral lesion • Unmanageable hindfoot instability t2.6
of the tibiotalar joint • Acute/chronic infection t2.7
• Physeal growth arrest • Severe vascular/neurologic deficiency t2.8
• Tibial torsion • Neuropathic disorders t2.9
• Tibial fracture malunion Relative: t2.10
• Realignment before total ankle arthroplasty • Patient noncompliance t2.11
• Tibiotalar arthrodesis malunion • Age >70 years t2.12
• Deformities caused by neurologic/muscular • Impaired bone quality of the distal tibia or talus t2.13
conditions • Tobacco use t2.14
• Congenital talipes equinovarus sequelae • Insulin-dependent diabetes mellitus t2.15
• Rheumatoid ankle • Chronic skin abnormalities or soft-tissue defects t2.16
• Hemophilic arthropathy t2.17
153 correct a posttraumatic deformity [24]. Same deformity, which may lead to poor results of the 186
154 concept was adopted in the 1960s by Russian surgical treatment. Moreover, the medial and lat- 187
155 authors, which led to several publications [25, eral compartments need to be examined to evaluate 188
156 26]. However the first study to systematically if it is necessary to reconstruct or release ligaments. 189
157 report results of patients that underwent a supra- An evaluation of the foot dorsiflexion is mandatory 190
158 malleolar osteotomy was published in the mid- to eventually perform an Achilles tendon lengthen- 191
159 1990s by Takakura [27]. In this study Takakura ing. Subtalar joint mobility has to be evaluated to 192
160 reports midterm results of supra-malleolar oste- estimate the potential compensation capability 193
161 otomies performed on 18 patients affected by a after the planned surgery. The last parameter to 194
162 primary form of ankle arthritis with a varus evaluate is lower limb length to anticipate any pos- 195
163 deformity of stages 2 and 3 according to sible discrepancy in extension which may influence 196
164 Takakura’s own classification (Table 20.3). He the kind of osteotomy to perform. 197
165 reported excellent results in six patients, good The possible surgeries are the following: 198
166 results in nine, and sufficient results in three. A
167 later evaluation performed by Takakura himself • In plus osteotomies: According to the type of 199
168 involved the same procedure applied for the treat- deformity they may be performed on the medial 200
169 ment of posttraumatic deformities in nine or lateral surface of the tibia. It’s possible to 201
170 patients; the procedure showed excellent results maintain or minimally increase the length of 202
171 in four cases, good results in two, and sufficient operated limb. Normally it is applied on a tricor- 203
172 results in three cases [28]. Thanks to Takakura’s tical autologous bone graft collected from same- 204
173 relevant publications over the following decades side iliac crest or instead an allograft can be 205
174 many international studies were published used. These osteotomies are contraindicated in 206
175 involving the use of corrective osteotomies in the presence of previous extended surgical scars, 207
176 deformity treatment, developing new treatment infections, poor tissue regeneration potential, 208
177 algorithms and rehabilitative protocols. and vascular deficit. Based on the osteotomy 209
angle it is possible to perform multiplanar cor- 210
178 20.4.1.1 Preoperative Planning rection. When compared to osteotomies in 211
179 In the surgical planning of the correction of a defor- minus they seem to require longer to consoli- 212
180 mity it is crucial to correctly identify the deformity date, even if some studies deny this result [27]. 213
181 site [18]. It’s necessary to identify the rotational • In minus osteotomies: As before, they may 214
182 center and the deformity angle (CORA). Besides be performed on the medial or lateral surface 215
183 the CORA, from a radiographic point of view, it is of tibia. The main disadvantage is the short- 216
184 mandatory to obtain panoramic weight-bearing ening of the operated limb, which has to be 217
185 X-rays of lower limbs in order to identify any other considered during preoperative planning. 218
t3.1 Table 20.3 Takakura’s classification [1] be at the joint surface or there is a hidden mal- 253
t3.2 Stage Radiographic findings union the osteotomy should be performed 254
t3.3 1 No joint-space narrowing, but early sclerosis approximately 4–5 cm proximally to distal mal- 255
t3.4 and osteophyte formation leolus extremity [29]. An osteotomy performed 256
t3.5 2 Narrowing of the joint space
somewhere else from CORA’s level leads to an 257
t3.6 3a Obliteration of the joint space limited to the
t3.7 medial malleolus facet with subchondral bone inevitable misalignment between axis of proxi- 258
t3.8 contact mal and distal segment (Fig. 20.5). 259
t3.9 3b Obliteration of the joint space advanced to the In plus or in minus wedge osteotomies 260
t3.10 roof of the talar dome with subchondral contact (Fig. 20.6): Osteotomy site should be identified 261
t3.11 4 Obliteration of the joint space with complete
t3.12 bone contact
avoiding excessive periosteum removal. A 262
Kirschner wire is positioned at the level of the 263
osteotomy site parallel to joint surface to be used 264
219 The absence of grafts is the main advantage as guide. While performing the bone saw cut 265
220 of this procedure, besides shorter consolida- water irrigation is crucial in order to avoid ther- 266
221 tion time as reported in literature [29, 30]. mic bone damage. Osteotomy is completed with 267
222 • Dome-shaped osteotomies: Technically the an osteotome to prevent soft-tissue damage. The 268
223 more challenging to perform, they may repre- periosteum on the opposite side of the osteotomy 269
224 sent the best choice in some specific cases. should be preserved as it’s supposed to work as a 270
225 Specific guidelines to perform this technique keystone in obtaining correction. 271
226 are not yet universally codified. According to Dome-shaped osteotomy (Fig. 20.6): The 272
227 Krähenbühl [31] deformities over 10° angle shape of the osteotomy can be created with vari- 273
228 represent the optimal indication; on the other ous techniques. Generally, a single pin is inserted 274
229 hand Knupp [1] reserves this procedure for parallel to joint line with the aim to work as 275
230 cases with preserved joint congruency. The osteotomy’s rotational center. Bicortical holes
276
231 main disadvantage of this procedure is repre- are then performed as guide to the following 277
232 sented by the mono-planar correction, since osteotomy with micro-oscillating saw. The distal 278
233 multi-planar corrections are not possible. fragment is then mobilized to correct the 279
234 • Peroneal osteotomies: Peroneal shortening or deformity. 280
235 lengthening osteotomies find indication in
236 nonunions associated to fractures in external
237 rotation which lead to fibula’s rotational short-
238 ening. Correcting the fibula’s deformity allows
239 to restore a normal tibiofibular syndesmosis.
240 Barg and Mangone proposed in their publica-

241 tions a simple formula to calculate the degree of
242 correction secondary to both in plus and in minus
243 osteotomies [32, 33] (Fig. 20.4).
244 In the eq. H stands for the height of wedge to
245 implant or remove, α stands for the amount of
246 deformity and potential degrees of hypercorrec-
247 tion, and Ø represents tibia’s diameter at the oste-
248 otomy site.
249 20.4.1.2 Surgical Procedure Fig. 20.4 Equation to establish the wedge size to implant
or remove in order to gain correction of a deformity. To be
250 If osteotomy’s purpose is to correct a deformity it noted: α absolute value is represented by the CORA and Ø
251 should be performed at CORA’s level. If the represents the diameter of the tibia at the level of the
252 deformity (and therefore the CORA) is found to CORA
Fig. 20.5 An osteotomy performed away from CORA’s level leads to misalignment between the axis of distal and
proximal tibia
a b
Fig. 20.6 (a) Minus osteotomy to correct varus malalignment performed at CORA’s level. (b) Dome-shaped osteot-
omy to correct valgus deformity performed at CORA’s level
281 Peroneal osteotomy (Figs. 20.7, 20.8, 20.9, to perform a peroneal osteotomy in plus or in 284
282 and 20.10): In order to ensure a normal anatomy minus. It is mandatory to perform it at the same 285
283 and appropriate functionality it is often necessary level of the tibial osteotomy. 286
287 20.4.1.3 Postsurgical Treatment

288 The first postsurgical treatment consists of a boot
289 cast and non-weight bearing. The length of this
290 phase is still debated. Stamatis and Myerson
291 describe a protocol of boot cast excluding weight
292 bearing for 10–14 weeks until obtaining radio-
293 graphic evidence of bone healing [29]. On the other
294 hand, Mulhern et al. suggest a shorter period
295 (6–8 weeks) with progressive weight bearing in the
296 following month; according to their protocol full
297 functional recovery is fulfilled in 6–12 months [18].
298 20.5 Intra-articular Surgery
299 20.5.1 Reconstructive Treatment

300 of Malleolar Malunions
301 The reconstructive treatments of malleolar mal-

302 unions are usually performed through fibular
303 reconstructions in order to influence tibiofibular
304 syndesmosis; this procedure is often associated
305 with a medial ligamentous reconstruction. It is
306 mandatory to correct any eventual malunions of
307 posterior malleolus or any embeds in medial tib-
308 ia’s plafond [34].
309 20.5.2 Reconstructive Treatment

310 in Outcomes of Distal
311 Articular Tibial Fractures
312 Complex distal articular tibial fractures are

313 often associated with chondral and soft-tissue
314 lesions [35]. Most of these fractures are caused
315 by high-energy trauma with axial load, which Fig. 20.7 In plus fibular osteotomy to correct length
316 damages articular cartilage, and, during a period deficit
317 of years, leads to posttraumatic osteoarthritis.
318 Resulting deformities may be treated through plafond it may be necessary to perform a medial 325
319 articular salvage techniques such as those from malleolar osteotomy. 326
320 Rammelt [35] (Table 20.4).
321 Surgical procedure (Fig. 20.11) • Anterior approach: A classic dorsal incision 327
322 Distal articular tibial fracture malunions is performed followed by capsulotomy and 328
323 may be approached through anteromedial, ante- exposition of the tibial plafond and talar 329
324 rior, or anterolateral approach. To reach the tibial dome. The anteromedial and anterolateral 330
Fig. 20.8 Deformity
outcomes in fibular
fracture with tibial
hyperpressure at the
medial talus dome
Fig. 20.9 Postsurgical
X-ray of fibular
lengthening through
graft from tibia’s bulb
and repair of chondral
defect, along with
cleanup, by placing a
scaffold with autologous
medullar mononuclear
cell concentrate
331 fracture fragments need to be separated in debridement of sclerotic/necrotic tissue is 337

332 order to gain access to central or posterior performed in order to create a microenviron- 338
333 malunion. Unstable intra-articular fragments ment suitable for bone healing. In case of 339
334 need to be removed. Minor cartilage deterio- fibular malunions a fibular osteotomy is usu- 340
335 rations are usually treated with microfrac- ally performed in order to get free access to 341
336 ture procedures. In case of nonunion, and mobilization of distal fragments. 342
Fig. 20.10 Postsurgical
X-ray 18 months later
t4.1 Table 20.4 Guidelines according to Rammelt osteotomy is performed. The stabilization of 356
t4.2 Indications Contraindications fragments is achieved via plates and screws. 357
t4.3 Young, active Severe osteoarthritis in
t4.4 patients weight-bearing areas
Good bone quality Impaired bone quality
t4.5
20.6 Malunions During Growth 358
t4.6 Adequate cartilage Chronic soft-tissue or bone
t4.7 coverage infection
t4.8 Good patient Scarce patient compliance Besides an articular mismatch and evident defor- 359
t4.9 compliance mities, the outcomes of these malunions are dif- 360
t4.10 Comorbidities ficult to predict, due to patient’s skeletal age. It 361
may cause an early sealing of epiphysis and bone 362
rod formation. 363
343 Eventual bone loss is treated with bone These synostoses are classified according to 364
344 grafts. The stabilization of the osteotomy Ogden [36] in: 365
345 site is obtained via plates and screws.
346 • Medial malleolar osteotomy: An important • Peripheral: predisposing to angular deformities 366
347 shortening of medial malleolus requires a ded- • Linear: extending from front to rear in the sag- 367
348 icated osteotomy in order to restore normal ittal plane 368
349 malleolus’s clamp anatomy. • Central: in the plafond’s midportion, causing a 369
deformity of the joint line 370
350 Posterior approach: Isolated malunions of the
351 posterior joint line may be treated through a pos- In case of bone rod the excision surgery has to be 371
352 teromedial or posterolateral approach. Hallux performed when there’s a 2 years of growth expec- 372
353 long flexor muscle is retracted medially to protect tancy and less than 50% of tibia’s plafond involved 373
354 the vascular-nervous bundle. Any intra-articular [37]. Angular deformities associated to rod have 374
355 fragment needs to be removed. Then, a corrective been described as liable of spontaneous correction 375
a b c
Fig. 20.11 Treatment of an intra-articular malunion through lateral plafond-plasty associated to a peroneal lengthening
osteotomy. (a) Initial deformity. (b) Plafond-plastic with screw and bone graft. (c) Peroneal lengthening osteotomy
376 if <15° in patients under 10 years or <10° in chil- obtained articular alignment, a better perfor- 392
377 dren older than 10 years. If the deformity exceeds mance in potential replacement or articular 393
378 these values a corrective osteotomy is required. blockade surgeries. 394
379 20.7 Conclusions References 395
380 In tibiotalar fracture among many outcome sce- 1. Knupp M. The use of osteotomies in the treat- 396
ment of asymmetric ankle joint arthritis. Foot Ankle 397
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1
2
Current Concepts in the Treatment
of Osteoarthritis of the Ankle
21
3 Yasuhito Tanaka
4 21.1 Introduction 21.1.1 Conservative Therapy 28
5 Osteoarthritis (OA) occurs in the ankle less fre- The chondrocytes of the ankle differ from those 29
6 quently than in the knee or hip, which are also of the knee in that they are more resistant to 30
7 weight-bearing joints, comprising about 4% of degeneration and better able to repair themselves 31
8 all OA [1]. The level of subjective impairment in after being damaged [9, 10]. Therefore, the 32
9 end-stage OA of the ankle is equivalent to that of effects of the appropriate conservative therapy 33
10 end-stage nephropathy or congestive heart fail- can be significant. However, while sufficient evi- 34
11 ure, and it causes a comparable level of impair- dence regarding conservative therapy for the 35
12 ment of hip OA [2, 3]. Posttraumatic OA is a more common OA of the knee has been accumu- 36
13 common form of ankle OA in young people that lated, few reports have discussed the effects of 37
14 can lead to long-term, potentially lifetime impair- conservative therapy for OA of the ankle. 38
15 ment [3, 4]. Therefore, the role of effective thera-
16 pies is significant. 21.1.1.1 Lifestyle Guidance 39
17 Post-fracture OA, most commonly from While no studies have demonstrated the efficacy 40
18 malleolar and pilon fractures [5], makes up a of dieting for OA of the ankle, it is considered 41
19 large proportion of ankle OA cases [6]. Other appropriate to recommend that patients lose 42
20 causes include joint instability and abnormal weight. Patients can also be advised to avoid 43
21 ankle morphology, such as varus deformity of movements that cause pain in their daily lives or 44
22 the articular surface of the distal tibia. Treatment to reduce the weight-bearing load on the ankle by 45
23 must take the cause into consideration, as well using handrails or canes. 46
24 as the stage of the disease, especially in varus-
25 type OA of the ankle (Fig. 21.1) [7, 8]. This 21.1.1.2 Pharmacotherapy 47
26 chapter presents a general outline of treatment Nonsteroidal anti-inflammatory drugs (NSAIDs) 48
27 strategies. are the standard internal analgesic, and there are 49
several skin patches and liniments that contain 50
NSAIDs. The subcutaneous tissue of the ankle is 51
thin, which makes it easier for external medica- 52
tions to exert their effects. 53
Y. Tanaka (*)
Intra-articular steroid injections are effective 54
Nara Medical University, Kashihara, Japan during periods of severe inflammation accompa- 55
e-mail: yatanaka@naramed-u.ac.jp nied by intra-articular edema. Hyaluronic acid 56
© ISAKOS 2019 237

https://doi.org/10.1007/978-3-662-58704-1_21
238 Y. Tanaka
a b c d e
Fig. 21.1 Takakura-Tanaka classification of varus-type contact was limited to the medial malleolus. (d) Stage
ankle osteoarthritis. (a) Stage I: no narrowing of the joint IIIb: obliteration extended to the roof of the dome of the
space, but early sclerosis and formation of osteophytes. talus. (e) Stage IV: obliteration of the whole joint space
(b) Stage II: narrowing of the medial joint space. (c) Stage with complete bone contact
IIIa: obliteration of the joint space with subchondral bone
57 injections are also commonly used. The efficacy ankle ligament injuries are also effective for 87
58 of hyaluronic acid, including its anti-inflammatory ankle OA. If ankle OA is caused by a foot defor- 88
59 effects, lubricating action, ability to supply nutri- mity, prosthetic shoes may improve load dispari- 89
60 ents to the cartilage, and ability to improve pain ties inside the ankle. 90
61 thresholds, has been demonstrated by many stud-
62 ies [11–13]. 21.1.1.6 Shoe Inserts 91
Custom-made shoe inserts have shown effective- 92
63 21.1.1.3 Exercise Therapy ness in varus and valgus-type OA of the ankle. In 93
64 Posttraumatic ankle OA frequently involves lim- varus OA, an insert is used to wedge the anterior 94
65 ited range of motion (ROM) in adjacent joints as and lateral sides, which disperses the weight con- 95
66 well as the ankle. Pain can arise from improper centrated on the anterior and medial ankle 96
67 weight distribution on the foot. Therefore, active (Figs. 21.2 and 21.3) [16, 17]. Valgus OA is 97
68 ROM training is important, and care should be treated with an insert with medial arch support. 98
69 taken to stretch the tendons around the ankle. Treating varus-type ankle OA using a shoe 99
70 Training of the peroneal muscle is particularly insert with a lateral wedge is effective up to stage 100
71 important in OA following injury to the lateral IIIa, in which obliteration of the joint space stops 101
72 ligament. Standing on the toes so that the head of at the medial malleolus, but not in advanced cases 102
73 the first metatarsal presses against the ground can of stage IIIb or higher. Up to stage IIIa, valgus of 103
74 strengthen the peroneal muscle. the subtalar joint compensates for varus of the 104
articular surface of the distal tibia; however, this 105
75 21.1.1.4 Physical Therapy compensatory function is known to break down 106
76 Heat therapy is performed as in cases of regular when stage IIIb is reached [18]. Treating stage 107
77 OA. Hot packs and underwater jet massage are IIIb cases with a lateral wedge is ineffective 108
78 used to warm the surface layers, while ultra- because it pushes the heel from the lateral side, 109
79 microwave, microwave, and ultrasonic therapies which causes increase of the varus deformity. 110
80 can be used to heat deeper areas. Regular use of a
81 thermal insulation layer is also beneficial.
21.1.2 Surgery 111
82 21.1.1.5 Orthotic Therapy
83 Ankle instability sometimes causes OA of the If conservative therapy is unsuccessful, surgery 112
84 ankle. Joint incongruity and instability can mark- can be considered. Owing to the variety of 113
85 edly increase stress inside the joint [14, 15]. potential surgical approaches, accurate diagnosis 114
86 Braces that have been developed for the lateral of the disease stage is critical. 115
21 Current Concepts in the Treatment of Osteoarthritis of the Ankle 239
Fig. 21.2 Insoles with

lateral wedges
a b
Fig. 21.3 Effect of an insole with lateral wedge. Medial joint space is opened with an insole with lateral wedge. (a)
Without an insole. (b) With an insole
21.1.2.1 Joint Preservation Surgery by bony or soft tissue [19], though its effects are
limited in cases of advanced ankle OA [20].
Arthroscopic Debridement Symptomatic improvement in cases with no car-
Arthroscopic debridement yields positive out- tilage remaining is difficult using arthroscopic
comes in anterior impingement syndrome caused debridement alone.
240 Y. Tanaka
116 Distraction Arthroplasty 23 years) of old lateral ligament injuries and 144
117 While arthrodesis is often indicated for posttrau- found osteoarthritic changes in only 6 of 46 cases 145
118 matic OA in young people, distraction arthro- (13%), which suggests the involvement of bony 146
119 plasty may be indicated if there is a desire to factors besides instability. Lateral ligament 147
120 conserve joint mobility. In this procedure, a joint reconstruction is often combined with surgery to 148
121 external fixator is used to stretch the joint while correct bone alignment [27]. Since tibiofibular 149
122 mobilizing it until the cartilage can repair. This is ligament injury can also cause OA of the ankle, 150
123 reported to produce positive short-term outcomes ligament reconstruction may be indicated in such 151
124 [21]. While much about its mechanism remains cases. 152
125 unclear, it is a good option to try before consider-
126 ing total ankle arthroplasty (TAA) or Corrective Osteotomy 153
127 arthrodesis. Osteotomy is an important surgical style for 154
improving a joint’s biomechanical environment 155
128 Ankle Lateral Ligament Reconstruction and achieving functional recovery. In cases of 156
129 and Distal Tibiofibular Ligament malunion after malleolar fracture with mild 157
130 Reconstruction osteoarthritic changes, the aim is to correct the 158
131 Many studies have demonstrated a close relation- deformity. Anatomical correction of the lateral 159
132 ship between ankle instability and OA of the malleolus is important [28]. In cases of shorten- 160
133 ankle [22, 23]. Under loading, the talus sublux- ing, the talus is displaced laterally, for which 161
134 ated anteriorly onto the tibial pilon, which creates lengthening of the lateral malleolus is indicated 162
135 a shearing force on the articular surface that can (Fig. 21.4) [29]. If there is persistent subluxation 163
136 cause OA [24]. Lateral ligament reconstruction is of the ankle, scar tissue filling the medial gutter 164
137 effective for ankle OA accompanied by ankle must be removed. Low tibial osteotomy is indi- 165
138 instability, and Takao et al. [25] reported that cated in cases with remnant cartilage, such as in 166
139 ligament reconstruction and arthroscopic early closure of the epiphyseal line or tibial frac- 167
140 debridement produced positive outcomes in stage ture malunion [30, 31]. 168
141 II ankle OA. However, it does not appear that The morphological characteristics of varus- 169
142 joint instability alone can cause OA. Löfvenverg type OA of the ankle include inversion and ante- 170
143 et al. [26] examined the long-term courses (18– rior opening of the articular surface of the distal 171
a b c
Fig. 21.4 Fibular osteotomy for posttraumatic osteoarthritis (Maisonneuve fracture). (a) Pre-op. (b) Post-op 9 months.
(c) Post-op 2 years
172 tibia, which are evaluated by measuring the

173 angles formed by the tibial shaft and the articular
174 surface of the distal tibia—the tibial anterior sur-
175 face (TAS) angle and tibial lateral surface (TLS)
176 angle on anterior-posterior (AP) and lateral
177 weight-bearing ankle radiographs [32, 33]. These
178 angles are smaller in the presence of varus-type
179 OA of the ankle. Stage II or IIIa cases with this
180 kind of deformation are good indications for low
181 tibial osteotomy [8]. In some cases, there is a
182 large opening of the lateral joint space of the
183 ankle on weight bearing. This procedure is also
184 indicated when weight-bearing talar tilt angle—
Fig. 21.5 Minimally invasive plate osteosynthesis tech-
185 the angle between the articular surface of the dis- nique during low tibial osteotomy
186 tal tibia and the superior surface of the talus—is
187 less than 10° on anteroposterior weight-bearing
188 ankle radiographs [8]. The operation involves am als who use their feet relatively often, such as in 220
189 open-wedge osteotomy at 5 cm proximal to the jobs that require prolonged standing. In cases of 221
190 tip of the medial malleolus, followed by the cre- posttraumatic OA after a pilon or talar fracture, it 222
191 ation of a wedge for an autogenous bone graft or can be difficult to preserve joint functionality; 223
192 an artificial bone or an artificial bone, while therefore, arthrodesis is often selected. As com- 224
193 simultaneously performing osteotomy on the pared with arthrodesis for the knee or hip joints, 225
194 fibula (Figs. 21.5, 21.6, and 21.7). The objective patients who undergo this procedure for the ankle 226
195 is to correct the varus deformity of the articular report minimal inconvenience to their daily lives. 227
196 surface of the distal tibia in order to redistribute However, progression of OA to adjacent joints 228
197 the load concentrated on the medial ankle to the remains a potential issue [35, 36]. 229
198 lateral side and to slightly overcorrect the TAS Although more than 30 surgical techniques 230
199 angle to 93–96° and the TLS angle to 81–84°. have been reported, they can broadly be catego- 231
200 Better outcomes are observed with overcorrection rized according to the approaches, which include 232
201 than with undercorrection. However, studies of anterior, posterior, lateral, and endoscopic. 233
202 clinical outcomes indicate that there are limits to Selection of the surgical style varies by institu- 234
203 what can be achieved with this kind of regular tion. We often use an anterior sliding graft in cases 235
204 low tibial osteotomy in stage IIIb cases. Teramoto with severe varus or valgus deformity of the ankle. 236
205 et al. [34] reported positive outcomes using distal This involves collecting a prism- shaped graft 237
206 tibial oblique osteotomy (DTOO) in stage IIIb fragment from the anterior surface of the tibia that 238
207 cases. This involves no osteotomy to the fibula includes cortical bone and embedding it in a trian- 239
208 and creation of an oblique osteotomy from 4 to gular hole created in the talar neck [36]. Staples 240
209 5 cm proximal to the tip of the medial malleolus are used to immobilize the talocrural joint, and 241
210 to just superior to the tibiofibular joint (Figs. 21.8 screw fixation is used between the bone graft and 242
211 and 21.9). The objective is to shut the opening of the tibia. Partial weight bearing with a walking 243
212 the lateral ankle gutter and achieve the stability of cast begins at 2 weeks postoperatively, with full 244
213 the ankle. It is also indicated in cases with large weight bearing at 4 weeks and cast removal after 245
214 weight-bearing talar inclination. 5 or 6 weeks. Allowing weight bearing in the early 246
postoperative stages puts traction on the posterior 247
215 21.1.2.2 Ankle Arthrodesis articular surface of the ankle from the tension of 248
216 Ankle arthrodesis is currently considered the the Achilles tendon. The limb is fixed slightly 249
217 gold standard treatment for end-stage ankle externally rotated and in between plantar flexion 250
218 OA. It is indicated in stage IIIb or IV cases with and dorsiflexion and varus and valgus. Failing to 251
219 advanced osteoarthritic changes and in individu- correct varus deformities in particular can lead to 252
242 Y. Tanaka
a b c
Fig. 21.6 Low tibial osteotomy (stage III-a 64-year-old female). Joint space opened after surgery. A low tibial osteot-
omy is a good indication for osteoarthritis stage III-a. (a) Pre-op. (b) Immediate after operation. (c) Post-op 5 years
a b
Fig. 21.7 Regenerated fibrocartilage. (a) Articular cartilage was completely disappeared at the time of low tibial oste-
otomy. (b) Regenerated fibrocartilage was totally covered on the same area 1 year after the surgery
253 postoperative pain [36]. Arthroscopic fixation is tion is performed using cannulated screws from 260
254 possible if ankle varus or valgus is no greater than the medial side of the distal tibia with fluoroscopic 261
255 15° and the osseous defect is not large. guidance. The duration of cast immobilization is 262
256 Arthroscopic curettage of remaining cartilage and the same as in the anterior approach. It is also 263
257 the subchondral plate is performed with a sharp similar to the anterior approach in that there is 264
258 curette and ablator until bleeding from the graft little postoperative pain and synostosis occurs 265
259 bed is confirmed (Fig. 21.10), at which point fixa- relatively quickly (Fig. 21.11). If the ankle and 266
a b
Fig. 21.8 Osteotomy technique of distal tibial oblique oste- distal tibiofibular joint was temporally fixed with a Kirschner
otomy. (a) An oblique cut was made using a thin osteotome wire for preventing iatrogenic intra-articular fracture. The
following multiple drilling with a Kirschner wire. (b) The osteotomy site is gently opened using a thin osteotome
a b
Fig. 21.9 Distal tibial oblique osteotomy (53-year-old female). (a) Pre-op. (b) Post-op 2 years and 3 months
267 subtalar joint need to be immobilized simultane- screws in intramedullary nails. Using this method, 271
268 ously owing to severe foot deformity or osteoar- good visualization can be obtained and the bone 272
269 thritic changes to the subtalar joint, it is helpful to graft collected from the fibula can be used to per- 273
270 use a lateral approach with transverse locking form immobilization. 274
244 Y. Tanaka
a b
Fig. 21.10 Arthroscopic ankle arthrodesis. (a) Removing residual articular cartilage with a curette. (b) Subchondral
bone plate was removed using an abrader
a b
Fig. 21.11 Arthroscopic ankle arthrodesis (57-year-old at 2 months after surgery and gaps were filled out by
male). There were gaps at an anterior and posterior side of regenerated bone. (a) Immediate after surgery. (b) Post-op
the ankle at immediate after surgery. Bone union achieved 2 months
275 21.1.2.3 T otal Ankle Arthroplasty implant. In 39 reports (1262 total cases) on ankle 305
276 (TAA) arthrodesis, the reoperation rate was 9%, with the 306
277 Ankle replacement designs were associated with primary reason being nonunion. According to the 307
278 poor outcomes up to the 1980s, and TAA received score of American Orthopaedic Foot and Ankle 308
279 little attention for many years. However, advances Society, the mean clinical assessment of TAA 309
280 in biomaterials and surgical techniques starting in was 78.2 points, while that of ankle arthrodesis 310
281 the 1990s led to the development of several new was 75.6 points (max. 100 points), leading to the 311
282 types of artificial ankle joints that markedly conclusion that the outcomes were roughly 312
283 improved outcomes [37, 38]. According to our equivalent. That said, the procedure is generally 313
284 research, more than 30 different types of ankle recommended in patients who are at least 314
285 replacements are currently used worldwide. 50 years old and have varus or valgus deformity 315
286 Unconstrained joints with three- component ≤15°, though successful outcomes can be diffi- 316
287 designs are mainstream, and positive outcomes cult to achieve in cases of severe obesity. TAA is 317
288 have been reported using the STAR ankle since the the preferred choice for patients who are affected 318
289 1980s [39]. However, 5-year survival rates of 70% bilaterally or who have impairments in adjacent 319
290 have been reported, with 16% of patients opting joints, as arthrodesis can severely limit ROM. 320
291 not to repeat the surgery, which indicates a degree The TNK ankle we use is made of alumina 321
292 of dissatisfaction [40]. Artificial joints with two- ceramic, which has had its surface treated with 322
293 component designs have continued to improve and beads to improve adhesion with the bone since 323
294 are now being used around the world. The TNK 1991 [41]. Calcium phosphate paste came into 324
295 ankle developed at Nara Medical University is a clinical use starting in 2000. At our institution, its 325
296 semi-constrained variety of this type [41]. normal concentration is diluted two to five times 326
297 In terms of indications, it can be difficult to before being applied to surfaces. To further increase 327
298 determine when to use TAA and when to use bone bonding, the joint is placed on bone marrow 328
299 ankle arthrodesis. Haddad et al. [42] carried out a aspirate when it is inserted. Overall, TNK ankle 329
300 systematic review on the differences in outcomes outcomes are characterized by low revision rates. 330
301 between TAA and ankle arthrodesis. In ten Of the first 70 cases, the revision surgeries were 331
302 reports (852 total cases) on the intermediate out- performed in only 3 cases. Furthermore, nowadays 332
303 comes of TAA, the reoperation rate was 7%, with we devised an artificial total talar prosthesis which 333
304 the primary reason being loosening of the was made by alumina ceramic (Fig. 21.12) [43]. If 334
a b
Fig. 21.12 Alumina ceramic total talar prosthesis. (a) Alumina ceramic total talar prosthesis. (b) Combined total ankle
arthroplasty
246 Y. Tanaka
a b
Fig. 21.13 Total ankle arthroplasty using an artificial talus (4 years after the surgery). (a) AP weight-bearing view. (b)
Dorsiflexion. (c) Plantar flexion
335 the talus in the patients is severely destroyed, total 3. Glazebrook M, Daniels T, Younger A, Foote CJ, Penner 350
336 ankle arthroplasty using a total talar prosthesis M, Wing K, Lau J, Leighton R, Dunbar M. Comparison 351
of health-related quality of life between patients with 352
337 (combined TAA) is selected. Combined TAA using end-stage ankle and hip arthrosis. J Bone Joint Surg 353
338 an artificial talus can also be performed in cases of Am. 2008;90:499–505. 354
339 severe talar deformation (Fig. 21.13). 4. Al-Mahrouqi MM, MacDonald DA, Vicenzino B, 355
Smith MD. Physical impairments in adults with ankle 356
osteoarthritis: a systematic review and meta-analysis. 357
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496 Relat Res. 2004;424:130–6.
1 Jones Fractures
22
2 K. C. Doan and Kenneth J. Hunt
3 22.1 Introduction Jones fracture, or fracture of the base of the fifth 27

metatarsal at the meta-diaphyseal junction enter- 28
4 Fractures involving the base of the fifth metatar- ing the fourth–fifth inter-metacarpal joint 29
5 sal were first described in 1902 by Sir Robert (Fig. 22.1), accounts for about 3–10% of all meta- 30
6 Jones. In his paper, “Fracture of the Base of the
7 Fifth Metatarsal Bone by Indirect Violence,”
8 Jones introduced the first controversy surround-
9 ing fractures of the base of the fifth metatarsal.
10 Over the years, understanding of fractures about
11 the base of the fifth metatarsal has evolved; how-
12 ever treatment controversies have persisted.
13 Multiple classification systems, treatment strate-
14 gies, and surgical techniques have been devel-
15 oped over the years to address this diverse group
16 of fractures. Due to the complex bony and liga-
17 mentous anatomy, mechanics, and blood supply
18 of the proximal fifth metatarsal [1], these frac-
19 tures continue to challenge orthopedic surgeons
20 and the patients in which the fractures occur.
21 22.2 Epidemiology
22 and Importance
23 Fractures of the fifth metatarsal are the most com-

24 mon fracture in the foot. The fifth metatarsal is the
25 most commonly fractured metatarsal, comprising
26 about 68% of all metatarsal fractures [2]. The
K. C. Doan · K. J. Hunt (*)

Department of Orthopaedic Surgery, University
of Colorado School of Medicine, Aurora, CO, USA Fig. 22.1 Oblique radiograph demonstrating Jones
e-mail: kenneth.j.hunt@ucdenver.edu fracture
© ISAKOS 2019 249

https://doi.org/10.1007/978-3-662-58704-1_22
250 K. C. Doan and K. J. Hunt
31 tarsal fractures. Fractures more proximally and jump or fall from height, or a cutting-type maneu- 76
32 more distally to this are also common, with frac- ver in athletes. This differentiation is important 77
33 tures of the tuberosity proximally being the most as subacute and stress fractures of the fifth meta- 78
34 common [1]. These are avulsion-type fractures of tarsal are more prevalent in patients with cav- 79
35 the peroneus brevis attachment and are com- ovarus deformity and metatarsus adductus [2, 5], 80
36 monly, and perhaps inaccurately, referred to as and successful treatment of this specific injury 81
37 “pseudo-Jones” fractures. Stress fractures often pattern is highly dependent on recognition of this 82
38 occur more distally approaching the diaphysis, deformity. In addition to a comprehensive history 83
39 and have been reported to be rare, constituting and physical examination, it is necessary to eval- 84
40 only about 1% of all metatarsal fractures in a large uate the patient medical comorbidities. Blood 85
41 series [3]. These are important to recognize due to supply to the area of the base of the fifth metatar- 86
42 their underlying mechanism of injury, healing sal is tenuous as it is a well-recognized watershed 87
43 rates, and subsequent treatment strategies. area. Treating any underlying medical comorbid- 88
44 Base of the fifth metatarsal fractures are com- ities which contribute to poor vascular supply 89
45 mon in a large patient demographic and do not could theoretically improve postoperative out- 90
46 distribute in the standard bimodal distribution comes both in the surgical and nonsurgical set- 91
47 seen in other traumatic orthopedic injuries. These tings. Appropriate imaging should always be 92
48 fractures, conversely, are seen often in athletic obtained including weight-bearing anteroposte- 93
49 populations and show the highest incidence rior, oblique, and lateral foot radiographs at the 94
50 between the ages of 20 and 50 years [2]. As Jones time of initial evaluation. Given the subacute or 95
51 originally described, this is likely due to the chronic nature of some of these fractures how- 96
52 mechanism of injury. Recently, new evidence ever it can occasionally take 3–6 weeks before 97
53 also suggests that intrinsic anatomic factors may radiographs show evidence of fracture reabsorp- 98
54 play an important role. Base of the fifth metatar- tion [3]. In this and other instances, it may be 99
55 sal fractures are reported after a wide variety of appropriate to obtain advanced imaging to evalu- 100
56 acute mechanisms, or can be of insidious onset. ate patients with a concerning history or physical 101
57 They can also present with subtle or exam but without radiologic evidence of fracture. 102
58 difficult-to-interpret symptoms of pain to the lat- MRI, or technetium bone scan, can show acute 103
59 eral aspect of the foot. It is important to note that inflammation in the area of an occult fracture, 104
60 a large portion of these injuries arise from rela- and CT can be of particular use when evaluating 105
61 tively minor trauma, or from repetitive impact for refracture or bone healing and cortical union. 106
62 athletic activities, making it imperative to have a In order to successfully treat fractures about 107
63 high index of suspicion when dealing with all the base of the fifth metatarsal, multiple classifi- 108
64 patients, especially athletes with lateral mid-foot cation systems have been described. The two 109
65 pain. most common classification systems in use today 110

are the anatomic classification system first 111
described by Lawrence and Bottle, and the radio- 112
66 22.3 Evaluation and Treatment graphic appearance classification system 113
67 Considerations described by Torg [1, 4]. The anatomic classifica- 114

tion system divides the base of the fifth metatar- 115
68 It is important to obtain a thorough history and sal into three zones. Zone 1 is the most proximal 116
69 physical examination of the patient being evalu- at the level of the peroneus brevis insertion on the 117
70 ated for a fracture of the base of the fifth metatar- tuberosity which can involve the metatarsal– 118
71 sal. Often, in the history the patient will recall cuboid joint. Zone 2 is located at the meta- 119
72 several weeks of discomfort prior to the inciting diaphyseal junction at the level of the fourth/fifth 120
73 event that brought them for evaluation [4]. intermetatarsal joint—the so-named Jones 121
74 Conversely, these fractures may be the result of fracture. Zone 3 extends distally an additional 122
75 an acute trauma in isolation such as an MVC, 1.5 cm into the diaphysis of the fifth metatarsal. 123
22 Jones Fractures 251
124 Torg’s radiographic appearance classification there is no longer tenderness to palpation at the 169
125 system attempts to qualitatively describe the fracture site. The average time to union is sited 170
126 chronicity of the fracture. Type I therefore repre- around 15–19 weeks [10]. Additionally, nonop- 171
127 sents an acute fracture with sharp margins and erative management has nonunion rates approach- 172
128 minimal cortical hypertrophy or periosteal reac- ing 30% and an increased rate of refracture when 173
129 tion. Type II is a more delayed healing picture compared to operative management [10]. 174
130 demonstrating early intramedullary sclerosis, Operative management conversely has union 175
131 bone reabsorption, and associated periosteal rates around 96% which occur on average at 176
132 reactions. Type III is a fracture nonunion with 6–8 weeks and also allows earlier return to sport 177
133 wide fracture line, periosteal new bone, and com- with less risk of refracture [10]. Zone 3 injuries 178
134 plete obliteration of the metal medullary canal should be differentiated between acute and 179
135 with sclerotic bone. Both of these classification chronic. Acute injuries in a nonathletic popula- 180
136 systems help guide treatment strategies by identi- tion can be offered a trial of nonoperative man- 181
137 fying which fractures will do well when treated agement; however subacute and chronic fractures 182
138 nonoperatively with or without orthotics [6], especially in athletes are recommended to 183
139 which patients should be evaluated for a defor- undergo surgical fixation possibly with bone 184
140 mity leading to their fracture [5], and which will graft augmentation [5]. A recent decision analy- 185
141 require specific surgical interventions for optimal sis model indicated that given current healing 186
142 outcome [7, 8]. rates, operative treatment is the preferred treat- 187
143 The majority of fractures of the base of the ment approach in elite athletes, consenting 188
144 fifth metatarsal will heal without surgical inter- patients who prefer to limit the risk of nonunion, 189
145 vention [1, 4, 6, 9]. Zone 1 fractures typically do and patients with evidence of stress fractures 190
146 well with nonoperative management, even in the with delayed or nonunion [11]. 191
147 setting of displacement greater than 2 mm [9].
148 Some unacceptably displaced fractures, particu-
149 larly with a stepoff at the joint, may require fixa- 22.5 Surgical Techniques 192
150 tion with percutaneous pinning, tension band, or
151 hook plate internal fixation. It is also important Outpatient surgical fixation of base of the fifth 193
152 to consider orientation of fracture lines in this metatarsal fractures can be preformed using per- 194
153 zone in the skeletally immature, such as in cutaneous, limited open, and open techniques 195
154 Iselin’s disease, or apophysitis of the fifth meta- depending on the specific fracture pattern, fixa- 196
155 tarsal will show only the normal longitudinally tion construct, and other factors, like chronicity. 197
156 oriented apophysis on radiographs. Zone 2 frac- Regional block with monitored anesthesia care 198
157 tures also often heal regularly with nonoperative such as a popliteal or ankle block is reasonable; 199
158 management; however there are some drawbacks however the authors prefer general anesthesia 200
159 to nonoperative management especially in the for ease of positioning as well as limiting risks of 201
160 athletic population which will be discussed in nerve complications. Appropriate patient posi- 202
161 depth in subsequent sections. Zone 3 fractures tioning is critical to allow adequate fluoroscopic 203
162 need consideration of mechanism of injury and imaging to be obtained (Fig. 22.2). The authors 204
163 foot alignment to develop appropriate treatment recommend ensuring that all views can be 205
164 approach [3, 5]. obtained adequately before draping is pre- 206
formed, especially if a percutaneous approach is 207
going to be used. The patient is positioned supine 208
165 22.4 Nonoperative Management on the operating table with a bolster under the 209
affected extremity. This allows for internal rota- 210
166 Nonoperative management requires prolonged tion and adequate exposure of the lateral aspect 211
167 non-weight bearing, initially at least 6–8 weeks of the foot. A well-padded tourniquet is placed 212
168 until radiographs show evidence of healing and on the affected thigh; however it is not routinely 213
with the metatarsal shaft distally. The intramed- 238

ullary canal can be assessed in relation to these 239
using fluoroscopy. A single incision is used prox- 240
imal to the base of the tuberosity in line with the 241
intramedullary canal. The incision is traced at 242
appropriate level proximal to the tuberosity about 243
2 cm in length. After the skin is sharply incised, 244
blunt dissection is carried down to the base of the 245
fifth metatarsal. It is important to realize that the 246
sural nerve lies superficially here, and the pero- 247
neus brevis and lateral band of the plantar fascia 248
are at risk with this approach; all should be pro- 249
tected throughout the procedure. A Kirschner 250
wire is introduced and appropriate starting point 251
is assessed. It is important to utilize the “high and 252
inside” start point in order to get appropriate tra- 253
jectory within the intramedullary canal. This cor- 254
relates with the most dorsal and medial aspect of 255
Fig. 22.2 Photographs demonstrating positioning for
Jones fracture fixation with the sterile image intensifier the base of the fifth metatarsal without entering 256
adjacent to the operating table the metatarsal-cuboid joint. The K wire is then 257
advanced using fluoroscopic imaging. The posi- 258
214 inflated. Intravenous antibiotics are administered tion of the guidewire must be centered within the 259
215 prior to incision, and the extremity is prepped medullary canal on all views, and advanced to the 260
216 and draped in standard fashion, usually with the level of the distal metatarsal shaft where there is 261
217 entire limb to the level of the tourniquet exposed consistently a curvature which limits screw 262
218 to allow for adequate knee flexion to obtain fluo- length. A cannulated drill with soft-tissue protec- 263
219 roscopic imaging. The importance of fluoros- tor is then used, again utilizing fluoroscopy and 264
220 copy for assessing fracture reduction, screw alternating between forward and reverse func- 265
221 length, screw diameter, hardware starting point, tions, to ream over the wire and prevent cortical 266
222 intramedullary position, and fracture compres- perforation. The wire is maintained in the meta- 267
223 sion cannot be overstated, as each fixation tarsal, and a second wire can be used to measure 268
224 method has specific pearls and pitfalls for opti- the length of the partially threaded screw. The 269
225 mizing fixation and mediating risk of failure or screw length is then checked prior to insertion by 270
226 iatrogenic injury. obtaining an image to confirm all threads are dis- 271
tal to the fracture line. 272
A solid screw of at least 4.5 mm diameter is 273
227 22.6 Intramedullary Screw selected. The largest diameter screw that will fit 274
228 Fixation in the canal is selected. Most of the time, this is a 275
5.5 or 6.5 mm diameter solid screw. The screw is 276
229 The most common method of zone 2 and 3 fifth finally inserted under fluoroscopy to confirm 277
230 metatarsal fractures remains the single intramed- compression and prevent malrotation or iatro- 278
231 ullary screw. This section focuses on intramedul- genic fracture (Fig. 22.3). It is important that the 279
232 lary screw fixation for primary fixation of acute screw is not of excessively large diameter that 280
233 or chronic fractures of the base of the fifth could risk fracture of the metatarsal from circum- 281
234 metatarsal. ferential stresses. It is also important that the 282
235 Use of a single percutaneous intramedullary screw is not too long as the fifth metatarsal canal 283
236 screw begins with identification of the surface is nonlinear and if a cortex is engaged distraction 284
237 landmarks. The tuberosity can be palpated along can occur (Fig. 22.4). Once final images are 285
a b
Fig. 22.3 (a) Anteroposterior, (b) oblique, and (c) lateral radiographs demonstrating healed Jones fracture with intra-
medullary screw fixation
286 obtained, the wound can then be irrigated and 22.7 Biologic Adjuncts 290
287 closed in layers above the screw head. If possible,
288 the periosteum should be closed over the screw Use of bone graft and biologics in the treatment of 291
289 head and the rest of the wound closed in layers. both acute and revision fractures is also a consid- 292
eration for operatively managed fractures. This 293
has increased relevance with the surge of new 294
products on the market and in the media. New 295
methods for less invasive harvesting, along with 296
improved processing, have made the availability 297
of these products much greater. Given the vascu- 298
lar watershed of the fifth metatarsal, some authors 299
are proponents of routine use of bone graft or 300
other biologic materials, while others use this 301
only in at-risk cases or in the revision setting. 302
In cases with significant sclerosis and non- 303
unions, the addition of orthobiologic adjuncts can 304
be helpful. In fractures with significant sclerosis, 305
the senior author’s preferred technique includes 306
percutaneous curettage and debridement of the 307
fracture site (Fig. 22.5a). A curette is used to 308
remove sclerotic bone and a K wire to drill into 309
bone to promote bleeding (Fig. 22.5b). The result- 310
ing gap can be filled with autograft or allograft 311
bone, or a combination. We have previously 312
reported on this technique with excellent results, 313
including elite athletes [12]. Further outcome 314
Fig. 22.4 CT scan images demonstrating a long screw
abutting distal fifth metatarsal cortex. Fracture nonunion studies are required to differentiate which fracture 315
is evident types or patient populations would benefit from 316
grafting or biologics in the acute scenario. 317
a b
Fig. 22.5 (a) Photograph and (b) fluoroscopic image demonstrating curettage of non-united fracture site
318 22.8 Compression Plate Fixation o ccasionally for athletes who are at high risk of 322
nonunion or refracture [13]. Specific low-pro- 323
319 Plating of fifth metatarsal fractures can be very file plantar plates have been developed to pre- 324
320 useful for certain fracture patterns, revision vent prominence and counter traction forces 325
321 cases, and nonunions (Fig. 22.6), and seen especially in the competitive athletic 326
Fig. 22.6 Plate fixation for Jones fracture nonunion

Fig. 22.7 Fluoroscopic images following plate fixation
327 population [10]. The incision for a plate fixa- 22.9 R

evision IM Screw and Plate 351
328 tion construct is centered over the fracture site w/Grafting 352
329 over the lateral foot, slightly plantar. Skin and
330 soft tissues are dissected carefully down to In revision settings, or in the case of delayed or 353
331 bone with care to preserve superficial sensory nonunion, we recommend the routine use of bio- 354
332 nerves if encountered (usually sural nerve is logic augmentation to the previously described 355
333 more dorsal than incision). Periosteum is reduction and fixation strategies. Either a single 356
334 incised and fracture site debrided, minimizing or two-incision approach can be used, but the 357
335 exposure to preserve vascular supply using fracture site should be universally exposed. This 358
336 standard principles of fracture compression is to allow fracture-site debridement of any callus 359
337 and fixation. Once the fracture is reduced and or fibrous scar, removal of any prior fixation, and 360
338 provisionally fixed using either manual reduc- confirmation of anatomic reduction. The scle- 361
339 tion or fracture reduction clamps, the plate is rotic fracture margins should be drilled with 362
340 applied. Pre-contoured, low-profile compres- small-diameter K wire to promote and confirm 363
341 sion plates optimize fit and allow fracture-site blood flow with the “paprika sign.” [11] The 364
342 compression with eccentric screw placement in author prefers the use of autologous cancellous 365
343 dynamic holes. The fracture reduction, com- bone graft from the iliac crest applied directly at 366
344 pression, and fixation should then be confirmed the fracture site. In the case of revision IM nail, a 367
345 radiographically in orthogonal planes. The screw of at least 1 mm diameter larger than the 368
346 incision is then copiously irrigated and closed prior screw is then inserted as described in prior 369
347 in layers, again with the attempt to close peri- sections. In the rare case of a large or segmental 370
348 osteum over hardware. Figure 22.7 demon- bone deficit, we recommend the use of iliac crest 371
349 strates final fluoroscopic films of the plate cortico-cancellous autograft in combination with 372
350 osteosynthesis technique. bone marrow aspirate concentrate. 373
374 22.10 Postoperative Care athletes in the NBA and NFL have shown safe 415
and successful return to sport with operative 416
375 Postoperatively the patient is immobilized in a fixation. 417
376 cast or splint. Any sutures are removed at the The decision between fracture fixation with 418
377 2-week postoperative appointment. The patient is intramedullary screw and plantar lateral plating 419
378 progressed to weight bearing as tolerated in a should be tailored to individual fracture patterns 420
379 short walker boot at the 2–4-week timeframe. and patient needs. The optimal screw size and 421
380 Between 6 and 8 weeks, the fracture site is usu- other properties such as cannulation vs. solid 422
381 ally minimally tender to palpation and shows shaft, fully or partially threaded, or variable angle 423
382 radiographic evidence of healing. If the patient is pitch are subjects of contention in the literature. 424
383 able to ambulate in clinic without pain, they are Biomechanical studies comparing strength and 425
384 then transitioned to supportive athletic shoe with resistance to stress of different screw properties 426
385 custom orthotic insert at the 6–8-week post-op are numerous [4, 6, 15], and current consensus 427
386 visit. For both primary and revision fixation, ath- from the American Orthopaedic Foot and Ankle 428
387 letic patients will typically begin noncontact run- Society states “Operative intervention in the form 429
388 ning and sport-specific rehabilitation programs of an intramedullary solid screw is the treatment 430
389 with anticipated return to sport around of choice.” In addition, a shared decision-making 431
390 10–12 weeks. When the athlete returns to sport, model analyses indicated strong preference for 432
391 an orthotic that has a full-length lateral post that surgical treatment [16]. The decision to use plan- 433
392 extends proximal to the cuboid is utilized. This is tar lateral plating can also be tailored to specific 434
393 also beneficial to accommodate hindfoot varus patient needs, and recent biomechanical studies 435
394 and metatarsus adductus. have shown increased cyclical and maximal load 436
to failure of this construct over IM screws [13]. 437
This is an important consideration in athletes 438
395 22.11 Outcomes where quicker return to sport is desired and the 439
most stable and durable construct is desirable. 440
396 Base of the fifth metatarsal fractures comprise a Further research comparing the many IM screw 441
397 diverse group of injuries, and an equally diverse and plate fixation strategies focusing on healing 442
398 body of literature regarding treatment strategies rates, return to sport, and clinical outcomes is 443
399 and outcomes. In two large systematic reviews, needed before definite recommendation could be 444
400 acute fractures treated nonoperatively were noted made, but reduction of the fracture, an adequate 445
401 to have about a 75% union rate, while operatively biologic and mechanical environment, and a sta- 446
402 treated fractures with an intramedullary screw ble construct are indicated to optimize healing. 447
403 had a union rate approaching 96%. Revision and

404 nonunion cases have similar successful results
405 with multiple studies showing union rates >95% 22.12 Summary 448
406 [7, 8, 11, 12]. Another advantage of surgical

407 fixation is the faster rate of fracture union. The Fractures of the base of the fifth metatarsal are a 449
408 average time to union of surgically fixed fractures diverse and challenging problem for the treating 450
409 is about 8–10 weeks sooner than nonoperatively orthopedic surgeon. As surgical fixation strate- 451
410 managed fractures [9, 14]. This can be of critical gies have evolved, outcomes are well understood, 452
411 importance for return to sport, especially when and patient demands continue to increase, the 453
412 taking into consideration that nonoperatively threshold for surgical intervention has lowered. 454
413 managed fractures have higher rates of nonunion During the shared decision-making process, all 455
414 and refracture. Multiple studies on professional factors including union rates, time to union, and 456
457 increased risk of refracture associated with non- 6. Monteban P, van den Berg J, van Hees J, Nijs S, 490
458 operative management should be discussed with Hoekstra H. The outcome of proximal fifth metatar- 491
sal fractures: redefining treatment strategies. Eur J 492
459 the patient. The optimal fixation strategy and Trauma Emerg Surg. 2017;44(5):727–34. 493
460 decision of the most appropriate fixation con- 7. Begly JP, Guss M, Ramme AJ, Karia R, Meislin 494
461 struct should be tailored to the individual fracture RJ. Return to play and performance after Jones frac- 495
462 pattern and patient factors. If performed well in a ture in national basketball association athletes. Sports 496
Health. 2016;8(4):342–6. 497
463 compliant patient, excellent outcomes with early 8. Lareau CR, Hsu AR, Anderson RB. Return to play 498
464 return to sport can be anticipated both in acute in national football league players after opera- 499
465 and revision scenarios. There is a trend toward a tive Jones fracture treatment. Foot Ankle Int. 500
466 more conservative return-to-sport strategy fol- 2016;37(1):8–16. 501
9. Lee TH, Lee JH, Chay SW, Jang KS, Kim 502
467 lowing surgical repair to further reduce refracture HJ. Comparison of clinical and radiologic outcomes 503
468 rates. Further study will help delineate which between non-operative and operative treatment 504
469 patients will benefit further from realignment in 5th metatarsal base fractures (Zone 1). Injury. 505
470 surgeries, specific fixation constructs, as well as 2016;47(8):1789–93. 506
10. Porter DA. Fifth metatarsal Jones fractures in the ath- 507
471 biologic supplementation as the treatment of base lete. Foot Ankle Int. 2018;39(2):250–8. 508
472 of the fifth metatarsal fractures continues to 11. Japjec M, Staresinic M, Starjacki M, Zgaljardic
509
473 evolve. I, Stivicic J, Sebecic B. Treatment of proximal 510
fifth metatarsal bone fractures in athletes. Injury. 511
2015;46(Suppl 6):S134–6. 512
12. Hunt KJ, Anderson RB. Treatment of Jones fracture 513
474 References nonunions and refractures in the elite athlete: out- 514
comes of intramedullary screw fixation with bone 515
475 1. Bryan D, Den Hartog M. Fx proximal fifth metatarsal. grafting. Am J Sports Med. 2011;39(9):1948–54. 516
476 J Am Acad Orthop Surg. 2009;17:458–64. 13. Duplantier NL, Mitchell RJ, Zambrano S, et al.
517
477 2. Petrisor BA, Ekrol I, Court-Brown C. The epidemiol- A biomechanical comparison of fifth metatarsal 518
478 ogy of metatarsal fractures. Foot Ankle Int. 2006. Jones fracture fixation methods. Am J Sports Med. 519
479 3. Wamelink KE, Marcoux JT, Walrath SM. Rare proxi- 2018;46(5):1220–7. 520
480 mal diaphyseal stress fractures of the fifth metatarsal 14. Hunt KJ, Reiter MJ, Axibal DP, Varner K. Management 521
481 associated with metatarsus adductus. J Foot Ankle of fifth metatarsal fracture and refracture in athletes. 522
482 Surg. 2016;55(4):788–93. Oper Tech Orthop. 2018;28:61–6. 523
483 4. Thomas B, Dameron J. Proximal fifth metatarsal frac- 15. James Jastifer M, McCullough KA. Fatigue bending 524
484 tures: selecting the best treatment option. J Am Acad strength of Jones fracture specific screw fixation. Foot 525
485 Orthop Surg. 1995;3(2):110–4. Ankle Int. 2018;39(4):493–9. 526
486 5. Yoho RM, Vardaxis V, Dikis J. A retrospective review 16. Bishop JA, Braun HJ, Hunt KJ. Operative versus
527
487 of the effect of metatarsus adductus on healing time nonoperative treatment of Jones fractures: a deci- 528
488 in the fifth metatarsal Jones fracture. Foot (Edinb). sion analysis model. Am J Orthop (Belle Mead NJ). 529
489 2015;25(4):215–9. 2016;45(3):E69–76. 530
1 Hallux Rigidus
23
2 Stephanie L. Logterman and Kenneth J. Hunt
3 23.1 Background during push-off is oftentimes the inciting 30

mechanism. 31
4 Hallux rigidus refers to osteoarthritis of the first Patients often present with pain and stiffness 32
5 metatarsophalangeal (MTP) joint and is the most of the first MTP joint. Initially, the pain is located 33
6 common degenerative joint disease in the foot dorsally and then progresses to diffuse joint pain. 34
7 [1]. In athletes, hallux rigidus is the most com- Patients usually report pain during activity, espe- 35
8 mon pathology of the first MTP joint and causes cially with toe off. They may also note a dorsal 36
9 considerable disability in this population [2]. prominence that becomes painful from inflam- 37
10 Despite its relative frequency in athletes, hallux mation due to shoe wear. On exam, patients often 38
11 rigidus has received minimal consideration in the have tenderness to palpation at the first MTP 39
12 sports literature. During the gait cycle, the first joint in addition to restricted dorsiflexion (usu- 40
13 MTP joint receives about 119% of the bodies’ ally <30°), dorsal osteophytes, and synovitis. 41
14 weight with each step [3]. Hallux rigidus is char- Hallux rigidus is classified radiographically with 42
15 acterized by joint pain and limited motion of the three grades. On X-ray, grade I hallux rigidus is 43
16 first MTP joint, specifically dorsiflexion. The characterized by mild to moderate osteophyte 44
17 natural history of the disease involves cartilage formation with preservation of the joint space, 45
18 degeneration with osteophyte formation dorsally while grade II involves moderate osteophyte for- 46
19 and associated pain that gradually progresses to mation with evidence of joint space narrowing 47
20 involve the entire first MTP joint [4]. The exact and subchondral sclerosis (Fig. 23.1). Grade III 48
21 etiology of the disease has yet to be fully eluci- changes on X-ray demonstrate significant osteo- 49
22 dated; however, several potential causes exist. phyte formation with severe loss of the first MTP 50
23 Traumatic injury and osteochondral lesions to the joint space and subchondral cyst formation [1]. 51
24 articular surfaces, in addition to biomechanical Initial nonoperative management of hallux 52
25 and structural factors such as hallux valgus, rigidus includes foot orthosis, shoe modifica- 53
26 hypermobility of the first ray, and metatarsus tions, or steroid injections [1]. Activity modifica- 54
27 adductus, are just a few associated factors and tion is not practical option for high-level athletes. 55
28 potential causes [5–7]. In the athletic population, For symptomatic patients who have failed con- 56
29 repetitive hyperextension of the first MTP joint servative management, many different surgical 57
options exist. The most common surgical inter- 58
S. L. Logterman · K. J. Hunt (*) ventions include cheilectomy, arthroscopic chei- 59
Department of Orthopaedic Surgery, University lectomy, and arthrodesis. Joint-destructive 60
of Colorado School of Medicine, Aurora, CO, USA procedures such as arthrodesis provide definitive 61
e-mail: kenneth.j.hunt@ucdenver.edu
© ISAKOS 2019 259

https://doi.org/10.1007/978-3-662-58704-1_23
260 S. L. Logterman and K. J. Hunt
Fig. 23.1 Lateral radiograph of the forefoot demonstrating a dorsal osteophyte, joint space narrowing, and subchondral
sclerosis
62 and predictable results; however, motion- osteophyte, presence of loose bodies, and pres- 84
63 preserving surgeries like hemiarthroplasty or ence of a lateral osteophyte seen on radiographs 85
64 synthetic cartilage implant may be more advanta- also help to guide decision-making as a lateral 86
65 geous in some patients, although there is little spur is not amenable to minimally invasive chei- 87
66 data in athletes. Currently in the literature, there lectomy and may necessitate the use of an acces- 88
67 is fair evidence in support of arthrodesis (grade sory portal if an arthroscopic procedure is 89
68 B) and poor evidence (grade C) for cheilectomy pursued. Open cheilectomy remains the gold 90
69 and implant arthroplasty for the treatment of hal- standard for treatment of early hallux rigidus; 91
70 lux rigidus [8]. however, percutaneous and arthroscopic tech- 92
niques are minimally invasive. It is recommended 93
to obtain an MRI preoperatively to assess for any 94
71 23.2 Cheilectomy joint degeneration that may not be obvious on 95
X-ray when considering a percutaneous proce- 96
72 Cheilectomy involves resection of both the dorsal dure as a percutaneous cheilectomy does not 97
73 osteophyte and the dorsal one-third of the meta- allow for visualization of the joint surface. An 98
74 tarsal head articular surface. Furthermore, any arthroscopic cheilectomy is typically chosen 99
75 loose bodies are also removed and a synovec- when the surgeon desires a minimally invasive 100
76 tomy is performed. The procedure was first procedure but also needs to also assess the articu- 101
77 described by Mann and DuVries in 1979 [9]. lar surface, such as when a central osteochondral 102
78 Currently, there are multiple methods for per- lesion is suspected. 103
79 forming a cheilectomy including open, Cheilectomy is most often indicated for early- 104
80 arthroscopic, and percutaneous. Surgeons need to stage hallux rigidus (grades I and II); however, 105
81 consider the athlete’s functional expectations and some authors advocate for the procedure regard- 106
82 the clinical examination when choosing the type less of stage of involvement [10–12]. It is usually 107
83 of cheilectomy to perform. The size of the dorsal performed for athletes presenting with mild first 108
23 Hallux Rigidus 261
109 MTP joint dorsiflexion stiffness and dorsal pain not typically necessary in athletes. It is important 125
110 without through-range symptoms, rest pain, or to achieve at least 80° of dorsiflexion intra-op 126
111 plantar pain and with a negative grind test [13]. since dorsal scar formation will limit ROM in 127
112 Cheilectomy may be considered so long as no some cases post-op (Fig. 23.2). Arthroscopic and 128
113 significant bone loss exists despite radiographic minimally invasive cheilectomy techniques have 129
114 evidence of advanced joint degeneration. This is been described and are associated with less post- 130
115 due to the fact that the radiographic grading sys- operative swelling and improved motion postop- 131
116 tem does not correlate well with the potential for eratively [15] (Figs. 23.3 and 23.4). 132
117 joint-preserving surgery nor is it predictive of Cheilectomy offers many advantages includ- 133
118 outcome [14]. ing preserving motion and maintaining joint sta- 134
119 The open cheilectomy technique is typically bility. It also has a low morbidity and may allow 135
120 performed through a dorsomedial or dorsolateral for secondary procedures in the future. In addi- 136
121 incision. Great caution must be used to avoid tion, arthroscopic and percutaneous techniques 137
122 injury or scarring of the EHL tendon and dorso- may offer less swelling and a shortened recovery 138
123 medial cutaneous nerve. Release of plantar adhe- time after surgery. While cheilectomy relieves 139
124 sions can be helpful to restore motion, but this is pain in athletes, it does not result in normal h allux 140
a b c
Fig. 23.2 (a) Intraoperative view of the first MTP joint after dorsal osteophyte excision. (b) Improved dorsiflexion to
at least 80° after cheilectomy. (c) Shows radiographic evidence of improved postoperative first MTP dorsiflexion
a b
Fig. 23.3 (a) Lateral portal placement for arthroscopic cheilectomy. (b) Arthroscopic image demonstrating the dorsal
metatarsal after osteophyte excision
a b
Fig. 23.4 (a) Preoperative and (b) postoperative first MTP dorsiflexion, respectively, following MTP arthroscopic
cheilectomy
141 function [2]. It is also important to consider the there is little to no evidence of effectiveness and 171
142 impact of alignment on the condition and treat- longevity for MTP implants in athletes. Due to 172
143 ment outcomes. Patients are more likely to have the magnitude and direction of forces at the hal- 173
144 associated hallux valgus interphalangeus defor- lux MTP joint, it is likely that many athletic 174
145 mities with hallux rigidus. Osteotomy techniques, activities would put substantial stress on an MTP 175
146 like a combined Moberg and Akin osteotomy, can implant putting it at risk of early failure and 176
147 be a helpful adjunct to restore the alignment and potentially leading to further degenerative 177
148 mechanics of the hallux [16]. changes, deformity, and performance challenges. 178
149 The success rates for cheilectomy range from However, for the nonathletic population, there 179
150 72 to 100% for early-stage hallux rigidus with are a number of implants available for end-stage 180
151 worse results for advanced joint degeneration in hallux rigidus. These include metallic implants, 181
152 multiple retrospective case series [17–20]. In interposition arthroplasty, and nonmetallic hemi- 182
153 athletes, open cheilectomy offers 90% good and arthroplasty (Fig. 23.5). Results of polyvinyl 183
154 excellent results at a mean 5-year follow-up [2]. alcohol hemiarthroplasty (Cartiva) were shown 184
155 Two studies examining the results of arthroscopic in one series to be equivalent to MTP fusion for 185
156 cheilectomy found 67% good to excellent out- grade 2 hallux rigidus with greater maintenance 186
157 comes; however, these studies both had small of motion and significant improvement in FAAM 187
158 sample sizes [21, 22]. In two different matched scores [4]. This implant provides a smooth articu- 188
159 comparisons of percutaneous vs open cheilec- lar surface and a buffer space in the joint which 189
160 tomy, both groups demonstrated high patient can help reduce bone friction with dorsiflexion of 190
161 satisfaction postoperatively [23, 24]. Loveday the MTP joint. There is currently no data on com- 191
162 et al. showed a 94% satisfaction rate after percu- patibility of this technique with athletic activities. 192
163 taneous cheilectomy at mean 12-month follow- However, in the right patient, these options may 193
164 up with those patients who were dissatisfied prove to be useful tools to provide pain relief and 194
165 were noted to have grade III degenerative maintenance of motion. 195
166 changes [25].
23.4 Arthrodesis 196

167 23.3 MTP Arthroplasty
Arthrodesis involves fusion of the first MTP 197
168 Joint replacement implants were originally joint. Arthrodesis is usually considered for end- 198
169 designed to not only preserve the motion of the stage degenerative changes (grade III or IV) or 199
170 first MTP joint but to also relieve pain. Currently, after failure of joint-sparing procedures. It should 200
23 Hallux Rigidus 263
a b
Fig. 23.5 (a) Intraoperative image demonstrating a large, central osteochondral defect of the first metatarsal articular
surface. (b) Photograph of polyvinyl alcohol hemiarthroplasty applied to the defect
201 rarely be considered for first-line treatment of ture on later generation implants which provide 227
202 hallux rigidus in athletes. Multiple techniques both compression and rigid fixation demonstrates 228
203 exist to promote arthrodesis including lag screw significantly lower nonunion rates. 229
204 with dorsal plate, oblique lag screw, staple, or
205 crossed Kirschner wires. Furthermore, there are
206 many different techniques for preparing the joint 23.5 Summary 230
207 surfaces including simple cartilage excision and
208 use of saw, cone, or socket for planar cartilage Hallux rigidus is a common problem in athletes 231
209 excision and finally conical reamer [26–28]. that causes pain and limited motion of the first 232
210 While the ultimate fixation method may be sur- MTP joint. Most athletes will note improvement 233
211 geon dependent, the ideal type of fixation should or resolution of symptoms with conservative 234
212 lead to high fusion rates, have low complication management. For those with persistent symp- 235
213 rates, and be reproducible. In a study by Politi toms, the standard surgical technique includes an 236
214 et al., fixation with an oblique interfragmentary open debridement with cheilectomy. In patients 237
215 lag screw with a dorsal plate produced the most with hallux rigidus interphalangeus, this tech- 238
216 biomechanically stable construct to promote first nique can be successfully augmented with an 239
217 MTP joint fusion and was nearly twice as strong osteotomy to correct alignment and joint 240
218 as an oblique lag screw alone [29]. Arthroscopic mechanics. Arthroscopic and minimally invasive 241
219 fusion techniques have been described, but there techniques are also growing in popularity. While 242
220 is little available outcomes data to show short- or first MTP joint arthrodesis provides predictable 243
221 long-term superiority over open techniques [30]. pain relief, joint fusion limits great toe dorsiflex- 244
222 Complications from this procedure include non- ion, which can impair athlete’s ability to partici- 245
223 union, malunion, infection, symptomatic hard- pate in running and jumping sports. Additional 246
224 ware, and stress fracture of the metatarsal. research is necessary to determine the long-term 247
225 Historical nonunion rates are as high as 30% in outcomes of some modern techniques and 248
226 the literature [29]. However, more recent litera- implants. 249
250 References 15. Hunt KJ. Hallux metatarsophalangeal (MTP) joint

298
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1 Hallux Valgus for Athletes
24
2 Yasuhito Tanaka
3 24.1 Pathogenesis valgus because the medial side of the big toe 29
bears weight. Joint laxity may also be involved 30
4 Many athletes complain of painful hallux valgus. because hallux valgus occurs more commonly in 31
5 With respect to its pathogenesis, however, studies women athletes. 32
6 have found that lesion severity is not greater than Valgus of the big toe and varus of the first 33
7 that in ballet dancers who put their forefeet to metatarsal are closely related [6]. The causal site 34
8 very hard use compared with ordinary people [1, of the first metatarsal varus is the first tarsometa- 35
9 2], and no evidence supports that hallux valgus tarsal (TMT) joint, which is affected by the varus 36
10 occurs more frequently among athletes. In terms of the surface of the first TMT joint [7, 8]. The 37
11 of the association between the onset of its symp- bony prominences of the medial side of the head 38
12 toms and sports, although it is true that individu- of the first metatarsal are important as a pathol- 39
13 als with healthy feet who play sports do not ogy of hallux valgus, and large bony prominences 40
14 develop hallux valgus, those who engage in may cause symptoms in athletes, even if the val- 41
15 intense sports who tend to develop hallux valgus gus of the big toe is only mild. 42
16 may be more likely to exhibit symptoms, which If valgus of the big toe progresses, the first 43
17 may progress more rapidly [3]. Particularly, MTP joint becomes subluxated, disturbing the 44
18 when the metatarsophalangeal (MTP) joint of the balance of the muscles around the big toe [9]. 45
19 big toe is valgus, the medial collateral ligament The flexor hallucis brevis (medial head/lateral 46
20 becomes damaged and causes the onset of hallux head), abductor hallucis, and adductor hallucis 47
21 valgus [4, 5] (Fig. 24.1). Excluding such cases of (transverse head/oblique head) muscles, which 48
22 post-traumatic hallux valgus, the causes of hallux are all intrinsic muscles, all terminate at the first 49
23 valgus in athletes are the same as those in nonath- proximal phalanx via the plantar plate. The two 50
24 letes. That is, feet with metatarsus primus varus sesamoid bones also lie within the plantar plate, 51
25 or “Egyptian feet” whose big toe is longer than and this structure is termed the “sesamoid com- 52
26 the second toe are prone to develop hallux valgus. plex.” The big toe pronates, and the abductor hal- 53
27 In flat feet, the medial longitudinal arch drops, lucis is twisted around the underside, causing 54
28 causing the foot to pronate, and it tends to become subluxation of the first MTP joint (Fig. 24.2). 55
Y. Tanaka (*)
Department of Orthopaedic Surgery, Nara Medical
University, Kashihara, Nara, Japan
e-mail: yatanaka@naramed-u.ac.jp
© ISAKOS 2019 265

https://doi.org/10.1007/978-3-662-58704-1_24
266 Y. Tanaka
Fig. 24.1 Hallux valgus

caused by the medial
collateral ligament
injury. Arrow: Torn
portions of the medial
collateral ligament of
the first
metatarsophalangeal
joint
such that skin erosion may form even if the defor- 63

mity is mild. The skin turns red in the acute 64
phase, and the patient still complains pain at rest 65
in extreme cases. Bursitis-induced swelling may 66
also be present. If the big toe pronates, the dorsal 67
Extensor hallucis longus cutaneous nerve is twisted around to the medial 68
Adductor hallux muscle side and compressed, causing pain. Weight bear- 69
Transverse head ing is also concentrated at the bottom of the 70
Oblique head medial side of the head of the metatarsal, result- 71
ing in callus formation. Many athletes without 72
Abductor hallux Flexor hallucis longus hallux valgus are already calloused in this area, 73
and calluses are not a symptom even if hallux 74
valgus is present in most cases. Rather, callouses 75
Fig. 24.2 Intrinsic and extrinsic muscles around the first are concentrated on the heads of the second and 76
metatarsophalangeal joint in hallux valgus
subsequent metatarsals because the deformity 77
prevents full weight bearing on the big toe, caus- 78
ing painful calluses. Many patients with hallux 79
56 24.2 Diagnosis valgus also have hammer toe in the second to 80
fifth toes, causing midfoot pain and callus forma- 81
57 24.2.1 Clinical Symptoms tion on the backs of the toes. Although severe 82
hallux valgus presenting as crossing of the big 83
58 Pain is the main symptom, and the most common toe over the second toe is rare in athletes, first ray 84
59 manifestation is pain due to the medial protrusion dysfunction means that weight is placed on the 85
60 of the head of the first metatarsal. In most ath- lateral ray, which may cause stress fracture of the 86
61 letes, it normally improves when the shoes are second or subsequent metatarsals or Morton’s 87
62 removed, but the intensity of their movements is disease [10]. 88
24 Hallux Valgus for Athletes 267
89 24.2.2 Radiographic Diagnosis the first and second metatarsals (M1M2 angle, 100
normally <10°) is evaluated as an indicator of 101
90 The basic method of evaluating a deformity is metatarsus primus varus. The congruence of the 102
91 weight-bearing dorsoplantar foot radiography. first MTP joint and arthritic changes are also 103
92 Severity is assessed in terms of the hallux valgus scrutinized. Although joint congruence is pre- 104
93 angle (HV angle) formed between the axes of the served in the early stages, subluxation occurs if 105
94 first proximal phalanx and the first metatarsal the condition progresses. In younger patients, 106
95 (normally <15°). HV angle of <20°, between joint congruence may be maintained despite 107
96 ≥20° and <40°, and ≥40° are considered mild, severe hallux valgus deformity because the distal 108
97 moderate, and severe, respectively. Some athletes joint surface of the first metatarsal becomes val- 109
98 may complain of pain if the angle is <15°. The gus [11] (Fig. 24.3a). This must be considered 110
99 intermetatarsal angle formed between the axes of when deciding on surgery, and the distal 111
a b
Fig. 24.3 Distal metatarsal articular angle (DMAA). (a) perpendicular to the axis of the first metatarsal and the
A hallux valgus foot with large DMAA. (b) The measur- joint surface of the first metatarsal head
ing method of DMAA which is an angle between a line
268 Y. Tanaka
112 etatarsal articular angle (DMAA) between a

m exercise therapy techniques are effective, and 153
113 line perpendicular to the axis of the first metatar- patients should also practice flexing the toes 154
114 sal and the joint surface of the first metatarsal intentionally while walking. They should also be 155
115 head should be measured (Fig. 24.3b). taught how to perform hallux valgus exercises, 156
116 Displacement of the sesamoid bones also indi- such as varus movements of the big toe, to correct 157
117 cates an abnormal course of the intrinsic the deformity and eliminate pain (Fig. 24.4) [12]. 158
118 muscles. Initially, attempts to move this toe outward result 159
in its plantar flexion, but with manual interven- 160
tion and persistence, many patients with even 161
119 24.3 Treatment advanced hallux valgus can move the toe in the 162
varus direction. This technique should always be 163
120 24.3.1 Conservative Treatment taught because it is useful for athletes, who are 164
highly motivated. 165
121 24.3.1.1 Shoes
122 The sports shoes normally used by the patient 24.3.1.3 Insoles, Orthoses, 166
123 should be checked initially. Approximately 1-cm and Taping 167
124 space should be present beyond the toes, and Insoles are prescribed to correct the alignment of 168
125 moving the toes freely while the shoes are on is the feet or legs and distribute the concentration of 169
126 important. In addition, the instep should be pressure that causes pain. If there are calluses on 170
127 checked whether it is firmly held by the laces, the undersides of the heads of the second to the 171
128 preventing the foot from sliding forward within fourth metatarsals, the function of the big toe will 172
129 the shoe. If the shoes fit poorly, the patient should be impaired, and the weight-bearing pattern dur- 173
130 be advised to change them. If they severely coming walking is often shifted to the lateral side. 174
131 press the inside ball area, pushing out that part of The aims of the prescription are to create a medial 175
132 the shoes from the inside before putting them on arch to correct the forefoot pronation and meta- 176
133 may help alleviate compression of the medial tarsus primus varus and to form a midfoot pad to 177
134 side of the first MTP joint. If pain occurs only decompress the heads of the second to fourth 178
135 when the sports shoes are worn, the shoes should metatarsals that cause midfoot pain. Boosting the 179
136 be taken off whenever possible, and avoid wear- abductor hallucis muscles also creates a force 180
137 ing these for long periods. that acts to correct the hallux valgus deformity 181
during weight bearing. Corrective orthoses that 182
138 24.3.1.2 Stretching and Therapeutic do not fit inside shoes cannot be used during 183
139 Exercise sports activities; hence, soft orthoses worn 184
140 Preserving joint flexibility by stretching is impor- between the toes should be used instead. Taping 185
141 tant. The midfoot is held down on both sides with is readily accepted by athletes, and they should 186
142 one hand to correct the varus of the first metatar- be taught simple taping methods for correcting 187
143 sal, and the other hand slowly pulls the big toe hallux valgus. 188
144 inwards while keeping it under traction. Plantar/
145 dorsiflexion stretches are performed at the same 24.3.1.4 Ultrasound-Guided 189
146 time. Stretching the Achilles tendon and plantar Neurolysis 190
147 fascia is also important to reduce the strain on the Many patients with hallux valgus develop a pseu- 191
148 forefoot [10]. Patients should perform these doneuroma of the digital nerve on the dorsal side 192
149 stretches together with whole-body stretches of the first MTP joint, for which ultrasound- 193
150 when warming up. Improving toe function, guided neurolysis may be effective in some cases 194
151 including that of the big toes, is essential for alle- (Fig. 24.5). It may be worth attempting conserva- 195
152 viating midfoot pain. Towel gathering and other tive treatment just once. Excessive dorsiflexion 196
a b
Fig. 24.4 Abductor hallucis exercise. (a) Close the big toe. (b) Open the big toe
Fig. 24.5 Ultrasound-
guided neurolysis
270 Y. Tanaka
197 of the MTP joint is required particularly by danc- because soft tissue release is also required in 217
198 ers, and because hallux valgus surgery n ecessarily severe cases [13]. Because good range of motion 218
199 reduces the range of motion of the joint, in prin- is maintained when distal osteotomy alone is 219
200 ciple, conservative therapy is used if they are still performed using Chevron or Mitchell osteot- 220
201 dancing. omy, it is recommended if pain is affecting com- 221
petitiveness (Fig. 24.6) [10, 13–15]. Patients in 222
their late teens who have recently stopped grow- 223
202 24.3.2 Surgical Treatment ing recover particularly rapidly, and in these 224
patients, this surgery is performed if the defor- 225
203 In cases of post-traumatic hallux valgus, surgery mity is mild or moderate [13]. Restricted range 226
204 is performed to repair the medial collateral liga- of motion can be prevented by minimizing the 227
205 ment [5]. However, the decision to treat athletes damage to the soft tissue region. For active 228
206 surgically must be made with caution. In surgi- dancers, however, neurotomy (Fig. 24.7) is 229
207 cal procedures that require the release of soft sometimes considered as a procedure because it 230
208 tissue around the first MTP joint, changes in does not diminish the range of motion of the 231
209 joint alignment may reduce the range of motion first MTP joint. Curative surgery for severe 232
210 [12]. This can significantly reduce the competi- cases in adult patients should only be recom- 233
211 tiveness in disciplines that require excessive mended after they have retired from dancing 234
212 dorsiflexion of this joint, such as dancing and [13, 16, 17]. One study has reported the treat- 235
213 sprinting in athletics. Osteotomy of the first ment of such patients who nevertheless request 236
214 metatarsal is currently the most popular proce- surgery by double osteotomy comprising distal 237
215 dure, but for athletes, the correction should be osteotomy and proximal phalangeal osteotomy 238
216 performed while the deformity is still mild without soft tissue release [18]. 239
a b c
Fig. 24.6 Mitchell procedure. Eighteen-year-old female. after the surgery and continues playing softball 4 years
Semiprofessional softball player. (a) Before operation. (b) after the surgery. Dorsiflexion of the first metatarsopha-
Eleven weeks after the surgery. (c) Four years after the langeal joint is 70°
surgery. She could attend the national athletes meet 1 year
a b
Fig. 24.7 Neurotomy of the medio-dorsal cutaneous nerve of the hallux. (a) A neurotomy is performed at the proximal
side of pseudoneuroma. (b) A resected nerve
240 References 10. Baxter DE. Bunion deformity in elite athletes. In: 272
Baxter DE, editor. The foot and ankle in sport. St. 273
Louis: CV Mosby; 1995. p. 259–64. 274
241 1. Einarsdóttir H, Troell S, Wykman A. Hallux valgus in
11. Coughlin MJ. Juvenile hallux valgus: etiology and 275
242 ballet dancers: a myth? Foot Ankle Int. 1995;16:92–4.
treatment. Foot Ankle Int. 1995;16:682–97. 276
243 2. Davenport KL, Simmel L, Kadel N. Hallux valgus in
12. Samoto N, Higuchi K, Sugimoto K, Tanaka Y,
277
244 dancers: a closer look at dance technique and its impact
Takakura Y. Electromyographical evaluation of the 278
245 on dancers' feet. J Dance Med Sci. 2014;18(2):86–92.
effect on the active abduction exercise of the big toe 279
246 3. Quirk R. Common foot and ankle injuries in dance.
for hallux valgus deformity. J Jap Soc Surg Foot. 280
247 Orthop Clin North Am. 1994;25:123–33.
2000;21:12–6. 281
248 4. Fabeck LG, Zekhnini C, Farrokh D, Descamps PY,
13. Howse J. Disorders of the great toe in dancers. Clin 282
249 Delincé PE. Traumatic hallux valgus following rup-
Sports Med. 1983;2:499–505. 283
250 ture of the medial collateral ligament of the first
14. Lillich JS, Baxter DE. Bunionectomies and related 284
251 metatarsophalangeal joint: a case report. J Foot Ankle
surgery in the elite female middle-distance and mara- 285
252 Surg. 2002;41:125–8.
thon runner. Am J Sports Med. 1986;14:491–3. 286
253 5. Covell DJ, Lareau CR, Anderson RB. Operative treat-
15. Giotis D, Paschos NK, Zampeli F, Giannoulis D,
287
254 ment of traumatic hallux valgus in elite athletes. Foot
Gantsos A, Mantellos G. Modified Chevron oste- 288
255 Ankle Int. 2017;38(6):590–5.
otomy for hallux valgus deformity in female ath- 289
256 6. Hardy RH, Clapham JCR. Observation on hallux val-
letes. A 2-year follow-up study. Foot Ankle Surg. 290
257 gus. Based on a controlled series. J Bone Joint Surg.
2016;22:181–5. 291
258 1951;33-B:376–91.
16. Mann RA. Great toe disorders. In: Baxter DE, editor. 292
259 7. Haines R, McDougall A. The anatomy of hallux val-
The foot and ankle in sport. St. Louis: CV Mosby; 293
260 gus. J Bone Joint Surg. 1954;36B:272–93.
1995. p. 245–58. 294
261 8. Tanaka Y, Takakura Y, Kumai T, Samoto N, Tamai
17. MacMahon A, Karbassi J, Burket JC, Elliott AJ,
295
262 S. Radiographic analysis of hallux valgus. A two
Levine DS, Roberts MM, Deland JT, O'Malley MJ, Yu 296
263 dimensional coordinate system. J Bone Joint Surg.
J, Mancuso CA, Ellis SJ. Return to sports and physi- 297
264 1995;77-A:205–13.
cal activities after the modified lapidus procedure 298
265 9. Tanaka Y, Takakura Y, Takaoka T, Akiyama K, Fujii
for hallux valgus in young patients. Foot Ankle Int. 299
266 T, Tamai S. Radiographic analysis of hallux valgus
2016;37:378–85. 300
267 in women on weightbearing and non-weightbearing.
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268 Clin Orthop. 1997;336:186–94.
osteotomy for correction of hallux valgus. Foot Ankle.
269
1991;12:7–14.
270
271
1
2
Special Consideration
and Perioperative Management
25
3 for Turf Toe Injuries
4 Monique C. Chambers, Lorraine Boakye,
5 Arthur R. McDowell, Stephanie M. Jones,
6 Alan Y. Yan, and MaCalus V. Hogan
7 25.1 Introduction severe injury patterns, players who sustain the 31

injury have a mean return to play of 10 days [2]. 32
8 Foot injuries are the third leading cause of foot
9 injuries in NCAA athletes that have to be removed
10 from competition, with a large number attributed 25.2 Anatomic Relationship 33
11 to the hallux metatarsophalangeal (MTP) joint
12 [1]. Turf toe injuries occur when there is a strain The first metatarsophalangeal (MTP) joint con- 34
13 to the first MTP joint complex. An increasing rate nects the midfoot to the forefoot of the great toe 35
14 of musculoskeletal injuries in athletes has been and is stabilized by several anatomical structures 36
15 linked to athletic activity on artificial surfaces. that make up the plantar complex. The flexor hal- 37
16 Artificial turfs tend to be less shock absorbent lucis brevis (FHB) runs along the plantar surface 38
17 resulting in greater force distributed throughout of the metatarsal bone and inserts at the base of the 39
18 the body. Strain on the forefoot, as occurs in turf proximal phalanx, crossing over the MTP joint. 40
19 toe injuries, are common in athletes that partici- The FHB splits into the medial and lateral tendons 41
20 pate in football or other contact sports. Prior sur- that conjoin with the abductor and adductor hallu- 42
21 veys have revealed as many as 83% of turf toe cis, respectively (Fig. 25.1). The tibial and fibular 43
22 injuries in professional football players occur on sesamoids are two osseous structures that run 44
23 an artificial turf [1]. Athletes are 14 times more within the sheath of the flexor hallucis tendons and 45
24 likely to sustain a turf toe injury during active are connected by the intersesamoid ligament 46
25 competition compared to practice [2]. (Fig. 25.2). The sesamoids share the load placed 47
26 Biomechanical studies that investigate the impact on the forefoot with full weight bearing. The 48
27 of artificial surfaces suggest that greater torque medial head bears more of the weight bearing 49
28 and strain is applied to the forefoot compared to force, as it sits more directly under the metatarsal 50
29 natural grass [3]. Turf toe injuries can be quite head. They also function similarly to the pulley 51
30 debilitating or even career ending. With less system on the thumb and aid in mobility of the 52
flexor tendons during planted dorsiflexion of the 53
great toe. There is a thick, fibrous plantar structure 54
M. C. Chambers that envelopes the sesamoids and makes up the 55
Baylor College of Medicine, Houston, TX, USA capsular ligamentous complex. On the medial and 56
L. Boakye · A. R. McDowell · S. M. Jones lateral aspect of the MTP joint are collateral liga- 57
A. Y. Yan · M. V. Hogan (*) ments that ensure proper alignment from varus 58
University of Pittsburgh, Pittsburgh, PA, USA and valgus forces. These structures work in con- 59
e-mail: hoganmv@upmc.edu
© ISAKOS 2019 273

https://doi.org/10.1007/978-3-662-58704-1_25
274 M. C. Chambers et al.
MEDIAL LATERAL
Proximal phalanx
Flexor hallucis longus Plantar plate
Phalangeosesamoid
ligament
Phalangeosesamoid
ligament
Sesamoids
Metatarsosesamoid Metatarsosesamoid
ligament ligament
Intersesamoid
First metatarsal
ligament
Flexor Flexor
hallucis brevis hallucis brevis
Fig. 25.1 A plantar view of the plantar plate ligament complex of the first MTP joint. (Original artwork by Stephanie
M. Jones, BA; Universityof Pittsburgh, Pittsburgh, PA)
Detail should focus on the mechanism of injury, 66

force applied, and the structures that are likely 67
damaged. A keen assessment of specific signs 68
and symptoms can help distinguish turf toe from 69
other hallux injuries. Other injuries may include 70
claw toe, mallet toe, MTP dislocation, fracture, 71
and/or sesamoid injuries. 72
Fig. 25.2 A medial view of the plantar-sesamoidal com-
plex. The flexor hallucis brevvis muscle runs along the
plantrar surface of the 1st MT and the medial sesmoind
lies just beneath the 1st MT head. (Original artwork by 25.3.1 Mechanism of Injury 73
Stephanie M. Jones, BA; University of Pittsburgh,
Pittsburgh, PA) The plantar complex bears up to 60% of the 74
body’s normal weight and stabilizes the MTP 75
60 cert to provide the stability necessary in daily and joint during dorsiflexion [4]. The capsular MTP 76
61 high-level athletic activity. complex can sustain up to eight times body 77
weight during jumping and running activities [5]. 78
In turf toe injuries, one or more structures of the 79
62 25.3 Initial Evaluation plantar complex of the first MTP joint are injured. 80
Patients will often report an injury that involves 81
63 The initial evaluation should assess for risk fac- planting the foot in fixed equinus with forced 82
64 tors related to turf toe injuries, such as type of dorsiflexion of the first MTP. This typical mecha- 83
65 athletic shoe or surface when the injury occurred. nism of forward momentum during axial loading 84
25 Special Consideration and Perioperative Management for Turf Toe Injuries 275
compromised based on the severity of injury and 104

involvement of the flexor and/or extensor ten- 105
dons. Additionally, patients should be assessed 106
for integrity of the flexor hallucis longus (FHL) 107
and the ability to dorsiflex the great toe. Patients 108
may also have changes in gait evidenced by a 109
quick return to heel strike during the gait cycle. 110
25.3.3 Diagnostic Evaluation 111
Patients with hyperextension injuries must 112

undergo diagnostic evaluation with weight bear- 113
ing anteroposterior, lateral, and oblique foot 114
radiographs. An axial sesamoid and forced dorsi- 115
Flexor flexion view can also be obtained. Normal radio- 116
hallucis graphs allow for comparison of the sesamoids 117
brevis
relative to the joint, as well as proximal displace- 118
Separated ment of the medial sesamoid that normally sits 119
sesamoid directly under the metatarsal head. Patients who 120
components
sustained significant axial force may have a sesa- 121
Fig. 25.3 Demonstrates mechanism that occurs in turf moid fracture. 122
toe injuries with an axial load on the hyperextended foot Discrepant radiographic evaluation, relative to 123
(Original artwork done by Stephanie M. Jones, BA; the clinical evaluation, should be further investi- 124
University of Pittsburgh, Pittsburgh, PA)
gated with more advanced imaging. A bone scan 125
reveals increased inflammation around the MTP 126
85 causes forced hyperextension of the plantar plate joint and may signal a stress fracture of the proxi- 127
86 and sesamoid complex of the first MTP joint mal phalanx or the sesamoids. If a bone scan is 128
87 (Fig. 25.3) [6]. Patients may complain of a stiff positive, then pursing magnetic resonance imag- 129
88 great toe that is swollen and tender with shoes or ing (MRI) would be appropriate. A MRI would 130
89 socks touching the toe. Patients with limited dor- also assess for a stress fracture of the proximal 131
90 siflexion may have concomitant tendinous phalanx and would more clearly show a disrup- 132
91 injuries. tion or partial tear of the plantar plate complex 133
(Fig. 25.4). 134
92 25.3.2 Physical Examination

25.4 Preoperative Optimization 135
93 Patients often have signs of ecchymosis or swell- and Risk Assessment 136
94 ing of the MTP joint or on the plantar surface.
95 Localized tenderness to palpation may be present Injuries may vary in severity from a soft tissue 137
96 on the plantar or medial surface. Malalignment of damage to a dislocated MTP joint. Turf toe inju- 138
97 the hallux may also be present and should be ries have been classified based on the structural 139
98 visualized both on physical and radiographic damage to the plantar plate complex. Injury clas- 140
99 examination. One should check for gross insta- sification helps to guide management and aids in 141
100 bility with a vertical Lachman (dorso-plantar determining prognosis (Table 25.1). Patients with 142
101 drawer) test, as well as varus and valgus force to Grade I and II injuries are often managed conser- 143
102 the MTP joint to assess the collateral ligaments. vatively with RICE therapy and immobilization 144
103 Both passive and active range of motion may be with a walking boot. Anti-inflammatory medica- 145
a b
Fig. 25.4 Sagittal (a) and axial (b) MRI of the hallux MTP joint depicting high-grade partial thickness disruption of
the plantar plate complex
Table 25.1 Management of Turf Toe Injuries by Classification t1.1
Grade Short name Description/symptoms Management Prognosis t1.2

I Sprain • Stretched plantar complex • RICE protocol Return to play t1.3
• Point tenderness • NSAIDS WBAT t1.4
• Minimal effusion • Tapping t1.5
II Partial tear • Widespread tenderness and • Walking boot Return to play in 2 weeks t1.6
bruising • 3–14 day rest ~10–14 days activity lost t1.7
• Limited ROM due to pain and • Surgical repair if t1.8
moderate effusion nonoperative trial fails t1.9
III Complete • Severe swelling/bruising • Cast Longer recovery t1.10
tear • Pain w/passive ROM • Surgical repair (3–4 months post-op) t1.11
• Difficultly weight bearing t1.12
146 tion can also help reduce acute inflammation and 25.5 Surgical Techniques 165
147 help manage symptoms of pain and swelling.
148 Athletes remain weight bearing as tolerated dur- Surgical intervention for turf toe injury is often 166
149 ing this period. Gradual progression into low undertaken after nonoperative management has 167
150 impact activities should be trialed prior to full failed for mild injuries or in the case of severe 168
151 return to play. injuries. Severity is imparted by retraction of 169
152 Patients who fail conservative management or sesamoids, fracture of sesamoids with diastasis, 170
153 have more severe injuries should be prepared for hallux-valgus deformity, and intra-articular frac- 171
154 surgical intervention. In the young athlete, one ture fragments. These factors cause a relative 172
155 should not forego proper assessment of comor- discontinuity between the sesamoids and hallux 173
156 bidities and risk for poor surgical outcomes. A MP joint during motion. Discontinuity of struc- 174
157 thorough discussion regarding the patient’s future tures causes instability of the MTP joint [7]. 175
158 aspirations for athletic activity should be explored Relative indications include loss of push off 176
159 to appropriately align expectations. Coaches, strength, progressive deformity, or clawing of 177
160 players, and family members can be a part of this toes [8]. Intrinsic minus position of toes is 178
161 discussion. However, medical decision should be caused by MTP extension and interphalangeal 179
162 guided based on what is in the best interest of the joint flexion [8]. Competitive athletes in particu- 180
163 patient’s physical, mental, and emotional best lar will often identify a significant loss of plantar 181
164 interest. restraint when attempting to push off during 182
183 play. Criteria for surgical intervention in the ath- dissection of the tendons of the adductor hallucis 228
184 letic population include sport of choice and pri- and flexor hallucis brevis is used to expose the 229
185 mary position. sesamoid. Once the sesamoid is exposed, a small 230
186 The goal of surgery is restoration of function rongeur or curette may be used for local debride- 231
187 via restoration of anatomy [9]. The plantar plate ment. The soft tissue is then examined including 232
188 is advanced and reattached to the base of the the flexor hallucis longus and plantar plate. 233
189 proximal phalanx, thus enabling the sesamoid Primary repairs are performed lateral to medial. 234
190 to move in conjunction with the hallux during Stability may be evaluated clinically or with 235
191 dorsiflexion. Plantar soft tissue repair is per- intraoperative fluoroscopy. Further repair may be 236
192 formed end to end with nonabsorbable sutures achieved with suture anchors or trans-osseous 237
193 if there is only a capsular defect [8]. If there is tunnels and headless screws to the base of the 238
194 no residual soft tissue connection, it is recom- proximal phalanx [10]. The defect in the capsule 239
195 mended to trans-osseous bone anchors or bone overlying the sesamoid is then closed with 2-0 240
196 tunnels [8]. absorbable suture. Subcutaneous tissue is approx- 241
197 In the case of mixed injury pattern that imated with 3-0 absorbable suture. Skin may be 242
198 includes a valgus deformity and associated loss closed with 3-0 nylon with simple interrupted 243
199 of push off, special attention must be paid to stitches or vertical mattress stitches. Final immo- 244
200 injury of the medially based structures. The hall- bilization may be in a standard AO posterior slab 245
201 mark of surgical intervention includes a relief of splint with side bars or a short-leg cast. Special 246
202 the deforming force via tenotomy of the adductor attention is paid to ensure that there is a plantar 247
203 and repair of medial structures (including the plate built in to protect the toes. 248
204 abductor and joint capsule) with correction of Sutures are removed at the first postoperative 249
205 resultant deformity via a modified McBride [9]. clinic visit which is usually ~14 days postopera- 250
206 The patient is positioned supine with a lower tively. Postoperative protocol emphasizes early 251
207 extremity tourniquet and prepped and draped in passive range of motion to prevent contracture 252
208 the usual fashion. Intraoperative fluoroscopy is and limited motion of sesamoids. Patients are 253
209 essential for dynamic evaluation of pre- and post- non-weight bearing immediately post-op and 254
210 operative dorsiflexion of the great toe. begin progressive weight bearing after first post- 255
211 A medial plantar incision is most often used op appointment. Patients are transitioned from 256
212 for the approach and may be carried out in an rigid immobilization to a hard-soled shoe prior to 257
213 extra- or intra-articular fashion. Other options for resuming preoperative footwear. The expected 258
214 surgical approach include dorsolateral or purely return to sport is usually around 3–4 months 259
215 plantar approach [7]. Key tenants of intervention postoperatively. 260
216 include repair or excision of sesamoid based on
217 fracture pattern, repair of fracture, debridement
218 of obvious osteochondral defects and repair or 25.6 Postoperative Course 261
219 reconstruction of plantar plate.
After surgery, the great toe should be immobi- 262
lized in 5–10° of plantarflexion with a toe spica 263
220 25.5.1 Plantar Approach splint. Patients are non-weight bearing immedi- 264
ately post-op and begin progressive weight bear- 265
221 The plantar approach is carried over the inter- ing after first post-op appointment. However, 266
222 metatarsal space via a curvilinear incision on the postoperative protocol emphasizes early passive 267
223 border of the metatarsal fat pad or a “J” extending range of motion to prevent contracture and lim- 268
224 along the flexor crease at the base of the hallux ited motion of sesamoids. Passive range of 269
225 [10]. The lateral plantar digital nerve courses motion may begin 1 week after surgery. Range 270
226 over the lateral sesamoid. It is retracted medially of motion exercises help to minimize the forma- 271
227 with the metatarsal fat pad for protection. Sharp tion of arthrofibrosis at the sesamoid-metatarsal 272
273 articulation. Excessive dorsiflexion should be III turf toe injuries who have failed conservative 316
274 avoided in the postoperative period to protect the management have been shown to have success- 317
275 surgical reconstruction [11]. Patients should ful outcomes with operative intervention [13]. 318
276 remain non-weight bearing for 4 weeks with a Multiple studies have reported on the respective 319
277 protective boot or removable splint. While sleep- operative and nonoperative outcomes of turf toe 320
278 ing, a removable bunion splint with a plantar injuries. Anderson et al. performed a study on 321
279 restraint should be worn. After 4 weeks, pro- 19 athletes with severe turf toe injuries [14]. Of 322
280 tected weight bearing in a boot may be initiated those athletes, nine required operative repair 323
281 [6]. Pool therapy may be initiated at this time. and no postoperative complications were 324
282 The progression weight bearing activity should observed. Additionally, only two athletes were 325
283 be determined clinically based on the individual unable return to full athletic activity. Coker 326
284 patient’s level of pain and stiffness [11]. Around et al. [15] and Clanton et al. [1] both report joint 327
285 8 weeks, the patient may discontinue wearing a stiffness and pain as the most common long- 328
286 protective boot and transition into a stiff-soled term complications in their respective study 329
287 shoe. The patient may increase activity to groups. A more recent study by Brophy et al. 330
288 medium-impact activities, such as elliptical evaluated previous turf toe injuries in profes- 331
289 training [8]. When able to comfortably perform sional American football players and reported 332
290 medium-impact activities, the patient may pro- increased hallux plantar pressure, as well as 333
291 ceed to high-impact activities such as jogging decreased passive metatarsal phalangeal dorsi- 334
292 and running. Activities involving cutting and flexion [16]. With regard to rehabilitation, Nihal 335
293 jumping should only be initiated once the patient et al. [12] report a 25–50% incidence of limited 336
294 is able to sprint without pain [11]. Most patients dorsiflexion and pain after 6 months of 337
295 return to full activity in 16 weeks. However, it rehabilitation. 338
296 may take 6–12 months for full recovery [11].
25.9 Conclusion 339

297 25.7 Complications
Turf toe injuries continue to plague athletes 340
298 During operative management of first MTP joint who participate in high-impact or contact 341
299 sprains, care should be taken to reduce the risk of sports. Athletes who have sustained a turf toe 342
300 infection and neurovascular damage, particularly injury may experience a significant increase in 343
301 as the plantarmedial digital nerve may be predis- missed days of competition or career ending 344
302 posed to injury during the surgical approach [10]. sequela. Keen assessment and management of 345
303 Hallux rigidus is a late sequela of turf to injuries. players with turf toe injuries likely has a major 346
304 However, depending on the level of severity, impact on prognosis. For patients with less 347
305 hallux rigidus may require treatment with chei- severe injuries, return to play is often achieved 348
306 lectomy or arthrodesis. Turf toe injuries may also without operative intervention. The hallmarks 349
307 lead to progressive forefoot deformities such as of operative interventions include sesamoid 350
308 hallux valgus, hallux varus, or “cock-up toe” due excision and/or fixation as well as tendon 351
309 to hallux-interphalangeal joint flexion contrac- transfer when soft tissue repair is insufficient. 352
310 ture [6]. However, if indicated, operative intervention 353
may be necessary to restore pre-injury func- 354
tion. Surgical management for turf toe injuries 355
311 25.8 Outcomes often includes sesamoid excision, sesamoid 356
fixation, and/or tendon transfer. The modified 357
312 Most turf toe injuries are mild and when diag- McBride technique is also often used to restore 358
313 nosed early can be managed nonoperatively. medial and lateral soft tissue balance. Futher 359
314 However, severe turf toe injuries have the poten- investigation is necessary to identify both 360
315 tial to be career ending [12]. Patients with grade player-specific factors and environmental fac- 361
362 tors, such as hallux valgus deformity and ath- 7. Srinivasan R. The Hallucal-Sesamoid complex: 389
363 letic surface, that may predispose to turf toe normal anatomy, imaging, and pathology. Semin 390
Musculoskelet Radiol. 2016;20(2):224–32. 391
364 injuries. Better follow-up is also needed to 8. Mason LW, Molloy AP. Turf toe and disor- 392
365 assess long-term functional outcomes and like- ders of the sesamoid complex. Clin Sports Med. 393
366 lihood of reinjury following turf toe injuries in 2015;34(4):725–39. 394
367 the athletic population. 9. Anderson RB. Sports foot and ankle injuries: an 395
update. VuMedi web resource. 2018 . https://www. 396
vumedi.com/video/turf-toe-jones-fracture. Accessed 397
20 Sept 2018. 398
368 References 10. Anderson RB. Repairing turf toe injuries. AOFAS 399
web resource. 2013. https://www.aofas.org/PRC/ 400
369 1. Clanton TO, Butler JE, Eggert A. Injuries to the meeting/Documents/RepairingTurfToeInjuries.pdf. 401
370 metatarsophalangeal joints in athletes. Foot Ankle. Accessed 23 Sept 2018. 402
371 1986;7(3):162–76. 11. McCormick JJ, Anderson RB. Rehabilitation follow- 403
372 2. George E, Harris AH, Dragoo JL, Hunt KJ. Incidence ing turf toe injury and plantar plate repair. Clin Sports 404
373 and risk factors for turf toe injuries in intercollegiate Med. 2010;29(2):313–23. 405
374 football: data from the national collegiate athletic 12. Nihal A, Trepman E, Nag D. First ray disorders in ath- 406
375 association injury surveillance system. Foot Ankle letes. Sports Med Arthrosc Rev. 2009;17(3):160–6. 407
376 Int. 2014;35(2):108–15. 13. Hainsworth L, McKinley J. The management of
408
377 3. Drakos MC, Taylor SA, Fabricant PD, Haleem turf toe—a systematic review. Br J Sports Med. 409
378 AM. Synthetic playing surfaces and athlete health. J 2017;51(2):A7–8. 410
379 Am Acad Orthop Surg. 2013;21(5):293–302. 14. Anderson RB. Turf toe injuries of the hallux meta- 411
380 4. Stokes IA, Hutton WC, Stott JR, Lowe LW. Forces tarsophalangeal joint. Tech Foot Ankle Surg. 412
381 under the hallux valgus foot before and after surgery. 2002;1:102–11. 413
382 Clin Orthop Relat Res. 1979;142:64–72. 15. Coker TP, Arnold JA, Weber DL. Traumatic lesions of 414
383 5. Nigg BM. Biomechanical aspects of running. the metatarsophalangeal joint of the great toe in ath- 415
384 Biomechanics of running shoes. Champaign (IL): letes. Am J Sports Med. 1978;6(6):326–34. 416
385 Human Kinetics Publishers; 1986. p. 1–25. 16. Brophy RH, Gamradt SC, Ellis SJ, Rodeo SA, Warren 417
386 6. McCormick JJ, Anderson RB. The great toe: failed RF, Hillstrom H. Effect of turf toe on foot contact 418
387 turf toe, chronic turf toe, and complicated sesamoid pressures in professional American football players. 419
388 injuries. Foot Ankle Clin. 2009;14(2):135–50. Foot Ankle Int. 2009;30:405–9. 420
1 Ankle Arthroplasty
26
2 Jin Woo Lee and Kwang Hwan Park
3 26.1 Introduction Courville et al. [3] reported that TAA is more 29
cost-effective than arthrodesis. During the past 30
4 26.1.1 Total Ankle Arthroplasty 30 years, TAA in its early days showed high fail- 31
5 (TAA) ure rates due to inadequate implant design, defec- 32
tive surgical instruments, lack of adequate 33
6 Most orthopedic surgeons are well aware of the surgical techniques, unskilled cement use, and 34
7 treatment options for end-stage osteoarthritis of excessive bone cutting, which resulted in the loss 35
8 the hip joint or knee joint since the protocols are of proper joint stability and normal joint mechan- 36
9 well established. However, selecting the appro- ics [4]. Despite such disappointing results of 37
10 priate treatment option for ankle osteoarthritis is TAA in its early days, dissatisfaction with 38
11 challenging from the initial stages for most ortho- arthrodesis, and promising results of arthroplasty 39
12 pedic surgeons and ankle specialists. Primary in the knee and hip joints have enabled continued 40
13 (degenerative) osteoarthritis rarely arises in the research for TAA. Following the development of 41
14 ankle joint, as in the knee or hip joints; however, second-generation implants, third-generation 42
15 secondary osteoarthritis due to trauma is more implants have been developed and are currently 43
16 common in the ankle [1]. Surgical treatment in clinical use. Recently developed implants, 44
17 options for end-stage ankle osteoarthritis include which have compensated the defects of conven- 45
18 total ankle arthroplasty and arthrodesis. tional implants, show improved implant survival 46
19 Arthrodesis, which is recognized as the treatment and postoperative clinical outcomes [5]. Results 47
20 of choice for end-stage ankle osteoarthritis to of TAA are promising as Pyevich et al. [6] 48
21 date, may cause excessive loading to nearby recently reported a satisfactory rate of 93% in a 49
22 joints, and result in osteoarthritis, and may affect 3- to 10-year follow-up study and Knecht et al. 50
23 normal gait due to limited range of motion. [2] reported an implant survival rate of 90%, 51
24 Conversely, TAA enables near-normal gait since 5 years after the procedure. 52
25 the range of motion is mostly preserved.
26 Moreover, patients find it easier to walk on
27 uneven surfaces and TAA reduces the load to 26.1.2 Brief History of Total Ankle 53
28 nearby joints and prevents osteoarthritis [2]. Arthroplasty 54
J. W. Lee (*) · K. H. Park TAA was introduced by Lord and Marotte [7] in 55
Department of Orthopaedic Surgery, Yonsei 1970 using first-generation implants, consisting 56
University College of Medicine, Seoul, South Korea of polyethylene tibial and metal talar implants. 57
e-mail: LJWOS@yuhs.ac
© ISAKOS 2019 281

https://doi.org/10.1007/978-3-662-58704-1_26
282 J. W. Lee and K. H. Park
58 The first-generation implants included uncon- surgical technique may be difficult and possesses 106
59 strained type models of Smith and Newton, and a risk of dislocation of the bearing, and thus may 107
60 the constrained type models Mayo, Oregon, and result in higher rates of polyethylene wear 108
61 TPR. Results of TAA using first-generation between the tibial implant and the bearing. The 109
62 implants were generally poor. In a 3-year follow- 2-component prosthesis system with fixed bear- 110
63 up study using the Smith implant, Dini and
ing includes Agility, INBONE, Eclipse, SALTO 111
64 Bassett [8] reported that satisfactory results were Talaris, ESKA Rudigier, and TNK, while the 112
65 obtained only in 50% of patients with posttrau- 3-component system with mobile bearing 113
66 matic arthritis and in 40% of patients with rheu- includes HINTEGRA, STAR, Mobility, Buechel- 114
67 matoid arthritis. Kitaoka and Patzer [9] reported Pappas, and Ramses. 115
68 an implant failure rate of 36% in a 2-year follow- The third-generation implants are non- 116
69 up study after using Mayo’s implants. The rea- cemented and are based on a design that empha- 117
70 sons for the failure of the first-generation implants sizes soft tissue balancing. The design minimizes 118
71 include the use of cement, over- or under- bone cutting and most implants have adopted 119
72 constraint, and lack of understanding of the soft movable bearing systems [10]. Movable bearing 120
73 tissue and ligament balancing, by means of surgi- systems are superior in terms of positional move- 121
74 cal techniques. Constrained type implants ments, owing to the second interface between the 122
75 resulted in excessive loosening since the stress tibial area and the polyethylene insert. Minimal 123
76 was concentrated to the cement-bone junction, stress is applied to the ligaments of the ankle 124
77 and unconstrained type implants showed high joint and wear rates of the polyethylene implants 125
78 incidence of dislocations. In addition, the first- are improved [11]. Metals used for the implants 126
79 generation implants in general showed high rates include alloys such as cobalt-chromium and 127
80 of subsidence and osteolysis. cobalt-chromium and titanium, with an addi- 128
81 Based on the failures of the first-generation tional porous coating with hydroxyapatite or tita- 129
82 implants, second-generation implants, with sev- nium for implant fixation to the bone resection 130
83 eral improvements, were developed. In the margin. 131
84 second-generation implants, the porous coating
85 on its surface allowed fixation to be achieved by
86 press fit instead of cement, and the durability of 26.1.3 Total Ankle Arthroplasty vs. 132
87 the polyethylene was improved. Implants were Ankle Arthrodesis 133
88 designed in a more anatomical and more biome-
89 chanical approach. The second-generation TAA and ankle arthrodesis (AA) are accepted 134
90 implants can be classified into 2 groups accord- surgical treatment options for end-stage ankle 135
91 ing to the number of components and by the bear- arthritis. Although arthrodesis has been consid- 136
92 ing material used: the 2-component system ered the surgical standard for end-stage arthritis, 137
93 consists of a fixed bearing and the 3-component it may result in functional limitations due to alter- 138
94 system is equipped by a mobile bearing. Since ations in gait and loss of range of motion of the 139
95 the polyethylene bearing and tibial implant are ankle [12, 13]. TAA provides restoration of ankle 140
96 adhered, the 2-component system with fixed kinematics and more natural ankle function [14, 141
97 bearing possesses higher constraint and confor- 15]; however, it has the disadvantages of higher 142
98 mity. This leads to lower dislocation rates, but the reoperation and complication rates [9, 16]. There 143
99 implant may be under higher shear force. is an ongoing debate concerning the superior sur- 144
100 However, the contact between the talar implant gical treatment for end-stage ankle arthritis; 145
101 and the bearing remains low and may lead to although, the available evidence is insufficient to 146
102 lower constraint and higher polyethylene wear. conclude that one procedure is superior to the 147
103 The 3-component system with mobile bearing other [2, 3]. 148
104 may lower shear force by maintaining balance A systematic review of 13 level IV studies 149
105 between conformity and constraint. However, the reported that the overall failure rate for TAA with 150
26 Ankle Arthroplasty 283
151 second- or third-generation implants was approx- arthritis are good candidates for TAA because 195
152 imately 10% at 5 years with a wide range (0–32%) bilateral ankle fusion generally has a detrimental 196
153 reported among different centers [17]. A litera- influence on gait and functional outcome [17, 18, 197
154 ture review of the national registry data from 24]. 198
155 Norway, Sweden, and New Zealand reported that Another indication for TAA is the salvage of 199
156 the average revision rate was 21.8% at 5 years painful nonunion or malunion of a prior ankle 200
157 and 43.5% at 10 years after TAA with second- or fusion [25, 26]. Conversion of fused ankle to 201
158 third-generation implants [18]. A literature TAA is a technically demanding procedure that 202
159 review of AA has described a nonunion rate rang- should be performed only if remaining bone 203
160 ing from 3% to 15% after AA [19]. In a recent stock is sufficient and soft tissue conditions are 204
161 level II study comparing these two procedures, not overly compromised [26]. 205
162 the revision rate in the TAA group (17%) was
163 approximately twofold higher than that in the AA
164 group (7%) [6]. The higher revision rate after 26.2.2 Contraindications 206
165 TAA seems to be due to the complexity of ankle
166 replacement surgery and the unique biomechan- Acute or chronic infections and Charcot neuroar- 207
167 ics of the ankle joint [6]. The complication rate of thropathy are absolute contraindications for TAA 208
168 TAA has been reported to be greater than that of [5, 27]. 209
169 AA, and the mean revision rate at the 5-year fol- In patients with avascular necrosis of the talus, 210
170 low-up has been reported to be 11% for AA and the use of a standard prosthesis component may 211
171 21% for TAA [6, 9, 16]. lead to significant subsidence and loosening of 212
the talar component and failure [28, 29]. 213
Avascular necrosis of the talus is considered to be 214
172 26.2 Patient Selection an absolute contraindication for 215
TAA. Neuromuscular disorders, and poor- 216
173 26.2.1 Indications glucose control or diabetic polyneuropathy in 217
diabetic patients are considered contraindications 218
174 TAA was developed to reduce pain and retain for TAA. Relative contraindications of TAA 219
175 motion of the ankle joint in patients with ankle include patients with severe instability, or patients 220
176 arthritis. With improvement of surgical out- with significant varus or valgus deformity (>10°) 221
177 comes, indications for TAA have increased [30, 31]. 222
178 recently. In general, TAA is indicated in patients The relative contraindications for TAA also 223
179 with end-stage ankle arthritis who have sufficient include severe osteoporosis, immunosuppressive 224
180 bone stock available in the tibia and talus to sup- therapy, and smoking [5]. Smoking is another 225
181 port prosthesis. Unlike the hip and knee, ankle relative contraindication because it is associated 226
182 osteoarthritis mostly arises as a consequence of with higher risk of perioperative complications, 227
183 trauma [20, 21]. Optimal candidates for TAA including wound breakdown [32]. The negative 228
184 include young, nonobese patients, nonsmokers, effects of smoking have been studied relative to 229
185 patients with low activity levels, patients with no fusion, and fracture healing. It is well known that 230
186 ankle deformity, and ROM-preserved ankles. smokers have more difficulties with wound heal- 231
187 Other common indications for TAA are sys- ing as compared with nonsmokers in TAA [33]. 232
188 temic (rheumatoid) arthritis [12, 13, 19].
189 Secondary osteoarthritis due to pathologies,
190 such as hemophilia [14, 15], gout [16, 22], postin- 26.2.3 Preoperative Considerations 233
191 fectious arthritis [6], and avascular necrosis [23],
192 may be candidates for TAA, but due to various Age is an important factor in a patient’s long- 234
193 surgical outcomes, indications for surgery remain term outcome following TAA. The higher physi- 235
194 controversial. Patients with bilateral ankle osteo- cal demands of younger patients may lead to 236
237 prosthesis failure. The ankle is more often Ankle range of motion, muscle function 285
238 affected by posttraumatic arthritis; these patients (e.g., tibial and peroneus muscles), and liga- 286
239 may already have some soft tissue injury from ment stability should also be assessed. The 287
240 the previous trauma. The anterior soft tissue decreased dorsiflexion of ankle often makes 288
241 envelope of the ankle is relatively thin when com- Achilles tendon contracted and shortened. 289
242 pared with those of other joints where arthro- Posterior tibial tendon dysfunction with hind- 290
243 plasty is performed. For these reasons, medical foot valgus can lead to laxity of the medial liga- 291
244 issues that may compromise healing need to be ment complex. Peroneus tendon dysfunction 292
245 evaluated. with hindfoot varus can lead to laxity of the lat- 293
246 History of diabetes, smoking, inflammatory eral ligament complex. The latter must be veri- 294
247 arthritis (RA), vascular disease, neuropathy, fied before surgery to determine whether 295
248 immunosuppression, neurologic disease, and additional operations should be performed 296
249 osteoporosis must be verified before any proce- together with the TAA. 297
250 dure. Althoff et al. [34] found that age <65 years, Osteoporotic patients may have poor bone 298
251 low body mass index, obesity, diabetes, inflam- quality and quantity in the distal tibia or talus to 299
252 matory arthritis, peripheral vascular disease, and support the prosthesis. This can lead to poor bony 300
253 hypothyroidism are strongly associated with an ingrowth and instability of the implant. In par- 301
254 increased risk of postoperative infection after ticular, the tibial components lose fixation and 302
255 TAA. Whalen et al. [32] showed that there is a subsidence occurs more often. To reduce the 303
256 statistically significant increase in the incidence occurrence of these problems, larger alternatives 304
257 of wound breakdown in TAA patients with a long can be used, but medial malleolar fractures may 305
258 history of smoking. occur. 306
259 Uncontrolled diabetes and vascular insuffi- Weight-bearing radiographs should be 307
260 ciency are also known to have a deleterious effect reviewed for any coronal or sagittal plane 308
261 on healing postoperative incisions around the malalignment to allow proper planning for cor- 309
262 foot and ankle. However, diabetic patients with rection interventions. It is critical to evaluate the 310
263 good glycemic control without neuropathy can alignment of the hip and knee as well. Neutral 311
264 be treated by TAA. alignment is essential to maximize the prosthesis 312
265 Raikin et al. [35] demonstrated that rheuma- longevity. If malalignment is present, radio- 313
266 toid arthritis is a leading risk factor for wound graphs from the hip to the ankle may be required. 314
267 infection; patients with inflammatory arthritis are Any signs of avascular necrosis (AVN) of the 315
268 more likely to require additional treatment or sur- distal tibia or the talar body should be noted. 316
269 gery to manage wound complications than those Collapse and subsidence of the prosthesis may 317
270 without inflammatory arthritis. occur more commonly in patients with AVN, 318
271 Immunosuppressive treatments are often indi- since bone ingrowth is deteriorated in such 319
272 cated as rheumatoid arthritis (RA) increases the patients. Magnetic resonance imaging (MRI) is 320
273 risk of wound dehiscence and postoperative helpful in assessing the presence and severity of 321
274 infections. AVN [38]. 322
275 Neurological disease can affect the survivor-
276 ship of an implant as well as postoperative func-
277 tion. Varus or valgus malalignment of the ankle 26.3 Preoperative Planning 323
278 due to muscle spasticity can lead to edge loading
279 and early failure of the implant. Detailed history taking and physical examination 324
280 In young patients, high demands for physical is necessary. Evaluation for limb alignment, gait, 325
281 activity can cause edge loading and prosthesis range of motion, and muscle function should also 326
282 wear that may lead to prosthesis failure [36, 37]. be conducted. Besides clinical examination, 327
283 Running or excessive exercise should be restricted radiologic examination should also be 328
284 in these patients. performed. 329
330 26.3.1 Clinical Examination should be assessed routinely because lower leg 356
muscle atrophy is common in end-stage osteoar- 357
331 Inspection of the foot and ankle in many posi- thritis [44]. 358
332 tions (sitting, standing, and walking) should be
333 performed, which allows the differential com-
334 parison of changes on weight-bearing vs. non- 26.3.2 Radiologic Examination 359
335 weight-bearing movements. Skin and soft tissues
336 should be carefully evaluated, with special atten- Weight-bearing radiographs with an anteropos- 360
337 tion given to previous surgical scars. The eventu- terior view of the ankle and anteroposterior and 361
338 ally observed pathological findings should be lateral views of the ankle are used on radiologic 362
339 compared with the unaffected limb. Ankle align- examination (Fig. 26.1). Weight-bearing is 363
340 ments are generally performed with the patient in important in radiographs because non-weight- 364
341 standing position, while Hindfoot stability bearing radiographs are commonly misread 365
342 assessment is performed with the patient in the [45, 46]. 366
343 sitting position [39, 40]. Visual alignment assess- Any deformities or potential degenerative 367
344 ment is often not sufficiently accurate, which changes in the adjacent joints should be identi- 368
345 means careful interpretation is needed for ankle fied and carefully analyzed. Deformities may 369
346 and hindfoot assessment [41]. occur on any level in patients with osteoarthritic 370
347 A goniometer is used to assess the range of ankles. The standing position is appropriate for 371
348 motion of the tibiotalar joint and is positioned comparison of radiographs before and after the 372
349 along the lateral border of the leg and foot. surgery. To measure the hindfoot deformities, the 373
350 These measurements using the goniometer are hindfoot alignment view is needed. 374
351 performed in a weight-bearing position accord- It is necessary to thoroughly evaluate 375
352 ing to the method described by Lindsjo et al. malalignment and instability during preoperative 376
353 [42] The Iowa Ankle Range of Motion is another planning. Both conditions can result in sublux- 377
354 useful option for the assessment of ankle dorsi- ation and edge loading of the UHMWPE insert, 378
355 flexion and stiffness [43]. Basic muscle function progressive deformity, and high early failure 379
Fig. 26.1 A 84-year-

old-women with
osteoarthritis of left
ankle. Preoperative
standing AP and Lateral
view shows the varus
ankle
380 rates [47–50]. Most authors agree that correction

381 of varus or valgus deformity may be limited, and
382 a deformity more than 20 ° has been suggested as
383 a contraindication for TAA [51].
384 In the frontal plane, the degree of alignment
385 of the ankle is formed by the anatomic axis of
386 the tibia and a line perpendicular to the articu-
387 lar surface of the dome of the talus on a stand-
388 ing anteroposterior radiograph [47, 52]. For
389 angle alignments of less than 10 ° of varus or
390 valgus, the joint is thought to be neutral, and is
391 only considered to be varus or valgus when the
392 alignment is above 10 ° [47]. The talar tilt angle
393 is defined by the tibial and talar articular sur- Fig. 26.2 Buechel-Pappas prosthesis
394 faces of the ankle joint on a standing anteropos-
395 terior radiograph. For talar tilt angles above
396 10 °, the joint is defined as incongruent [48].
397 Deformities can be located at the joint level
398 (usually owing to anatomic joint line malalign-
399 ment or to ankle degeneration) or proximally
400 (usually due to a tibial fracture) [53]. If an
401 abnormal alignment of more than 10 ° in any
402 plane is present above the level of the ankle
403 joint, corrective osteotomy must be undertaken
404 at the site of the deformity before total ankle
405 replacement [51]. If the deformity of the ankle
406 is located at the joint level, an algorithmic
407 approach to soft tissue balancing in varus Fig. 26.3 Agility prosthesis
408 ankles is recommended, including gradual
(Fig. 26.2). The prosthesis is composed of flat 424
409 release of the medial deltoid ligament, along
tibial plate, polyethylene inlay, and biconcave 425
410 with additional procedures [54].
trochlear talar component. Deep trochlear sulcus 426
411 A computed tomography (CT) scan can be
angle prevent bearing subluxation. Buechel et al. 427
412 used to assess joint mismatch or bone defects. In
[58] reported a survival rate of 92% after 12 years. 428
413 patients with degenerative changes of the adjacent
Doets et al. reported a survival rate of 89% at the 429
414 joint, single photon emission computed tomogra-
follow-up of 10 years [47]. Despite the long-term 430
415 phy (SPECT-CT) might be used in the adjacent
results, Buechel-Pappas prosthesis is currently 431
416 joint to analyze changes in form and biological
not available. 432
417 activity [55, 56]. Preoperative MRI can be used to
418 assess pathological changes of the tendon, avas-
419 cular necrosis, and ligament injuries [57]. 26.4.2 Agility Ankle Prosthesis 433
The Agility prosthesis is a semi-constrained two- 434

420 26.4 Prosthesis component design. The prosthesis is composed 435
of titanium tibial and cobalt-chromium talar 436
421 26.4.1 Buechel-Pappas Prosthesis components (Fig. 26.3). Bone resection was min- 437
imized and the syndesmosis fused to increase the 438
422 The Buechel-Pappas prosthesis is rotationally surface area for the tibial component and limit 439
423 unconstrained, mobile-bearing system subsidence. 440
Fig. 26.4 Hintegra prosthesis
441 The Agility prosthesis was most commonly

442 used in the United States, and has the longest
443 follow-up [27, 59, 60]. However, high revision Fig. 26.5 STAR prosthesis
444 and reoperation rates were reported [61, 62]. As a
445 result, the prosthesis has been replaced by other and talar components are made of a cobalt–chro- 472
446 implants [63]. mium alloy with coated surfaces allowing bone 473
ingrowth. 474
Nunley et al. [67] evaluated 82 consecutive 475
447 26.4.3 HINTEGRA Total Ankle patients and reported that TAA with STAR 476
448 Prosthesis prosthesis was associated with significant 477
improvement in terms of pain, function, and 478
449 The HINTEGRA total ankle design is an uncon- quality of life. 479
450 strained, three-component system that provides Daniels et al. [68] reported that TAA with the 480
451 inversion-eversion mobility (Fig. 26.4). The tibial STAR design led to good clinical outcomes at 481
452 component has a flat, 4-mm-thick plate with 6 intermediate to long-term follow-up, but 29% of 482
453 pyramidal peaks. The talar component is coni- the ankles required polyethylene bearing 483
454 cally shaped, with a smaller radius on the medial exchange and/or metal component revision. 484
455 side. It has 2.5-mm-high rims on each side that
456 ensure stable positioning and guide the antero-
457 posterior translation of the mobile bearing. The 26.4.5 Salto Total Ankle Prosthesis 485
458 anterior shield of this component increases pri-
459 mary bone support [64]. Salto prosthesis is mobile-bearing implant 486
460 Barg et al. [65] analyzed the survivorship of (Fig. 26.6). The tibial component has the flat and 487
461 722 ankle arthroplasty. The overall survival rates smooth surface toward the mobile bearing. It 488
462 were 94% and 84% after 5 and 10 years. The allows translation and rotation. The 3-mm medial 489
463 midterm survivorship of the HINTEGRA implant rim protects the polyethylene from impingement 490
464 was comparable with that of other third- with the medial malleolus. The tibial component 491
465 generation total ankle replacements. has a fixation peg. The shape of talar component 492
is similar to the natural talar anatomy. The ante- 493
rior width is wider than the posterior, and the lat- 494
466 26.4.4 STAR (Scandinavian Total eral flange has a larger curvature radius than the 495
467 Ankle Replacement) Total medial. 496
468 Ankle Arthroplasty Wan et al. [69] reviewed 59 ankles operated 497
by Salto prosthesis and reported that the short- 498
469 The STAR prosthesis is a mobile-bearing pros- term prosthesis survival was 94.9%. Hofmann 499
470 thesis and has one of the longest histories in ankle et al. [70] reported that in a study of 81 ankles, 500
471 replacement surgery (Fig. 26.5) [66]. The tibial the implant survival rate was 97.5% in the mean 501
Fig. 26.6 Salto prosthesis
502 follow-up of 5.2 years. Stewart et al. [71] found a

503 survival rate of 95.8% in at least 5-year follow-up
504 and significant improvements in the VAS and
505 AOFAS score.
506 26.4.6 INBONE Total Ankle System
507 The tibial and talar components are made of Fig. 26.7 INBONE prosthesis
508 cobalt–chromium with a titanium plasma spray
509 coating. INBONE system has been changed in inlay (Fig. 26.8). The tibial component has a flat 524
510 design to reduce component failure. The articular surface and a short, conical stem. The 525
511 INBONE total ankle has a talar component with talar component is designed to leave the malleo- 526
512 a central sulcus, providing additional coronal sta-
lar surface intact, and has a central longitudinal 527
513 bility (Fig. 26.7). sulcus. The stability of the talar component is 528
514 In contrast to all other total ankle system, the
enhanced by two pegs on its non-articulating 529
515 INBONE total ankle system uses intramedullary aspect. The non-articulating surfaces are porous 530
516 referencing for placement of the tibial compo- coated to provide bone ingrowth [72]. The PE 531
517 nent and requires more fluoroscopy time than insert creates a conforming, congruent interface 532
518 other prosthesis. with a deep sulcus on the talar component, and 533
has a flat surface on the tibial side to minimize 534
shear stresses. 535
519 26.4.7 Mobility Ankle System Muir et al. [73] performed 178 total TAA. They 536
had satisfactory results over 85% of all patients at 537
520 The Mobility prosthesis is unconstrained three- the average 4-year follow-up, but there is a sig- 538
521 component systems composed of cobalt- nificant incidence of persistent pain, particularly 539
522 chromium porous coated tibial and talar on the medial side, for which we were unable to 540
523 components and a mobile-bearing polyethylene establish a cause. 541
Fig. 26.9 TNK prosthesis
of soft tissues is a secondary transformation 561

that generally arises as a consequence of trauma 562
or long-standing angular malalignment. In gen- 563
eral, medial-lateral soft tissue balancing 564
requires release of contracted soft tissue on the 565
Fig. 26.8 Mobility prosthesis concave side of the deformed ankle. Release of 566
contracted medial soft tissue in varus ankles is, 567
542 26.4.8 TNK Total Ankle Prosthesis for the most part, quite different from the 568
release of contracted lateral structures in valgus 569
543 TNK ankle is semi-constrained, two-component ankles. 570
544 system (Fig. 26.9). It is made of alumina ceramic Even if bone cuts can be made to establish 571
545 and its interface with bone is coated with alumina anatomic alignment, proper soft tissue balance 572
546 beads. This prosthesis combines biocompatibility is required to maintain alignment throughout 573
547 of alumina ceramics with a design that facilitates the range of motion. It is important, therefore, 574
548 fixation to bone. that surgeons be provided with a rationale and 575
549 The third-generation implants have made predictable techniques to perform soft tissue 576
550 improvements in the high incidence of aseptic release, as well as indications regarding addi- 577
551 loosening of the first- and second-generation tional procedures commonly performed in bal- 578
552 implants. Studies by the designer reported favor- ancing varus and valgus ankle in primary 579
553 able results using the third-generation TNK pros- TAA. 580
554 thesis [74].
26.5.1 Anterior Approach 581
555 26.5 Surgical Techniques

556 for Ligament Balancing Most implants are inserted using the anterior 582
557 and Malalignment approach. A 10–15 cm incision is made at the 583

anterior portion of the ankle joint, laterally to the 584
558 In most end-stage arthritic ankles, some degree tibialis anterior tendon and along the extensor 585
559 of instability, deformity, contracture, or combi- hallucis longus (EHL) tendon. The superficial 586
560 nation of these elements is present. Contracture medial branch of the peroneal nerve is d iscovered 587
588 and retracted laterally. Next, the incision of the 26.5.2.1 M edial Release and Gap 610
589 extensor retinaculum in line with the EHL ten- Balancing 611
590 don and the medial retraction of the EHL are Ligament balance is achieved by progressively 612
591 performed. On applying this approach, attention releasing medial soft tissue until the length of the 613
592 should be taken not to damage the neurovascular lateral ligamentous structures is reached. The 614
593 structure, which is located behind the EHL. After extent of the release can be monitored by periodi- 615
594 the joint capsule is exposed, the longitudinal cally inserting lamina spreaders or using a liga- 616
595 incision is applied. The incision must be suffi- mentous tension meter to gauge alignment. 617
596 cient to ensure the ankle joint is exposed. Alternatively, trial components can be inserted, 618
597 Following the identification of the lateral and guiding the ankle through by applying varus and 619
598 medial gutters, the osteophytes at the tibia and valgus stress to the ankle. 620
599 the talar neck are excised. Implant stability must Following the surgical procedure and ankle 621
600 be secured by proper bone cutting, and soft tis- joint exposure, removal of the periarticular 622
601 sue balancing. After the implantation, insertion osteophytes from the distal tibia and talus can be 623
602 of the drainage tube, followed by layered clo- performed to effectively lengthen the medial 624
603 sure, is performed. capsuloligamentous tissue. Posterior osteo- 625
phytes of the distal tibia should be carefully 626
removed because they can lead to heterotopic 627
604 26.5.2 Operative Procedure ossification [75] or restrict the sagittal plane 628
605 for Varus Ankle range of motion of the ankle. Next, soft tissue 629
balancing corrects any talar tilt before proceed- 630
606 If the deformity of the ankle is located at the joint ing to making cuts in bone. Gradual release of 631
607 level, the algorithmic approach to soft tissue bal- the deltoid ligament should be performed at its 632
608 ancing in varus ankle is recommended distal insertion using a curved osteotome 633
609 (Fig. 26.10). (Fig. 26.11). It is important to release all compo- 634
nents of the deep deltoid ligament, including the 635
anterior tibiotalar, tibionavicular, and posterior 636
Varus Ankle tibiotalar ligaments. This gradual release tech- 637
nique was developed to alleviate the risk of 638
Medial release
Incongruent Congruent
Varus Varus
Regular High
Tibial cutting Tibial cutting
Lateral
opening?
Yes No
Lateral Symmetrical
plication ligament balancing
Fig. 26.10 Treatment algorithm in varus ankle

osteoarthritis Fig. 26.11 Medial release by using an osteotome
639 medial ligamentous instability (or osteonecrosis are subcutaneous at this level. The peroneus 685
640 of the talus) after extensive stripping from the brevis insertion at the base of the fifth metatarsal 686
641 talus, and to optimize ligamentous balancing. is observed and the peroneus longus is identified 687
642 After bone preparation, trial components are adjacent to the peroneus brevis tendon. The pero- 688
643 then positioned and varus and valgus stress is neus longus tendon is transected at its most distal 689
644 applied to the ankle to assess balancing. The portion in full plantar flexion and eversion of the 690
645 ankle is inspected for residual medial tightness ankle is performed to allow sufficient harvesting 691
646 or lateral gapping in a neutral position. In ankles of the tendon. A suture anchor can be used at the 692
647 with moderate to severe varus, the medial com- base of the fifth metatarsal, immediately plantar 693
648 partment of the ankle commonly remains tighter and lateral to the insertion of the peroneus brevis 694
649 than the lateral compartment. A more definitive tendon. The peroneus longus tendon is sutured 695
650 medial release should be performed at this time under moderate tension while the foot is held in a 696
651 to balance the ankle. Once all the extra-articular slightly plantarflexed and everted position. This 697
652 deformities are noted, such as tightness in the provides sufficient eversion power postopera- 698
653 posterior tibial tendon, patients may require a tively. A side-to-side tenodesis is then performed 699
654 further incision to release the relevant between the residual peroneus longus and brevis 700
655 contracture. tendons. Degeneration or attritional rupture of 701
the peroneal tendon is often present, which may 702
656 26.5.2.2 Lateral Plication-Peroneus be associated with an extended varus deformity 703
657 Longus Transfer to Peroneus of the ankle; if such is the case, all abnormal- 704
658 Brevis appearing tendon should be debrided and 705
659 Any residual imbalance in the supine position tubularized. 706
660 can result in subluxation or dislocation of the
661 UHMWPE insert component on weight-bearing 26.5.2.3 Calcaneal Osteotomy 707
662 movements. After the ligamentous imbalance has been man- 708
663 The modified Brostrom procedure [76] is pre- aged, the alignment of the hindfoot should indi- 709
664 ferred when the lateral ligamentous complex is cate whether calcaneal osteotomy should be 710
665 spared. In patients with long-standing varus ankle performed. Frequently, varus deformity of the 711
666 arthrosis, however, varus deformity is commonly hindfoot is associated with varus ankle osteoar- 712
667 associated, to some extent, with chronic lateral throsis. Correcting the hindfoot deformity before 713
668 ankle instability. Varus deformity is frequently or simultaneously with the TAA is essential to 714
669 associated with loss of the anterior talofibular achieve optimal long-term results. Numerous cal- 715
670 ligament and calcaneofibular ligament, as well as caneal osteotomies have been reported with good 716
671 anteriorly displaced talus. In such cases, several clinical results, such as lateral displacement oste- 717
672 nonanatomic reconstruction procedures can be otomy, which translates the posterior fragment 718
673 performed. Satisfactory results have been 5–10 mm laterally, and triplanar osteotomy [78], 719
674 achieved with a peroneus longus tendon transfer which corrects all 3 planes of the cavovarus 720
675 to the base of the fifth metatarsal, [54] as deformity by lateral translation of the tuberosity 721
676 described by Kilger et al. [77]. This procedure fragment coupled with lateral closing of the 722
677 effectively enhances lateral ankle stability and wedge osteotomy to correct varus and proximal 723
678 weakens plantar flexion force over the first meta- sliding of the tuberosity fragment and to adjust 724
679 tarsal. In addition, this procedure is easily com- the calcaneal posture of the hindfoot and subtalar 725
680 bined with TAA. arthrodesis. The lateral closing wedge osteotomy 726
681 To perform this procedure, a small, longitudi- was introduced by Dwyer [79]. It has commonly 727
682 nal incision is made over the base of the fifth been used for the correction of the heel varus in 728
683 metatarsal. The sural nerve and small saphenous combination with TAA, because it is technically 729
684 vein courses follow posterior to the tendon and easy and requires only a few additional minutes. 730
a b c
Fig. 26.12 Hindfoot varus after TAA was noticed. Calcaneal closing wedge osteotomy should be considered.
Intraoperative heel varus (a), postoperative heel alignment view (b) and lateral view (c)
731 The procedure involves making a short, lateral, varus can drive plantarflexion of the first ray. As 755
732 oblique incision directly posterior to the peroneus the plantarflexed first ray forces the heel and 756
733 tendons, performing a lateral-based wedge oste- ankle into varus [80], a dorsal closing wedge 757
734 otomy and tapering the wedge to, but not through, osteotomy should be performed on the first meta- 758
735 the medial cortex. After closing the gap, the cor- tarsal by TAA. Through a small incision on the 759
736 rection of the varus deformity is ensured. While dorsum of the first metatarsal base, approxi- 760
737 holding the osteotomy in the desired position, 2 mately 1 cm distal to the first tarsal-metatarsal 761
738 guide pins are inserted to determine the correct joint, a dorsal-based wedge of the bone is 762
739 position for the insertion of the cannulated can- removed using a sagittal saw. Cuts in the first 763
740 cellous screws. When the first pin engages the metatarsal should be angled obliquely to allow 764
741 proximal fragment, a bone hook can help to pull for easier screw insertion. The most troublesome 765
742 the guide pin laterally to minimize the gap and to complication to date has been transfer metatar- 766
743 compress the bony surfaces together. Two 6.5- salgia, attributable to an excess dorsiflexion of 767
744 mm cancellous screws with partial threads are the distal fragment, resulting from too much bone 768
745 inserted perpendicular to the osteotomy site and resection. Once the osteotomy is created, it is 769
746 positioned slightly posterior and lateral on the important to preserve enough of the proximal 770
747 tuberosity segment, angled anteriorly and slightly fragment for screw placement by avoiding the 771
748 medially (Fig. 26.12). region at the beginning of the osteotomy, which 772
is too close to the first tarsal-metatarsal joint. 773
749 26.5.2.4 Dorsiflexion Osteotomy After the metatarsal is elevated, 2 guide pins can 774
750 of the First Metatarsal be inserted from the proximal-dorsal to the 775
751 Once the ankle and hindfoot alignment is cor- plantar-distal aspect of the metatarsal. Two head- 776
752 rected, the surgeon should inspect the level of the less compression screws are inserted over the 777
753 metatarsal heads by holding the foot in a neutral guide wires to engage both cortices for maximal 778
754 position. Correction of the hindfoot and ankle compression (Fig. 26.13). 779
a b
Fig. 26.13 Dorsiflexion osteotomy of the first metatarsal bone. Postoperative foot anteriorposterior view (a) and lateral
view (b)
780 26.5.3 Operative Procedure then be opened and pulled down using a bone 792
781 for Valgus Ankle reduction clamp to distract the lateral malleolus 793
distally. An autologous iliac crest bone graft or 794
782 Valgus ankle deformity is rare and often associ- structural allograft bone graft is interposed into 795
783 ated with malunion after ankle fractures and with the osteotomy site, whereas the distal segment is 796
784 posterior tibial tendon dysfunction. The most distracted. It is positioned firmly using a plate 797
785 common scenario of malunion after ankle fac- and screws. The amount of lengthening and the 798
786 tures is the shortening and external rotation of the rotational correction of the fibula necessary can 799
787 fibula, which can develop if the fixation of the be difficult to determine. Comparison radio- 800
788 fibula is inadequate [81]. To correct valgus ankle graphs of the contralateral ankle or the articular 801
789 deformity, a transverse osteotomy is made above contact between the fibula and the lateral edge of 802
790 the level of the syndesmosis using a lateral trans- the talus may be helpful to determine the appro- 803
791 malleolar approach. The syndesmosis should priate amount of correction to be performed. 804
805 The majority of valgus deformities occur sec- 26.5.4 Additional Procedures 830
806 ondarily to an advanced posterior tibial tendon
807 dysfunction. The progressive deformity results in 26.5.4.1 Heel Cord Lengthening 831
808 forefoot supination with medial column instabil- Patients with end-stage ankle arthrosis who 832
809 ity and eventually pes planovalgus. The foot undergo TAA often have a contracture of the 833
810 deformity must be managed before addressing gastrocnemius- soleus complex. Recognition of 834
811 the ankle to obtain a stable plantigrade foot. tight heel cord is also possible by observing the 835
812 Procedures to be performed to correct posterior limitation of ankle dorsiflexion. If a minimal dor- 836
813 tibial tendon dysfunction include medial dis- siflexion of 10 ° cannot be achieved through 837
814 placement calcaneal osteotomy, lateral column TAA, heel cord lengthening can be considered as 838
815 lengthening, soft tissue procedures (e.g., flexor an option. It can be achieved by either gastrocne- 839
816 digitorum longus tendon transfer, repair of the mius recession or percutaneous tendo-Achilles 840
817 deltoid and spring ligament), and/or plantarflex- tendon lengthening, depending on the results of 841
818 ion osteotomy of the first ray. In patients with the Silfverskiold test. 842
819 rigid fixed deformity of the hindfoot, multiple Gastrocnemius recession Also known as the 843
820 arthrodeses are considered the procedures of Strayer procedure, is a treatment option for 844
821 choice, including isolated subtalar arthrodesis, patients who have heel cord tightness in which 845
822 isolated talonavicular arthrodesis, talonavicular the chief cause of contracture is in the gastrocne- 846
823 and calcaneocuboid arthrodesis, and triple mius alone. A posterior longitudinal incision is 847
824 arthrodesis [82]. These procedures can shift the made over the middle of the calf at the level of 848
825 heel contact point laterally to obtain a planti- the musculotendinous junction. After exposing 849
826 grade, stable foot, and thus reduce stress on the the gastrocnemius aponeurosis, a transverse inci- 850
827 lateral tibiotalar joint. The algorithm that is sion is made through it. The surgeon can control 851
828 suggested for the treatment of a valgus ankle is tension by dorsiflexing the ankle to the desired 852
829 shown in Fig. 26.14. angle (>10 °). The paratenon and deep fascia are 853
Valgus Ankle
Malunions following
PTTD stage 4
ankle fractures
Fibular malunion Regular

Tibial malunion
with shortening tibial cutting
Lateral open Medial closing Subtalar No Subtalar or talonavicular

wedge OT wedge OT motion? corrective fusion
Yes
Calcaneus medial
TAR sliding OT
FDL transfer ±
Repair of deltoid/
spring ligament
First ray flexion OT
Fig. 26.14 Treatment algorithm in valgus ankle osteoarthritis. TAA must be followed by correction of PTTD
deformity
854 then carefully repaired to prevent adhesion to the would be too extensive a procedure for the 901
855 overlying skin. patient’s limb to tolerate in a single setting. 902
856 Percutaneous lengthening of the Achilles Therefore, the patient’s condition and the sur- 903
857 tendon Tendo-Achilles tendon lengthening is geon’s skill should be considered when com- 904
858 indicated when both the gastrocnemius and bining these procedures with TAA 905
859 soleus contribute to heel cord tightness through simultaneously. 906
860 an open or percutaneous approach. Percutaneous
861 teno-Achilles tendon lengthening is usually per-
862 formed using the triple hemisection technique,
863 described in detail by Hatt and Lamphier [83]. 26.6 Complications 907
864 Percutaneous tendo-Achilles lengthening is pref-

865 erable to open procedures because the former is 26.6.1 Surgical Wound Problems 908
866 quick and free of complications [84] and is easy

867 to combine with TAA. Regardless of approach, Along with medial malleolar fractures, postoper- 909
868 particular attention should be taken to avoid ative complications related to surgical wounds 910
869 complete rupture of the Achilles tendon that can are the most common complications after sur- 911
870 occur during overzealous dorsiflexion of the gery, with an incidence rate of about 10% [93, 912
871 ankle. 94]. Negative pressure wound therapy is effective 913

for wounds with large dehiscence and preserved 914
872 26.5.4.2 Hindfoot Fusion extension zone. When the wound is connected 915
873 Patients with end-stage arthrosis of the ankle into the ankle joint, methods such as implant 916
874 joint frequently present with malalignment in the removal, free flap, or arthrodesis are necessary 917
875 coronal plane, but also with degenerative change (Fig. 26.15). 918
876 or deformity affecting the adjacent joints [51, 85,

877 86]. For these reasons, TAA occasionally requires
878 adjunctive procedures to the hindfoot along with
879 aforementioned procedures in order to obtain a
880 plantigrade foot. Poor results for TAA have been
881 reported in younger and patients with higher
882 demanding movement requirements and hindfoot
883 arthrodesis [87]. Performing various hindfoot
884 fusions simultaneously with TAA or as a staged
885 procedure before TAA, Kim et al. [88] recently
886 reported good midterm outcomes in their attempt
887 to address the challenges of hindfoot arthritis and
888 deformity in TAA.
889 Subtalar fusion and/or talonavicular fusion
890 are most frequently combined with TAA [72,
891 88], and, if necessary, these can also be per-
892 formed with triple arthrodesis to create a planti-
893 grade foot in TAA. The calcaneocuboid joint is
894 usually spared if there is no evidence of arthro-
895 sis, because sparing of this joint can reduce non-
896 union [89, 90] and further adjacent joint arthritis
897 [91, 92].
898 Hindfoot procedures can be performed either
899 as simultaneous or staged operations; however, Fig. 26.15 Wound dehiscence along the incision after
900 arthrodesis of the hindfoot combined with TAA primary TAA
a b
Fig. 26.16 Ankle AP (a) and Lateral (b) view at the follow-up of 5 months. Medial malleolar stress fracture was seen
on radiographs
919 26.6.2 Medial Malleolar Fractures 26.6.4 Postoperative Infection 937
920 Medial malleolar fractures occur in 20% of all Infection after TAA occurs in 0–2% of all cases, 938
921 cases [47, 93] and causes include careless saw which is rare and is similar to that of total hip 939
922 use, excess traction of the medial malleolus, arthroplasty or total knee arthroplasty [6, 47, 94]. 940
923 improper positioning, and size of the tibial Adequate patient selection is crucial for preven- 941
924 implant. Since medial malleolar fractures may be tion of infection. Thorough investigation for cur- 942
925 discovered subsequently in postoperative plain rent infection is necessary in patients with a prior 943
926 films, attentive intraoperative observation is history of ankle joint infection or osteomyelitis. 944
927 needed (Fig. 26.16). Assessment of vascular problems, skin disease, 945
and long-term corticosteroid or immunodepres- 946
sant use is needed, since such patients are at 947
928 26.6.3 Malalignment higher risk of postoperative infections after 948
TAA. Adequate hemostasis throughout the sur- 949
929 Malalignment is reported in 4–45% of all cases gery, handling the soft tissue with minimal dam- 950
930 [6, 47]. For prevention of malalignment, intraop- age can lower the risk of postoperative infections. 951
931 erative confirmation of the alignment of the cut- Protocols for treating infection after TAA are 952
932 ting guide in both coronal and sagittal planes are similar to those of TKA or THA. Cellulitis or 953
933 necessary. Malalignment that existed preopera- superficial infection may be easily controlled by 954
934 tively must be corrected gradually or immedi- irrigation, debridement, and antibiotic use if the 955
935 ately during TAA using surgical techniques such intra-articular infection is not present and the 956
936 as osteotomy or tendon transfer. wound is closed properly layer by layer. Acute 957
958 pyogenic infection requires irrigation, debride- is triggered by osteolytic reactions or bone cyst 983
959 ment, replacement of the polyethylene bearing, reactions caused by polyethylene wear parti- 984
960 and antibiotic use. Subacute or chronic infection cles. The primary cause of osteolysis is the 985
961 requires removal of the implant, antibiotic- malalignment of the implant and incongruent 986
962 eluting cement, antibiotic coverage, staged revi- articular surface between the implant and the 987
963 sion arthroplasty, or arthrodesis. polyethylene bearing, which leads to edge 988
loading. For radiological evaluation of the 989
implant positioning, Hintermann et al. [96] 990
964 26.6.5 Subsidence and Migration have suggested the following classification: the 991
α angle is the angle between the axis of the 992
965 Subsidence is generally a result of deficient bone tibia and the tibial implant on AP film, the β 993
966 ingrowth or inadequate component support dur- angle is the angle between the axis of the tibia 994
967 ing weight-bearing activities. Strenuous exercise and the tibial implant on the lateral film, and 995
968 or being overweight may bear stress on the the γ angle is the angle for the talar bone on the 996
969 implant and may trigger subsidence. Severe lateral film. 997
970 destruction of the talus body or patients with Hintermann et al. [96] defined loosening of 998
971 rheumatoid arthritis has higher incidence rates the tibial implant as a difference in the α or β 999
972 [95]. Progressive subsidence is also associated angle of over 2 °, or a radiolucent line of over 1000
973 with small-sized tibial implants, or >10 ° of pre- 2 mm, and the loosening of the talar implant was 1001
974 operative deformity [6, 47]. However, since sta- defined as the difference in the γ angle of over 5 ° 1002
975 bilization of the uncemented implant requires or a difference in the length of c or d of over 1003
976 6 months of time for stabilization, moderate 5 mm (Fig. 26.17). However, plain films can 1004
977 implant subsidence and migration can occur dur- falsely minimize the degree and extent of osteol- 1005
978 ing the early postoperative phases. ysis, true AP and lateral films are hard to obtain at 1006
each follow-up, and measuring the distance using 1007
Picture Archiving Communication System is 1008
979 26.6.6 Aseptic Loosening inaccurate. Thus, the Hintermann’s method pos- 1009
980 and Osteolysis sesses several limitations. Hanna et al. [97] 1010
insisted that CT scans can aid early detection of 1011
981 While migration of implant is associated with osteolysis, and can measure the extent of osteoly- 1012
982 early failure of implant stabilization, osteolysis sis in a more precise matter. 1013
a b c d
Fig. 26.17 The reference lines and angles on the AP view (a), and lateral view (b). Follow-up AP and lateral view
shows the osteolysis around the tibial and talar components (c, d)
a b
Fig. 26.18 Lateral view shows heterotrophic ossification which occurred after TAA. Postoperative ankle lateral view
((a), (b), different cases)
1014 26.6.7 Impingement and release of the deltoid ligament, with additional 1035
1015 Heterotrophic Ossification modified Brostrom techniques, the modified 1036
Evans technique, autologous or allogenic liga- 1037
1016 Impingement and heterotrophic ossification after ment transfer using the peroneus brevis or ham- 1038
1017 TAA is very frequently observed, and some studies strings, depending on the degree of instability. 1039
1018 have reported an incidence rate of collision of Cases with valgus deformity may require recon- 1040
1019 approximately 63% [87, 98]. Exposure of the can- struction of the deltoid ligament. However, the 1041
1020 cellous bone at the resection margin may cause het- surgical technique is difficult, and results have 1042
1021 erotrophic ossification (Fig. 26.18). In order to not been verified to date. 1043
1022 prevent such events, bone wax may be spread to the
1023 resection margin, or high-pressure washing may be
1024 performed. Selection of an adequately sized implant 26.6.9 Adjacent Joint Arthritis 1044
1025 and excision of osteophytes may reduce the inci-
1026 dence of impingement after TAA. If impingement is Pain may occur in nearby joints after TAA. If 1045
1027 present, the use of smaller-sized talar implants is osteoarthritis of the hindfoot is thought to be the 1046
1028 recommend. Heterotrophic ossification after TAA cause of pain, preoperative CT scans or injection 1047
1029 is reported to occur in 7–64% of cases, and Bai et al. of local anesthetics, concurrent or staged 1048
1030 [99] have reported that heterotrophic ossification arthrodesis after TAA must be considered. 1049
1031 may be related to pain and contraction [93, 100]. Though the incidence rate of hindfoot arthritis in 1050
TAA is lower than in AA, it cannot be com- 1051
pletely prevented. In a 9-year follow-up study in 1052
1032 26.6.8 Instability patients who underwent TAA using Agility 1053
implants, talonavicular arthritis occurred in 15% 1054
1033 Ligament balancing during TAA must be per- of cases, and subtalar arthritis occurred in 19% 1055
1034 formed. Varus deformity after TAA requires of cases [101]. 1056
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1424 lar joints for correction of symptomatic hindfoot periprosthetic lucency after total ankle arthroplasty: 1450
1425 malalignment. Foot Ankle Int. 2006;27(9):661–6. helical CT versus conventional radiography. Foot 1451
1426 91. Astion DJ, Deland JT, Otis JC, Kenneally S. Motion Ankle Int. 2007;28(8):921–6. 1452
1427 of the hindfoot after simulated arthrodesis. J Bone 98. Spirt AA, Assal M, Hansen ST Jr. Complications 1453
1428 Joint Surg Am. 1997;79(2):241–6. and failure after total ankle arthroplasty. J Bone Joint 1454
1429 92. Knupp M, Schuh R, Stufkens S, Bolliger L, Surg Am. 2004;86(6):1172–8. 1455
1430 Hintermann B. Subtalar and talonavicular arthrod- 99. Bai L-B, Lee K-B, Song EK, Yoon TR, Seon 1456
1431 esis through a single medial approach for the correc- JK. Total ankle arthroplasty outcome comparison 1457
1432 tion of severe planovalgus deformity. Bone Joint J. for post-traumatic and primary osteoarthritis. Foot 1458
1433 2009;91(5):612–5. Ankle Int. 2010;31(12):1048–56. 1459
1434 93. Wood P, Deakin S. Total ankle replacement: 100. Kim B, Choi W, Kim Y, Lee J. Total ankle replace- 1460
1435 the results in 200 ankles. J Bone Joint Surg. ment in moderate to severe varus deformity of the 1461
1436 2003;85(3):334–41. ankle. Bone Joint J. 2009;91(9):1183–90. 1462
1437 94. Anderson T, Montgomery F, Carlsson Å. 101. Knecht SI, Estin M, Callaghan JJ, Zimmerman MB, 1463
1438 Uncemented STAR total ankle prostheses: three to Alliman KJ, Alvine FG, et al. The Agility total ankle 1464
1439 eight-year follow-up of fifty-one consecutive ankles. arthroplasty: seven to sixteen-year follow-up. J Bone 1465
1440 J Bone Joint Surg Am. 2003;85(7):1321–9. Joint Surg Am. 2004;86(6):1161–71. 1466
1441 95. Hopgood P, Kumar R, Wood PL. Ankle arthrod-
1442 esis for failed total ankle replacement. J Bone
Part IV 1
Tendons and Biology 2

1 Biologics in the Foot and Ankle
27
2 Kimberly Allen, Enrique Feria-Arias,
3 Christopher Kreulen, and Eric Giza
4 27.1 Epidemiology 27.2 Tendon Biology 27
5 Tendon injuries are common in sports and can Tendon is connective tissue that connects muscle to 28
6 be difficult to treat. Tendon injuries account for bone. A tendon produces motion by transferring 29
7 30% of the $30 billion spent every year on mus- muscle contraction to the skeletal structure [9]. 30
8 culoskeletal injuries in the USA alone [1, 2]. Tendons insert into bone via four transitional tis- 31
9 While observing U.S. Division I collegiate ath- sues of increasing modulus: (1) tendon, (2) uncalci- 32
10 letes participating in 37 sports, Raikin, Garras, fied fibrocartilage, (3) calcified fibrocartilage, and 33
11 and Krapchev found that foot and ankle injuries (4) bone [2]. A tendon has a highly organized hier- 34
12 accounted for 27% of all musculoskeletal inju- archical structure. Fibrils are the small unit, and 35
13 ries [3]. Basketball, in particular, has a relatively they are formed by triple helical collagen mole- 36
14 high incidence of tendon injuries compared to cules [10]. Bundles of fibrils form fibers and are 37
15 other sports [4]. Lievers et al. examined the rate then organized together with tenocytes to form fas- 38
16 of foot and ankle injuries in collegiate American cicles [2]. Fascicles are bundled together with 39
17 football and found that the rate of foot and ankle endotenon in between and epitenon surrounding 40
18 injuries was 15 per 10,000 athletic sessions [5]. the bundles [11]. Endotenon and epitenon are cel- 41
19 In tendon healing, primary healing is prolonged lular, loose connective tissues, but the endotenon 42
20 and recurrence rates as high as 30% have been also contains fibroblasts, which produce mostly 43
21 reported [6–8]. Given the high cost of foot and type I collagen and are also responsible for the 44
22 ankle injuries, it is important to understand the healing process [2]. Finally, surrounding the outer 45
23 current challenges facing the treatment of ten- layer of epitenon is the paratenon which, together 46
24 don injuries, as well as identify optimal treat- with the epitenon form the peritenon, is the most 47
25 ment strategies for rehabilitating athletes external sheath of the tendon [2, 10]. Tendons are 48
26 effectively. comprised of 90% collagen, with collagen type I 49
being the most abundant (Figs. 27.1 and 27.2) [10]. 50
27.3 Tendon Healing 51

K. Allen · E. Feria-Arias · C. Kreulen · E. Giza (*)
Department of Orthopaedics, Foot and Ankle Surgery,
University of California-Davis, Davis Medical
There are three main phases of tendon healing: (1) 52
Center, Sacramento, CA, USA inflammation, (2) proliferation, and (3) remodel- 53
e-mail: egiza@ucdavis.edu ing [9]. These phases are distinct but can overlap 54
© ISAKOS 2019 305

https://doi.org/10.1007/978-3-662-58704-1_27
306 K. Allen et al.
Tendon
Tendon and
enthesis
Muscle
Tendon
Tenocytes
Non
calcified
Calcified
fibrocartilage
Bone
Collagen
fiber
Fig. 27.1 Basic tendon morphology (Drez and Delee Orthopaedic Sports Medicine Chapter 1 Basic Science and
Injury of Muscle, Tendon, and Ligament)
Fig. 27.2 Tendon insertion Tendon Unit Fascicle Collagen Fiber Collagen Fibril Collagen Molecule
histology Epitendinium
Crimp
Endotenon
Nerve
and 280 nm
Blood
Vessels
Fibroblast 64 nm
α1 α2
500 µm 20–200 µm 1–20 µm 100nm 1nm
with timing depending on the injury [9]. During sic cells of the innate immune system (e.g.,
the initial phase of inflammation, cytokines are neutrophils, monocytes, and macrophages) [6].
released from the damaged site that attract extrin- These cells invade the injured tissue to clean up
27 Biologics in the Foot and Ankle 307
liferate tendon cells and ECM [9]. Extrinsic healing 81

involves fibroblasts and inflammatory cells from 82
Collection of whole peripheral tissue that infiltrate the injury site to stim- 83
blood samples in
anticoagulated tubes ulate repair and remodeling [13, 14]. The intrinsic 84
healing, by contrast, pulls cells from the endotenon 85
First spin
and epitenon of the tendon itself [13]. Collagen 86
fibers then start to organize along the longitudinal 87
axis of the tendon, which restores tendon stiffness 88
and tensile strength [9, 14]. After approximately 89
10 weeks, the maturation stage starts, which includes 90
Transfer of the
buffy coat
an increase in collagen fibril crosslinking and the 91
(upper layer) to production of more mature tendinous tissue [9]. 92
empty tubes Research has focused on the different stages 93
and mechanisms of tendon healing to determine 94
the process for optimal regeneration and to aug- 95
ment biomechanical performance after injury. 96
Second spin
Mixing the
platelets Ready to use PRP Growth factors, stem cells, and the potential 97
into lower
1/3rd of
sources of both, such as platelet-rich plasma, are 98
plasma discussed in this review, as well as the delivery 99
Platelet technologies, scaffolds, and tissue engineering 100
pellets strategies comprised of multiple biologics. 101
Fig. 27.3 Platelet-rich plasma preparation

27.4 Platelet-Rich Plasma 102
55 the damaged area by engulfing cellular debris via
56 phagocytosis [6]. Fibroblasts are also recruited to Platelet-rich plasma (PRP) is an approved biologic 103
57 the injury site and begin to synthesize collagen currently in use for tissue regeneration in bones, 104
58 type III and other components of the extracellular cartilages, ligaments, and tendons [9]. PRP injec- 105
59 matrix (ECM) [9]. This fibroblast recruitment and tions deliver a concentrated amount of activated 106
60 production of collagen and ECM components is a platelets capable of releasing growth factors to the 107
61 key step in tendon healing [6, 11]. damaged tendon site [7]. PRP made the sports 108
62 The proliferation stage then begins and can news headlines in June of 2018 when it was 109
63 last several weeks [12]. It is characterized by released that NBA’s first-round draft pick Lonzo 110
64 continued type III collagen deposition by Ball of the Los Angeles Lakers underwent PRP 111
65 recruited fibroblasts, along with other ECM com- therapy for a left knee contusion that sidelined him 112
66 ponents, to form multicellular layers of epitenon for the final eight games of the 2017–2018 regular 113
67 cells to replace injured or torn tendon [10]. The season [15]. However, many studies on the effi- 114
68 fibroblasts also produce and secrete growth fac- cacy of PRP therapy for various tendon injuries 115
69 tors, such as TGFB, BFGF, IGF-1, and VEGF, have returned mixed results [7, 16]. Activated PRP 116
70 that stimulate angiogenesis in the repair site [10]. releases growth factors almost immediately after 117
71 The lineage of these fibroblasts and the various being added to the tendon site and have a short 118
72 growth factors that work with them are key areas half-life of only minutes to hours making the tim- 119
73 of research to understand tendon repair [6]. ing of injection critical [7]. It has been found that 120
74 The third stage is the remodeling stage, which changing the balance of native biologics by using 121
75 begins about 6–8 weeks after injury [12]. During PRP too early in the tendon healing process may 122
76 the remodeling phase, type III collagen is replaced have a detrimental effect [7]. In contrast, adding 123
77 by type I collagen and there is a decrease in cellular- platelet-derived growth factors on day 7 post-sur- 124
78 ity and matrix production [13]. It is thought that gery in animals models show improved results in 125
79 there are two different mechanisms, extrinsic heal- cellular maturation and tensile strength compared 126
80 ing and intrinsic healing, that work together to pro- to application during surgery (Fig. 27.3) [17]. 127
308 K. Allen et al.
128 Meta-review of PRP experiments and clinical 27.5.1 PDGF 171

129 trials suggest it can effectively increase the rate
130 of healing, but may not improve the end outcome PDGF (Platelet-derived Growth Factor) strongly 172
131 results [8, 18]. Seijas at el. found that the use of influences healing immediately after injury by 173
132 PRP accelerated remodeling of tendon grafts stimulating the synthesis of other growth factors, 174
133 used in anterior cruciate ligament repairs by 48% such as IGF-1 and TGF-B, and promoting gen- 175
134 compared to the control group but did not eral angiogenic, chemotactic, and mitogenic 176
135 improve the overall outcome after 1 year [18]. activity in the tissue [2]. PDGF persists for over 177
136 Another prospective controlled study found that 6 months at the site of injury and plays an 178
137 the use of a PRP matrix that delivered a slow important role in the remodeling stage through 179
138 release of growth factors to posterosuperior rota- the synthesis of proteoglycans, collagen, non- 180
139 tor cuff tears decreased the re-tear rate to 14% collagenous protein, and DNA [21, 22]. 181
140 compared to 50% in the control group at Recombinant human PDGF promotes tendon 182
141 13 months postop [19]. While the re-tear rate was repair in animal models [2]. Hildebrand et al. 183
142 improved, overall long-term function remained found that PDGF-BB (the highest affinity ligand) 184
143 unchanged [19]. significantly increased the quality of healing 185
when injected into the injury site of the MCL of 186
rabbits on the basis of mechanical testing [23]. 187
144 27.5 Growth Factors Tokunaga et al. found the use of a PDGF-BB 188
impregnated hydrogel sheet in a rat rotator cuff 189
145 Growth factors are small peptide signaling mol- injury model improved collagen fiber orienta- 190
146 ecules controlling many aspects of tendon repair, tion, ultimate failure loads, stiffness, and stress 191
147 including local recruitment of inflammatory and to failure at 12 weeks relative to controls [24]. 192
148 stem cells to the site of injury, cell proliferation Clinical trials have been conducted on the effi- 193
149 and differentiation, and ECM synthesis [20]. cacy of PDGF therapy and shown to improve the 194
150 Growth factors bind to cell surface receptors ini- healing of periodontal osseous defects post-sur- 195
151 tiating intracellular signaling cascades that result gery [25]. 196
152 in DNA transcription or regulation [12]. Tendon
153 injury stimulates the production of a variety of
154 growth factors including bFGF, BMPs, CTGF 27.5.2 TGF-β 197
155 (connective tissue growth factor), IGF-1, PDGF,
156 TGFβ1 -β2 -β3, and VEGF [9]. Growth factors Transforming growth factor beta (TGF-β1, β2, 198
157 are upregulated following injury and active dur- β3) is active in almost all stages of tendon healing 199
158 ing multiple stages of the healing process [20]. [20]. Other members of the TGF superfamily, 200
159 The effect of growth factors on tendon healing including bone morphogenetic proteins (BMPs) 201
160 has been extensively studied in vitro using teno- and growth differentiation factors (GDFs), have 202
161 cyte and stem cell cultures, and in vivo with ten- been studied extensively for their role in tendon 203
162 don injury animal models. Results are promising, healing [6, 9]. TGF-β1 is one of the main growth 204
163 but no human clinical studies investigating factors involved in tendon development and is 205
164 recombinant growth factors in tendon healing responsible for lineage specific differentiation in 206
165 have occurred [9]. A deeper understanding of the most mesenchymal-derived cell-lines, including 207
166 synergies and antagonisms among growth factors tenocytes [6, 12]. TGF-β1 is profuse in healing 208
167 and with other molecules, along with improved and scar formation and has been shown to 209
168 techniques for the temporal and spatial delivery improve tendon healing in animal models [26]. 210
169 of growth factor therapy are necessary for clini- However, the positive effects of TGF-β1 are 211
170 cal application [20]. dose-dependent and supra-physiologic levels of 212
213 TGF-β1 in tendons are associated with adhe- trations of IGF-1 may act in a negative feedback 257
214 sions, as well as fibrous and chondroid tissue loop to switch off early gene expression 258
215 deposition [6, 20]. involved in inflammation [20]. 259
216 Consistent with these activities, attenuation of
217 TGF-β1 signaling by either antibodies or anti-
218 sense oligonucleotides reduces scarring and 27.5.4 bFGF 260
219 adhesion formation in animal models during
220 healing [27–29]. This is also supported by studies Basic fibroblast growth factor (bFGF) is one of 261
221 of TGF-β1 in the healing of fetal tendon tissue the main growth factors involved in tendon devel- 262
222 [6]. In the bovine model of scarless tendon heal- opment and upregulated in mature tenocytes, 263
223 ing it has been shown that TGF-β1 expression fibroblasts, and inflammatory cells in the early 264
224 and inflammatory cell infiltration are signifi- stages of healing [9]. Fukui et al. treated MCL 265
225 cantly higher in adult healing tendons than in injuries in rabbits with varying does of recombi- 266
226 fetal tendons, while the fetal isoforms (TGF-β2 nant bFGF carried by a fibrin gel, and recorded 267
227 and -β3) contribute to regenerative healing with- early formation of repair tissue relative to con- 268
228 out scar tissue formation [6]. Balancing the trols [52]. Kobayashi et al. found similar results 269
229 expression of the different TGF-β isoforms, by investigating bFGF-enhanced repair in canine 270
230 inhibiting TGF-β1 and exogenous administration ACL injuries [31]. Defects were introduced into 271
231 of β2 and β3, holds promise as a strategy to pro- the anteromedial bundle, a region with low heal- 272
232 mote regenerative tendon healing with less scar ing potential, and treated with bFGF-impregnated 273
233 tissue formation [6, 12, 20]. pellets. The early stages of healing were posi- 274
tively influenced by bFGF, with improved neo- 275
vascularization, histology, and orientation of 276
234 27.5.3 IGF-1 collagen fibers relative to controls [31]. More 277
research is necessary to characterize the thera- 278
235 Insulin-like growth factor-1 (IGF-1) is promi- peutic value of bFGF treatment in modulating 279
236 nent in the early stages of tendon healing [9]. tendon healing [6]. 280
237 The primary effects of IGF-1 on tendon healing
238 are mitogenesis, the stimulation of fibroblasts
239 and tenocyte proliferation at the site of injury 27.5.5 VEGF 281
240 during inflammation, and collagen and ECM
241 production during remodeling [20]. In rabbit Vascular endothelial growth factor (VEGF) pro- 282
242 flexor tendons, IGF-1 stimulated tenocyte promotes angiogenesis and is active in all stages of 283
243 liferation with associated increases in collagen tendon healing [9]. VEGF is expressed in tendon 284
244 and proteoglycan synthesis [6]. In an equine sheet fibroblasts and VEGF mRNA peaks 10 days 285
245 superficial digital flexor tendinitis model, intra- after surgery [6, 9]. Zhang et al. used VEGF 286
246 lesional injections of IGF-I increased cell pro- injections in a murine model of Achilles tendi- 287
247 liferation and collagen synthesis, reduced nopathy and found significant increases in the 288
248 overall lesion size, and increased mechanical tensile strength of healing tendons compared to 289
249 strength compared to control tendons [30]. control tendons [32]. Local injections of VEGF 290
250 There are no reports of IGF-1 application in into the healing site of patellar tendons in rats 291
251 human flexor tendon conditions, but clinical increased load to failure [9]. VEGF increases 292
252 application of recombinant IGF-1 in flexor ten- TGF-β1 expression; whether benefit is derived 293
253 don disruption in racehorses has improved the from VEGF directly or from its secondary signal- 294
254 rate of return to sustained athletic activity [12]. ing activity is still undefined [6, 9]. 295
255 As one of the main components in the inflam- The synergistic effect of growth factors in ten- 296
256 matory cascade, it is thought that high concen- don healing has created interest in combination 297
310 K. Allen et al.
298 therapies. However, the results of experiments scaffolds are made of decellularized tendon scaf- 342
299 involving more than one growth factor have been folds (DTS) containing native tendon ECM [36]. 343
300 mixed [9, 20]. This highlights the need for more These biologic ECM scaffolds have been found 344
301 research on the expression patterns, concentra- to show improved tendon repair. Healing closely 345
302 tions, and kinetics necessary for optimal growth resembles original tenocyte activity regarding 346
303 factor application [33]. Due to their limited half- collagen arrangement, growth factors, biocom- 347
304 life in vivo, the direct local delivery of growth fac- patibility, and biomechanical characteristics [36]. 348
305 tors has limited use, and more advanced strategies One advantage of DTSs is their biodegradability 349
306 for sustained, safe, and reproducible delivery are in vivo, which combined with the production of 350
307 necessary [2]. Much research has been done on new ECM by the host cells, can aid in tissue 351
308 the development of smart scaffolds, microcap- remodeling and complete repair [36]. 352
309 sules, coated sutures, porous sutures, fibrin-hepa- Synthetic scaffolds offer stronger mechanical 353
310 rin delivery systems, etc. that will provide properties and more controlled growth factor 354
311 controlled release of factors at suitable doses for delivery options compared to biologic scaffolds 355
312 an appropriate measure of time [2, 9]. Stem cells [34]. Wang at el. found synthetic scaffolds seeded 356
313 transduced with growth factors and direct modu- with growth factors such as autologous or alloge- 357
314 lation by way of gene therapy are other promising neic fibroblasts, in rabbit Achilles tendons, 358
315 technologies being explored [2, 6]. While no con- improved overall strength, load bearing, and 359
316 sensus exists on the best methods for in vivo Young’s modulus ratings [37]. Autologous- 360
317 growth-factor therapy, further research will eluci- seeded scaffolds tested the closest to normal 361
318 date measures for controlled spatiotemporal uninjured Achilles tendons in mechanical analy- 362
319 release of the factors, improve long-term stability sis relative to cell-free or allogeneic-seeded scaf- 363
320 and expression patterns and ultimately optimize folds at 7 and 13 months postop [37]. Cell-seeded 364
321 the healing outcome for tendon injuries [34]. scaffolds also help increase ECM production by 365
directing the orientation of new cell growth along 366
the direction of the fiber [34]. 367
322 27.6 Scaffolds for Delivery Further advancements such as “smart” artifi- 368
323 Method cial scaffolds and tissue engineering can custom 369
deliver various growth factors and/or stem cells 370
324 Scaffolds are one technique for achieving tighter at a dynamic rate that responds to the surround- 371
325 control over the delivery rate of growth factors as ing environment [33, 34]. Scaffolds seeded with 372
326 well as providing mechanical augmentation and stem cells could deliver growth factors optimally 373
327 structural support [35]. Scaffolds serve as to stimulate cell differentiation and maturation 374
328 space-filling substrate for new tissue to grow and [35, 38]. The combination of mesenchymal stem 375
329 can be seeded with stem cells or exogenous cells (MSCs), specifically bone marrow derived 376
330 growth factors [33]. Scaffolds made from devital- mesenchymal stem cell (BMSC), used in con- 377
331 ized tissues retain numerous endogenous mor- junction with scaffolds has been largely studied 378
332 phogens and have been available on the evaluating potential improvement to the biome- 379
333 commercial market for years [33, 35]. chanics of tendons post-injury [35]. Tissue engi- 380
334 Demineralized bone matrixes (DBM), first intro- neering seeks to create biological tissue 381
335 duced almost 50 years ago, are an early example replacements using autologous cells that will 382
336 of scaffolding technology [33]. avoid rejection [39]. Tissue engineering could 383
337 Scaffolds can be natural, synthetic, or a com- offer an appealing delivery strategy; however, 384
338 bination, each offering advantages and disadvan- researchers have yet to pinpoint which specific 385
339 tages [34]. Tissue remodeling does not typically biologics, in what exact amounts, and at what 386
340 occur extensively during natural tendon healing precise point along the healing timeline provides 387
341 and could offer improved outcomes [36]. Natural the optimal outcome [33]. 388
Self-Renewal
MSC
Progenitor cells
Other ?
Differentiation
Pre-hypertrophic Myocyte
Osteoblast Chondrocyte
Maturation
Hypertrophic
Osteocytes Chondrocyte Stromal Cell Myotube Adipocyte
Fig. 27.4 Mesenchymal stem cell differentiation (Human Bone Marrow Mesenchymal Stem Cells: A Systematic
Reappraisal Via the Genostem Experience)
389 27.7 Mesenchymal Stem Cells are time and duration dependent. Working with a 411
rat tissue model, Kraus et al. found MSCs 412
390 Mesenchymal stem cells (MSCs) are multipotent improved tendon repair in regard to load bearing 413
391 cells that have the potential to become fibroblasts, and stiffness when used during the first 14 days 414
392 tenocytes, chondrocytes, osteoblasts, myocytes, of early healing stages relative to the later 415
393 and adipocytes as well as generate multiple 14–28 day period [42]. Later-stage MSC therapy 416
394 growth factors [35]. MSCs also have paracrine may have contributed to detrimental results com- 417
395 functions favorable to angiogenesis and improved pared to the control (Fig. 27.4) [42]. 418
396 healing [40, 41]. In early research, MSCs were Multipotent MSCs can be chemically and 419
397 thought to be beneficial because of their multipo- physically directed to selectively differentiate into 420
398 tent ability; however, more recently it has been tenocytes [43, 44]. Hoffman et al. found that by 421
399 found that the paracrine functions that stimulate transfecting Smad8, a signaling-mediating agent 422
400 and support the regenerative state of the healing of bone morphogenetic protein (BMP), MSCs dif- 423
401 tissue is the dominant beneficial characteristic of ferentiated favorably into tenocytes while inhibit- 424
402 MSCs for tendon healing [40]. Research suggests ing the osteogenesis pathway [44]. Scleraxis 425
403 that the healing potential of MSCs could be dose- (Scx) is a transcription factor in the basic helix- 426
404 dependent [40]. Chamberlain at el. used rat loop-helix family (bHLH) that controls embry- 427
405 medial collateral ligaments and found that with onic tendon formation [43, 45]. Studies show that 428
406 low dosage (1 × 106), compared to a higher dos- MSCs expressing the transcription factor scler- 429
407 age (4 × 106), MSCs exhibited less of an inflam- axis causes MSCs to preferentially differentiate 430
408 matory response driven by M1 macrophages and into tenocytes over other lineages [43, 45]. The 431
409 their inflammatory-inducing cytokines [40]. addition of Scx to MSCs increases the expression 432
410 Other research suggest that the healing benefits of target genes by binding to specific promoters 433
312 K. Allen et al.
434 during transcription that directs MSCs to tenocyte use of ASCs for tendon repair treatment could 479
435 differentiation [43, 45]. This guided increase of provide a less expensive and time-consuming 480
436 tenocyte expression improved cellular organiza- option providing similar, if not improved results 481
437 tion and maturation of the injured tendon com- compared to MSCs [48]. 482
438 pared to the use of MSCs alone [43, 45]. Studies have been done to separate ASCs into 483
439 The use of viral vectors to deliver engineered various subpopulations with differing differenti- 484
440 growth factors into stem cells has also showed ation potential with some populations favoring 485
441 favorable results. Gene-altered growth factors that tenocyte generation [49]. Gonçalves et al. 486
442 have been transfected into stem cells using viral showed that by identifying and only using the 487
443 vectors, notably adenovirus and adeno-associated ASC populations that expresses tenomodulin 488
444 virus (AAV), showed improved tendon repair (TNMD), a marker for tendons and ligaments, an 489
445 compared to naïve stem cells [12]. Specifically, increase of upregulation for tenocyte generation 490
446 MSCs that were transfected with VEGF using as well as collagen I and collagen III can be 491
447 AAV showed an increase of the beneficial ana- achieved compared to general, unsorted ASCs 492
448 bolic growth factor TGF-β [12]. Another study [49]. Researchers used the TNMD+ ACSs with 493
449 evaluating equine tendonitis showed that MSCs growth factor supplementation to achieve 494
450 transfected with IGF-1 using adenovirus exhib- increased tenocyte generation [49]. However, 495
451 ited improved tenocyte morphology and biome- even without any growth factors, TNMD+ cells 496
452 chanical parameters compared to naïve MSCs still expressed tendon markers in high amount 497
453 [12]. These gene-enhanced stem cells with trans- [49]. This novel research identifying and imple- 498
454 fected growth factors can be injected directly in menting tenocyte-driven subpopulations of 499
455 the repair site or be built into scaffolds [12]. In rat ASCs opens new areas of study for improved 500
456 rotator cuff models, fibroblasts that were trans- tendon tissue engineering. 501
457 duced with PDGF-β and IGF-1 and integrated
458 into synthetic scaffolds showed improved teno-
459 cyte proliferation, cellular repair, and collagen 27.9 Directed Tenocyte 502
460 formation [12, 46]. These selective tenocyte dif- Differentiation 503
461 ferentiation methods using genetically modified
462 MSCs show a promising direction for further There has been continued research to further 504
463 study towards optimal tendon repair [44, 47]. identify new ways of only generating new teno- 505
cytes from other stem cells. One of the more 506
recent studies successfully demonstrated teno- 507
464 27.8 Adipose-Derived Stem Cells genic induction using human embryonic stem 508
cells (hESC) [50]. Researchers delivered BMP12, 509
465 While MSCs, specifically BMSCs (bone-marrow BMP13, and ascorbic acid to hESCs for 40 days 510
466 stem cells), were the choice in early studies for and achieved new tenocyte growth similar to 511
467 stem cell tendon therapy, adipose-derived stem native tenocytes in morphology [50]. 512
468 cells (ASCs) have recently been shown as effec- Neural crest stem cells (NCSCs) derived from 513
469 tive and even faster in proliferation and tenocyte induced pluripotent stem cells (iPSCs) are multipo- 514
470 differentiation compared to MSCs [39, 48]. tent and also have the ability of forming tenocytes 515
471 Cultivating MSCs ex vivo prior to implantation is among other mesenchymal lineages [51]. One study 516
472 labor and time consuming [39]. ASCs, in con- found that iPSC-derived NCSCs improved tendon 517
473 trast, have potential for tendon regeneration repair at 4 weeks and generated fetal tendon-related 518
474 in vivo with low donor site morbidity [39, 48]. matrix proteins, tenogenic differentiation factors 519
475 Using ASCs for cellular therapy allows for the and increased the rate of endogenous repair [51]. 520
476 potential of a one-step procedure where ASCs These selective tenocyte differentiation methods 521
477 could be harvested and delivered back to the ten- could pave the way for novel tendon engineering 522
478 don repair site during the same surgery [48]. The with improved results [50]. 523
524 27.10 Summary recovery after arthroscopic supraspinatus repair? 572

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527 and newer tendon therapies utilized several of the tendon healing with platelet-rich plasma: a prospec- 577
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528 aforementioned innovations in combination. 2012;40(6):1282–8. 579
529 Engineered growth factors, stem cells and various 9. Docheva D, Müller SA, Majewski M, Evans 580
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532 In addition to these techniques, more research is direct.com/science/article/pii/S0169409X14002786 584
533 being done to examine selective tenocyte differen- 10. Halper J. Progress in Heritable Soft Connective
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534 tiation from multipotent and pluripotent stem cells, Tissue Diseases [Internet]. Vol. 802. 2014. http://link. 586
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537 clinical research has been found to regenerate 2005;87(1):187–202. 590
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539 dons. However, these advancements along with based approaches to tendon regeneration. J Shoulder 592
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http://www.eurekaselect.com/openurl/content.
1 Peroneal Tendon Injuries
28
2 P. A. D. van Dijk, G. M. M. J. Kerkhoffs,
3 and C. N. van Dijk
4 28.1 Introduction edge of the peroneal tendons’ anatomy and clini- 16

cal presentation of the associated pathologies is 17
5 Improved knowledge based on recent literature essential to optimize management of peroneal 18
6 confirmed that peroneal tendon injuries are a tendon injuries. This chapter provides an over- 19
7 serious cause of posterolateral ankle symptoms view of the anatomy of the peroneal tendons and 20
8 following acute or chronic lateral ankle sprains the clinical presentation, diagnostics, and man- 21
9 [1, 2]. These injuries, however, are often misdiag- agement of associated injuries. Moreover, it pro- 22
10 nosed as lateral ankle ligament pathology, result- vides a step-by-step description of the peroneal 23
11 ing in suboptimal management, which may lead tendoscopy procedure. 24
12 to long-term sequelae and more chronic pathol-
13 ogy requiring invasive treatment. Therefore,
14 accurate diagnosis and prompt treatment in an 28.2 Anatomy and Function 25
15 early stage is important [2, 3]. Adequate knowl- of the Peroneal Tendons 26
P. A. D. van Dijk There are two peroneal muscles: the peroneus bre- 27
Department of Surgery, OLVG, Amsterdam, vis (PB) and the peroneus longus (PL) muscle. 28
The Netherlands Together they form the lateral compartment of the 29
Academic Center for Evidence Based Sports lower leg, or “the peroneal compartment.” The 30
Medicine (ACES), Amsterdam, The Netherlands peroneal tendons act as the primary evertors and 31
Amsterdam Collaboration for Health and Safety in abductors of the foot. In this manner, they play an 32
Sports (ACHSS), Amsterdam, The Netherlands important role in providing the active lateral ankle 33
G. M. M. J. Kerkhoffs stability, in the foot’s eversion strength, and stabi- 34
Department of Orthopedic Surgery, Academic lization of the lateral column of the foot during 35
Medical Center, Amsterdam, The Netherlands stance. It remains unclear if one of the tendons has 36
Academic Center for Evidence Based Sports greater contractile strength than the other. While 37
Medicine (ACES), Amsterdam, The Netherlands early research found that the force generating 38
Amsterdam Collaboration for Health and Safety in capacity of the PL was twice as high as the PB, a 39
Sports (ACHSS), Amsterdam, The Netherlands more recent study suggested that the PB was the 40
C. N. van Dijk (*) more effective foot evertor [4]. 41
Department of Orthopedic Surgery, Academic The PL originates at the lateral condyle of the 42
Medical Center, Amsterdam, The Netherlands
tibia, the lateral aspect of proximal fibular head, 43
FIFA Medical Center of Excellence, Madrid, Spain the intramuscular septa, and the adjacent fascia. 44
e-mail: c.niekvandijk@anklecare.org
© ISAKOS 2019 317

https://doi.org/10.1007/978-3-662-58704-1_28
318 P. A. D. Dijk et al.
45 The PB originates more distally on the fibular [11, 12] (Fig. 28.2). Historically it has been 94
46 shaft and inter-osseous membrane. Where the PL assumed that the peroneal tendons have critical 95
47 muscle becomes tendinous 3–4 cm proximal to avascular zones around the distal fibular tip and 96
48 the distal fibular tip, the PB muscle usually runs the cuboid bone, playing a role in the develop- 97
49 up to 2 cm more distally [5]. In some cases, the ment of pathologies [13]. Recent research, how- 98
50 PB musculotendinous junction occurs beyond the ever, found no evidence to support these avascular 99
51 fibular tip, better known as a low-lying muscle zones [12]. 100
52 belly [6, 7]. There is no consensus in literature
53 whether this variation predisposes the tendons to
54 pathology [7]. PB
55 Around the fibular tip both tendons share a PL
56 common fibro-osseous tunnel in which the PB is
57 anteromedially located from the PL and flattened
58 against the fibula. This tunnel is formed by the
59 superior peroneal retinaculum (SPR), the deep
60 posterior compartment fascia, and the retromal-
61 leolar groove of the fibula which is buttressed by
62 a fibrocartilagenous ridge [8]. The SPR provides
63 stability of the tendons within the groove and is
64 therefore critical in preventing the tendons to
65 dislocate.
66 Distal to the fibular tip, the tendons are sepa- Fig. 28.1 After curling around the fibular tip, the tendons
67 rated by the calcaneal peroneal tubercle. Here, course posteroinferolaterally. The peroneus brevis (PB)
68 each tendon enters an individual fibrous tunnel, tendon inserts at the base of the fifth metatarsal, the pero-
neus longus (PL) tendon runs more distally and after turns
69 secured by the inferior peroneal retinaculum. A plantarly at the cuboid groove, it inserts at the plantar side
70 cadaveric study found the peroneal tubercle to be of the medial cuneiform and the first metatarsal base
71 considered prominent in 29% of specimens,
72 which may lead to pain and damage to the ten-
73 dons [7].
74 After curling around the fibular tip, the ten-
75 dons course posteroinferolaterally; the PB
76
77
inserts at the base of the fifth metatarsal while
the PL tendon runs more distally and after turn-
Vi PL
78 ing plantarly at the cuboid groove, it inserts at
79 the plantar side of the medial cuneiform and the
first metatarsal base (Fig. 28.1). At the level
80
81 where the PL curls around the cuboid bone, an os TSh
82 peroneum (OP) is found in up to 4–30% of spec-
83 imen [9, 10]. The OP protects the PL tendon
84
85
from damage at the location where it redirects
from the lateral to the medial aspect of the foot,
PB
86 but has also been associated with peroneal ten- Vi
87 don pathology [9, 10].
88 The superficial peroneal nerve innervates both
89 tendons and blood is supplied by the peroneal
90 artery and branches of the anterior tibial artery. Fig. 28.2 Axial view of the common vincula (Vi).
Vascular branches run through the vincula formed by the
91 Branches run through a common vincula formed distal fibers of the peroneus brevis (PB) muscle belly and
92 by the distal fibers of the PB muscle belly and penetrate the tendons over their entire length. *Ths
93 penetrates the tendons over their entire length Tendonsheath, PL Peroneus longus
28 Peroneal Tendon Injuries 319
101 28.3 Peroneal Tendon Injuries tion, and necrosis [15, 25]. Macroscopically, the 146
tendon’s surface changes to dull, predominantly 147
102 During inversion of the ankle, the peroneal ten- brown and/or gray, and irregular thickening. If 148
103 dons are exposed to high mechanical loads and left unaddressed, chronic tendinopathy can even- 149
104 remain under significant pressure within the tually lead to fibrosis, synovial proliferation, 150
105 retromalleolar groove [1, 14, 15]. Recurrent ankle hypertrophy and stenosis of the tendon within its 151
106 sprains amplify these loads, chronically squeezing tendon sheath [26]. 152
107 the PB in between the PL and the retromalleolar

108 groove [15]. In this way, the PB is predisposed to
109 hypertrophic tendinopathy, recurrent stenosis, 28.3.2 Tears and Ruptures 153
110 tearing, or rupturing of the tendon [1]. As dis-

111 cussed in the “Anatomy and Function of the The recent peroneal tendon consensus statement of 154
112 Peroneal Tendons” (Sect. 28.2), several anatomi- the ESSKA-AFAS defined tears as partial (either 155
113 cal variabilities may predispose the tendons to simple or complex) longitudinal tendon tears that 156
114 pathology. Other predisposing factors include do not result in complete discontinuity of the mus- 157
115 rheumatoid arthritis, psoriatic arthritis, diabetic cle tendon unit. Ruptures were defined as transverse 158
116 neuropathy, calcaneal fractures, fluoroquinolone discontinuity, resulting in complete dissociation of 159
117 use, and local steroid injections [16–22]. the muscle and tendon at that level [23]. 160
118 Pathology of the peroneal tendons may occur The prevalence of peroneal tendon tears in gen- 161
119 anywhere along the course of the tendons, but is eral population remains unclear, but cadaveric stud- 162
120 most often found within the areas where the tendons ies found tears in 11–38% of specimens [27, 28]. 163
121 are exposed to the greatest stress: around the lateral With the PB tendon being squeezed in between the 164
122 malleolus (PB), the peroneal tubercle (PB and PL), PL tendon and the bony fibular groove, it is most 165
123 or within the cuboid groove (PL). In general, pathol- prone to tear at that level [29, 30]. A cadaveric study 166
124 ogy linked to the peroneal tendons is categorized found a PB tendon tear in 87.5% of the specimen, 167
125 into three types: (1) tendinopathy (tendinitis, teno- while a PL tendon tear was found in only 12.5% 168
126 synovitis, tendinosis, and stenosis), (2) partial or [31]. Another study found concomitant tears in both 169
127 complete (“rupture”) peroneal tendon tears, and (3) tendons in 38% of patients treated operatively for 170
128 subluxation or dislocation [23]. Other pathologies peroneal tendon tears [3]. 171
129 causing posterolateral ankle symptoms include

130 chronic lateral ankle instability, posterior ankle
131 impingement, avulsion or calcification of the poste- 28.3.3 Subluxation and Dislocation 172
132 rior talofibular ligament (PFTL), bony spurs, rheu- of the Peroneal Tendons 173
133 matoid arthritis, and disorders of the posterior
134 compartment of the subtalar joint [24]. Peroneal tendon dislocation has been reported 174
in 0.3–0.5% of all traumatic ankle injuries and 175
is most prevalent in the athletic population 176
135 28.3.1 Tendinopathy: Tendinitis, performing sports that require short cutting 177
136 Tenosynovitis, Tendinosis, movement, such as soccer, gymnastics, and 178
137 and Stenosis skiing [32]. 179
Dislocation occurs when one or both tendons 180
138 Chronic peroneal tendinitis and tenosynovitis are displaced from the retromalleolar groove, 181
139 may lead to degeneration of each tendon’s colla- typically provoked by sudden eccentric contrac- 182
140 gen fibrils, also known as tendinosis. In recent tion of the peroneal muscles against acute plan- 183
141 literature, however, it is preferred to only use the tarflexion of the inverted foot or forced 184
142 term tendinopathy. Microscopically, tendinosis is dorsiflexion during eversion. The PL tendon is 185
143 characterized by increase of mucoid ground sub- more prone to dislocate than the PB tendon, due 186
144 stance, loss of collagen continuity, hyperplasia of its anatomical location in between the PB tendon 187
145 the tenocytes or fibroblasts, hypervasculariza- and the SPR. 188
189 Peroneal tendon dislocation is generally along the course of the peroneal tendons that 231
190 classified in four grades [23, 33, 34]. Grade worsens with activity. Other symptoms reported 232
191 one, found in over 50% of the cases, includes include swelling, tenderness, giving way and lat- 233
192 cases where the SPR is subperiosteally ele- eral ankle instability. Differentiation between 234
193 vated from the fibula. In grade two, around peroneal tendinopathy and tearing of the tendon 235
194 33%, the SPR is elevated together with the during physical examination is difficult; a tendon 236
195 fibrocartilagenous ridge. In grade three, tear may appear with less pain but more weak- 237
196 approximately 13%, the SPR is completely ness and swelling. In case of dislocation, the 238
197 ruptured off the fibula together with a cortical patient may report a popping or snapping 239
198 fragment [33]. Grade four, which is rarely sensation. 240
199 diagnosed, includes cases with a ruptured pos- Findings during physical examination include 241
200 terior part of the retinaculum [34]. More recent, a recognizable tenderness over the peroneal ten- 242
201 Raikin added an extra classification of intra- dons, crepitus, and swelling. Active dorsiflexion 243
202 sheath subluxation, with the SPR remaining and eversion often exacerbate pain, and muscle 244
203 intact while the peroneal tendon change from strength can be weaker when compared to the 245
204 their natural position within the retromalleolar contralateral side. In tears, pain may be exacer- 246
205 groove [35]. In type A, the PL lies deep in rela- bated on acute loosening of resistance during the 247
206 tion to the PB, and in type B, the PL subluxates provocation test [29, 36]. Possible dislocation of 248
207 through a tear within the PB [35]. the tendons sometimes can often be provoked 249
during physical examination by combined active 250
dorsiflexion and eversion [37]. 251
208 28.3.4 (Painful) Os Peroneum
209 Syndrome
28.5 Additional Diagnostics 252
210 The (painful) os peroneus syndrome (POPS) is a
211 relatively uncommon condition and forms an While thorough patient history and physical 253
212 umbrella term for different types of pathology examination is key to pinpoint the exact diagno- 254
213 associated with the OP [9]: (1) entrapment of the sis, in most cases additional diagnostics are 255
214 OP and PL tendon as a result of an hypertrophic required to rule out other pathologies and to cre- 256
215 peroneal tubercle, (2) (partial) PL tear, (3) rup- ate an optimal treatment strategy. 257
216 ture of the PL, (4) acute fracture of the OP or To rule out acute and chronic osseous patholo- 258
217 diastasis of a multipartite OP, and (5) chronic gies such as fractures, spurs, or calcifications, 259
218 fracture of the OP associated with PL stenosing weight-bearing radiographs in anteroposterior 260
219 tenosynovitis. and lateral direction are recommended. Moreover, 261
in case of type 3 peroneal tendon dislocation, a 262
small avulsion fracture of the lateral malleolus or 263
220 28.4 P
atient History and Clinical “fleck sign” may be visible on the anteroposterior 264
221 Examination view (Fig. 28.3) [38]. 265
For evaluation of the peroneal tendons and 266
222 In the opinion of the authors, careful patient his- surrounding structures, MRI remains the stan- 267
223 tory and clinical examination is the most impor- dard diagnostic test [29] with a reported sensitiv- 268
224 tant key to proper diagnosis of peroneal tendon ity and specificity of 84–90% and 72–75%, 269
225 injuries. Acute injuries are often reported as “an respectively [39, 40]. Normal peroneal tendons 270
226 ankle sprain that never resolved,” while chronic appear with homogenous signal intensity on T1- 271
227 disorders occur after a gross ankle inversion and T2-weighted images. Abnormalities include 272
228 trauma in the medical history or in patients with a C-shaped tendon, clefts, irregularity of the ten- 273
229 chronic lateral ankle ligament instability. Patients don contour, and increased signal intensity due to 274
230 typically present with lateral ankle pain or pain fluid within the tendon sheath (Fig. 28.4) [41, 275
the importance of evaluating the tendons in both 282

settings. 283
Ultrasound (US) has several advantages in 284
comparison to MRI; it is less expensive, can be 285
employed in the outpatient clinic, and has the 286
ability of dynamic evaluation of the tendons. The 287
last matter makes it easier to diagnose dynamic 288
injuries such as (episodic) subluxation, disloca- 289
tion, and tears that are not seen on MRI. It must 290
be taken into account, however, that the quality of 291
the US is strongly correlated with the quality of 292
the observer. Abnormalities visible on US include 293
tendon thickening, peritendinous fluid within the 294
tendon sheath, ruptures, and luxation of the 295
Fig. 28.3 In case of type 3 peroneal tendon dislocation, a tendon(s) over the fibular tip. 296
small avulsion fracture of the lateral malleolus or “fleck
sign” may be visible on the anteroposterior view Peroneal tendoscopy should be reserved for 297
patients with a high clinical suspicion of peroneal 298
pathology, but absence of positive findings or 299
inconclusive abnormalities on imaging [40, 43]. 300
It is highly sensitive and specific for both static 301
and dynamic injuries and provides an easy transi- 302
tion to (minimally invasive) treatment [40, 44]. 303
28.6 Treatment 304
While there is only limited evidence, conserva- 305

tive management is the first step in treatment of 306
peroneal tendon injuries, including a period of 307
rest, immobilization to reduce symptoms, or 308
activity modification [23]. Physical therapy is 309
recommended in order to strengthen the peroneal 310
and surrounding muscles. When symptoms per- 311
sist longer than 3 months, there exists mounting 312
evidence for the use of shockwave therapy [23]. 313
If conservative treatment fails, surgical treat- 314
ment should be considered. Especially in tears 315
and dislocation, surgery is required in most cases 316
Fig. 28.4 A C-shaped and irregular peroneus brevis ten-

since these pathologies rarely heal themselves [3, 317
don with increased signal intensity due to fluid within the 31, 45]. According to the recent peroneal tendon 318
tendon sheath; suggestive for a peroneal tendon tear consensus statement of the ESSKA-AFAS, the 319
first choice of operative treatment of peroneal 320
276 42]. An increased signal intensity, however, can tendon tears includes debridement and tubular- 321
277 also be seen in asymptomatic patients due to the ization of one or both tendons. Only in cases this 322
278 so-called magic angle effect [26]. While this is not feasible, single stage autograft with the 323
279 effect only appears on T1-weighted images, in hamstrings or side-to-side tenodesis is recom- 324
280 tears these signal abnormalities are found on both mended. If one of the tendons is deemed irrepa- 325
281 T1- and T2-weighted images. This underscores rable, it is recommended to perform debridement 326
327 and tubularization on the reparable tendon and an additional predisposing factors should also be 375
328 autograft or tenodesis procedure on the irrepara- assessed [54, 55]. Additional procedures such as 376
329 ble tendon. If neither of the tendons can be a lateralizing calcaneal osteotomy may be neces- 377
330 repaired and the proximal muscle tissue is sary in case of hindfoot varus [14]. 378
331 healthy, single stage autograft is recommended
332 [2, 3, 23].
333 When treating dislocation operatively, multi- 28.7 Peroneal Tendoscopy: 379
334 ple operative techniques have been described, all A Step-by-Step Description 380
335 with the primary purpose to restabilize the ten- of the Procedure 381
336 dons back into the retromalleolar groove by
337 restoring the anatomy of the superior peroneal A peroneal tendoscopic procedure can be per- 382
338 tunnel. The different techniques can generally be formed in the outpatient clinic under local, 383
339 divided into four groups: (1) repair or replace- regional, epidural, or general anesthesia. Optimal 384
340 ment of the SPR, (2) deepening of the retromal- portal access is achieved in lateral decubitus 385
341 leolar groove, (3) bone-block procedures, and (4) position with the foot supine, allowing access to 386
342 enhancement of the SPR by rerouting of other both the anterior and the posterior aspect of the 387
343 soft tissue structures. The latter two are associ- ankle when an open procedure is required. In 388
344 ated with relatively high complication rates, and case an arthroscopic procedure in conjunction 389
345 therefore over the last years attention is drawn to with tendoscopy is considered, the patient is best 390
346 the first two categories. Studies looking at repair placed in semi lateral position in order to facili- 391
347 of the SPR, with or without concomitant groove tate access to the anterior as well as to the lateral 392
348 deepening, show promising outcomes, high satis- ankle. 393
349 faction, and a 83–100% rate of return to sports Before anesthesia is administered, the patient 394
350 [35, 46]. Evidence showed that the combination is asked to actively evert the foot in order to 395
351 of SPR repair and retromalleolar groove deepen- locate the tendons and to draw their course on the 396
352 ing provides significant higher return to sports skin. Moreover, the portal locations and the 397
353 rates as compared to SPR repair alone (p = 0.022) course of the superficial peroneal nerve are 398
354 [47], and therefore the combination of (endo- marked. Next, a tourniquet is placed around the 399
355 scopic) groove deepening and retinaculum repair upper leg to optimize visualization and a support 400
356 is recommended in athletes [23]. is placed under the leg to promote free ankle 401
357 Over the last year, peroneal tendoscopy has motion during surgery. 402
358 become more appreciated as a treatment modal- In most cases, the use of two portals is suffi- 403
359 ity [11, 43, 48, 49]. Not only does it accommo- cient. First, the distal portal is created 2–3 cm 404
360 date an accurate diagnostic tool as noted in Sect. distal to the posterior tip of the lateral malleolus 405
361 28.5, it is also associated with functional (Fig. 28.5). An incision is made through the skin, 406
362 improvements in patients with peroneal tendon followed by penetration of the tendon sheath by a 407
363 injuries. The primary indication for peroneal mosquito clamp. A 2.7 mm 30° arthroscope is 408
364 tendoscopy is posterolateral pain due to tenosy- introduced and the tendon sheath is filled with 409
365 novitis, subluxation or dislocation, partial tears saline using a low pressure, low flow pump of 410
366 or postoperative adhesion [11]. Recent studies 50–70 mmHg. Some surgeons prefer a 4 mm 411
367 report a relatively low rate of complications with scope, which produces an increased flow under a 412
368 reduced costs and earlier recovery when com- lower pressure [44]. Passing the larger diameter 413
369 pared with traditional open procedures [40, scope through the retinaculum, however, can be 414
370 50–53]. challenging [48]. The second portal is made 415
371 Inadequate management of anatomical abnor- under direct vision of the scope by introducing a 416
372 malities may lead to persistent pain and dysfunc- spinal needle, approximately 2–3 cm proximal to 417
373 tion on the longer term. Therefore, during the posterior edge of the lateral malleolus 418
374 operative treatment of peroneal tendon injuries, (Fig. 28.5). 419
420 Inspection of the tendons starts around 6 cm ing area. A concavity in the retromalleolar 446
421 proximal to the posterior edge of the lateral groove can be created using a 3.5 mm burr. To 447
422 malleolus. At this level, a thin membrane splits prevent the tendons from damage, the surface 448
423 the tendon compartment into two separate of the groove is smoothened and possible sharp 449
424 chambers. Running more distally, the tendons edges are rounded. After finishing the proce- 450
425 share one compartment. Rotating the scope dure, the stability of the tendons within the 451
426 over and in between the tendons and within the groove can be tested. Only in case of persistent 452
427 tendonsheath, the complete course of the ten- instability after the groove deepening proce- 453
428 dons can be evaluated. In case of significant dure, a ruptured SPR is sutured with the use of 454
429 tenosynovitis, complete tenosynovectomy suture anchors [23]. The authors prefer the 455
430 using a shaver can be performed in order to endoscopic groove deepening technique by 456
431 allow better visualization of possible patholo- means of the 2 portal hindfoot approach since 457
432 gies including tears, ruptures, dislocation, and it provides a better overview of both tendons 458
433 stenosis [44]. and the groove itself. Moreover, it allows bet- 459
434 In patients with subluxating or dislocating ter judgment on the amount of deepening both 460
435 tendons, fibular groove deepening can be per- in width and in depth [56]. 461
436 formed using the tendoscopic technique. In When a tendon tear is found, a mini-open 462
437 should be taken into account, however, that the approach is required for optimal debridement of 463
438 limited workspace around the fibular tip makes the degenerative tissue. Depending on the amount 464
439 this procedure time consuming and challeng- of tissue removed, the tendon is tubularized using 465
440 ing. When performing a tendoscopic groove the buried sutures knot and a running technique 466
441 deepening, it is therefore preferred to create an (Fig. 28.6). 467
442 extra portal 4 cm proximal to the posterolateral
443 portal [56]. To minimize the risk of iatrogenic
444 tendon damage, two Kirschner wires are used
445 to keep the peroneal tendons out of the work-
Fig. 28.5 The location of the portals (marked in black) in

relation to the lateral malleolus (yellow): (a) The distal
portal is created 2–3 cm distal to the posterior tip of the Fig. 28.6 In case of a peroneal tendon tear, a mini-open
lateral malleolus. (b) The proximal portal is located approach is required for optimal debridement of the
2–3 cm proximal to the posterior edge of the lateral degenerative tissue followed by tubularization of the
malleolus remaining tendon
468 At the end of the procedure, all portals are 28.10 Pearls and Pitfalls 509
469 closed by sutures to prevent sinus formation.
1. While MRI and US can be helpful tools in the 510
management of peroneal tendon injuries, 511
470 28.8 Rehabilitation accurate patient history and clinical examina- 512
tion is the key to adequate diagnosis and 513
471 Adequate rehabilitation is an important factor treatment. 514
472 for optimal management of peroneal tendon 2. Peroneal tendoscopy should be reserved for 515
473 injuries and should be individualized for each patients with a high clinical suspicion of pero- 516
474 patient [57]. For optimal rehabilitation the sur- neal pathology, but absence of positive find- 517
475 geon must distinguish whether or not the SPR is ings on imaging. It is highly sensitive and 518
476 repaired. specific for both static and dynamic injuries 519
477 In cases the SPR is not repaired, rehabilita- and provides an easy transition to (minimally 520
478 tion should be goal-based with the promotion of invasive) treatment. 521
479 early mobilization, rather than time-based. If 3. In peroneal tendoscopy, identify the location 522
480 surgery included repair of the retinaculum, of the peroneal tendons by asking the patient 523
481 rehabilitation should start with 2 weeks of non- to actively evert the foot and draw the course 524
482 weight bearing in a lower leg cast, followed by of the tendons on the skin before starting a 525
483 4 weeks of weight bearing in a cast or a walker surgical procedure. Moreover, localize the 526
484 boot. 2 weeks after the procedure, active range maximal pain spot and mark this on the skin. 527
485 of motion can be started. It is important that the In this way, a clear reference for your portals 528
486 tendons are not loaded until 6 weeks after repair and intraoperative reference point is 529
487 of the SPR [23]. created. 530
4. Identify the posterior talofibular ligament and 531
the calcaneofibular ligament before initiating 532
488 28.9 Conclusions the work on the posterior distal fibular surface 533
during a groove deepening procedure to pre- 534
489 Recent literature confirmed that peroneal tendon vent iatrogenic damage. 535
490 injuries are a serious cause of posterolateral ankle 5. Introduction of the surgical instruments must 536
491 symptoms following acute or chronic lateral be performed smoothly without any resistance 537
492 ankle sprains, and can be very debilitating. To to prevent iatrogenic tendon damage. Increase 538
493 prevent the tendons from chronic damage and of fluid pressure during the tendoscopy allows 539
494 deterioration, early diagnosis and treatment is for more working space, thereby preventing 540
495 important. While MRI and US are both helpful iatrogenic damage. 541
496 tools in diagnosing peroneal tendon injuries, 6. Don’t include retinacular tissue during clo- 542
497 accurate patient history and clinical examination sure of the portals in order to prevent 543
498 is the key to adequate diagnosis and manage- adhesions. 544
499 ment. Conservative management remains the first

500 choice of treatment, but most cases of peroneal
501 tendon tears, ruptures and dislocation require sur-
502 gical intervention. With an advantageous charac- References 545
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1
2
Concept of the Hindfoot
Endoscopy
29
3 Jin Woo Lee and Bom Soo Kim
4 29.1 Introduction copy using two posterior portals has been rapidly 29
popularized due to its ease of procedure and low 30
5 Posterior ankle pain is a frequently observed prob- complication rate [2–6]. 31
6 lem, especially in athletics or active patients. Various The concept of lateral hindfoot endoscopy 32
7 pathologies can be associated with pain or discomfort includes posterior ankle arthroscopy, subtalar 33
8 in the posterior aspect of the ankle. Intra-articularly, arthroscopy, and hindfoot endoscopy (Fig. 29.1). 34
9 osteochondral lesions located in the posterior aspect When the arthroscope is introduced in the extra- 35
10 of the ankle joint or in the posterior facet of the subta- articular space, “arthroscopy” becomes a misnomer 36
11 lar joint, as well as loose bodies, osteophytes, and and hence “endoscopy” is more appropriate. 37
12 synovitis, can cause hindfoot pain. Extra-articular Practically, however, distinguishing between the 38
13 pathologies include tenosynovitis of the flexor hallu- two terminologies is less important due to the simi- 39
14 cis longus (FHL) tendon, posterior impingement due larity of the procedures. Therefore, “hindfoot endos- 40
15 to os trigonum, inflammatory tissue, or hypertrophic copy” can be used as a generalized terminology 41
16 posterior capsule or intermalleolar ligaments. when endoscopy is used to treat intra- and extra- 42
17 Due to the anatomic complexity and deep articular lesions in the posterior aspect of the ankle. 43
18 location, open approaches provide limited visual-
19 ization and cause difficulties in the surgical pro-
20 cedures despite large skin incisions and extensive 29.2 Surgical Technique 44
21 soft tissue dissections. Open approaches accom-
22 pany greater postoperative pain and require pro- 29.2.1 Patient Position and Setup 45
23 longed rehabilitation.
24 Minimal invasive approach to the posterior The patient is placed on the operating table in a 46
25 aspect of the ankle using endoscopy provides prone position. A pneumatic tourniquet is applied 47
26 good visualization with less morbidity compared around the upper thigh. A small bump is placed 48
27 to the open approach. Since its first introduction under the ankle joint (Fig. 29.2). 49
28 by van Dijk et al. [1] in 2000, the hindfoot endos- To perform endoscopy for the lesions located 50
in the extra-articular space, traction of the joint is 51
J. W. Lee (*) not necessary. For most of the lesions located in 52
Department of Orthopaedic Surgery, Yonsei University the posterior aspect of the talus, dorsiflexion of 53
College of Medicine, Seoul, South Korea
e-mail: LJWOS@yuhs.ac
the ankle is usually enough to expose the lesion. 54
In such cases, relaxing the gastrocnemius muscle 55
B. S. Kim
Department of Orthopaedic Surgery, Inha University
by slightly flexing the knee joint is helpful to ease 56
College of Medicine, Incheon, Korea the ankle dorsiflexion. 57
© ISAKOS 2019 327

https://doi.org/10.1007/978-3-662-58704-1_29
328 J. W. Lee and B. S. Kim
Posterior ankle
Arthroscopy
Posterior ankle
Endoscopy
Subtalar joint
Arthroscopy
FHL Tendoscopy
Posterolateral
portal
Posteromedial
Fig. 29.1 Hindfoot endoscopy is a comprehensive termi- Lateral portal
nology encompassing the posterior ankle and subtalar malleolus
arthroscopy, posterior endoscopy, and FHL tendoscopy
Fig. 29.3 Portal placement. The portals are placed in a

same level, at the tip of the lateral malleolus, both about
5 mm away from the lateral and medial border of the
Achilles tendon
lateral and medial border of the Achilles tendon 64

(Fig. 29.3). Care should be paid not to place the 65
portals too close to the Achilles tendon because 66
injury of the Achilles tendon by arthroscopic 67
instruments can result in focal enlargement of the 68
tendon and chronic pain. At the same time, injury 69
of the sural nerve must be avoided when making 70
the posterolateral portal. 71
The posterolateral portal is always made first. 72
A small vertical stab wound is made to incise the 73
skin. A straight mosquito clamp is inserted to 74
split the subcutaneous tissue. The mosquito 75
clamp is then directed towards the first webspace 76
until the tip touches the bony structure (Fig. 29.4). 77
Fig. 29.2 Patient position and the arthroscopic setup. The clamp is then exchanged for an arthroscopic 78
The patient is placed on the operating table in prone posi- cannula with a blunt trocha. A 4 mm arthroscope 79
tion. A pneumatic tourniquet is applied around the upper is inserted through the cannula [1]. 80
thigh. A small bump is placed under the ankle joint. Most
of the hindfoot endoscopic procedures can be performed
The posteromedial portal is made in the 81
without joint distraction same way on the medial aspect of the Achilles 82
tendon. A shaver is inserted through the pos- 83
teromedial portal directing laterally towards 84
58 29.2.2 Portal Establishment the proximal shaft of the arthroscope. Once the 85
59 and Approach tip of the shaver touches the shaft of the arthro- 86
scope, the shaver tip is moved anteriorly 87
60 A standard hindfoot endoscopy [1] utilizes two towards the ankle using the arthroscope shaft as 88
61 portals, posterolateral and posteromedial. The a guide. When the shaver tip reaches the bone, 89
62 portals are placed in a same level, at the tip of the the arthroscope is slightly withdrawn to visual- 90
63 lateral malleolus, both about 5 mm away from the ize the tip of the shaver. Once the shaver tip is 91
29 Concept of the Hindfoot Endoscopy 329
mosquito clamps are touched in a triangulation 107

fashion, the mosquito clamps are spread a few times 108
to make a working space at the posterior aspect of 109
the talus. Care should be paid not to proceed the 110
clamps too deep medially. Once the working space 111
is made, the mosquito clamps are exchanged with 112
the arthroscope laterally and shaver medially. 113
This way, less shaving of the soft tissue is 114
required and faster approach to visualize the pos- 115
terolateral tubercle of the talus is possible. 116
Blind insertion of the two mosquito clamps 117
directed towards the posterior talar tuberosity 118
Posterior can be safely performed because the neurovas- 119

talar cular bundle is away from the initial working 120
process space. A cadaveric study reported that introduc- 121
ing arthroscopic instruments into the posterior 122
Calcareous
Talus aspect of the ankle with the patient in prone 123
position can be safely performed without gross 124
injury to the posterior neurovascular structures. 125
The average distance between the cannula and 126
adjacent anatomic structures after dissection was 127
3.2 mm (range, 0–8.9 mm) to the sural nerve, 128
4.8 mm (range, 0–11.0 mm) to the small saphe- 129
nous vein, 6.4 mm (range, 0–16.2 mm) to the 130
tibial nerve, 9.6 mm (range, 2.4–20.1 mm) to the 131
posterior tibial artery, 17 mm (range, 19–31 mm) 132
to the medial calcaneal nerve, and 2.7 mm 133
Fig. 29.4 Direction of the mosquito clamp. A straight

(range, 0–11.2 mm) to the flexor hallucis longus 134
mosquito inserted into the posterolateral portal is moved tendon [7]. 135
deep anteriorly towards the first webspace until the tip Once the endoscopy is introduced, identifying 136
touches the bony structure the flexor hallucis longus, medial to the os trigo- 137
num or the Stieda process is the first step in the 138
92 visualized, working space is created by shaving hindfoot endoscopy. Flexion and extension 139
93 the extra-articular soft tissue in front of the tip movement of the great toe can help identifying 140
94 of the arthroscope [1]. the FHL tendon. 141
Flexor hallucis longus tendon is an important 142
landmark separating the safe zone lateral to the 143
95 29.2.3 Tips and Pitfalls tendon from the danger zone medial to the 144
tendon. Since the neurovascular bundle is in close 145
96 An alternative method that the authors found to approximation with the FHL, a special attention 146
97 be useful is to use two straight mosquito clamps should be paid not to use the shaver medial to the 147
98 to make the initial working space (Fig. 29.5). FHL tendon. 148
99 Insert one mosquito clamp through the postero-
100 lateral portal, directed towards the first webspace.
101 The tip of the mosquito clamp usually lands on 29.3 O
s trigonum and Hindfoot 149
102 the posterolateral tubercle of the talus or os Endoscopy 150
103 trigonum.
104 A second mosquito clamp is inserted through Os trigonum is one of the most common indica- 151
105 the posteromedial portal directing towards the tip of tion for hindfoot endoscopy [2]. Os trigonum is 152
106 the first mosquito clamp. Once the tips of the two an accessory bone or separated Stieda process at 153
a b
Fig. 29.5 Authors’ preferred technique using two straight towards the tip of the previously inserted mosquito clamp,
mosquito clamps. (a) The first mosquito clamp is inserted in a triangulation fashion. (b) Spreading the mosquito
from the posterolateral portal, directed towards the first clamps right behind the bony structure helps creating the
webspace until the tip lands on bony structure. The second working space with less shaving of the soft tissue
mosquito clamp is inserted from the posteromedial portal,
154 the posterior aspect of the talus. Direct impinge- full activity was achieved at an average of 180
155 ment of the os trigonum between tibia and calca- 1.5 months with no limitations at an average of 181
156 neus during ankle plantar flexion can cause pain. 7.8 months after surgery. Out of 24 cases, one 182
157 It can also be associated with inflammation caus- transient posterior tibial nerve calcaneal branch 183
158 ing fluid collection and soft tissue impingement. neurapraxia has occurred. López Valerio et al. [9] 184
159 When the arthroscope is first introduced at the reported similar outcomes after endoscopic exci- 185
160 posterior aspect of the ankle, poor visualization sion of os trigonum in 20 soccer players. The 186
161 makes it difficult to find the os trigonum. mean time until the players’ return to previous 187
162 However, since os trigonum is at or near the usual level of sports was 46.9 days (SD = 25.96). 188
163 landing site of the arthroscopic instruments
164 directed towards the first webspace, it can be eas-
165 ily palpated with the shaver tip. Shaving of the 29.4 Osteochondral Lesion 189
166 soft tissue around the hard round bony structure of the Talus and Posterior 190
167 will reveal the os trigonum. Ankle Arthroscopy 191
168 In order to remove the os trigonum, the liga-
169 mentous structures, the posterior talofibular liga- Most of the osteochondral lesions are located in 192
170 ment laterally and the flexor hallucis longus the anterior 2/3 of the talar dome [10], easily 193
171 retinaculum medially, should be released using approached with conventional anterior ankle 194
172 arthroscopic scissors. If the os trigonum is com- arthroscopy. Posteriorly located lesions account 195
173 pletely separated from the talus, it can be easily for 13% of the cases [10]. If the joint space is nar- 196
174 removed with a grasper. If os trigonum is par- row, such lesions do not allow access from the 197
175 tially attached with the talar body, an arthroscopic anterior portals. 198
176 burr can be used (Fig. 29.6). Posteriorly located osteochondral lesions are 199
177 Weiss et al. [8] reported the satisfactory out- more easily approached through the posterior 200
178 comes of endoscopic excision of a symptomatic portals with the patient in prone position. The 201
179 os trigonum performed in 24 patients. Return to standard posterolateral and posteromedial portals 202
a b c
d e
Fig. 29.6 Os trigonum associated with tear of the flexor with the os trigonum. (d) Tear of the FHL tendon due to
hallucis longus tendon. (a) Os trigonum at the posterior repeated impingement by the os trigonum and the fibro-
aspect of the talus. (b) Endoscopic view of the os trigo- osseous tunnel. (e) After removal of the os trigonum and
num. (c) The FHL tendon running in close approximation debridement of the FHL tendon
203 can be used, but about 1/2 in. proximally placed

204 portals gives better access to the ankle joint. 29.5 F
lexor Hallucis Longus 224
205 In order to enter the joint space, the posterior Tenosynovitis 225
206 joint capsule and the fatty tissue behind the ankle and Tendoscopy 226
207 is removed. Care should be paid not to injure the
208 neurovascular tissue medial to the FHL. Once the Inflammation within the FHL tendon sheath is 227
209 joint capsule is removed, the posterior-inferior another frequent cause of posterior ankle pain. 228
210 tibiofibular ligament and the ankle joint space are Repeated great toe flexion movement and over- 229
211 visualized (Fig. 29.7). use of the FHL tendon cause inflammation within 230
212 A cadaveric study reported that an average of the tendon sheath. Stenosis of the fibro-osseous 231
213 54% (range, 42–73%) of the talar dome could be tunnel due to hypertrophic soft tissue can cause 232
214 visualized from the posterior arthroscopic wear and tear of the FHL tendon. Impingement 233
215 approach without traction [7]. Ankle dorsiflexion with the freely movable os trigonum can also 234
216 brings more than 1/3 of the posterior talar dome injure the FHL tendon. 235
217 into exposure. Slight knee flexion to release the FHL tenosynovitis can be easily diagnosed 236
218 gastrocnemius can help ankle dorsiflexion in with MRI scans. Increased synovial fluid in 237
219 patients with gastrocnemius tightness. Manual T2-weighted images are diagnostic of FHL teno- 238
220 traction of the hindfoot or noninvasive traction of synovitis. However, mere fluid collection within 239
221 the ankle joint using ankle harness can open the the FHL tendon sheath due to overflow of the 240
222 tibiotalar joint, allowing access to more anteri- increased joint fluid from the ankle joint or the 241
223 orly located lesions. subtalar joint should be differentiated. 242
a b c
d e
Fig. 29.7 Posteriorly located osteochondral lesion of osteochondral lesion of the talus. (c) Ankle dorsiflexion
the talus. (a, b). The patient was referred to our clinic exposes the posterior talar dome out of the tibial cover-
after failure of anterior arthroscopic approach. Tight age. (d, e) Successful removal of the damaged cartilage
joint space, especially with intact ligamentous structures, and microfracture using the posterior arthroscopic
makes it difficult to approach the deep posteriorly located approach
243 Debridement of the FHL tenosynovitis can inserted through the posteromedial portal into the 262
244 be performed using the conventional two FHL tendon sheath. The rod is passed bluntly, 263
245 posteromedial and posterolateral portals [6] or distally to penetrate the plantar muscles in the 264
246 by utilizing additional plantar portal in the sole. A stab wound is made in the skin to help exit 265
247 sole [3]. the sole and create the plantar portal. With the 266
248 After debridement of the hypertrophic scar tis- Wissinger rod placed between the plantar portal 267
249 sue at the orifice of the fibro-osseous tunnel, the and the posteromedial portal, the arthroscopic 268
250 FHL tendon sheath is entered with the arthro- cannula is inserted through the plantar portal 269
251 scope. In order to enter the tendon sheath, 2.7 mm using the rod as a guide. This safely places the 270
252 or 2.9 mm arthroscope is recommended. arthroscopic cannula into the FHL tendon sheath. 271
253 Inflammatory synovitis and degenerated vinculae The rod is then removed and exchanged with 272
254 is debrided. Due to the angulation from the pos- arthroscope. 273
255 terolateral portal, simultaneous visualization and With the arthroscope placed in the FHL ten- 274
256 instrumentation into the tendon sheath is limited don sheath through the plantar portal, arthroscopic 275
257 to the proximal aspect. instruments can be inserted through the postero- 276
258 If further instrumentation is required, addi- medial portal into the FHL tendon sheath. If nec- 277
259 tional portal is established in the sole by use of a essary, the plantar portal and the posteromedial 278
260 Wissinger rod (Fig. 29.8). With the arthroscope portal can be used interchangeably for visualiza- 279
261 in the posterolateral portal, the Wissinger rod is tion and instrumentation. 280
a b c
d e
Fig. 29.8 Tenosynovitis of the FHL tendon and tendos- (d) Using the Wissinger rod as a guide, arthroscopic can-
copy utilizing additional plantar portal. (a) Increased fluid nular is inserted through the plantar portal. The rod is then
collection along the FHL tendon sheath. (b, c) With the exchanged with the arthroscope. (e) Tendoscopic view of
arthroscope in the posterolateral portal, a Wissinger rod is the FHL tendon showing tenosynovitis and degenerated
inserted in the posteromedial portal, though the FHL ten- vinculae
don sheath, and exited in the plantar aspect of the sole.
281 Possible complications associated with the tendon sheath and increase the risk of injury, care 297
282 FHL tendoscopy includes injury of the medial should be paid to avoid ankle dorsiflexion [12]. 298
283 and lateral plantar nerve [3, 11–13]. Since the FHL tendoscopy using the conventional two 299
284 nerve runs in close approximation with the FHL portals is easier and carries less risk of complica- 300
285 tendon sheath, special caution and gentle manipu- tion compared to the three-portal technique. 301
286 lation of the instruments is required. Lui et al. However, the two-portal technique offers limited 302
287 [11] performed a cadaveric study and reported inspection and instrumentation. The three-portal 303
288 that while the proximal half of the tendon sheath technique utilizing additional plantar portal is 304
289 is thick and fibrous, the distal half of the sheath is technically more demanding and carries higher 305
290 thin and membranous, exposing the nearby nerve risk of complication, but allows full inspection 306
291 at greater risk of injury. Therefore, facing the and better instrumentation. Therefore, the authors 307
292 shaver opening towards the tendon and away from recommend starting with the two portals, inspect 308
293 the sheath, as well as minimizing the use of suc- the proximal aspect of the FHL tendon and 309
294 tion, is recommended, especially in the distal half depending on the necessity of deeper instrumen- 310
295 of the FHL tendon [11, 12]. Furthermore, since tation, decide on proceeding with the plantar 311
296 ankle dorsiflexion brings the nerve closer to the portal. 312
313 29.6 Haglund Deformity portal is placed at the retrocalcaneal space, and 333
314 and Endoscopic fluoroscopic guidance can be helpful. It is recom- 334
315 Calcaneoplasty mended to place the first portal as close as possi- 335
ble to the superior edge of the calcaneus and also 336
316 Enlarged posterior superior calcaneal promi- as far posterior as possible [16]. Care should be 337
317 nence or the Haglund deformity can cause swell- paid not to injure the sural nerve when placing 338
318 ing and pain as a result of repeated mechanical the lateral portal. Slight plantar flexion of the 339
319 irritation. Formation of a thick skin callosity not ankle allows the instrumentation in the retrocal- 340
320 only makes shoe wear difficult but can also be a caneal space. The second portal is created on the 341
321 cosmetic problem. contralateral side using the Wissinger technique. 342
322 The Haglund deformity can be resected either The enlarged posterior superior calcaneal promi- 343
323 by open incision or by endoscopic technique nence is resected using arthroscopic burr 344
324 [14]. Endoscopic resection of the Haglund defor- (Fig. 29.9). 345
325 mity has the benefits of minimal invasive surgery When performing endoscopy in the retrocal- 346
326 including less postoperative pain, faster recovery, caneal space, a special care should be paid to 347
327 and superior cosmetic satisfaction [14–16]. avoid injury of the nearby Achilles tendon. 348
328 The patient is placed on the operating table in Injury of the Achilles tendon can lead to 349
329 prone position with a bump under the ankle. The Achilles tendinopathy or delayed rupture after 350
330 first portal can be created on medial or lateral, the surgery. Protection of the Achilles tendon 351
331 depending on the surgeon’s preference, at the by the hooded side of the burr is recommended. 352
332 level of the superior aspect of the calcaneus. The Also, placing the portal too close to the border 353
a b c
d e
Fig. 29.9 Haglund deformity resected endoscopically. portals are placed at the level of the superior border of the
(a, b) Prominent posterior superior eminence of the calca- calcaneus on each side of the Achilles tendon. (d)
neus resulting in painful callosity. (c) Portal placement for Successful removal of the bony prominence. (e) Reduced
the endoscopic removal of the Haglund deformity. The callosity at 3 months after the surgery
354 of the Achilles tendon should be avoided to Endoscopic calcaneoplasty or resection of 399
355 reduce the risk of tendon injury by the the Haglund deformity is a minimally invasive 400
356 instruments. technique with low morbidity. Van Dijk et al. 401
[14] reported generally satisfactory outcomes in 402
21 cases of endoscopic calcaneoplasty without 403
357 29.7 Complications any surgical complications. Out of 30 cases of 404
endoscopic bony and soft tissue decompression 405
358 The endoscopic approach for the treatment of of the retrocalcaneal space, Ortmann and 406
359 hindfoot and ankle pathology is safe with a low McBryde [15] reported one case of an Achilles 407
360 incidence of complications. Donnenwerth and tendon rupture 3 weeks after surgery and one 408
361 Roukis [17] performed a systematic review study case of insufficient resection. 409
362 which included a total of 452 ankles that received
363 posterior hindfoot endoscopy. Overall, 17 com-
364 plications (3.8%) occurred, including 5 wound- References 410
365 healing problems, 4 cases of recurrent symptoms,
366 3 cases of neuritis of the medial calcaneal nerve, 1. van Dijk CN, Scholten PE, Krips R. A 2-portal endo- 411
367 3 cases of transient incision anesthesia, 1 trau- scopic approach for diagnosis and treatment of poste- 412
rior ankle pathology. Arthroscopy. 2000;16:871–6. 413
368 matic sural neuroma, and 1 transient superficial 2. Spennacchio P, Cucchi D, Randelli PS, Van Dijk 414
369 peroneal neuritis. Among these complications, NC. Evidence-based indications for hindfoot 415
370 only 8 (1.8%) persisted or required additional endoscopy. Knee Surg Sports Traumatol Arthrosc. 416
371 treatment or operative intervention: 2 wounds 2016;24:1386–95. 417
3. Lui TH. Flexor hallucis longus tendoscopy: a tech- 418
372 required surgical debridement, 2 reoperations nical note. Knee Surg Sports Traumatol Arthrosc. 419
373 were required for recurrent symptoms, 1 injec- 2009;17:107–10. 420
374 tion was needed for recurrent symptoms, there 4. Smyth NA, Zwiers R, Wiegerinck JI, Hannon CP, 421
375 were 2 cases of persistent medial calcaneal neuri- Murawski CD, Van Dijk CN, Kennedy JG. Posterior 422
hindfoot arthroscopy: a review. Am J Sports Med. 423
376 tis, and 1 resection of the traumatic sural neu- 2014;42:225–34. 424
377 roma was performed. 5. Willits K, Sonneveld H, Amendola A, Giffin JR, 425
378 Kim and Choi [18] reported the outcomes of Griffin S, Fowler PJ. Outcome of posterior ankle 426
379 10 patients who received flexor hallucis longus arthroscopy for hindfoot impingement. Arthroscopy. 427
2008;24:196–202. 428
380 tendoscopy using 3-portals. Of these, 9 were sat- 6. Smyth NA, Murawski CD, Levine DS, Kennedy 429
381 isfactory but 1 experienced ongoing lateral plan- JG. Hindfoot arthroscopic surgery for posterior ankle 430
382 tar nerve symptom. Lui et al. [12] also reported 2 impingement: a systematic surgical approach and case 431
383 cases of lateral plantar nerve neuropraxia after series. Am J Sports Med. 2013;41(8):1869–76. 432
7. Sitler DF, Amendola A, Bailey CS, Thain LMF, 433
384 FHL tendoscopy using 3-portals. Since ankle Spouge A. Posterior ankle arthroscopy: an anatomic 434
385 dorsiflexion brings the posterior tibial nerve in study. J Bone Joint Surg Am. 2002;84–A:763–9. 435
386 contact with the arthroscope during tendoscopy, 8. Weiss WM, Sanders EJ, Crates JM, Barber FA. 436
387 ankle dorsiflexion should be avoided [12]. Arthroscopic excision of a symptomatic os trigo- 437
nometry. Arthroscopy. 2015;31(11):2082–8. 438
388 Lui and Chan [19] performed a cadaveric 9. López Valerio V, Seijas R, Alvarez P, Ares O, 439
389 study and proved that the neurovascular bundle Steinbacher G, Sallent A, Cugat R. Endoscopic 440
390 is at risk during instrumentation of the postero- repair of posterior ankle impingement syndrome 441
391 medial ankle through the posteromedial portal due to os trigonum in soccer players. Foot Ankle Int. 442
2015;36:70–4. 443
392 but was safe through the posterolateral portal. 10. Raikin SM, Elias I, Zoga AC, Morrison WB, Besser 444
393 It is recommended to use the posterolateral MP, Schweitzer ME. Osteochondral lesions of the 445
394 portal as the instrumentation portal and the talus: localization and morphologic data from 424 446
395 modified or more proximally established pos- patients using a novel anatomical grid scheme. Foot 447
Ankle Int. 2007;28:154–61. 448
396 teromedial portal as the visualization portal 11. Lui TH, Chan KB, Chan LK. Cadaveric study of zone 449
397 while dealing with pathology of the posterome- 2 flexor hallucis longus tendon sheath. Arthroscopy. 450
398 dial ankle [19]. 2010;26:808–12. 451
452 12. Lui TH. Lateral plantar nerve neuropraxia after FHL 16. Jerosch J. Endoscopic calcaneoplasty. Foot Ankle
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453 tendoscopy: case report and anatomic evaluation. Clin N Am. 2015;20:149–65. 466
454 Foot Ankle Int. 2010;31:828–31. 17. Donnenwerth MP, Roukis TS. The incidence of
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455 13. Lui TH, Chan KB, Chan LK. Zone 2 flexor hallucis complications after posterior hindfoot endoscopy. 468
456 longus tendoscopy: a cadaveric study. Foot Ankle Int. Arthrosc J Arthrosc Relat Surg. 2013;29:2049–54. 469
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458 14. van Dijk CN, van Dyk GE, Scholten PE, Kort
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459 NP. Endoscopic calcaneoplasty. Am J Sports Med. cis longus tenosynovitis. J Korean Foot Ankle Soc. 472
460 2001;29:185–9. 2013;17:294–301. 473
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1 Foot and Ankle Tendoscopy
30
2 Phinit Phisitkul, Chris C. Cychosz,
3 and Craig C. Akoh
4 30.1 Introduction endoscopic electrocautery probes has facilitated 24

the endoscopic procedures to be performed 25
5 Tendoscopy was introduced by Wertheimer since widely. Surgical indications for tendoscopy in the 26
6 1995 [1]. It was subsequently popularized by van foot and ankle include diagnostic procedures, 27
7 Dijk by extending multiple applications in the decompression, lysis of adhesion, loose body 28
8 foot and ankle [2–4]. The limits of tendoscopy removal, excision, tenotomy, tendon lengthening, 29
9 have been challenged by numerous surgeons and tendon transfers [10–12]. Contraindications 30
10 around the world, especially Dr. Lui who reported for tendoscopy are active overlying infection and 31
11 versatile use of tendoscopy of both lower and extensive postsurgical scarring. 32
12 upper extremities [5–8].
13 Tendoscopy involves minimally invasive sur-
14 gery with the use of endoscopic instrumentation 30.2 Principles of Tendoscopy 33
15 to visualize and treat tendon pathologies. Its ben-
16 efits are minimizing surgical morbidities such as Most of the tendoscopy are performed under fluid 34
17 pain, scar tissue, infection, and wound complica- irrigation such as normal saline which can 35
18 tions. Additionally, tendoscopic technique allows improve distension of the tendon sheath and avoid 36
19 for up to 50 times magnification and excellent interference of the view from blood. Occasionally, 37
20 illumination under endoscopic visualization [9]. dry tendoscopy can be used with a slotted cannula 38
21 The advancement in endoscopic instrumentation such as for gastrocnemius recession [13]. Low- 39
22 such as smaller diameter cameras, more special- pressure flow up to 40 mmHg or gravity flow pro- 40
23 ized power instrument, and the availability of vides adequate irrigation while minimizing fluid 41
extravasation [14]. The diameter of the endo- 42
P. Phisitkul (*) scopic camera and its cannula is critical to the 43

Department of Orthopaedics, TriState Specialists, success of the procedure. In general, the largest 44
Sioux City, IA, USA camera that can fit comfortably in the tendon 45
e-mail: phinit-phisitkul@uiowa.edu sheath or paratendinous space should be used. A 46
C. C. Cychosz standard 4 mm, 30° camera is ideal for most pro- 47
Department of Orthopaedics, University of Iowa, cedures involving larger structures such as the 48
Iowa City, IA, USA
e-mail: Christopher-cychosz@uiowa.edu Achilles and the proximal flexor hallucis longus 49
(FHL) tendons. A 2.7 mm, 30° camera is ideal for 50
C. C. Akoh
Department of Orthopaedics, University of smaller structures such as the distal FHL and most 51
Wisconsin, Madison, WI, USA other tendoscopy in foot and ankle. It is common 52
© ISAKOS 2019 337

https://doi.org/10.1007/978-3-662-58704-1_30
338 P. Phisitkul et al.
53 that the shaft of the camera is used as a retractor as

54 it is placed strategically next to the tendon.
55 Endoscopic portals are usually made in line
56 with the tendon guided by preoperative markings
57 or direct palpation. Tendon sheath injection with
58 normal saline can facilitate portal placement but
59 it is not routinely necessary. Portals are com-
60 monly located proximal and distal to the lesion as
61 determined from preoperative evaluation and
62 imaging studies. Surgeon should keep a mini-
63 mum of one centimeter of soft tissue tunnel
64 between the skin incision and the location of
65 interest to avoid endoscopic camera dislodge-
66 ment. The practice of using one finger to stabilize
67 the endoscopic shaft at the portal can be extremely
68 helpful in keeping the camera in place [4]. Portals
69 are mostly created diagonally, so the visualiza- Fig. 30.1 Endoscopic gastrocnemius recession is dem-
70 tion and instrumentation can be interchanged to onstrated using a slotted cannula and a retrograde knife
71 cover the length of the lesion. In cases where ten-
72 don adhesion is expected, an endoscopic trocar or A medial portal is created approximately 2 cm 94
73 a hemostat can be used to strip the tendon from distal to the gastrocnemius muscle belly and just 95
74 surrounding scar tissue prior to camera insertion dorsal to the palpable gastrocnemius tendon. A 96
75 to improve visualization. slotted cannula and trocar is inserted from medial 97
76 During the learning curve period, the surgeon to lateral along the plane superficial to the gas- 98
77 should not hesitate to convert an endoscopic trocnemius tendon. The lateral portal is created 99
78 approach to an open procedure if needed. Patients inside out. A 4 mm endoscope is inserted from 100
79 should be informed and consented for the possi- the medial portal and the gastrocnemius tendon is 101
80 bility that an open approach may be required. visualized. The plane of the procedure can be 102
adjusted using a plane-finder and reinsertion of 103
the cannula into the correct plan. The gastrocne- 104
81 30.3 Achilles mius tendon is released using a retrograde knife 105
from the lateral portal (Fig. 30.1). The camera 106
82 30.3.1 Indications and the retrograde knife can be switched to com- 107
plete the release of the tendon medially. The 108
83 Endoscopy has substantial role in the treatment ankle should be able to dorsiflexion past 10° 109
84 of Achilles tendon related conditions such as gas- afterwards. 110
85 trocnemius contracture, Achilles tendinopathy, The patient can start progressive weight- 111
86 Achilles tendon rupture within the first 10 to bearing in the boot right away. The boot is weaned 112
87 14 days, and retrocalcaneal bursitis. off at 4–6 weeks. 113
30.3.2.2 Tenolysis and Longitudinal 114

88 30.3.2 Surgical Techniques Tenotomies 115
Positioning: Prone. 116
89 30.3.2.1 Gastrocnemius Recession Instruments: 4 mm 30° endoscope, 4.5 mm 117
90 Positioning: Supine or prone. shaver, electrocautery, retrograde knife, number 118
91 Instruments: Slotted cannula and trocar, 11 scalpel. 119
92 plane-finder, cotton-tip applicators, 4 mm 30° The tendon enlargement is located by palpation. 120
93 endoscope, retrograde knife. The proximal medial portal is created 2 cm proxi- 121
30 Foot and Ankle Tendoscopy 339
Fig. 30.2 Achilles tendoscopy is shown with a shaver

removing adhesion between the Achilles tendon (star) and
the overlying fibrous tunnel (arrow)
122 mal to the tendon enlargement and the distal lateral

123 portal is created 2 cm distally. A hemostat is used
124 to create a plain around the Achilles tendon from
125 both portals. It is common to encounter significant Fig. 30.3 Patient is placed in prone position with the foot
126 scar adhesion anteriorly. A 4 mm 30° camera is just beyond the end of bed. The arthroscope is inserted
127 inserted into the anterior aspect of the Achilles ten- from the distal-medial portal
128 don. A 4.5 mm shaver is introduced from the other
129 portal for the debridement of scar adhesion The location of Achilles tendon rupture is 151
130 (Fig. 30.2). A plantaris tendon may be found in the identified by palpation of a gap on the posterior 152
131 anteromedial aspect of the Achilles tendon and it aspect of the distal hindfoot. Six portals are cre- 153
132 may be resected if indicated. If there is a compo- ated on the medial lateral aspects of the Achilles 154
133 nent of stenosing tenosynovitis, the anterior aspect tendon at the level of the rupture, 5 cm proxi- 155
134 of the fibrous tunnel of the Achilles tendon can be mally, and 5 cm distally (Fig. 30.3). A hemostat 156
135 released longitudinally using an electrocautery. is used to create a plain around the ruptured 157
136 Mass occupying lesions such as ganglion cysts, Achilles tendon. With the 4 mm 30° camera 158
137 accessory muscle, and low-lying soleus muscle from the distal medial portal, a number two non- 159
138 may be excised. If there is significant component absorbable suture is passed across the proximal 160
139 of intratendinous lesions, longitudinal tenotomies aspect of the tendon using a bird-beak suture 161
140 can be performed using a retrograde knife from grasper under direct visualization to ensure that 162
141 one of the portals or if number 11 scalpel percuta- the sural nerve is not captured by the suture 163
142 neously under direct visualization. (Fig. 30.4). This step is also critical as tendinous 164
143 The patient can start progressive weight- tissue accounts for only posterior 20% of the 165
144 bearing in the boot right away. The boot is weaned stump. Two sets of sutures are placed at the 166
145 off at 4–6 weeks. proximal stump to create a box and a crisscross 167
configuration. The camera is removed, and the 168
146 30.3.2.3 Tendon Repair distal repair is performing the same fashion 169
147 Positioning: Prone. without the use of an endoscope. The two sets of 170
148 Instruments: 4 mm 30° endoscope, bird-beak sutures are tied in the position of maximum 171
149 suture grasper, number two nonabsorbable plantarflexion after the ankle is moved through 172
150 sutures. range of motion. 173
Fig. 30.5 The endoscopic image demonstrates adequate

Fig. 30.4 A suture grasper is used to retrieve the end of
excision of the retrocalcaneal bursa and prominent pos-
the nonabsorbable suture as it is passed through the tendi-
terosuperior aspect of the calcaneus (star). Room between
nous portion (star) of the proximal tendon stump
the Achilles tendon insertion (arrow) and the calcaneal
tuberosity is shown
174 The patient is immobilized in a boot with the
175 ankle at 20° of plantarflexion for 2 weeks. The completed when the two K wires are seen endo- 200
176 patient can start ankle range of motion without scopically. Attention should be paid to remove 201
177 dorsiflexion beyond neutral at 2 weeks. At adequate amount of bone at the most distal 202
178 4 weeks, the boot is adjusted to 10° of plan- aspect where the Achilles tendon inserts and 203
179 tarflexion and the patient can start progressive medial and lateral edges of the calcaneal tuber- 204
180 weight-bearing. At 6 weeks, the boot is as osity (Fig. 30.5). Percutaneous longitudinal 205
181 adjusted to neutral and patient can do full weight- tenotomies can be performed under endoscopic 206
182 bearing. The boot is discontinued at 10–12 weeks guidance using number 11 scalpel if there is 207
183 postoperatively. associated Achilles tendon degeneration and 208
enlargement. 209
184 30.3.2.4 Retrocalcaneal Bursectomy The patient can start progressive weight- 210
185 and Decompression bearing in the boot right away. The boot is weaned 211
186 Positioning: Supine or prone. off at 2 weeks. 212
187 Instruments: 4 mm 30° endoscope, 5.5 mm
188 shaver, number 11 scalpel.
189 Two K wires or spinal needles are inserted 30.3.3 Outcomes of Achilles 213
190 under fluoroscopic guidance into the calcaneal Tendoscopy 214
191 tuberosity to guide the amount of bone resec-
192 tion. A medial and a lateral portal are made on Van Dijk and Scholten published the first case 215
193 each side of the Achilles tendon insertion at the series reporting Achilles tendoscopy outcomes in 216
194 level of the superior aspect of the calcaneal 1997 [15]. Since that time the Achilles tendon 217
195 tuberosity. A hemostat is used to create a tract has become one of the most studied tendons 218
196 into the retrocalcaneal bursa. A camera is using tendoscopy, with most studies comprising 219
197 inserted, and a shaver is used to remove the level II-V evidence for the indications of tendon 220
198 inflamed synovial tissue, hypertrophic Achilles rupture repair, peritendinopathy, and midportion 221
199 tendon, and prominent bone. Bone resection is Achilles tendinopathy. 222
223 Tendoscopy has been utilized to visualize the to 92 (range, 74–100) postoperatively. No com- 270
224 tendon ends following acute or chronic rupture plications were reported. Another retrospective 271
225 during percutaneous Achilles tendon repair to series consisting of 24 patients who underwent 272
226 grant a more precise re-approximation [16]. paratenon debridement with longitudinal tenoto- 273
227 Halasi et al. reported a level II comparative study mies of the Achilles tendon resulted in 96% of 274
228 in which a group of 57 patients undergoing per- patients be symptom free at mean follow-up of 275
229 cutaneous Achilles tendon repair with the use of 7.7 years following surgery. Two complications 276
230 endoscopic visualization were compared to a were reported in this series including a keloid 277
231 group of 87 patients undergoing percutaneous scar as well as a seroma with chronic fistula [20]. 278
232 only technique. They found that the rerupture rate In 2012, Lui published a small case series of five 279
233 was 1.75% in the endoscopic group compared to patients with noninsertional Achilles tendinopa- 280
234 5.74% in the percutaneous only group; however, thy who underwent endoscopic Achilles tendon 281
235 this difference did not reach statistical signifi- debridement with FHL transfer [21]. He demon- 282
236 cance. A 2009 prospective series by Doral et al. strated an increase in Achilles Tendinopathy 283
237 including 62 patients with acute Achilles tendon Scoring System from 29.4 preoperatively to 89 at 284
238 ruptures repaired percutaneously with endo- an average follow-up of 19.8 months with no 285
239 scopic assistance reported similar results [17]. In complications. Vega et al. had previously reported 286
240 their series, 95% of patients returned to previous a similar size series of eight patients with chronic 287
241 level of sport at a mean of 11.7 weeks. At mean Achilles tendinopathy defined as a minimum 288
242 follow-up of 46 months there were no reruptures, symptom duration of 3 months [1]. These patients 289
243 no wounds problems, or other complications. underwent endoscopic debridement and were 290
244 Fortis et al. echoed these results in a 2008 series reported to all be pain free at a mean follow-up of 291
245 of 20 patients with acute or chronic Achilles ten- 27.1 months (range, 18–40). 292
246 don ruptures in which endoscopically assisted The use of gastrocnemius recession has been 293
247 repair of the Achilles was performed. All patients gaining popularity recently for expanding indica- 294
248 were reported to have good to excellent out- tions such as Achilles tendinopathy, diabetic fore- 295
249 comes. However, two patients experienced sural foot ulcers, metatarsalgia, and plantar fasciitis 296
250 neuralgia in this series. In 2018 Rungprai and [22]. Endoscopic, minimally invasive techniques 297
251 Phisitkul reported a series of 23 consecutive to release the gastrocnemius have been described 298
252 patients that underwent endoscopically assisted in the literature with promising results. Potential 299
253 percutaneous Achilles tendon repair using advantages over open techniques include decreased 300
254 4-strand core suture configuration via a 6-portal wound complications, improved cosmetic result, 301
255 technique with good results [18]. At a mean fol- and diminished postoperative pain [13]. The larg- 302
256 low-up of 54.1 months patients experienced a est case series (320 patients, 344 feet) of patients 303
257 mean VAS improvement from 7.9 to 0.1, SF-36 that underwent endoscopic gastrocnemius reces- 304
258 improved from a PCS component score 32.5 to sion for isolated gastrocnemius contracture found 305
259 44.7 and MCS from 47.9 to 51.4, and FAAM a significant increase in mean ankle dorsiflexion, 306
260 ADL from 26.1 to 83.0 and sports from 0 to 61.7. increasing from −0.8 ° to 11 ° at 13 months post- 307
261 Only one superficial portal infection was reported operatively [23]. SF-36 and FFI all increased sig- 308
262 in this series in a diabetic patient. nificantly in these patients, mean VAS decreased 309
263 Pearce et al. reported a retrospective series from 7/10 to 3/10 postoperatively. However, 3.1% 310
264 consisting of 11 patients with noninsertional experienced subjective plantarflexion weakness 311
265 Achilles tendinopathy who underwent Achilles and 3.4% in this series experienced sural nerve 312
266 tendoscopy in conjunction with plantaris tendon dysesthesia. A recent retrospective study compar- 313
267 release with a minimum follow-up of 2 years ing open vs. endoscopic release reported 314
268 [19]. The authors reported that mean AOFAS significantly lower complication rates following 315
269 hindfoot scores improved from 68 (range, 51–82) endoscopic release (26.8 vs. 2.6%) [24]. 316
317 Endoscopic techniques have also been shown to 30.4.2 Surgical Techniques 360
318 be beneficial in treating insertional disease includ-
319 ing posterior ankle impingement, subtalar arthritis, Positioning: Prone. 361
320 and retrocalcaneal bursitis [14]. Leitze et al. pub- Instruments: 2.7 mm and 4 mm 30° endo- 362
321 lished a prospective series including 33 heels (30 scope, 4 mm shaver, Wissinger rod, retrograde 363
322 patients) with chronic retrocalcaneal pain who knife. 364
323 underwent endoscopic decompression and com- The posterolateral portal is created at the level 365
324 pared results to a group of 17 heels (14 patients) in just distal to the tip of the lateral malleolus and 366
325 which an open technique was performed [25]. The just lateral to the Achilles tendon. The postero- 367
326 endoscopic group reported AOFAS scores of 87.5 medial portal for FHL tendoscopy is created at 368
327 postoperatively compared to 79.3 in the open the level of intersection between the plantar 369
328 group; however, this did not reach statistical sig- aspect of the first ray and the medial border of 370
329 nificance (p = 0.115). The endoscopic group expe- the Achilles tendon. This posteromedial portal is 371
330 rienced fewer complications including 3% vs. 12% slightly proximal compared to the posterolateral 372
331 infection rate, 10% vs. 18% sensory deficits, and portal. The visualization and examination of the 373
332 7% vs. 18% scar tenderness. posterior ankle joint is routinely performed for 374
333 Based on the above data it appears that tendos- posterior hindfoot endoscopy. The constricting 375
334 copy is a valuable tool that may be useful in fibrous tunnel at the entrance to the sustentacu- 376
335 assisting minimally invasive tendon rupture lum tali or low-lying muscle can be debrided 377
336 repair, noninsertional Achilles tendinopathy, ret- with a shaver or an endoscopic scissors. A probe 378
337 rocalcaneal bursitis, and gastrocnemius reces- can be used to retract the tendon together with 379
338 sion. While there remains a paucity of high-level neurovascular structures medially allowing a 380
339 evidence, current literature has shown good out- part of zone 2 to be accessed from posterior 381
340 comes overall. portals. 382
The entire zone 2 tendoscopy of the FHL ten- 383
don is made possible with the establishment of a 384
341 30.4 Flexor Hallucis Longus (FHL) plantar portal. This portal is created inside out by 385
inserting a Wissinger rod into the FHL tunnel to 386
342 30.4.1 Indications exit on the medial aspect of the arch of foot. This 387
portal is associated with risks of nerve injuries as 388
343 Tendoscopy has a role in the treatment of FHL it is approximately only 5 mm from the medial 389
344 related conditions such as stenosing tenosynovi- plantar nerve [12]. Zone 3 tendoscopy requires a 390
345 tis, tendon contracture, intratendinous ganglion combination of the plantar portal and a plantar 391
346 cyst, bacterial tenosynovitis, synovial chondro- toe portal located on the plant aspect of the proxi- 392
347 matosis, loose bodies, and tendon transfer. The mal phalanx of the great toe. This zone requires 393
348 FHL tendoscopy is divided into three zones. the use of 2.7 mm endoscope or smaller. A retro- 394
349 Zone 1 is located at the posterior ankle just proxi- grade knife can be used to release tight fascial 395
350 mal to the opening of the tunnel underneath the bands overlying the FHL tendon in cases of ste- 396
351 sustentaculum tali [10]. Zone 2 is from the tunnel nosing tenosynovitis in the distal aspect of the 397
352 underneath the sustentaculum tali to the knot of FHL tendon (Fig. 30.6). 398
353 Henry. Zone 3 is from the knot of Henry to the
354 tendon insertion on the distal phalanx of the great
355 toe. FHL symptoms related to posterior ankle 30.4.3 Outcomes of FHL Tendoscopy 399
356 impingement are usually treated with Zone 1 ten-
357 doscopy in conjunction with posterior hindfoot Tendoscopy has been studied for several different 400
358 endoscopy, which will be discussed more exten- indications regarding the flexor hallucis longus 401
359 sively elsewhere. tendon including FHL autograft harvest, release, 402
chondral drilling, etc.) with the majority of 429

patients having good to excellent results [29, 30]. 430
Only two complications were reported involving 431
nerve irritation. Smith and Berlet in 2009 per- 432
formed posterior ankle debridement, os trigonum 433
excision, and FHL release in 14 patients with 434
good to excellent results in 12 [31]. Two patients 435
in this series had tibial nerve neuritis 436
postoperatively. 437
Lui presented a case report including two 438
patients in which FHL tendoscopy was per- 439
formed for FHL tenosynovitis [32]. In this proce- 440
dure he included a portal in the arch of the foot 441
allowing access to zone 2 of the tendon. Both 442
patients experienced paresthesia over the lateral 443
sole and plantar fourth and fifth rays. 444
Electromyography studies confirmed the diagno- 445
Fig. 30.6 Zone 3 tendoscopy of the FHL tendon (star) is
shown with the patient in prone position. Constricting sis of lateral plantar nerve injury. Symptoms 446
fibrous tunnel (arrow) is released using a retrograde knife resolved in one patient by 5 months, and the other 447
continued to experience symptoms 1 year later. 448
In 2013 Lui published a retrospective series com- 449
403 and debridement. However, most studies cur- prising five patients who underwent zone 2 FHL 450
404 rently available are level IV and V evidence. The harvest for Achilles tendon augmentation and 451
405 series are often mixed indications and include a reported ATSS improved from a mean of 29.4 452
406 variety of concomitant hindfoot procedures. FHL preoperatively to 89 postoperatively without 453
407 tendoscopy was first described by van Dijk for complications [33]. 454
408 the treatment of chronic FHL tendonitis in an ath-
409 lete by means of 2-portal posterior ankle endos-
410 copy [26]. 30.5 Peroneus Brevis and Longus 455
411 Corte-real et al. in 2012 utilized tendoscopy
412 for FHL release in 27 patients [27]. The authors 30.5.1 Indications 456
413 found good-to-excellent results in 19 out of 27
414 patients with a mean postoperative AOFAS score Tendoscopy has been more extensively described 457
415 of 89. Complications including extensive fibrous to assess peroneal tendon conditions. Diagnostic 458
416 tissue proliferation and transient medial calca- endoscopy is an important tool to evaluate for 459
417 neal numbness were noted. Ogut et al. performed pathologies such as tendon tears, dislocations, 460
418 FHL tenolysis in a series of 59 patients and found intrasheath subluxation, loose bodies, prominent 461
419 an increase in mean AOFAS-hindfoot score peroneal tubercle, accessory tendons, and low- 462
420 improved from 56.7 to 85.9 with a complication lying muscle [6, 9, 18, 23]. Visualization of the 463
421 rate of 3.4% including sural nerve irritation and tendon conditions allows surgeon to be more pre- 464
422 neuroma in two patients [28]. cise in the placement of an open incision if 465
423 Concomitant procedures commonly per- needed. The ability of peroneal tendoscopy in the 466
424 formed with FHL release include os trigonum definitive treatment of various pathologies is 467
425 excision, posterior ankle debridement, and pos- growing as experienced endoscopists could 468
426 sible posterior capsulectomy. Van Dijk published excise torn tendons, low-lying muscle, peroneus 469
427 one of the largest series in 2006 including 146 quartus tendon, and groove deepening of the dis- 470
428 procedures (FHL release, os trigonum, osteo- tal fibula. 471
472 30.5.2 Surgical Techniques
473 Positioning: Supine with a bump underneath the

474 ipsilateral buttock.
475 Instruments: 2.7 mm and 4 mm 30° endo-
476 scope, 3.5 mm shaver, 4 mm barrel bur.
477 A proximal portal is created 2 cm proximal to
478 the tip of the lateral malleolus at the soft spot
479 behind fibula bone. A 2.7 mm trocar is inserted
480 into the peroneal tunnel along the posterior
481 aspect of the distal fibula. The distal portal is
482 created inside out at the location 2 cm distal to
483 the tip of the lateral malleolus and along the line
484 of peroneal tendons. A probe is inserted into the
485 distal portal to assist with evaluation for patholo-
486 gies. Surgeons should look for tears in the pero-
487 neal tendons, especially split tears of the Fig. 30.7 Peroneal tendoscopy of a runner with a severe
488 peroneus brevis, contour of the peroneal groove ankle sprain demonstrates a rupture of the superior pero-
489 at the distal fibula, integrity of the superior peroneal retinaculum. The peroneus brevis tendon (star) is
490 neal retinaculum, and low-lying peroneus brevis intact
491 muscle (Fig. 30.7). Dynamic examination is per-
492 formed by observing the peroneal tendons dur- instrumentation. Visualization of the distal por- 519
493 ing range of motion from inversion to eversion tion of peroneus longus tendon on the plantar 520
494 and vice versa. Debridement of partial tendon aspect of the foot can be facilitated by using an 521
495 tears, synovitis, peroneus quartus tendon, and accessory portal on the lateral aspect of the 522
496 low-lying muscle is performed using a 3.5 mm cuboid. 523
497 shaver. Groove deepening procedure is per-
498 formed preferably with a combination of 4 mm
499 30° endoscope and a 4 mm barrel bur. The 30.5.3 Outcomes of Peroneal 524
500 groove should be approximately 10 mm in width, Tendoscopy 525
501 6 mm in depth, and 15 mm in length but the
502 extent of groove deepening should be individu- Tendoscopy procedures allow for minimally 526
503 alized depending on the anatomy of each patient. invasive treatment of peroneal tendon patholo- 527
504 It is critical that the very distal aspect of the gies with reduced wound complications and scar- 528
505 groove is contoured aggressively to avoid abra- ring. Overall outcome studies for peroneal tendon 529
506 sion of peroneal tendons as they are directed endoscopic procedures are difficult to generalize 530
507 more anteriorly. given the heterogeneity of pathologies and lack 531
508 Access to the peroneal tubercle is achieved by of level I and II evidence [10–12]. Most patholo- 532
509 using the distal portal as described earlier and gies fall into three categories: (1) tenosynovitis 533
510 adding an accessory portal 1.5 cm distal to the and tendinitis, (2) subluxation and dislocation, 534
511 peroneal tubercle and along the peroneus longus and (3) tendon tear and rupture. 535
512 tendon. To remove the prominent peroneal tuber- Van Dijk was the first to report on the out- 536
513 cle, the septum between the peroneus longus and comes of posterior endoscopy for peroneal 537
514 brevis tendons must be detached using a shaver tendinitis [34]. In his series of nine patients with 538
515 or an endoscopic scissors. The bone is then the retromalleolar pain, he found that at a mean fol- 539
516 compressed using a 4 mm barrel bur until there is low-up of 19 months, 8 out of 9 patients were 540
517 no impingement to the tendons. The two portals symptom free without complications. Jerosch 541
518 can be used interchangeably for visualization and et al. studied 15 patients that underwent peroneal 542
543 tendoscopy between 1999 and 2004 for tenosy- vitis that underwent endoscopic peroneal groove 591
544 novitis (seven), low-lying muscle belly of the deepening for retrofibular pain [38]. At a mean 592
545 peroneus brevis (two), and peroneal tendon insta- 24 months follow-up, 6 out of 7 patients (86%) 593
546 bility (one), and partial peroneal tears (five). At a returned to sporting or job activities. 594
547 mean follow-up of 2.8 years, all patients were Peroneal tendon subluxation represents 595
548 asymptomatic and were able to participate in another subset of individuals with peroneal ten- 596
549 moderate athletic activities [35]. Vega et al. don pathology. Peroneal groove deepening has 597
550 reported the outcomes of 52 patients with heter- been advocated to reduce pressure on peroneal 598
551 ogenous peroneal tendon pathologies undergoing tendons to facilitate healing. Edwards et al. 599
552 tendoscopy debridement and peroneal groove showed that there is a wide variation of groove 600
553 deepening from 2008 to 2011 [36]. Their cohort depth, ranging from 0 mm to 3 mm deep [39]. 601
554 included peroneal tendon ruptures (24 patients), However, he also found that 11% of patients have 602
555 tenosynovitis (13 patients), recurrent peroneal a flat grove and 7% have a convex groove. A 603
556 tendon subluxation (7), intrasheath subluxation cadaveric study performed by Schon et al. 604
557 (6), and adhesions (2). Patients with distal pero- showed that deepening the peroneal groove by 605
558 neal tendon tears underwent a min-open repair. 6 mm reduced tendon pressure readings along the 606
559 They found that at a minimum 1 year, intrasheath middle and distal aspects of the peroneal groove 607
560 subluxation patients had 100% excellent results [40]. Vega et al. followed seven patients with 608
561 (mean AOFAS score increased from 79 to 99). In chronic peroneal tendon subluxation that under- 609
562 the recurrent peroneal tendon subluxation group, went tendoscopic deepening of the peroneal 610
563 5 out of 7 patients (71.4%) had excellent results groove without superior peroneal retinaculum 611
564 (AOFAS score increase from 75 to 93 postopera- repair. Four patients had complete disruption of 612
565 tively). The peroneal tendon rupture group only the superior peroneal retinaculum which also 613
566 had a 62.5% symptom free rate, with 12.5% of underwent repair. At a mean follow-up of 614
567 patients reporting no change in symptoms. 15.4 months, no patients had recurrent sublux- 615
568 Outcomes for treatment of isolated tenosyno- ation and the mean American Orthopaedic Foot 616
569 vitis without subluxation has been described in and Ankle Scores (AOFAS) improved from 75 to 617
570 the literature. Scholten and van Dijk assessed 23 93 postoperatively. There was one patient that 618
571 patients that underwent peroneal tendoscopy for continued to have subjective clicking without 619
572 tenosynovitis with a minimum follow-up of frank subluxation of the tendons. 620
573 2 years. Their results showed that there were no Intrasheath subluxation represents a group of 621
574 complications or recurrence of pathology [3]. patients that present with retromalleolar clicking 622
575 More recently, Kennedy et al. reviewed 24 con- without reproducible tendon dislocation [15]. 623
576 secutive patients (mean age 34 years) with iso- Raikin et al. reported 14 patients with intrasheath 624
577 lated peroneal pathology that underwent peroneal subluxation and intact superior peroneal retinac- 625
578 tendoscopy at a single institution [37]. All cases ulum confirmed on ultrasound. Type A intra- 626
579 received platelet-rich plasma as a biologic aug- sheath subluxations occurred when the anatomic 627
580 ment. At a mean follow-up of 33 months, the position of the peroneus longus and brevis 628
581 mean foot and ankle outcome score (FAOS) and switched at the peroneal groove with resisted 629
582 short form-12 (SF-12) improved from 57 to 86 dorsiflexion and eversion. Type B intrasheath 630
583 and 54 to 81, respectively. Nine patients under- subluxations occurred when the peroneus longus 631
584 went endoscopic peroneal groove deepening. subluxed through a longitudinal tear in the pero- 632
585 Two patients with greater than 10 mm tears neus brevis tendon. Recently, Guelfi et al. 633
586 underwent mini-open tubularization procedures. described a new subset of patients with combined 634
587 This series mostly comprised of patients with intrasheath peroneal tendon subluxation and con- 635
588 tenosynovitis and lacked patients with subluxat- comitant superior peroneal retinaculum injury 636
589 ing peroneal tendons. Lui studied seven patients [16]. These patients present with snapping at the 637
590 retrospectively with isolated peroneal tenosyno- peroneal tendon without frank subluxation. The 638
639 authors retrospectively followed 18 patients of 200 patients that underwent hindfoot arthros- 684
640 (mean age 29 years) undergoing tendoscopy for a copy, 31 patients undergoing tendoscopy for 685
641 mean follow-up of 45 months. They found that debridement and vinculum removal had good 686
642 twelve patients had a space occupying lesion and results [29]. In his series, partial repairs under- 687
643 underwent debridement. Six patients were found went a mini-open procedure. Chow’s case series 688
644 to have a superior peroneal retinaculum injury of six patients with stage I posterior tibial tendon 689
645 and underwent a peroneal groove deepening dysfunction did well with tendoscopic synovec- 690
646 without superior peroneal retinaculum repair. At tomy without progression to stage II disease [42]. 691
647 the final follow-up, the mean AOFAS scores These patients returned to work at 10 weeks and 692
648 improved from 76 preoperatively to 97 postoper- resumed sports at 6 months postoperatively. 693
649 atively. Additionally, there were no reported Khazen et al. performed tendoscopy for nine 694
650 recurrences among the cohort. patients with stage I posterior tibialis tendon dys- 695
651 Lastly, peroneal tendoscopy can be used in function, including three open tendon repairs for 696
652 conjunction with ankle and subtalar arthroscopy partial tears [43]. They found that patients with 697
653 [17]. Bare and Ferkel found that in 30 patients isolated tenosynovitis returned to work by 698
654 undergoing peroneal tendon procedures, 100% of 6 weeks and patients with tendon tears returned 699
655 patients had at least one intra-articular ankle to work by 10 weeks. Bernasconi et al. reported 700
656 derangement during arthroscopy [19]. In 16 patients with stage II posterior tibialis tendon 701
657 Bojanic’s series, 8 out of 13 tendoscopy proce- deficiency treated with tendoscopy. At a mean of 702
658 dures were performed in conjunction with ankle 25.6 months, VAS pain and SF-36 mental compo- 703
659 arthroscopy or open procedures. At 1 year fol- nent scores significantly improved [44]. Eighty 704
660 low-up, all patients did well without pain or percent of patients were relieved of symptoms. 705
661 clicking [17]. However, three patients underwent subsequent 706
open calcaneal osteotomy and posterior tibialis 707
tendon augmentation procedures. Most of these 708
662 30.6 Other Tendons in the Foot patients were found to have severe spring liga- 709
663 and Ankle ment injuries. 710
Although rarely utilized, tendoscopy debride- 711
664 Tibialis posterior tendinitis is commonly seen in ment of the tibialis anterior tendon and extensor 712
665 early stage planovalgus deformity [20]. tendons has been reported in the literature [45, 713
666 Tenosynovitis of the tibialis posterior tendon can 46]. Irritation along the tibialis tendon can arise 714
667 present with medial hindfoot pain at the navicu- from overuse, inflammatory conditions, or infec- 715
668 lar. Over time, the diseased tendon can rupture tion [47–49]. The utilization of tendoscopy 716
669 and lead to attenuation of the spring ligament and around the tibialis tendon and extensor tendon is 717
670 medial longitudinal arch collapse. Common non- riskier than other location given the close prox- 718
671 operative modalities include orthotic wear and imity of various neurovascular structures. Care 719
672 activity modification. When nonoperative treat- must be taken not to debride the extensor reti- 720
673 ment fails, tendoscopy debridement can provide naculum to prevent bowstringing of the extensor 721
674 pain relief and improved function. tendons [50]. Also, avoiding debriding the poste- 722
675 The results of tendoscopy for tibialis posterior rior aspect of the tibialis anterior tendon will pre- 723
676 tendinitis are favorable. Before endoscopy, vent disruption of its blood supply as it enters the 724
677 Johnson and Teasdall reported 90% good results paratenon from the medial tarsal artery [51]. 725
678 after open synovectomy of the posterior tibialis There have also been case reports of 726
679 tendon [21]. In 1995, Wertheimer was the first to pseudoaneurysms of the dorsalis pedis artery fol- 727
680 describe tendoscopy treatment of posterior tibial lowing tendoscopy of the extensor tendons [49, 728
681 tendon dysfunction [1]. Van Dijk soon reported 52, 53]. 729
682 his technique for tendoscopy debridement of the Lui reported in 2005 a small case series of 730
683 posterior tibialis tendon [41]. In van Dijk’s series three patients that underwent tendoscopic 731
732 debridement of the flexor digitorum longus for 5. Lui TH. Flexor hallucis longus tendoscopy: a tech- 777
nical note. Knee Surg Sports Traumatol Arthrosc. 778
733 metatarsalgia and flexor tenosynovitis. One 2009;17(1):107–10. https://doi.org/10.1007/s00167- 779
734 patient presented after a post-infective tenosyno- 008-0623-x. 780
735 vitis from a previous penetrating injury. The 6. Lui TH. Tendoscopy of peroneus longus in the sole. 781
736 other two patients presented with focal idiopathic Foot Ankle Int. 2013;34(2):299–302. https://doi. 782
org/10.1177/1071100712464954. 783
737 flexor tenosynovitis. At 2-year follow-up, all 7. Lui TH. Endoscopic ganglionectomy of palmar gan- 784
738 three patients had resolution of their metatarsal- glion via flexor carpi radialis tendoscopy. Arthrosc 785
739 gia without any complication [54]. Tech. 2017;6(5):e1459–e63. https://doi.org/10.1016/j. 786
eats.2017.06.002. 787
8. Lui TH. Flexor pollicis longus tendoscopy. Arthrosc 788
Tech. 2017;6(1):e249–e54. 789
740 30.7 Conclusion 9. Arya AV, Yan BM. Ultra high magnification endos- 790
copy: is seeing really believing? World J Gastrointest 791
741 Since the first description of tendoscopy more Endosc. 2012;4(10):462–71. https://doi.org/10.4253/ 792
wjge.v4.i10.462. 793
742 than two decades ago for the posterior tibial ten- 10. Cychosz CC, Phisitkul P, Barg A, Nickisch F, van Dijk 794
743 don, indications for this novel technique have CN, Glazebrook MA. Foot and ankle tendoscopy: 795
744 expanded to other tendons including the Achilles evidence-based recommendations. Arthroscopy. 796
745 tendon, flexor hallucis longus, peroneal longus 2014;30(6):755–65. https://doi.org/10.1016/j.arthro. 797
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746 and brevis, tibialis anterior, flexor digitorum lon- 11. Bernasconi A, Sadile F, Smeraglia F, Mehdi N,
799
747 gus, extensor hallucis longus, and extensor digi- Laborde J, Lintz F. Tendoscopy of Achilles, pero- 800
748 torum longus [1]. Techniques have been refined neal and tibialis posterior tendons: an evidence-based 801
749 since the original description as well as scope update. Foot Ankle Surg. 2018;24(5):374–82. https:// 802
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750 technology. Overall, good outcomes have been 12. Monteagudo M, Maceira E, Martinez de Albornoz 804
751 reported in the literature for the use of tendos- P. Foot and ankle tendoscopies: current concepts 805
752 copy. Advantages of tendoscopy include quicker review. EFORT Open Rev. 2016;1(12):440–7. https:// 806
753 recovery time and superior cosmetic result com- doi.org/10.1302/2058-5241.160028. 807
13. Phisitkul P, Barg A, Amendola A. Endoscopic reces- 808
754 pared to open procedures. As with most orthope- sion of the gastrocnemius tendon. Foot Ankle Int. 809
755 dic literature, there is a paucity of high-level 2017;38(4):457–64. 810
756 evidence supporting the use of the procedure, and 14. Spennacchio P, Cucchi D, Randelli PS, van Dijk
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757 currently most of evidence has been reported by NC. Evidence-based indications for hindfoot 812
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1 Insertional Achilles Tendinopathy
31
2 Gian Luigi Canata and Valentina Casale
3 31.1 Introduction terms of causes, histopathology, prognosis, and 29

treatment [3] (Fig. 31.1). 30
4 Insertional Achilles tendinopathy is a painful Insertional Achilles tendinopathy usually occurs 31
5 and debilitating condition, representing among in active people, whereas non-insertional injuries 32
6 one-third of all Achilles tendon pathologies [1]. are more frequent among older, less active, and 33
7 Patients of all ages and activity levels may be overweight people [2]. In a large retrospective 34
8 affected, especially running athletes [2]. study, Kvist et al. reported that 66% of competitive 35
9 Overuse injuries of the Achilles tendon must and recreational athletes had non-insertional tendi- 36
10 be distinguished between insertional (at the nopathy, while 23% had either retrocalcaneal bursi- 37
11 calcaneus- Achilles tendon junction) and non- tis or insertional Achilles tendinopathy [6]. A more 38
12 insertional (2–6 cm proximal to the calcaneus- recent study conducted by Mansur found that 16% 39
13 Achilles tendon junction) tendinopathies [3, 4]. of the active people presenting this condition end up 40
14 Among the insertional Achilles tendinopathies, quitting sports activity [7]. 41
15 a clear distinction should be made between the The insertional Achilles tendinopathy is 42
16 Haglund disease and all the other insertional located at the insertion of the Achilles ten- 43
17 pathologies. In fact, the term Haglund’s exosto- don onto the calcaneus, often associated with 44
18 sis is commonly referred to a clinical assessment the formation of bone spurs and calcifications at 45
19 characterized by pain and tenderness usually at the insertion site; the pain is mostly limited to the 46
20 the postero-lateral side of the calcaneus, where a midportion of the posterior aspect of the calca- 47
21 calcaneal prominence can often be felt [3]. neus, where the bone spur may be palpable; the 48
22 A further classification of the Achilles tendon dis- histopathologic process consists in an ossification 49
23 orders marks a clear difference between insertional of the enthesial fibrocartilage, and small tendon 50
24 tendinopathies, pre-insertional tendinopathies (or tears may occur at the tendon-bone junction [3]. 51
25 retrocalcaneal bursitis, an example is the Haglund’s Radiographic findings of the Achilles tendon 52
26 exostosis), and superficial calcaneal bursitis [5]. disorders appear differently according to the vari- 53
27 The Haglund disease and the other conditions, ous pathologic conditions [3]. 54
28 as the superficial Achilles bursitis, are different in In fact, ultrasonography (US) and CT scan are 55
helpful for evaluating patients with insertional 56
Achilles tendinopathy to show the presence of 57
G. L. Canata (*) · V. Casale ossification or bone spurs at the tendon insertion, 58
Centre of Sports Traumatology, Koelliker Hospital,
Torino, Italy with or without osteophytes along the tendon, cal- 59
e-mail: studio@ortosport.it caneal bony alterations and possible focal lesions 60
© ISAKOS 2019 349

https://doi.org/10.1007/978-3-662-58704-1_31
350 G. L. Canata and V. Casale
include hyperpronation, pes cavus, leg length 82

discrepancy, limited mobility of the subtalar 83
joint, as well as advancing age, obesity, diabetes, 84
hypertension, and use of steroids, estrogens, and 85
fluoroquinolone antibiotics [13–16]. The extrin- 86
sic predisposing factors are associated to changes 87
in training pattern, footwear, and running on 88
smooth, hard, and sloping surfaces [6, 17]. 89
A few studies analyzed the biomechani- 90
cal causes of this pathology; Maganaris et al. 91
reported that the affected site is usually “stress 92
shielded” [18]. When inflammation is pro- 93
longed, the bursa may become fibrotic and 94
reduces its lubricating function [19]. Repetitive 95
traumas determine cartilage-like changes within 96
the Achilles tendon, consequently leading to 97
intra-tendinous bone formation through endo- 98
chondral ossification [20]. 99
Among the many theories developed over the 100
years, Benjamin et al. reported that the ossifica- 101
tion process at the tendon insertion would not 102
depend on previous traumas and inflammations, 103
Fig. 31.1 Haglund calcaneal prominence and calcific
rather on an adaptive structural change. As the 104
insertional tendinopathy
bone-tendon junction surface increases, the ten- 105
don stands higher mechanical loads [21]. 106
61 within the tendon. CT scan specifically reveals the It has been demonstrated that the site of tendon 107
62 bone formation and its details, whereas magnetic degeneration is characterized by irregular-sized 108
63 resonance imaging (MRI) provides hyperintense tenocytes that are likely to develop apoptosis [2, 109
64 signals at tendon insertion [3, 8]. 22]. The result is a chronic mucoid and/or lipid 110
65 Insertional Achilles tendinopathy causes tendon degeneration, with potential fibrocarti- 111
66 intense heel pain, especially in the morning, and it laginous metaplasia and calcium hydroxyapatite 112
67 is exacerbated by activity [9]. Patients classically deposits [23–25]. 113
68 experience pain and swelling along the distal ten- Tendons are relatively avascular. Thereby, 114
69 don insertion into the calcaneus [10]. Symptoms neovascularization becomes the hallmark of a 115
70 are more intense during exercise, when ascend- chronic inflammation usually associated with the 116
71 ing stairs and running on hard surfaces. presence of mechanoreceptors and nerve-related 117
72 Clinically, there may be a palpable point of components [26, 27]. A retrocalcaneal bursitis 118
73 tenderness and swelling on the posterior aspect must be suspected if the patient complains of 119
74 of the calcaneal tuberosity, as well as a promi- pain and swelling anteromedially and anterolat- 120
75 nent calcaneal exostosis [11]. Thickening of the erally to the Achilles tendon [2]. 121
76 Achilles tendon may be present in case of chronic
77 inflammation [12].
31.3 Imaging 122
78 31.2 Pathophysiology It is widely assumed that insertional Achilles ten- 123

dinopathy is clinically diagnosed; nevertheless, 124
79 The etiology of the insertional Achilles tendinop- radiological imaging may be helpful to better 125
80 athy is multifactorial and several predisposing define the clinical assessment, as well as for the 126
81 factors have been proposed. Intrinsic risk factors preoperative planning if surgery is required [28]. 127
31 Insertional Achilles Tendinopathy 351
contraction, has not showed significant results 156

for insertional Achilles tendinopathies, although 157
this option has been proved to be effective in 158
case of non-insertional pain [2, 33]. The key 159
factor resides in the paratendon oxygen satura- 160
tion: changes in tendon and paratendon micro- 161
circulation are well documented in insertional 162
and midportion tendinopathy. The paratendinous 163
postcapillary filling pressure usually increases at 164
the superficial tendon insertional area [34]. The 165
eccentric-training program may reduce both the 166
augmented paratendinous capillary blood flow 167
and the pain [34]. 168
Whereas the eccentric training program for 169
Fig. 31.2 Radiological image of insertional calcific insertional tendinopathies does not guarantee the 170
Achilles tendinopathy same good results achievable in other tendon loca- 171
tions, several alternatives have been proposed: 172
128 Plain weight bearing radiographs of the foot infiltrations, electrostimulation, sclerotherapy, 173
129 are usually the first exam to be performed [28]: and others aim to stimulate healing process to 174
130 any alteration of the medial longitudinal arch of the degenerated tendon [7]. Nevertheless, the 175
131 the foot may be identified through the anteropos- low rate of success has led clinicians to promote 176
132 terior and the lateral views, and the presence of recovery by angiogenesis enhancing and diffu- 177
133 intra-tendinous calcifications or bony exostosis sion of cytokine molecules [7]. 178
134 can be detected [2] (Fig. 31.2). Extracorporeal shockwave therapy (ESWT) 179
135 Both MRI and US provide additional infor- actually stimulates neovascularization and angio- 180
136 mation to distinguish the different structural genesis at the tendon-bone junction, also causing 181
137 abnormalities detectable at the Achilles tendon epidermal nerve fibers degeneration and promot- 182
138 insertion [1]. Nevertheless, it must be consid- ing reinnervation [35–38]. Furia et al. reported 183
139 ered that the extreme sensitivity of MRI may the effectiveness of this treatment, compared 184
140 also identify structural abnormalities that with other conservative management strategies. 185
141 are not strictly related to clinical symptoms However, they suggested to avoid a local anesthe- 186
142 [29–31]. sia field block before the application of the shock 187
waves, as it could negatively influence treatment 188
effectiveness [13]. 189
143 31.4 Treatment Ultrasounds can be also used as a treatment 190
approach: by reducing swelling and pain in the 191
144 31.4.1 Nonoperative Management acute phase and increasing function in chronic 192
tendinopathies, they enhance tendon heal- 193
145 In the acute phase, an initial period of rest or ing process [39, 40]. High quality data are still 194
146 immobilization is advisable, associated with needed to confirm the efficacy of this treatment 195
147 modified activity [2]. option [41]. 196
148 Other conservative options include stretching Some authors propose local injections into 197
149 exercises, extracorporeal shock wave therapy, the the retrocalcaneal space, avoiding the use of 198
150 use of non-steroidal anti-inflammatory drugs, corticosteroids and local anesthetics; the risk 199
151 orthotics, and shoe modification: in particular, is to weaken the tendon tissue and to expose 200
152 heel lifts contribute to a consistent reduction of the tendon to rupture [42]. It has been also 201
153 the Achilles tendon tension [12, 32]. reported by Kleinman that local steroid injec- 202
154 Eccentric training, through which the tenon tions can increase the risk of an acute tendon 203
155 is lengthened during simultaneous muscular tear [43]. 204
205 31.4.2 Surgical Treatment the Achilles tendon includes a complete tendon 252
detachment [2] that should be avoided, whenever 253
206 Insertional Achilles tendinopathy is a distinct possible. As tendon reattachment may potentially 254
207 clinical entity from the pre-insertional tendi- predispose to risks of tendon ruptures [28], this 255
208 nopathy with retrocalcaneal bursitis and both are surgical technique is advisable only if more than 256
209 different from the midsubstance tendinopathy not 50% of the Achilles tendon has been detached 257
210 only concerning etiology and injury mechanism, [52]. However, a wide consensus among sur- 258
211 but also for treatment and rehabilitation ([3, 8, geons has not been reached yet. 259
212 14, 44]). Some authors have described the surgical man- 260
213 Patients who do not respond to conservative agement of calcific insertional tendinopathy with 261
214 management may require surgery. Surgical treat- a lateral, medial, or midline skin incision [55], 262
215 ment has been increasingly performed over the as well as J-shaped one [45], eventually followed 263
216 last decades. by a partial or full-thickness Achilles detach- 264
217 Most clinicians wait at least from 3 to ment from its insertion; however, no significant 265
218 6 months before proceeding with surgery [4]. clinical differences have been reported between 266
219 Surgical procedures include tendon debride- partial or no tendon detachment and a complete 267
220 ment, enthesiophyte resection, gastrocnemius tendon detachment [45]. According to some 268
221 elongation, and the posterior superior calcaneal authors, a central tendon splitting incision may 269
222 eminence removal in case of concomitant pre- be useful to better remove the degenerative tissue 270
223 insertional symptoms [2, 8, 44–46]. and the calcifications [10, 46, 55]. The real extent 271
224 In a recent review, two main categories of sur- of calcifications may not be appreciated through 272
225 gical treatment have emerged: debridement alone medial and/or lateral approaches, because they 273
226 and debridement combined with tendon aug- occur within the middle third of the degenerative 274
227 mentation in case of excessive tendon loss [47]. tendon insertion in 95% of cases [46]. 275
228 However, there is no specific evidence about A further example of skin incision is the trans- 276
229 which surgical technique may guarantee better verse Cincinnati approach, described by Maffulli 277
230 postoperative results. et al. [56]. The retrocalcaneal bursa may be resected 278
231 The main goal is to remove the degenera- to prevent postoperative recurrent pain [12]. 279
232 tive tissue and its associated ossification and, The open surgical approach may cause postop- 280
233 if needed, the posterior calcaneal eminence, erative complications, such as wound dehiscence 281
234 in addition to the retrocalcaneal spur resection and infection, sural nerve damage and tendon 282
235 [48]. After suturing the detached Achilles tendon necrosis scarring, especially if the classic longi- 283
236 fibers, tendon insertion reattachment and tendon tudinal extensile approach is performed [57]. In 284
237 augmentation may be subsequently required [49]. order to reduce the frequency of these events, some 285
238 Debridement of the degenerative tendon tis- authors have proposed less invasive approaches, 286
239 sue associated with osteotomy is known to be like the percutaneous technique ([58–63]). 287
240 effective for patients younger than 50 years, Surgical techniques focused on the treat- 288
241 with moderate tendon involvement [46, 50]. In ment of each specific pathology are clearly less 289
242 elderly patients, persistent pain and limited func- invasive and ease rehabilitation processes. Pre- 290
243 tion have been reported as possible postoperative insertional pathologies may be addressed with a 291
244 problems, probably due to a limited vasculariza- mini-open lateral access or endoscopically while 292
245 tion and a lower capacity for full recovery [51]. insertional calcifications and the debridement of 293
246 In rare cases, some authors propose the addition the degenerative tissue can be managed through 294
247 of the flexor hallucis longus (FHL) tendon trans- a direct Achilles tendon splitting (Figs. 31.3a,b, 295
248 fer to support and protect the debrided Achilles 31.4, 31.5). Moreover, given the blood supply 296
249 tendon [51–54]. The result is an improved plan- of the tendon is via the paratenon, a lateral or 297
250 tarflexion strength and a more effective heal- medial incision may disrupt the blood supply 298
251 ing capacity, especially if the debridement of [10, 46, 55, 64]. 299
a b
Fig. 31.3 Calcific insertional body excision (a); calcific bodies are removed (b)
Fig. 31.4 Achilles tendon suture after central tendon

splitting for a double calcification
300 An accurate preoperative clinical and radio-

301 logical evaluation is important for the exact local-
302 ization of the calcific area and allows a direct and
303 less invasive surgical approach.
304 If an Haglund’s deformity is present, the aim Fig. 31.5 Calcific insertional tendinopathy: Achilles ten-
305 is to remove the painful bony prominence of the don splitting and excision of the bony fragment. At the upper
306 posterosuperior corner of the calcaneus, as well as left, the incision for a concomitant Haglund deformity
to debride the diseased tendon, if necessary, and to 307

excise the inflamed bursal tissue [65]. The surgeon 308
must pay attention not to damage the tendon inser- 309
tion when removing the bony prominence [66] 310
(Figs. 31.6, 31.7, 31.8). Recently, the endoscopic, 311
the percutaneous, and the mini-open calcaneo- 312
plasty are the most described approaches [67–72]. 313
Fig. 31.6 Mininvasive calcaneoplasty for Haglund

deformity Fig. 31.7 The fragment excised
Fig. 31.8 Mini-open
technique for Haglund’s
deformity: bony
prominence resection
sparing the Achilles
insertion
314 31.5 Postoperative Management References 358

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1
2
Non-insertional Achilles
Tendinopathy: State of the Art
32
3 R. Aicale, D. Tarantino, and N. Maffulli
4 32.1 Anatomy of the Tendon begins about 12–15 cm proximal to its insertion, 23

becoming more marked in the distalmost 5–6 cm. 24
5 The Achilles tendon is formed by the confluence The tendon spirals approximately 90°, with the 25
6 of the gastrocnemius and soleus muscles. The medial fibres rotating posteriorly, and the poste- 26
7 soleus lies deep to the gastrocnemius muscle, rior fibres rotating laterally. Angiographic injec- 27
8 arising from the posterior surface of the upper tion techniques have demonstrated a zone of 28
9 tibia. The tendon inserts on the posterior surface hypovascularity 2–7 cm proximal to the tendon 29
10 of the calcaneus, distal to the postero-superior insertion. 30
11 calcaneal tuberosity. The Achilles tendon is not The number of intra-tendinous vessels, and 31
12 encased in a true synovial sheath, but is sur- the relative area occupied by them, is lowest 4 cm 32
13 rounded by paratenon, which is composed of from the calcaneal insertion [1]. 33
14 a single layer of cells. The paratenon is highly Within the extracellular matrix network, 34
15 vascularised, and it is responsible for the ten- tenoblasts and tenocytes constitute 90–95% of 35
16 don’s blood supply [1], through a series of trans- the cellular elements of tendons. The remaining 36
17 verse vincula which reach the tendon and act as 5–10% consists of fibrochondrocytes, synovial 37
18 passageways for vessels. The Achilles tendon cells of the tendon sheath, and endothelial cells 38
19 also receives blood from vessels arising at the and smooth muscle cells [2]. Collagen type 1 39
20 musculotendinous and osteo-tendinous junc- accounts for 65–80%, while elastin accounts for 40
21 tions. Healthy tendons are brilliant white, with about 2% of the dry mass of tendons. Tenocytes 41
22 a fibroelastic texture. The rotation of the tendon and tenoblasts lie between the collagen fibres 42
along the long axis of the tendon [2]. 43
R. Aicale · D. Tarantino Tendon innervation arises from three main 44
Department of Musculoskeletal Disorders, School of sources: 45
Medicine and Surgery, University of Salerno,
Salerno, Italy
• Cutaneous nerve trunks. 46
N. Maffulli (*) • Muscular nerve trunks. 47
Department of Musculoskeletal Disorders, School of
Medicine and Surgery, University of Salerno, • Peritendinous nerve trunks. 48
Salerno, Italy
Queen Mary University of London, Barts and the Nerve fibres cross and enter the endotenon 49
London School of Medicine and Dentistry, Centre for septa at the musculo-tendinous junction. Nerve 50
Sports and Exercise Medicine, Mile End Hospital, fibres penetrate the epitenon from plexuses in 51
London, UK
the paratenon. Most nerve fibres do not actually 52
e-mail: n.maffulli@qmul.ac.uk
© ISAKOS 2019 359

https://doi.org/10.1007/978-3-662-58704-1_32
360 R. Aicale et al.
53 enter the main body of the tendon, but they termi- The term ‘tendinopathy’ is preferred to the 98
54 nate as nerve endings on its surface. Nerve end- previously used term ‘tendinitis’ because does 99
55 ings of myelinated fibres function as specialised not convey the concepts of inflammation or 100
56 mechanoreceptors to detect changes in pressure degeneration [18, 19]. In tendinopathy the essen- 101
57 or tension. Unmyelinated nerve endings act as tial lesion is failed healing response [20]. 102
58 nociceptors, sensing and transmitting pain. Both The incidence of Achilles tendinopathy has 103
59 sympathetic and parasympathetic fibres have been reported to be as high as 37.3 per 100,000 in 104
60 been identified in tendons [3]. Autonomic pep- some European populations [21–23]. This condi- 105
61 tides such as neuropeptide Y and vasoactive intes- tion is the result of intrinsic and extrinsic factors 106
62 tinal peptide, which regulate vasoactivity, act in which contribute to the development of non- 107
63 tendons [3, 4]. insertional Achilles tendinopathy [24]. The first 108
64 Tendons transmit force generated by muscle ones are age, body habitus, nutrition, metabolic 109
65 to bone. They also act as a buffer, by absorbing diseases, genetic, lower limb malalignment, leg 110
66 external forces to limit muscle damage: this func- length discrepancy [25, 26] and limited ankle 111
67 tion requires mechanical strength, flexibility and dorsiflexion [27, 28]; the others are training 112
68 elasticity [2]. As collagen fibres deform, they errors, drugs including steroids and fluoroquino- 113
69 respond linearly to increasing tendon loads [5]. lones [29, 30], compression, disuse, and excess 114
70 The configuration is initially lost when the stretch loading [31]. 115
71 exceeds 2%, but is re-gained if the strain placed Among the metabolic diseases, the most 116
72 on the tendon remains at less than 4%. If strain important is dyslipidaemia, but measurement of 117
73 exceeds 8%, macroscopic rupture will occur [6, 7]. cholesterol in patients presenting Achillodynia 118
74 The tensile strength of tendons is related to this does not seem to be justified. The literature 119
75 thickness and collagen content: a tendon with a nevertheless suggests that it should probably be 120
76 cross-sectional area of 1 cm2 is capable of support- considered in patients with bilateral extensive 121
77 ing 500–1000 kg. Loading of the Achilles tendon disease or those who give a history of intermittent 122
78 reaches up to 9 kN during running (corresponding episodes of severe Achilles tendon pain lasting a 123
79 to 12.5 times the body weight), 2.6 kN during slow few days [32]. 124
80 walking and less than 1 kN during cycling [8]. Another retrospective study also found vari- 125
ous statistically significant associations between 126
tendinopathy and diabetes mellitus, obesity and 127
81 32.2 Introduction hypertension [33]. 128
82 Non-insertional Achilles tendinopathy is the

83 commonest pathological condition, representing 32.3 Clinical Presentation 129
84 between 55% and 65% of disorders [6, 9, 10].
85 The term ‘tendinosis’ was used by Puddu et al. Achilles tendinopathy has been described in asso- 130
86 [11] in 1976 to describe the histological changes, ciation with many different sporting activities, 131
87 which include loss of the normal collagenous but middle and long-distance runners have the 132
88 architecture and replacement with an amorphous greatest susceptibility to it [10, 24, 34–36]. The 133
89 mucinous material, hypercellularity, increased annual incidence in high-level club runners was 134
90 glycosaminoglycans and neovascularisation between 7% and 9% [37]. Tendinopathy typically 135
91 [12–14]. It was previously thought that inflam- occurs between 2 cm and 6 cm from the insertion 136
92 mation was not an important factor in the condi- of the Achilles tendon into the calcaneus [20]. 137
93 tion [12, 15]; however, recently the importance The major symptom in non-insertional Achilles 138
94 of inflammation in the pathological process has tendinopathy is pain, which can markedly inter- 139
95 been re-evaluated, and the inflammatory process fere with function and athletic activity. The pain 140
96 may be a contributory factor to the development is common on first moving after a period of rest 141
97 of tendinopathy [16, 17]. and it is most intense. A diagnosis of Achilles 142
32 Non-insertional Achilles Tendinopathy: State of the Art 361
143 tendinopathy is usually clinical on the basis of 32.4.2 Instrumental Diagnosis 187
144 history and presentation. Patients often present
145 pain and swelling on the posteromedial aspect of Imaging techniques, including ultrasound (US) 188
146 the tendon, and tenderness can usually be elicited and magnetic resonance imaging (MRI) scans, 189
147 with palpation over the swelling [31, 38]. can occasionally be useful to identify the nature, 190
148 The origin of pain in tendinopathy of the location and extent of a lesion[49, 50]. US may 191
149 main body of the Achilles tendon is, however, be particularly useful with the addition of power 192
150 controversial [39–41]. Abnormal neoinnervation Doppler, because the pain in Achilles tendi- 193
151 often accompanies the neovascularisation, and is nopathy seems to be related to areas of neovas- 194
152 thought to play a central role in the development cularisation [14, 44, 51]. Neonerves grow into 195
153 of pain [14, 42–44]. the tendon with the new vessels, and these can 196
transmit the pain of the tendinopathy [52–54]. 197
Treatment modalities which reduce the amount 198
154 32.4 Diagnosis of neovascularisation can lead to a reduction in 199
symptoms [52, 53, 55]. Equally, treatments that 200
155 32.4.1 Clinical Diagnosis have proven to be clinically effective have subse- 201
quently been shown to reduce neovascularisation 202
156 In addition to the swelling on the posteromedial within the tendon, although the evidence for this 203
157 aspect of the tendon and palpation pain, some clin- hypothesis has recently been challenged [39, 56]. 204
158 ical tests have been described for non-insertional Ultrasound may also be used to guide the various 205
159 Achilles tendinopathy diagnosis. They can be injection therapies available. 206
160 divided into palpation tests (tendon thickening, Few studies have compared ultrasound with 207
161 crepitus, pain on palpation, the Royal London MRI in the diagnosis of Achilles tendinopathy. 208
162 Hospital (RLH) test, the painful arc sign) and ten- Early studies seem to indicate that MRI scans 209
163 don loading tests (pain on passive dorsiflexion, are better for characterising degeneration in the 210
164 pain on single heel raise and pain on hopping). Achilles tendon [57, 58]. However, later research 211
165 The painful arc sign, in which a painful swell- has shown better accuracy with ultrasound when 212
166 ing moves with ankle movement, indicates tendi- compared with MRI scans in the detection of ten- 213
167 nopathy rather than paratendonitis [45]. Less pain dinopathy [59]. Greyscale ultrasonography was 214
168 of the swelling in ankle dorsiflexion is indicative more sensitive, whereas colour Doppler ultra- 215
169 of tendinopathy with the RLH test [46]. Maffulli sound had a higher association with patients’ 216
170 et al. studied sensitivity, specificity, reproducibil- symptoms [60]. 217
171 ity, and predictive value of palpation of the pain- Newer imaging modalities such as ultrasound 218
172 ful arc sign and of the Royal London Hospital tissue characterisation and sono-elastography 219
173 test in 10 patients with Achilles tendinopathy have yielded promising initial results in improv- 220
174 and in 14 asymptomatic subjects, and found no ing sensitivity, specificity and accuracy in diag- 221
175 evidence of a difference of the three assessment nosis [61, 62]. Further studies may be needed to 222
176 methods (p > 0.05); when the test were com- investigate their role and application in the man- 223
177 bined, the overall sensitivity was 0.586, and the agement of Achilles tendinopathy. 224
178 overall specificity was 0.833 [47].
179 Hutchinson et al. in 2013 studied the ten clini-
180 cal tests mentioned above and found that two 32.5 Treatment 225
181 tests (location of pain and pain to palpation)
182 are sufficient and accurate for clinical use [46]. 32.5.1 Conservative Management 226
183 A 2014 meta-analysis concluded that the most
184 appropriate clinical reference standard for diag- The first line of management for Achilles tendi- 227
185 nosis of Achilles tendinopathy needed further nopathy is conservative, and different treatments 228
186 investigation [48]. such as nonsteroidal anti-inflammatory drugs, 229
230 physical therapy, taping, cryotherapy, shock ening alone in terms of Victorian Institute of 278
231 wave therapy, hyperthermia and various periten- Sports Assessment—Achilles (VISA-A) scores 279
232 dinous injections have been used with varying and pain ratings at 4 months. The proportion of 280
233 success [54]. patients who were ‘completely recovered’ or 281
234 The management of Achilles tendinopathy ‘significantly improved’ on the Likert scale was 282
235 lacks evidence-based support, because few treat- also significantly better in the combined therapy 283
236 ment modalities have been investigated in ran- group (82%) compared with 56% in the strength- 284
237 domised controlled trials [54], and approximately ening alone group. 285
238 25% of patients do not respond to conservative ESWT, when compared with eccentric 286
239 management [63]. strengthening in a RCT, showed comparable 287
240 Good results have been reported with eccen- outcomes, with 60% of the patients completely 288
241 tric exercises [64, 65], but eccentric exercises recovered or significantly improved in both of 289
242 alone may not work in all patients [66]; however, the treatment groups and significantly better than 290
243 the mechanism of action is not completely under- those in the ‘wait and see’ control group [72]. 291
244 stood [65]. Eccentric exercises are the most effec- The success rate was lower than that seen in 292
245 tive conservative treatment for non- insertional other studies, possibly because one-third of the 293
246 Achilles tendinopathy. The most commonly used patients in this study were not athletic and results 294
247 protocol is the Alfredson’s protocol: the exer- are worse in these individuals [66]. In conclu- 295
248 cises are performed in three sets of 15 repetitions, sion, where available, ESWT should probably be 296
249 twice a day for 12 weeks [67]. the second line treatment. 297
250 This regime was demonstrated to be effective ESWT works on two aspects of the clini- 298
251 in a 2009 systematic review, and confirmed with cal response, namely tissue healing and pain 299
252 a meta-analysis in 2012, which outlined the best transmission. Regarding the second, ESWT can 300
253 pooled data supporting eccentric exercises, with change the histological appearance of dorsal root 301
254 the majority of the studies adopting Alfredson’s ganglion, modulating both central and periph- 302
255 protocol [68]. Hailing this as “probably the great- eral nervous system inducing long-term analge- 303
256 est single advance in the management of this sia [78]. Regarding tendon healing, ESWT can 304
257 condition in the past 20 years” [69], Alfredson increase the levels of factors involved in tissue 305
258 and other Scandinavian authors have reported healing TGF-β1 and IGF-I expression in a rat ten- 306
259 excellent results in prospective RCTs [70, 71]. dinopathy model [79] and significantly decrease 307
260 However, the proportion of good and excellent some interleukins [80] and matrix metallopro- 308
261 results in other studies using eccentric exercises teinases (MMPs) on cultured tenocytes [81]. 309
262 is definitely lower [66, 72]; this can result from Various injection therapies have been pro- 310
263 many factors, and the protocol requires motivated posed [82]. In a recent systemic review [83], only 311
264 and compliant patients. ultrasound-guided sclerosing polidocanol injec- 312
265 Other protocols, such as eccentric–concentric tions seemed to yield promising results, but these 313
266 progressing to eccentric (Silbernagel combined) results do not appear to have been duplicated 314
267 [70] and eccentric–concentric (Stanish and outside Scandinavia [84]. The use of platelet-rich 315
268 Curwin) [73], have been described. A systematic plasma (PRP) seems to be growing exponentially, 316
269 review showed that combined type exercise have especially among sports medicine physicians, but 317
270 equivalent results to the traditional Alfredson’s the only well-designed RCT published on PRP in 318
271 protocol [74]. Isotonic, isokinetic and concentric Achilles tendinopathy showed no significant dif- 319
272 loading have also been described, but are infe- ference in pain or activity level between PRP and 320
273 rior to the eccentric-type exercises [75, 76]. In a saline injection at 6, 12 or 24 weeks when com- 321
274 prospective randomised controlled study, Rompe bined with an eccentric stretching programme [85]. 322
275 et al. [77] showed that eccentric strengthening High volume image guided injections (HVIGI) 323
276 plus repetitive low-energy shock-wave therapy significantly reduce pain and improve function in 324
277 (ESWT) was better than eccentric strength- patients with resistant Achilles tendinopathy [86]. 325
326 The effects of HVIGI on neovascularisation and Multiple percutaneous longitudinal tenoto- 371
327 tendon thickness are not known. A prospective mies, which can be performed under ultrasound 372
328 study of 2009 [87] assessed the effect of HVIGI guidance, produce good results, with the further 373
329 (a mixture of 10 mL 0.5% bupivacaine hydro- advantage of being able to perform the procedure 374
330 chloride and 25 mg of hydrocortisone acetate, fol- under local anaesthesia in an outpatient setting 375
331 lowed by 4 × 10 mL of injectable normal saline) [99, 100]. 376
332 on patients’ function, neovascularisation and ten- Minimally invasive open debridement with 377
333 don thickness in a short-term 3-week follow-up. resection of the plantaris tendon has also shown 378
334 There was a statistically significant difference promising results with minimal complications 379
335 between baseline and 3-week follow-up in all in elite athletes and regular patients with non- 380
336 the outcome measures after HVIGI. In particu- insertional Achilles tendinopathy [38, 101–104]. 381
337 lar, neovascularisation was significantly reduced. There are no comparative studies between the 382
338 The high volume injection may produce local different minimally invasive approaches, and 383
339 mechanical effects, causing the neovascularity to therefore it is unclear whether it is necessary to 384
340 stretch, break or occlude [87]. perform longitudinal tenotomies or to excise the 385
plantaris tendon. 386
Therefore, minimally invasive surgical treat- 387
341 32.5.2 Surgical Management ment would appear to be a useful intermediate 388
step between failed conservative treatment and 389
342 Conservative treatment fails in between one- formal open surgery [54]. 390
343 quarter and one-third of patients, and surgical
344 intervention is required [88]. Open surgery has
345 shown varying success rates between 50% and 32.6 Conclusion 391
346 100% [89–92] with removal of intra-tendinous
347 lesions, and late-presenting lesions showing sig- Non-insertional Achilles tendinopathy is a pain- 392
348 nificantly fewer good to excellent results [93, ful and debilitating condition arising from a failed 393
349 94]. For non-insertional Achilles tendinopathy, healing response that can affect athletes and 394
350 surgery has traditionally involved a large inci- non-athletes alike. The majority of patients will 395
351 sion and excision of all of the pathological tis- respond to conservative treatment. For patients 396
352 sue, with or without augmentation with a tendon who fail conservative treatment, minimally inva- 397
353 transfer [95]. sive techniques show promising results with low 398
354 The main concern with open surgery is the complication rates, and may be a good option 399
355 risk of complications. A large series of 432 con- before open surgery. 400
356 secutive patients from a specialist centre reported
357 an overall complication rate of 11% [96]. These
358 may include skin edge necrosis, wound infection, References 401
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787 2015;49(23):1532–4.
1 Achilles Tendon Ruptures
33
2 Jon Karlsson, Olof Westin, Mike Carmont,
3 and Katarina Nilsson-Helander
4 33.1 Introduction degree of spiraling depends on the position of 26

the fusion between the two muscles. More distal 27
5 Acute Achilles tendon rupture is a common fusion increases the rotation. The insertion of the 28
6 sports-related injury. Most of the patients are tendon in the calcaneus is crescent shaped. This 29
7 middle-aged, participating in recreational activi- osteo-tendinous junction provides a fulcrum and 30
8 ties, such as tennis and badminton. increases the lever arm. The retrocalcaneal bursa 31
9 The rupture occurs in the majority of cases in the is located between the tendon and the calcaneus 32
10 midportion of the tendon, approximately 2–6 cm and reduces friction during motion [3]. 33
11 from the bony insertion to the calcaneus. Distal rup-
12 tures, in a few cases with avulsion (bony avulsion)
13 from the calcaneus, are less common. The Achilles 33.2 Biomechanics 34
14 tendon is the largest and most powerful tendon in
15 the human body. It is formed by the soleus and In terms of biomechanics, it is important to note 35
16 gastrocnemius muscles and is located in the poste- that it is the tendon itself that transmits the force, 36
17 rior superficial compartment of the leg. The aver- while the muscle-tendon unit, which consists of 37
18 age length of the Achilles tendon is 15 cm (range the tendon as well as its muscle and aponeuro- 38
19 11–26 cm) and mean width is 6.8 cm (4.5–8.6) [1]. sis, creates the whole unit. The Achilles tendon 39
20 The Achilles tendon is important for running can store energy and release it when necessary. 40
21 and jumping, the reason it can produce such When jumping on one leg 74% of the mechanical 41
22 forceful elastic recoil and elongation is due to the energy is stored and 16% of the total mechanical 42
23 spiraling of the tendon. It spirals 90° and in doing energy comes from the elastic recoil action of the 43
24 so produces an area of concentrated stress, with tendon. When force is applied to a tendon it will 44
25 the fulcrum in the ankle joint [2] (Fig. 33.1). The lengthen, the effect of this is demonstrated in the 45
stress-strain curve. The stress that is placed on the 46
tendon is calculated by dividing the force with 47
J. Karlsson (*) · O. Westin · K. Nilsson-Helander the cross-sectional area of the tendon and given 48
Department of Orhopaedics, Institute of Clinical
Sciences at Sahlgrenska Academy, University of as the percentage of change in tendon length dur- 49
Gothenburg, Gothenburg, Sweden ing loading; hence a thicker tendon is able to sus- 50
e-mail: jon.karlsson@telia.com; tain a higher load than a thinner one. To describe 51
jon.karlsson@vgregion.se the stiffness of the tendon, it is the slope of the 52
M. Carmont linear region of the stress-strain curve. When 53
Department of Orthopaedic Surgery, The Princess at rest the fibers of the Achilles tendon are in a 54
Royal Hospital, Telford, Shropshire, UK
© ISAKOS 2019 369

https://doi.org/10.1007/978-3-662-58704-1_33
370 J. Karlsson et al.
ever, it is clear that there is a wide variation and 67

that the incidence is increasing with values as 68
much as 55.2 per 100,000 in males. The reason 69
for this increment is that there is an increas- 70
ing number of ruptures in the over 60 years age 71
group, thought to be due to greater sports partici- 72
pation. Achilles tendon rupture is more common 73
in men than woman with a quote at 5:1 [5]. Two 74
age-related peaks have been reported. One in 75
the early 40s often related to a sporting activity 76
(recreational athletes) and one in the 60–65 years 77
age group, usually more associated with minor 78
trauma [6]. 79
33.4 Injury Mechanism 80
The mechanism of an Achilles tendon rupture 81

can be classified into three main categories 82
(Fig. 33.3): 83
–– Push-off with the weight-bearing foot while 84

the knee is extended. 85
–– Sudden unexpected powerful dorsiflexion of 86
the foot. 87
–– Forced dorsiflexion of the plantar flexed foot. 88
33.5 Etiology 89
Fig. 33.1 The Achilles tendon anatomy and rotation The etiology of an Achilles tendon rupture is 90
multifactorial. Degenerative changes may occur 91
in the tendon, which will reduce its strength 92
55 curly configuration. As seen in the figure they over time. This may explain the increase 93
56 become stretched at 1–3% and can return to its in incidence that has been correlated to the 94
57 former length when stretched. At more than 4% increasing participation in sporting activities in 95
58 the fibers microfailure starts. If further force is the middle aged (around 40 years of age and 96
59 applied after this the tendon will eventually older). Inflammatory disorders, such as rheu- 97
60 break, i.e., macroscopic failure (Fig. 33.2). Eight matoid arthritis, as well as chronic renal failure 98
61 per cent is often quoted in the literature as when and diabetes have been shown to increase the 99
62 macroscopic failure starts [4]. risk of rupture. The role of corticosteroid injec- 100
tions as a risk factor has been much debated and 101
it is generally thought that the use of corticos- 102
63 33.3 Incidence teriod may increase the risk of r upture, but the 103
evidence is in fact limited. It is also noted that 104
64 The incidence of Achilles tendon ruptures has repeated microtrauma leads to long- standing 105
65 been extensively researched lately. It had been weakness of the tendon, which over time might 106
66 reported to be 18 per 100,000 in the 1990s; how- lead to rupture. 107
33 Achilles Tendon Ruptures 371
Stress (N/mm2)
Physiological Overuse injury Tendon rupture
Rupture
Microscopic
failure
Straighten
fibers
Strain (%)
0 2 4 6 8 10
Crimped
fibers
Fig. 33.2 Tendon stress-strain curve
Fig. 33.3 The mechanism of an Achilles tendon rupture
108 33.6 Clinical Signs for chronic rupture along with passive hyper- 115
dorsiflexion of the ankle. Sometimes the clinical 116
109 Patients often describe an Achilles tendon rup- presentation can be difficult and it is well known 117
110 ture as a sudden acute snap in their calf just above that up to 20% of acute ruptures may be missed 118
111 the ankle, as if someone had kicked them from in the early phase by patients and physician, and 119
112 behind onto the heel [7]. This is then followed may be mistaken for an ankle sprain. 120
113 by weakness and difficult to bear weight. Poor Physical examination may be a challenge. 121
114 balance and altered gait are more common signs Sometimes the plantar flexion weakness that one 122
123 suspects with a tendon rupture can be masked by causes a deformation of the triceps surae muscle 153
124 the posterior tibial, plantar, and peroneus mus- with synchronized bowstringing of the Achilles 154
125 cles. It is important to note that patients with a tendon away from the tibia. The test is negative 155
126 totally ruptured Achilles tendon can still walk on if plantar flexion occurs, which indicates that the 156
127 the injured foot, something that may be confus- tendon is intact. If there is no plantar flexion and/ 157
128 ing to the attending clinician. The tendon gap can or clear difference from the contralateral side, the 158
129 be difficult to palpate due to swelling and hema- test is positive. 159
130 toma. It is important to understand this and be
131 able to clinically examine an Achilles tendon in
132 order to reduce the incidence of missed diagno- 33.6.1 Surgical or Nonsurgical 160
133 sis. Several specific tests have been described. Treatment 161
134 In most cases there are no warning symptoms
135 and the injury is related to one distinct ankle The superiority of surgical or nonsurgical treat- 162
136 trauma. Almost always the rupture is total, and ment is still debated, together with the timing of 163
137 partial Achilles tendon rupture is very rare, espe- rehabilitation, for instance weight-bearing, early 164
138 cially in cases with a specific and classic symp- or delayed motion and whether functional brac- 165
139 toms, like “pop” sensation, which is localized to ing should be used or not. Treatment decisions 166
140 the midportion of the tendon. The diagnosis is depend on a patient’s individual requirements, 167
141 clinical in the first place and there is no need to participation in sports activity, acceptance of 168
142 rely on either ultrasonography and/or magnetic brace use, and perception of risk. 169
143 resonance imaging (MRI) [8–10]. The diagnosis
144 of mid-substance rupture is clinical with positive
145 Thompson’s test (calf squeeze test) [11], an abnor- 33.6.2 Nonsurgical Treatment 170
146 mal resting posture, particularly on knee flexion
147 and almost always a palpable gap in the tendon. Traditional methods of nonsurgical treatment 171
148 The Thompson test, also named the Simmonds include cast immobilization for 3-months fol- 172
149 test, is performed with the patient in prone posi- lowed by physiotherapy referral [BOFAS]. Other 173
150 tion with the ankles hanging of the bed or with established methods of nonsurgical treatment 174
151 the knee flexed and the ankle free in the air include the use of bespoke braces [12], boots 175
152 (Fig. 33.4). The examiner squeezes the calf which with wedges [13, 14], controlled ankle motion 176
Fig. 33.4 Thompson’s
test
177 walkers [15], and conforming vacuum walkers shortening of the tendon. On the other hand, the 222
178 with graduated ankle posture [16]. Meta-analyses risk of elongation is more pronounced and needs 223
179 have suggested similar re-rupture rates to those to be avoided, as elongation will lead to reduced 224
180 of surgical treatment, for nonsurgical manage- plantar flexion strength and dysfunction [22]. 225
181 ment when early weight-bearing and range of
182 motion exercises are adopted [17].
183 Nonsurgical management with protocols 33.8 Surgical Technique 226
184 include an assessment after 2 weeks of cast
185 immobilization [16, 18]. If abnormal resting pos- The skin incision is usually 5–6 cm long. A pos- 227
186 ture to the ankle or a palpable gap is still pres- teromedial incision is preferred to reduce the risk 228
187 ent surgical repair is recommended. Nonsurgical of iatrogenic sural nerve injury. The paratenon is 229
188 treatment in the presence of greater than 1 cm visualized and incised longitudinally. The frayed 230
189 separation of the tendon ends has been shown to ends of the tendon are then visualized and mobi- 231
190 lead to significant dysfunction [19]. lized. Suture placement is placed in the proximal 232
191 Re-rupture rates in nonoperative treatment and distal ends. The distal stump is usually around 233
192 may be minimized further by the prolonged 2–3 cm long and good suture stability can be 234
193 wearing of braces for as much as 4 months for achieved with locking sutures proximal and distal 235
194 vulnerable activities [16, 18]. to the frayed rupture ends. The surrounding tissues 236
must always be handled with great care in order 237
to enable closure and optimize blood flow in the 238
195 33.7 Surgical Treatment vascular paratenon, enhancing tendon healing and 239
reduce the risk of wound breakdown and infection. 240
196 Open surgery (end-to-end repair) is considered to The frayed tendon ends are carefully apposed with 241
197 be the gold standard surgical procedure and with the foot in plantar flexion. There are several differ- 242
198 experience the length of the skin incision can be ent suture techniques with Kessler, Bunnell, and 243
199 minimized to only 5–6 cm long [20] [Karlsson]. Krackow sutures being most commonly used [23]. 244
200 Studies have not shown any advantage of fascial A recently described technique is based on 245
201 turn-down flaps [21] (however, this technique can both core and circumferential sutures. This may be 246
202 be used for re-ruptures or ruptures with delayed pre- termed stable repair [24]. In fact, the purpose is to 247
203 sentation). The end-to-end technique is appositional create such stable construct that immediate weight- 248
204 repair and can be performed without any augmenta- bearing (possible without any postoperative 249
205 tion up to approximately 3 weeks. The important immobilization) is achieved. The two core sutures 250
206 contraindications are skin conditions (wounds, vari- consist of non-absorbable sutures with a modified 251
207 cose veins), peripheral vascular diseases, and heavy Kessler technique. The double Kessler locking 252
208 smoking, where the risk of infection is high. loop is placed well away from the rupture site in 253
209 The open end-to-end repair can be performed order to increase strength. Care must be taken not 254
210 in local anesthesia, or regional or general anes- to damage the core sutures by needle passage. The 255
211 thesia. The patient is placed in the prone posi- ankle is held in 20–30° of plantar flexion, mimick- 256
212 tion and tourniquet is not needed. Prophylactic ing the other non-injured side and the sutures are 257
213 antibiotics and antithrombotic treatment is rec- tied using four throws (Fig. 33.5). During rehabili- 258
214 ommended. The feet are located over a pillow tation the tendon may elongate as much as 1 cm 259
215 or hanging over the end of the operating table. It and in anticipation of this elongation the tendon is 260
216 is important to have the opportunity to measure tied in increased tension with the ankle in relating 261
217 the Achilles Tendon Resting Angle (ATRA) of increased plantar flexion or ATRA. When the core 262
218 both ankles to ensure the tendon is repaired 5–7° sutures are independently tied, a running circum- 263
219 tighter than on the non-injured [1]. Excessive ferential suture is added to augment the strength 264
220 plantar flexion, possible in flexible females, will of the repair [25]. Absorbable suture are used, 265
221 increase the risk of overtightening and thereby with a continuous interlocking horizontal mattress 266
Fig. 33.5 Illustration of

core suture
267 suture [26]. Finally, the paratenon is very carefully

268 repaired and thereafter absorbable subcutaneous
269 sutures and meticulous skin sutures. Interrupted
270 sutures are recommended for optimal skin tension.
271 33.9 Postoperative Management
272 The postoperative management is described as

273 accelerated rehabilitation, compared to tradi-
274 tional methods of 3 months cast immobilization
275 [27]. Even though the core sutures are strong and
276 will probably allow full range of motion training
277 already early on, a cast is recommended for the
278 first two weeks in order to rest the wound and
279 reduce the risk of wound breakdown and infec-
280 tion [24, 28]. Weight-bearing is not allowed
281 while the ankle is held in a temporary plaster cast
282 in plantar flexion. A walker brace with 2–3 heel
283 pads is applied after 2 weeks [24] (Fig. 33.6).
284 One heel pad is then removed every other week, Fig. 33.6 Walker brace
285 while weight-bearing is gradually increased. 9. Reiman M, Burgi C, Strube E, Prue K, Ray K, Elliott 330
A, et al. The utility of clinical measures for the diag- 331
286 Full weight-bearing can be allowed already after nosis of achilles tendon injuries: a systematic review 332
287 2 weeks. A standard rehabilitation protocol is with meta-analysis. J Athl Train. 2014;49(6):820–9. 333
288 used. The total rehabilitation time is approxi- 10. Dams OC, Reininga IHF, Gielen JL, van den Akker- 334
289 mately 6 weeks. Scheek I, Zwerver J. Imaging modalities in the diag- 335
nosis and monitoring of Achilles tendon ruptures: a 336
systematic review. Injury. 2017;48(11):2383–99. 337
11. Thompson TC. A test for rupture of the tendo achillis. 338
290 33.10 Summary Acta Orthop Scand. 1962;32:461–5. 339
12. Thermann H, Zwipp H, Tscherne H. Functional treat- 340
ment concept of acute rupture of the Achilles tendon. 341
291 Ruptures of the Achilles tendon are increasing. 2 years results of a prospective randomized study. 342
292 Treatment should be individualized to a Unfallchirurg. 1995;98(1):21–32. 343
293 patient’s requirements. 13. Willits K, Amendola A, Bryant D, Mohtadi NG,
344
294 Nonsurgical treatment provides good outcome Giffin JR, Fowler P, et al. Operative versus nonop- 345
erative treatment of acute Achilles tendon ruptures: 346
295 for patients with low physical activity demands. a multicenter randomized trial using accelerated 347
296 Surgical repair reduces re-rupture rate, mini- functional rehabilitation. J Bone Joint Surg Am. 348
297 mizes lengthening for the Achilles tendon, and 2010;92(17):2767–75. 349
298 optimizes plantarflexion strength following 14. Ingvar J, Tagil M, Fau - Eneroth M, Eneroth 350
M. Nonoperative treatment of Achilles tendon rup- 351
299 injury. ture: 196 consecutive patients with a 7% re-rupture 352
300 This stable surgical technique allows early rate. Acta Orthop. 2005;76(4):597–601. (1745-3674 353
301 range of motion training and early weight- (Print)). 354
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303 has been shown to be 0%. les tendon rupture: a randomized, controlled study 357
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308 techniques. Foot Ankle Surg. 2013;19(4):245–9.
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309 2. Edama M, Kubo M, Onishi H, Takabayashi T, Inai
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1
2
Minimally Invasive Repair of Acute
Achilles Tendon Ruptures Using
34
3 the Percutaneous Achilles Repair
4 System (PARS) Arthrex Device
5 A. Nguyen and J. Calder
34.1 Background
The Achilles tendon is formed from the merger

of the gastrocnemius and soleus muscles to insert
on the calcaneus. It is enclosed by a thin gliding
membrane paratenon, which provides nutrition
and vascular supply to the tendon [1].
The tendon is a viscoelastic structure, capable
of undergoing elongation and deformation in
response to stress. This is true only up to certain
levels of strain; if strains are between 4% and 8%
the Achilles tendon complex may be damaged,
and ruptures can occur if strains exceed 8% [2].
Acute rupture of the Achilles tendon can be
associated with a classic history of sudden onset
of pain, with almost exclusively no direct trauma
to the region. Patients give a typical history of
hearing a ‘pop’ and believing they were hit by
something or somebody.
Clinical examination reveals a loss of the
physiologic position of the affected ankle, and
can be evaluated with the patient prone with
both knees flexed. Comparison will reveal a rela-
tively more neutral to dorsiflexed position of the
injured side.
Ecchymoses and swelling is common, and a
A. Nguyen palpable gap can sometimes be felt at the region
Orthopaedic Surgery Department, Fortius Clinic,
London, Greater London, UK of injury. A calf squeeze test may show no ankle
plantar flexion.
J. Calder (*)
Orthopaedic Surgery Department, Fortius Clinic, Generally an X-ray is performed as baseline
London, Greater London, UK to exclude any bony pathology, but in general no
imaging studies are required for the diagnosis of
Department of Bioengineering, Imperial College,
South Kensigton Campus, London, UK Achilles tendon rupture. Dynamic ultrasound can
e-mail: james.calder@fortiusclinic.com be useful to aid surgical planning, especially in
© ISAKOS 2019 377
https://doi.org/10.1007/978-3-662-58704-1_34
6 the chronic setting, where tendon mobility and pared the PARS Arthrex system to open repair 51
7 tissue integrity can be questionable and more and found a significant reduction in total compli- 52
8 complex reconstructions may be required. cations (5% vs. 10.6%), with improved rates of 53
return to baseline activity [8]. 54
This system also allows for a knotless 55
9 34.2 Management approach at the repair site when combined with 56
the Speedbridge system; this has been shown to 57
10 There is controversy regarding the optimal man- produce excellent results in the elite athlete set- 58
11 agement of the acute Achilles rupture. Concern ting, where faster rehabilitation is made possible 59
12 for higher rates of re-rupture in non-operatively by fixation to bone in the distal os calcis, and 60
13 managed patients has led to a rise in the popular- there is a theoretical reduction in suture bulk and 61
14 ity of surgical intervention. This is balanced by knot slippage [9]. 62
15 the risks of infection, wound issues, and other To summarise, management decision-making 63
16 surgical and anaesthetic complications. should be patient focused, with a knowledge 64
17 The rate of re-rupture has been consistently of occupation and sporting level, medical co- 65
18 shown to be high with non-operative cohorts (as morbidities including smoking and vasculopathy, 66
19 high as 10–12% in many recent meta-analyses as well as patient wishes. 67
20 [3], as opposed to 1–2% for patients treated
21 operatively). These figures have been criticised
22 for including patients not participating in func- 34.3 Operative Technique Using 68
23 tional rehabilitation in the non-operative cohort PARS® 69
24 but recent studies continue to demonstrate higher
25 rates of re-rupture in non-operative (6.7%) vs. A general anaesthetic is typically used. The 70
26 operative (3.7%) Achilles injuries [4]. patient is positioned in the semi-prone position 71
27 Another proposed advantage of surgical treat- with the legs positioned prone, the hips semi- 72
28 ment over non-surgical is the reduced loss of prone and the upper body positioned lateral. 73
29 plantar flexion push-off strength. Several stud- Minimal bolster support is required. The upper- 74
30 ies have demonstrated relative push-off strength most arm is placed in an arm gutter and a sand- 75
31 is higher following surgical repair compared to bag may be placed under the iliac wing to prevent 76
32 non-operative management [5]. any forward tilt. A preoperative assessment of 77
33 Proponents of a surgical management also the patient to exclude significant limitation of 78
34 cite a return to functional activity and sports with hip external rotation or increased tibial torsion 79
35 surgical treatment. A recent systematic review should be performed, as this may in rare cases 80
36 demonstrated faster rehabilitation, reduced time make this positioning difficult. A fully prone 81
37 back to work, and better functional outcome after position may be used in this case. 82
38 surgery [6]. A tourniquet is applied around the thigh and 83
39 One of the major disadvantages of a surgi- inflated to 300 mmHg; this is easiest to apply 84
40 cal approach is the complication profile, notable before the patient is positioned semi-prone. 85
41 wound healing and infection. Open repair has Intravenous antibiotics are administered prior to 86
42 traditionally been performed with a large lon- inflation of the tourniquet. The feet are positioned 87
43 gitudinal incision and locking Krakow sutures over the end of the table with a pillow under both 88
44 to approximate the tendon ends. This has been tibiae to allow the gastrocnemius to relax slightly. 89
45 shown to have a higher rate of complications over It is desirable to prepare and drape both legs to 90
46 non-operative treatment, including wound prob- allow for comparison of foot position following 91
47 lems [7]. repair to ensure appropriate repair tension. 92
48 The percutaneous or mini-incision techniques Skin sterilisation below the knee is sufficient 93
49 have shown reduced rates of these potentially in the acute repair setting using an alcoholic 94
50 disastrous complications. A recent study com- chlorhexidine preparation solution. 95
34 Minimally Invasive Repair of Acute Achilles Tendon Ruptures Using the Percutaneous Achilles Repair… 379
96 A 2–3 cm incision is placed 1 cm below the

97 end of the proximal tendon stump. The inci-
98 sion can be made either vertically or horizon-
99 tally depending on preference; the authors have
100 experience with both with no significant compli-
101 cations. If made vertically, the incision is made
102 just to the medial side of the mid-posterior line.
103 Meticulous skin and tissue handling is imper-
104 ative throughout this procedure. After the skin
105 is incised, the paratenon, if not already opened
106 as a result of the injury, is incised. Often a gap
107 is then seen with strands of ruptured tendon vis-
108 ible. The tendon ends need to be identified for the
109 PARS device to be passed within the paratenon.
110 Dissection can be performed to identify and free
111 both the proximal and distal tendon ends using a
112 blunt curve Mayo scissor.
113 The tendon may be stabilised using a tendon
114 clamp, and the inner arms of the PARS jig are
115 now placed within the paratenon on either side of
116 the proximal tendon. Once inside, the inner arms
117 can be opened or closed by rotating the wheel on
118 the jig. The device is then inserted along either
119 side of the tendon. The muscle belly will usually
120 stop the device at an appropriate level (Fig. 34.1).
121 The jig has corresponding numbered holes
122 on either side to allow for passing of sutures. We
123 typically use suture tape, as it allows for stron-
124 ger hold, with a flatter profile of suture. There
125 are seven holes for suture options and holes 3 Fig. 34.1 Advancement of the PARS jig inside the
126 and 4 are obliquely orientated and designed for paratenon, with careful traction on the proximal tendon
127 a looped suture to pass through. This is a locking
128 suture. We typically use holes 1–5 for Achilles
129 fixation. Pass sutures through holes 1–5, to have
130 a configuration as shown. One looped suture is on
131 either side of the jig (Fig. 34.2).
132 The jig is then slowly withdrawn out of the
133 incision, and once the inner arms are seen, pull
134 the suture loose from the outer arms and remove
135 them from the wound to avoid getting stuck in the
136 holes of the outer jig (Fig. 34.3).
137 The number 2 hole suture is then passed under
138 suture 3 and 4 and through the loop on each side,
139 and then pulled through to achieve a locking
140 suture on each side (Figs. 34.4 and 34.5).
141 All steps are now repeated for the distal por-
142 tion of the tendon, to achieve the following final Fig. 34.2 Passage of sutures through the proximal ten-
143 configuration (Fig. 34.6). We recommend that it don and PARS jig
144 is essential to check each suture both proximally This will approximate the tendon and allow 161
145 and distally for pull out strength. If a suture for tying of the locking sutures which will not 162
146 pulls through the tendon on moderate tension, slide. Tie the locking sutures on each side with 5 163
147 then it needs to be redone. When testing pull out knots and then the final suture hole number 1 to 164
148 strength, pull the sutures in a direction parallel complete the repair (Fig. 34.7). 165
149 with the Achilles tendon to avoid strafing the skin A 2/0 vicryl epitendinous suture is then 166
150 and wound edge. used to augment the repair, with care to place 167
151 The tendon is now ready to be repaired. With knots on the deep surgical side. The paratenon 168
152 the foot in maximal plantar flexion, tie the suture is then loosely closed with 2.0 vicryl rapide, 169
153 from hole number 5 with 4 knots on each side. A and the small skin incision with interrupted 170
154 low sterile table at the end of the bed is useful to 3.0 nylon. A front slab is then applied in 20° 171
155 lay the foot on in a plantarflexed position, both equinus. 172
156 when exposing the tendon ends and when tying
157 the repair. This is useful to free up the surgical
158 assistant for other tasks. The height of the bed 34.4 Alternative Technique Using 173
159 can then be adjusted to obtain the optimal foot PARS/Speedbridge 174
160 position prior to tying the sutures.
This technique is a modified percutaneous tech- 175
nique that combines the benefits of percutaneous 176
repair with direct bone fixation, bypassing suture 177
Fig. 34.3 De-tensioning the suture construct to facilitate

removal of sutures and PARS jig Fig. 34.6 Final suture construct prior to knot tying
Figs. 34.4 & 34.5 Creation of the locked suture know on each side of the proximal tendon
500–1000 cycles of this construct in comparison 182

with a standard open Krakow suture repair [10] 183
(Fig. 34.8). 184
The surgical technique is identical in posi- 185
tioning, incision and preparation of the proxi- 186
mal stump with the PARS device. Two stab 187
incisions 2 cm apart are then made at the level 188
of the Achilles insertion over the calcaneus and 189
drilled using a 3.5 mm drill guide. These holes 190
are then tapped in preparation for two 4.75 mm 191
SwivelLock anchors (Figs. 34.9 and 34.10). 192
A Banana SutureLasso device is passed from 193
each of the two distal incisions to capture the 194
three sutures on each side of the tendon proxi- 195
mally, and these are pulled through into the distal 196
incisions (Fig. 34.11). 197
The anchors are then inserted at correct ten- 198
sion to achieve the final construct (Fig. 34.12). It 199
is possible to place an epitendinous suture at the 200
level of the proximal incision if desired. 201
Fig. 34.7 Suture tying with the foot (not shown) in

appropriate plantar flexion
34.5 Pearls and Pitfalls 202
Use gentle pressure in a downwards direction on 203

the tendon ends to hold the tendon in place when 204
passing the sutures. We have found in very rare 205
circumstances the proximal end of the tendon can 206
be difficult to transfix with percutaneous sutures. 207
In this case the PARS can be used for the distal 208
stump, and a ‘half-open’ approach can be used, 209
with a longer incision proximally. Given that it is 210
the distal portion of the wounds that in our expe- 211
rience is most affected by wound issues in the 212
open repair setting, this can be a useful adjunct 213
in the difficult case. 214
We have found it useful to vary the angle of 215
the jig slightly in the axial plane while passing the 216
sutures; this can facilitate sutures at a slightly dif- 217
ferent angle in the substance of the tendon, and is a 218
Fig. 34.8 Biomechanical comparison of PARS/ useful technique if sutures are pulling out on testing. 219
Speedbridge combination construct compared to open The authors use SutureTape® in distinction to 220
Krakow repair
a Fibrewire® or vicryl suture for repair. We have 221
found this to be a lower profile suture reducing 222
178 knots at the repair site as well as the potentially the size of knots and potential wound problems. 223
179 compromised tissue at the rupture site [9]. SutureTape has also been shown to have a higher 224
180 Biomechanical studies have demonstrated sta- ultimate load to failure and greater tissue pull- 225
181 tistically significantly less cyclic displacement at through strength than a #2 FibreWire [11]. 226
Figs. 34.9 & 34.10 Preparation of distal anchors after identical use of PARS jig in proximal tendon
Figs. 34.11 & 34.12 Sutures passage to distal anchor site and final construct after anchor insertion
227 In slight variation of the PARS only technique Acknowledgments All images courtesy of Arthrex Inc. 263
228 for suture knot tensioning, we have found that

229 tying the locking sutures off first is best for approx-
230 imation. Following this, we tie both sutures on one References 264
231 side of the Achilles tendon and slide the knot proxi-
1. Wagner E, Ortiz C. Mini-open Achilles tendon 265
232 mally by pulling on the suture on the opposite side. repair: perspective 2. In: Weisel S, editor. Operative 266
233 This leaves two knots proximally and away from techniques in orthopaedic surgery, vol. 4. 2nd ed. 267
234 the wound which we believe reduced the risk of Netherlands: Wolters Kluwer; 2016. p. 4985–90. 268
235 wound problems due to suture bulk. 2. Movin T, Ryberg A, McBride DJ, et al. Acute 269
rupture of the Achilles tendon. Foot Ankle Clin. 270
2005;10:331–56. 271
3. Soroceanu A, Sidhwa F, Glazebrook M, et al. Surgical 272
236 34.6 Post-operative Care vs nonsurgical treatment of acute Achilles tendon 273
rupture: a meta-analysis of randomized trials. J Bone 274
Joint Surg Am. 2012;94:2136–43. 275
237 The wound(s) are dressed with an absorbent 4. Renninger C, Kuhn K, Fellars T, et al. Operative and 276
238 dressing and the patient is placed in a plaster dor- nonoperative management of Achilles tendon rup- 277
239 sal slab with the foot in equinus of 20° to aid skin tures in active duty military population. Foot Ankle 278
240 perfusion for 2 weeks. Int. 2016;37(3):269–73. 279
5. Rosso C, Buckland D, Valderrabano V, et al. Long- 280
241 We advocate DVT prophylaxis for 2 weeks term biomechanical outcomes after Achilles tendon 281
242 whilst immobilised in a plaster slab; Achilles ten- ruptures. Knee Surg Sports Traumatol Arthrosc. 282
243 don injuries have the highest incidence of both 2015;23(3):890–8. 283
244 radiologic and clinically relevant venothrom- 6. Holm C, Kjaer M, Eliasson P. Achilles tendon 284
rupture-treatment and complications. A systematic 285
245 boembolic events in foot and ankle surgery in a review. Scand J Med Sci Sports. 2015;25(1):e1–10. 286
246 recent meta-analysis. The rate of DVT in general 7. Khan R, Carey SR. Surgical interventions for treating 287
247 events was 1% and 13% for clinical and radiolog- acute Achilles tendon ruptures. Cochrane Database 288
248 ical VTEs, respectively, and 7% and 35%, respec- Syst Rev. 2010;9:CD003674. 289
8. Hsu A, Carroll P, Anderson R, et al. Clinical outcomes 290
249 tively, for Achilles tendon ruptures [12]. and complications of percutaneous Achilles repair 291
250 Rest, non-weight bearing and elevation system vs. open technique for acute Achilles tendon 292
251 are advised to promote wound healing. From ruptures. Foot Ankle Int. 2015;36(11):1279–86. 293
252 2 weeks the patient may be placed into a remov- 9. McWilliam J, Mackay G. The internal brace for 294
midsubstance Achilles ruptures. Foot Ankle Int. 295
253 able boot with heel wedges and allowed to 2016;37(7):794–800. 296
254 weight bear with crutches. Active, gentle ankle 10.
Arthrex Research and Development. Achilles 297
255 plantar flexion and dorsiflexion to neutral is com- Midsubstance Speedbridge vs. Krakow for 298
256 menced at 3 weeks to minimise paratenon adhe- Midsubstance Achilles Tendon Rupture Repair. 2015. 299
11. Arthrex Research and Development. Mechanical
300
257 sion. Wedges are removed weekly and the ankle and Biomechanical Comparison testing of 1.3mm 301
258 should be plantigrade in the boot by 6 weeks and SutureTape Sutures. 2017. 302
259 the boot removed by 7–8 weeks. Passive dorsi- 12. Calder J, Freeman R, Ackermann P, et al. Meta-
303
260 flexion should be avoided. A graduated therapy analysis and suggested guidelines for prevention of 304
venous thromboembolism (VTE) in foot and ankle 305
261 programme should aim for full recovery by surgery. Knee Surg Sports Traumatol Arthrosc. 306
262 approximately 6 months. 2016;24:1409–20. 307
Part V 1
Special Considerations 2
1 Outcome
35
2 J. Nienke Altink, Jari Dahmen,
3 Gwendolyn Vuurberg, and Gino M. M. J. Kerkhoffs
4 35.1 Introduction foot and ankle [1–6]. The choice of a particular 20

outcome measure strongly depends on personal 21
5 Outcome measures are an important component preferences of the affiliated people, the specific 22
6 of medicine in its broadest sense. Outcome mea- outcome of interest, as well as the measurement 23
7 sures are of great clinical importance to monitor properties of the measurement tool [7, 8]. 24
8 treatment quality, to analyze the clinical effec- To be as complete, accurate, and objective as 25
9 tiveness, as well as to compare the effectiveness possible it is important to know which instruments 26
10 of different surgical or nonsurgical treatment are available when selecting specific outcome 27
11 options. Ideally, outcome measures are frequently measures. In this chapter we will outline an over- 28
12 and practically applied in the clinic, so that one view of the most important outcome measures that 29
13 can have a complete, accurate, and objective over- can be utilized in the assessment of foot and ankle 30
14 view of the actual situation of the patient at dif- problems. Furthermore, it is important to assess 31
15 ferent times in the treatment protocol. Moreover, the psychometric properties of the instrument you 32
16 an optimal outcome measure will be easily appli- want to use. Assessing the psychometric properties 33
17 cable in the clinics and will have low costs. of an outcome measure can help you determine if 34
18 Currently, a high number of outcome mea- the instrument actually fits its intended purpose. 35
19 sures are available to assess outcomes in the Therefore the aim of this chapter is to help you 36
understand how to assess the psychometric prop- 37
erties of outcome measures and to give a clear 38
J. N. Altink (*) · J. Dahmen · G. Vuurberg overview of the best available outcome measures 39
G. M. M. J. Kerkhoffs for foot- and ankle-related sports injuries. 40
Department of Orthopedic Surgery,
Amsterdam UMC, University of Amsterdam,
Amsterdam Movement Sciences,
Amsterdam, The Netherlands 35.2 Psychometric Properties 41

Medicine (ACES), Amsterdam, The Netherlands Psychometric properties are the properties of a 42
Amsterdam Collaboration on Health and Safety in tool or instrument which help determine how well 43
Sports (ACHSS), AMC/VUmc IOC Research Center, this tool or instrument actually measures what 44
Amsterdam, The Netherlands it intends to measure. To be able to adequately 45
e-mail: j.n.altink@amsterdamumc.nl;
assess if a certain outcome measure is fit for its 46
j.dahmen@amsterdamumc.nl;
g.vuurberg@amsterdamumc.nl; intended purpose it is essential to have some 47
g.m.kerkhoffs@amsterdamumc.nl basic understanding of psychometric properties. 48
© ISAKOS 2019 387

https://doi.org/10.1007/978-3-662-58704-1_35
388 J. N. Altink et al.
49 The most important psychometric properties 35.3 O

utcome Measures in Sports 89
50 include validity, reliability, and repeatability and Injury of the Foot and Ankle 90
51 will be discussed below.
35.3.1 Patient History 91
52 35.2.1 Validity The first step in assessing any foot or ankle 92

problem should always be history taking. 93
53 As stated in the Standards for Educational and Patient history is of vital importance in assess- 94
54 Psychological Testing (American Educational ing the symptoms, concerns, medical-, social-, 95
55 Research Association, American Psychological and psychological history. In this stage the 96
56 Association & National Council on Measurement problem of the patient needs to be identified. 97
57 in Education, 1999, p. 9) “Validity refers to the It can sometimes be a challenge to convert 98
58 degree to which evidence and theory support the this subjective information into objective and 99
59 interpretations of test scores entailed by proposed quantifiable information. On the other hand, 100
60 uses of tests.” More specifically this means three subjective information is also of great impor- 101
61 aspects are important regarding validity when tance. For example, an os trigonum causing 102
62 selecting outcome measures: pain following repeated, forceful plantarflex- 103
ion of the foot can have great impact on the 104
63 1. To which extent does the tool measure what it quality of life of a ballet dancer. However, for 105
64 intends to measure? the general population, not performing these 106
65 2. To which extent does the tool measure all fac- specific tasks at such a level, this would not 107
66 ets of the intended outcome? be a problem. Another problem that can only 108
67 3. To which extent is the measure related to the be identified with history taking is activity 109
68 outcome? avoidance. A patient can score zero points on 110
a numeric rating scale for pain, solely because 111
this patient avoids activities that would lead 112
69 35.2.2 Reliability and Repeatability to the particular pain. Therefore history tak- 113
ing is essential to identify problems and to 114
70 Reliability is a degree relating to the amount of individualize treatment. A tool that can be 115
71 random error in measurements. There are differ- very helpful to individualize treatment is goal 116
72 ent types of reliability which should be consid- attainment scaling (GAS). With the help of 117
73 ered when selecting outcome measures. GAS, specific goals that are important for an 118
individual patient can be identified, measured, 119
74 –– Test-retest reliability. This type of reliability and evaluated. 120
75 assesses the extent of agreement when testing
76 a tool in the same population at different time
77 intervals in case there is no change in out- 35.3.2 Physical Examination 121
78 come. Test-retest reliability can also be called
79 repeatability. Physical examination can be used to find the right 122
80 –– Inter-observer reliability. When assessing foot diagnosis as well as to assess recovery after treat- 123
81 and ankle problems it is important that differ- ment. Physical examination can be difficult to 124
82 ent health care professionals measure the objectify. Parameters such as height and weight 125
83 same outcomes when using the same tools. are easy to quantify. For other parameters, such 126
84 –– Intra-observer reliability. When performing as range of motion or strength, this is more dif- 127
85 the same measurement more than once, an ficult. Aids such as a dynamometer or a goniom- 128
86 observer should measure the same outcome eter can be useful to quantify these parameters 129
87 both times in case nothing in the outcome has and get a more reliable outcome, which can be 130
88 changed. assessed longitudinally. 131
35 Outcome 389
132 35.3.2.1 A merican Orthopedic Foot pleted by patients to measure their perceptions 174
133 and Ankle Society Score of their own functional status and well-being 175
134 (AOFAS) [13]. A distinction can be made between surveys 176
135 The American Orthopedic Foot and Ankle Society which are used to assess general health, pain or 177
136 score (AOFAS) is a clinician-reported tool which satisfaction levels and surveys which are used for 178
137 is designed to help physicians standardize the specific symptoms or health problems. Generic 179
138 assessment of patients with foot or ankle dis- health status measures are often less responsive 180
139 orders [9]. The survey contains both subjective to foot- and ankle-specific problems, but can be 181
140 and objective measures. The AOFAS score has highly useful to assess the impact of different 182
141 been developed for four different regions of the conditions on the quality of life or on the general 183
142 foot: the ankle-hindfoot, the midfoot, the meta- health of the patients. The most relevant PROMs 184
143 tarsophalangeal (MTP)-interphalangeal (IP) for injuries of the foot and ankle will be dis- 185
144 for the hallux, and the MTP-IP for the lesser cussed below. 186
145 toes. Each questionnaires covers three catego-
146 ries: pain, function, and alignment. Because the 35.3.4.1 S hort Form-36 and Short 187
147 AOFAS scale is such a widely used instrument it Form-12 188
148 offers good comparison between different stud- The SF-36 is a generic health measure that con- 189
149 ies. However, the AOFAS scales have never been tains a set of 36 questions in eight domains [14]. 190
150 validated for the evaluation of the treatment of The SF-36 is used to assess general health and 191
151 any foot and/or ankle pathology. contains both physical and mental measures. It 192
is a generic measure which means symptoms and 193
problems specific for a certain condition, treat- 194
152 35.3.3 Imaging ment or age group are not included. The SF-36 195
is a very useful tool for descriptive purposes and 196
153 A high number of standardized scoring sys- also for evaluating benefits of alternative treat- 197
154 tems exist for the radiological assessment of ments. A shorter form of this health survey is 198
155 foot and ankle problems. For example, the also available: the SF-12. This score adequately 199
156 Kellgren-Lawrence scale for the assessment of reproduces the physical and mental component 200
157 osteoarthritis [10]; the Weber classification for summary score which can be derived from the 201
158 ankle fractures [11]; or the Berndt and Harty SF-36 [15]. Because of the lower patient burden 202
159 Classification for osteochondral lesions of the of the SF-12 compared to the SF-36, the SF-12 203
160 talus [12]. The aim of this chapter is not to give may be preferred over the SF-36. 204
161 a complete overview of all the available scoring
162 systems in imaging. However, there is an impor- 35.3.4.2 EuroQualy of Life-5 205
163 tant key message in this paragraph: the most Dimensions (EQ-5D) 206
164 important aspect is to inspect and assess each Another instrument to measure general health 207
165 individual patient. For this, teamwork is essen- status is the EQ-5D. The EQ-5D is a generic mea- 208
166 tial; the treating clinician, radiologist, and patient sure developed by the EuroQol Group [16]. The 209
167 should collaborate closely in order to identify EQ-5D defines health in five domains: mobility, 210
168 the right diagnosis and subsequently come to the self-care, usual activities, pain/discomfort, and 211
169 optimal evidence-based treatment protocol. anxiety/depression. The EQ-5D is a useful tool 212
in assessing the general health status of patients. 213
170 35.3.4 Patient-Reported Outcome 35.3.4.3 F oot and Ankle Ability 214

171 Measures (PROMs) Measure (FAAM) 215
The Foot and Ankle Ability Measure (FAAM) is a 216
172 Patient-Reported Outcome Measures (PROMs) specific tool for foot and ankle problems and has 217
173 are standardized, validated questionnaires com- been developed with the objective to develop an 218
219 instrument that can be used to evaluate changes 35.3.4.7 Self-Reported Foot 264
220 in self-reported physical function for individuals and Ankle Scores (SEFAS) 265
221 with leg, ankle, and foot musculoskeletal disor- The self-reported foot and ankle score (SEFAS) 266
222 ders [17]. The FAAM consist of two subscales: the has been designed with the purpose to evaluate 267
223 activities of daily living (ADL) subscale and the disorders of the foot and ankle. This question- 268
224 sports subscale. The FAAM is a reliable, valid, and naire is validated in patients with arthritis of 269
225 responsive measure of self-reported physical func- the ankle and in patients with forefoot, midfoot, 270
226 tion for individuals with a broad range of musculo- hindfoot, and ankle disorders [4, 22]. In patients 271
227 skeletal leg, ankle, and foot disorders [17]. with great toe disorders or hindfoot disorders the 272
SEFAS showed similar or better psychometric 273
228 35.3.4.4 F oot and Ankle Disability properties compared to the AOFAS and was com- 274
229 Index (FADI) pleted much faster after surgery [23]. 275
230 The foot and ankle disability index (FADI) is
231 also a specific tool for foot and ankle problems. 35.3.4.8 Disease-Specific PROMs 276
232 Reliability and sensitivity of this score have Besides the PROMs specific for foot and ankle 277
233 been determined in patients with chronic ankle problems, there are also PROMs specifically 278
234 instability (CAI). A study by Hale and Hertel developed for a specific disease or condition. 279
235 [6] in 2005 concluded that the FADI appears to An example is the Cumberland Ankle Instability 280
236 be reliable in detecting functional limitations Tool (CAIT), which has been validated to assess 281
237 in subjects with CAI, sensitive to differences the severity of ankle instability [24]. Another 282
238 between healthy subjects and subjects with CAI example is the ankle osteoarthritis scale which is 283
239 and responsive to improvements in function after a valid and reliable instrument that specifically 284
240 rehabilitation in subjects with CAI. measures symptoms and disabilities related to 285
ankle osteoarthritis [25]. To obtain an evaluation 286
241 35.3.4.5 F oot and Ankle Outcome of the patient which is as complete as possible, 287
242 Score (FAOS) it is recommended to combine a generic health 288
243 The Foot and Ankle Outcome Score (FAOS) is measure, a foot- or ankle-specific health mea- 289
244 a specific tool for foot and ankle problems and sure, and, if available, a disease-specific PROM. 290
245 has been developed to assess the patients opinion
246 about a variety of foot- and ankle-related prob-
247 lems. The FAOS consist of five subscales: pain, 35.3.5 Complications and Recurrence 291
248 other symptoms, function in daily living (ADL), Rate 292
249 function in sport and recreation, and foot- and
250 ankle-related Quality of Life (QoL). Studies have To be able to adequately assess safety and effec- 293
251 shown that the FAOS is a valid and reliable tool tiveness of any surgical technique it is essential 294
252 in patients with osteoarthritis, ankle instability, to monitor complications and recurrence after 295
253 flatfoot deformity, and hallux valgus [18–21]. surgery. The Dindo-Clavien classification system 296
is an example of a classification system which 297
254 35.3.4.6 Foot Function Index can be used to monitor the nature and number of 298
255 The foot function index (FFI) tool has been devel- complications [26]. Additionally every surgeon 299
256 oped with the objective to measure impact of has to be able to inform his patients about the 300
257 foot pathology on function [2]. The FFI consists complications and recurrence rate prior to a sur- 301
258 of three subscales: pain, disability, and activity gical procedure. Despite the importance of ade- 302
259 restriction. The FFI is a useful tool for low func- quately reporting complications and recurrence 303
260 tioning individuals with foot disorders, but may rates, these are often underreported. Reporting 304
261 not be useful to assess individuals who function complications represent a conflict of interest for 305
262 at or above the level of independent activities of physicians despite the potential consequence of 306
263 daily living [1]. that underreporting complications and recurrence 307
35 Outcome 391
308 rates may lead to unexpected treatment failure or 13. Dawson J, Doll H, Fitzpatrick R, Jenkinson C, Carr 362
AJ. The routine use of patient reported outcome mea- 363
309 complications in future patient. A reason for this sures in healthcare settings. BMJ. 2010;340:c186. 364
310 can be the inherent fear of medicolegal conse- 14. Ware JE Jr, Sherbourne CD. The MOS 36-item short- 365
311 quences, even though over 95% of all surgical form health survey (SF-36). I. Conceptual framework 366
312 complications will never lead to a lawsuit [27]. and item selection. Med Care. 1992;30(6):473–83. 367
15. Jenkinson C, Layte R, Jenkinson D, Lawrence K, 368
313 Other reasons for underreporting complications Petersen S, Paice C, et al. A shorter form health 369
314 and recurrence rates can be the potential loss of survey: can the SF-12 replicate results from the 370
315 professional respect and a potential decrease in SF-36 in longitudinal studies? J Public Health Med. 371
316 patient referrals and revenue [28]. 1997;19(2):179–86. 372
16. Rabin R, de Charro F. EQ-5D: a measure of
373
health status from the EuroQol Group. Ann Med. 374
2001;33(5):337–43. 375
317 References 17. Martin RL, Irrgang JJ, Burdett RG, Conti SF, Van 376
Swearingen JM. Evidence of validity for the Foot 377
318 1. Agel J, Beskin JL, Brage M, Guyton GP, Kadel NJ, and Ankle Ability Measure (FAAM). Foot Ankle Int. 378
319 Saltzman CL, et al. Reliability of the foot function 2005;26(11):968–83. 379
320 index:: a report of the AOFAS outcomes committee. 18. Chen L, Lyman S, Do H, Karlsson J, Adam SP, Young 380
321 Foot Ankle Int. 2005;26(11):962–7. E, et al. Validation of foot and ankle outcome score for 381
322 2. Budiman-Mak E, Conrad KJ, Roach KE. The foot hallux valgus. Foot Ankle Int. 2012;33(12):1145–55. 382
323 function index: a measure of foot pain and disability. 19. Mani SB, Brown HC, Nair P, Chen L, Do HT, Lyman 383
324 J Clin Epidemiol. 1991;44(6):561–70. S, et al. Validation of the foot and ankle outcome score 384
325 3. Carcia CR, Martin RL, Drouin JM. Validity of the in adult acquired flatfoot deformity. Foot Ankle Int. 385
326 foot and ankle ability measure in athletes with chronic 2013;34(8):1140–6. 386
327 ankle instability. J Athl Train. 2008;43(2):179–83. 20. Roos EM, Brandsson S, Karlsson J. Validation of 387
328 4. Coster MC, Bremander A, Rosengren BE, Magnusson the foot and ankle outcome score for ankle ligament 388
329 H, Carlsson A, Karlsson MK. Validity, reliability, and reconstruction. Foot Ankle Int. 2001;22(10):788–94. 389
330 responsiveness of the self-reported foot and ankle 21. Golightly YM, Devellis RF, Nelson AE, Hannan MT, 390
331 score (SEFAS) in forefoot, hindfoot, and ankle disor- Lohmander LS, Renner JB, et al. Psychometric proper- 391
332 ders. Acta Orthop. 2014;85(2):187–94. ties of the foot and ankle outcome score in a community- 392
333 5. Halasi T, Kynsburg A, Tallay A, Berkes I. Development based study of adults with and without osteoarthritis. 393
334 of a new activity score for the evaluation of ankle Arthritis Care Res. 2014;66(3):395–403. 394
335 instability. Am J Sports Med. 2004;32(4):899–908. 22. Coster M, Karlsson MK, Nilsson JA, Carlsson
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336 6. Hale SA, Hertel J. Reliability and sensitivity of the A. Validity, reliability, and responsiveness of a self- 396
337 foot and ankle disability index in subjects with chronic reported foot and ankle score (SEFAS). Acta Orthop. 397
338 ankle instability. J Athl Train. 2005;40(1):35–40. 2012;83(2):197–203. 398
339 7. Martin RL, Irrgang JJ. A survey of self-reported out- 23. Coster MC, Rosengren BE, Bremander A, Brudin
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340 come instruments for the foot and ankle. J Orthop L, Karlsson MK. Comparison of the Self-reported 400
341 Sports Phys Ther. 2007;37(2):72–84. Foot and Ankle Score (SEFAS) and the American 401
342 8. Martin RL, Irrgang JJ, Lalonde KA, Conti S. Current Orthopedic Foot and Ankle Society Score (AOFAS). 402
343 concepts review: foot and ankle outcome instruments. Foot Ankle Int. 2014;35(10):1031–6. 403
344 Foot Ankle Int. 2006;27(5):383–90. 24. Hiller CE, Refshauge KM, Bundy AC, Herbert RD, 404
345 9. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Kilbreath SL. The Cumberland ankle instability tool: 405
346 Myerson MS, Sanders M. Clinical rating systems for a report of validity and reliability testing. Arch Phys 406
347 the ankle-hindfoot, midfoot, hallux, and lesser toes. Med Rehabil. 2006;87(9):1235–41. 407
348 Foot Ankle Int. 1994;15(7):349–53. 25. Domsic RT, Saltzman CL. Ankle osteoarthritis scale. 408
349 10. Holzer N, Salvo D, Marijnissen AC, Vincken KL, Foot Ankle Int. 1998;19(7):466–71. 409
350 Ahmad AC, Serra E, et al. Radiographic evaluation of 26. Dindo D, Demartines N, Clavien PA. Classification 410
351 posttraumatic osteoarthritis of the ankle: the Kellgren- of surgical complications: a new proposal with 411
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1
2
Outcomes Assessment
for the Athlete
36
3 J. Nienke Altink, Jari Dahmen,
4 and Gino M. M. J. Kerkhoffs
5 36.1 Introduction lar base as many sports include, for example, 21

jumping, cutting edge movement, and running. 22
6 Foot and ankle problems are highly common As such, they will be able to perform higher 23
7 in athletes. The ankle is the most commonly level activities even when recovering from 24
8 injured joint in sports and the ankle sprain is injury. This results in the potential of a ceil- 25
9 the most common injury of all joint injuries in ing effect in many existing scoring systems, as 26
10 sports practice [1, 2]. Injuries of the foot and was demonstrated in the Foot and Ankle Ability 27
11 ankle lead to considerable time lost to injury Measure (FAAM) [3, 4]. Secondly, athletes 28
12 and disability. Considering athletes and all have a different clinical and functional response 29
13 involved parties of this particular athlete, this to injury compared to the general population 30
14 may be a big problem. After an injury, athletes [3]. Another challenge is that many people, 31
15 wish to return to sport as quickly as possible. with different wishes, expectations, and goals, 32
16 However, deciding when exactly an athlete can can be involved. For example, the athlete, who 33
17 return to sport can be a complex and multifac- wants to return to sport as soon as possible; the 34
18 torial process. Firstly, athletes have a much coach, who wants the athlete to perform at least 35
19 higher demand on ankle function compared to as good as before his injury; and the treating 36
20 people who do not undertake sports on a regu- clinician, who wants safe return to sports with 37
prevention of re-injury. 38
This chapter will focus on the complex out- 39
comes assessment for the athlete which can make 40
return-to-play decision-making challenging. 41
J. N. Altink (*) · J. Dahmen · G. M. M. J. Kerkhoffs
Department of Orthopedic Surgery, Amsterdam Evaluation of specific sports-related risks will be 42
UMC, University of Amsterdam, Amsterdam discussed in this chapter, as well as factors which 43
Movement Sciences, Amsterdam, The Netherlands can modify the return to sport decision. Outcome 44
Academic Center for Evidence Based Sports measures to evaluate the general health status of 45
Medicine (ACES), Amsterdam, The Netherlands the athlete will however not be discussed in this 46
Amsterdam Collaboration on Health and Safety in chapter, as they have already been described in 47
Sports (ACHSS), AMC/VUmc IOC Research Center, the previous chapter of the present book. The 48
Amsterdam, The Netherlands
underlying aim of this chapter is to give the 49
e-mail: j.n.altink@amsterdamumc.nl;
j.dahmen@amsterdamumc.nl; reader insight into the current evidence regarding 50
g.m.kerkhoffs@amsterdamumc.nl sport-specific outcomes. 51
© ISAKOS 2019 393

https://doi.org/10.1007/978-3-662-58704-1_36
52 36.2 Sports-Related Risk • Type: The type of training and the stress 98
53 Assessment that increases with that type of injury. For 99
example, when a ballet dancer presents 100
54 After assessing the general health of the patient, with tendonitis of the Achilles tendon, the 101
55 the sports-related risks should be assessed [5]. stress can be reduced by quitting the regu- 102
56 The sports-related risks can give information lar training and performing exercises to 103
57 about the amount of stress that is applied to an stretch and strengthen the calf muscles in 104
58 injured tissue. If the amount of stress on tissue order to reduce stress on the Achilles ten- 105
59 is bigger than the capacity that the tissue can don instead. 106
60 withstand, the tissue in question shall not heal, • Time: In the optimal training duration there 107
61 and consequently injury or re-injury is likely has to be a balance between the duration of 108
62 to occur [5]. An important factor to assess the exercise that causes enough stress for the tis- 109
63 sports-related risks at injury is the type of sport sue to adapt. However, there should not be 110
64 that the athlete practices. Generally, noncontact stress to such an extent that the tissue damage 111
65 sports such as swimming pose a lower risk on is too severe to recover prior to the subsequent 112
66 acute injury compared to contact sports and high- training session. 113
67 impact sports, such as basketball or soccer [6].
68 Contact sports, at their turn, pose a lower risk at
69 acute injury compared to collision sports such 36.3 Risk Tolerance Modifiers 114
70 as rugby or boxing [6]. However, more factors
71 play a role in the sports-related risk of injuries. When the medical team has a clear image of the 115
72 For example, the competitive level of the ath- medical factors and the sports-related risks there 116
73 lete. To quantify the activity level specifically for is one more step that has to be assessed prior to 117
74 the ankle, the Ankle Activity Score (AAS) can making a treatment plan, that is, risk tolerance 118
75 be used [7]. This score is validated for the use modifiers [5]. Especially in high-level athletes 119
76 in ankle instability patients and can be used in there can be a high number of additional factors 120
77 the evaluation of treatment of patients with ankle that can be of influence considering the treatment 121
78 instability. plan. The StARRT framework describes common 122
79 Another manner to systematically assess and risk tolerance modifiers [5]. 123
80 categorize the amount of tissue stress is accord-
81 ing to the frequency, intensity, timing, and type • Timing: deciding when to treat can be very 124
82 (FITT) principle [5]. FITT is based on the prin- important for an athlete. For example, an ath- 125
83 ciple that there should be a training balance on lete and his treating physician may choose to 126
84 four domains: accept a higher risk of (re-)injury right before 127
an important match. 128
85 • Frequency: The optimal training frequency is • Pressure coming from the athlete: when an 129
86 when the training is frequent enough for the athlete desires to compete the risk tolerance is 130
87 tissue to adapt and infrequent enough for the higher. 131
88 tissue to heal and adaptation to occur. • External pressure: pressure on the athlete not 132
89 • Intensity: The optimal training intensity is primarily of personal nature. This pressure is 133
90 when there is a balance between overloading rather of external nature, derived from the 134
91 and overtraining. In cardiorespiratory sports affiliated parties (for instance the football 135
92 such as running, heart rate can be used to club, the coach, the manager, family mem- 136
93 objectify training intensity. In resistance bers, etc.). 137
94 training, workload (amount of weight lifted, • Masking the injury: in some cases analgesia 138
95 amount of repetitions and amount of rest can be effective to mask the injury so the 139
96 between sets) can be used to objectify train- athlete can continue to compete without doing 140
97 ing intensity. further damage. 141
36 Outcomes Assessment for the Athlete 395
142 • Conflict of interest: Financial motives can to participation or return to sport, but they do 185
143 motivate athletes to postpone treatment. For not need to return to performance. In other cases 186
144 example, right before a transfer period when it may not be realistic to aim for the athlete to 187
145 an athlete does not want potential buyers to return to his or her preinjury level. To come to 188
146 know about an injury. the best treatment plan and outcomes patients, 189
coaches and clinicians should work together in 190
an intensive manner. One should also pay close 191
147 36.4 Return to Sport attention to the psychological parameters that 192
can be involved concerning the return to sport 193
148 After the assessment of medical factors, sports- process [9]. A systematic review by Ardern et al. 194
149 related risks, and risk tolerance modifiers, the [10] focused on different studies including ath- 195
150 athlete and treating medical team can make a letes returning to sports after an ankle injury 196
151 decision about when an athlete can return to as well as reporting at least one psychosocial 197
152 sport. Return to sport is not just a decision at the property. This study concluded that there is pre- 198
153 end of a treatment process but a continuum influ- liminary evidence showing that positive psy- 199
154 enced by a number of factors [8]. When an ath- chological responses are associated with higher 200
155 lete is injured it may be necessary to completely rates of return-to-sports. This indicates that it is 201
156 remove an athlete from sport so that the athlete of clinical importance as a medical team to also 202
157 can recover. When recovering from an injury focus on the mental health of athletes. 203
158 there are a number of stages between removal
159 from sport and return to preinjury level or return
160 to performance. These stages will be discussed in 36.5 PROMS in Sports 204
161 the following paragraph:
A number of patient-reported outcome measures 205
162 • Removal from sport: Complete removal from (PROMs) have a sport-subscale or are specifically 206
163 sport can sometimes be the optimal treatment designed to assess outcomes in relation to sport. 207
164 option. In some acute cases it can be vital for These outcome measures can be utilized in the 208
165 the athletes’ health that the athlete will be outcome assessment of athletes after a specific 209
166 immediately removed from sport. In cases treatment protocol. PROMs for the foot and/or 210
167 where symptoms gradually increase over time, ankle with a specific sports subscale or PROMs 211
168 it may also be necessary to completely remove for the foot and/or ankle specifically designed to 212
169 the athlete from sport to in order to initiate or assess outcomes in relation to sport are described 213
170 speed up the recovery process. in this section of the book chapter. 214
171 • Return to participation: In this stage the ath-
172 lete is physically active but has not yet returned
173 to his or her desired sport [8]. The athlete is, 36.5.1 Sports Athletes Foot 215
174 for example, rehabilitating by following an and Ankle Score (SAFAS) 216
175 adjusted training program.
176 • Return to sport: The athlete has returned to his The Sports Athletes Foot and Ankle Score 217
177 desired sport but has not yet reached his or her (SAFAS) is a PROM which is developed with 218
178 preinjury level [8]. the purpose to create a valid, self-administered 219
179 • Return to performance: The athlete has score for high performing athletes [11]. The 220
180 returned to his desired sport at or above his scoring system was based on conducting inter- 221
181 preinjury level [8]. views with professional athletes, prior to actually 222
creating the scoring system itself. During these 223
182 Prior to starting treatment it is important to interviews, the athletes were asked to comment 224
183 discuss the return to sport continuum with the on existing scoring systems, such as the FAAM, 225
184 athlete. For some athletes it is enough to return the FAOS, and the FFI [4, 12, 13]. The athletes 226
227 who were requested to participate in these inter- ders for athletes and nonathletes [4]. The FAAM 269
228 view sessions participated in different types of consist of two subscales: the activities of daily liv- 270
229 sports, such as rugby, football, cricket, and so on. ing (ADL) subscale and the sports subscale. The 271
230 All athletes had had some type of foot and ankle sports subscale, on its turn, consists of eight ques- 272
231 injury, being associated with sports, in the past. tions aiming at assessing the level of difficulty of 273
232 The SAFAS is a valid instrument in the assess- specific sporting activities related to the move- 274
233 ment of sports-related foot and ankle problems ment of the lower extremity. The subscale, for 275
234 and it detects change between the healthy and example, consists of questions concerning jump- 276
235 injured high-level athlete [11]. The subscales ing, running, landing, performing low- impact 277
236 assessing the levels of symptoms, pain, daily liv- activities, and the level of ability of being able to 278
237 ing, and sports are all included in the SAFAS. participate in the desired sport of the patient. A 279
study by Carcia et al. [3] indicated that scores on 280
the sports subscale of the FAAM were greater in 281
238 36.5.2 Sports Ankle Rating System healthy athletes compared to athletes with chronic 282
239 (SARS) ankle instability (CAI) and were greater in ath- 283
letes who indicated that their ankles were normal 284
240 The sports ankle rating system (SARS) has been compared to athletes who indicated that their 285
241 developed to assess functional outcomes in patients ankles were nearly normal or abnormal [3]. 286
242 with ankle injuries and consists of the following
243 three instruments: The Quality of Life Measure
244 (QOL), the Clinical rating score, and the Single 36.5.4 FAOS Sports 287
245 Assessment Numeric Evaluation [14]. The results
246 of a study of Williams et al. [14] showed that the Although the previous chapter in the present 288
247 SARS is effective at assessing the impact of an book focused on the Foot and Ankle Outcome 289
248 ankle sprain on an athlete’s functional and psycho- Score (FAOS) in general, this chapter will devote 290
249 logical status; is responsive to changes in an athlete’s some of its information to the specific sports out- 291
250 ankle-related health status; and is valid and reliable come subscale of the FAOS questionnaire [13]. 292
251 in the assessment of the functional and psychoso- The questions focusing on the sports outcomes 293
252 cial status of athletes with lateral ankle sprains. The of a patient with foot and/or ankle pathology 294
253 authors chose to validate the SARS in patients hav- consist of a degree of difficulty when perform- 295
254 ing sustained an ankle sprain, as this is not solely ing specific tasks over the past week. These tasks 296
255 the most commonly occurring injury of the lower consist of running, squatting, jumping, twisting, 297
256 extremity in athletes, but also the most frequently and/or pivoting the injured foot/ankle, as well as 298
257 occurring injury in athletes overall. Further research kneeling. The FAOS is however more suitable to 299
258 concerning this specific system of scoring func- assess clinical outcomes at group level than for 300
259 tional outcomes in athletes should focus on validat- monitoring specific patients or athletes [15]. 301
260 ing the score in athletes suffering from other more
261 specific pathologies of the foot and ankle.
References 302
262 36.5.3 FAAM-Sports 1. Fong DT, et al. A systematic review on ankle injury 303
and ankle sprain in sports. Sports Med. 2007;37(1): 304
73–94. 305
263 The Foot and Ankle Ability Measure (FAAM) is 2. Hootman JM, Dick R, Agel J. Epidemiology of colle- 306
264 a specific tool for foot and ankle problems and giate injuries for 15 sports: summary and recommen- 307
265 has been developed with the objective to create an dations for injury prevention initiatives. J Athl Train. 308
2007;42(2):311–9. 309
266 instrument that can be used to evaluate changes 3. Carcia CR, Martin RL, Drouin JM. Validity of the 310
267 in self-reported physical function for individuals foot and ankle ability measure in athletes with chronic 311
268 with leg, ankle, and foot musculoskeletal disor- ankle instability. J Athl Train. 2008;43(2):179–83. 312
36 Outcomes Assessment for the Athlete 397
313 4. Martin RL, et al. Evidence of validity for the Foot 11. Morssinkhof ML, et al. Development and validation 334
314 and Ankle Ability Measure (FAAM). Foot Ankle Int. of the Sports Athlete Foot and Ankle Score: an instru- 335
315 2005;26(11):968–83. ment for sports-related ankle injuries. Foot Ankle 336
316 5. Shrier I. Strategic Assessment of Risk and Risk Surg. 2013;19(3):162–7. 337
317 Tolerance (StARRT) framework for return-to-play deci- 12. Budiman-Mak E, Conrad KJ, Roach KE. The foot 338
318 sion-making. Br J Sports Med. 2015;49(20):1311–5. function index: a measure of foot pain and disability. 339
319 6. Creighton DW, et al. Return-to-play in sport: J Clin Epidemiol. 1991;44(6):561–70. 340
320 a decision-based model. Clin J Sport Med. 13. Roos EM, Brandsson S, Karlsson J. Validation of 341
321 2010;20(5):379–85. the foot and ankle outcome score for ankle liga- 342
322 7. Halasi T, et al. Development of a new activity score ment reconstruction. Foot Ankle Int. 2001;22(10): 343
323 for the evaluation of ankle instability. Am J Sports 788–94. 344
324 Med. 2004;32(4):899–908. 14. Williams GN, et al. Evaluation of the sports
345
325 8. Ardern CL, et al. 2016 Consensus statement on ankle rating system in young, athletic individu- 346
326 return to sport from the First World Congress in als with acute lateral ankle sprains. Foot Ankle Int. 347
327 Sports Physical Therapy, Bern. Br J Sports Med. 2003;24(3):274–82. 348
328 2016;50(14):853–64. 15. Sierevelt IN, et al. Evaluation of the Dutch ver-
349
329 9. Clanton TO, et al. Return to play in athletes following sion of the Foot and Ankle Outcome Score 350
330 ankle injuries. Sports Health. 2012;4(6):471–4. (FAOS): Responsiveness and Minimally Important 351
331 10. Ardern CL, et al. A systematic review of the psycho- Change. Knee Surg Sports Traumatol Arthrosc. 352
332 logical factors associated with returning to sport fol- 2016;24(4):1339–47. 353
333 lowing injury. Br J Sports Med. 2013;47(17):1120–6.
1
2
Advances in Rehabilitation
Techniques
37
3 Konstantinos Epameinontidis, Mohsen Abassi,
4 and Pieter D’Hooghe
5 37.1 Introduction 37.2 B

lood Flow Restriction 24
Training 25
6 Injuries and disorders of the lower leg are very in the Rehabilitation Setting 26
7 common in athletes, particularly in high-impact
8 and contact sports. Clinicians constantly face the Athletes need to continuously provide training 27
9 challenge to assist athletes in restoring function stimuli to their bodies in order to develop benefi- 28
10 to pre-injury levels within the shortest possible cial adaptations and improve performance. The 29
11 timeframe. Current trends in sports rehabilita- same principle applies during all phases of sports 30
12 tion embrace this challenge and promote con- rehabilitation, but each phase has specific goals 31
13 cepts and techniques which provide evidence of to achieve, while certain restrictions may apply 32
14 a speedier return of homeostasis and function of (e.g., immobilization, or non-weight-bearing 33
15 the injured area, while carefully monitoring the conditions). It is widely acknowledged that the 34
16 load imposed on healing tissues. In this chapter, necessary initial protection of the injured limb, 35
17 we will present two different tools used at our with motion and/or weight-bearing restrictions, 36
18 institution, which assist in training of the lower will impose some strength loss and reduction 37
19 limb and assessment of the functional status of of muscle volume. Clinicians utilize therapeu- 38
20 the ankle joint. The interventional technique tic exercise regimes in an effort to counteract 39
21 is called blood flow restriction (BFR) training the negative effects of restrictions and activity 40
22 and the assessment tool is a new device called limitations. Low-intensity or low-load exercises, 41
23 QF-AROM for the ankle joint. when used appropriately, may reverse some of 42
the negative effects on joint range of motion and 43
local muscle activation, but do not offer sufficient 44
stimulus for strength development and muscle 45
growth. According to the American College of 46
K. Epameinontidis · M. Abassi Sports Medicine’s Position Stand on resistance 47
Rehabilitation Department, Aspetar Orthopedic and training, strength and hypertrophy gains can be 48
Sports Medicine Hospital, Doha, Qatar
e-mail: Konstantinos.epamino@aspetar.com; achieved with training loads that exceed 65–70% 49
Mohsen.abassi@aspetar.com of one repetition maximum (1 RM) [1]. However, 50
P. D’Hooghe (*) the use of these high loads may exceed the cur- 51
Department of Orthopedic Surgery, Aspetar rent loading capacity of the injured tissues and 52
Orthopedic and Sports Medicine Hospital, should be avoided, at least in the early phases of 53
Doha, Qatar rehabilitation. 54
e-mail: Pieter.dhooghe@aspetar.com
© ISAKOS 2019 399

https://doi.org/10.1007/978-3-662-58704-1_37
400 K. Epameinontidis et al.
55 Recently, it has been proposed to perform exercise, the predominant mechanism of action 100
56 low-load exercises (up to 30% of 1 RM) with is cell swelling [6]. When low-load exercise is 101
57 the addition of blood flow restriction (BFR) used, multiple mechanisms may play a role in the 102
58 to the exercising limb [2]. BFR is applied with hypertrophic and strengthening effects observed 103
59 the use of inflatable cuffs or elastic bands to the with BFR training [5]. 104
60 most proximal part of the limb. The aim of this
61 technique is to stop the venous return from the
62 muscles distal to the cuff and partially restrict the 37.2.2 How Is BFR Applied 105
63 arterial inflow to those muscles. The restriction in the Clinical Setting? 106
64 in the normal blood flow creates a hypoxic envi-
65 ronment and blood pooling, which in turn trigger In the rehabilitation setting, inflatable cuffs are 107
66 various biochemical cascades that lead to upreg- preferred for BFR use since they provide graded 108
67 ulation of muscle protein synthesis [3]. BFR exposure to restriction pressure and allow for pre- 109
68 originated in Japan and since the late 90s there’s cise measurement of pressure applied via the use 110
69 extensive scientific evidence suggesting that low- of a manometer. Complete arterial occlusion is 111
70 load training with BFR (LL-BFR) induces signif- not desirable due to increased risk of side effects, 112
71 icant gains in muscle strength and hypertrophy, while the extra pressure needed for complete 113
72 comparable to high-intensity resistance training occlusion does not seem to offer greater benefits 114
73 (HIRT) [4]. The obvious advantage of utilizing than partial occlusion. Various percentages of arte- 115
74 LL-BFR training on patient populations cannot rial occlusion have been reported in the literature, 116
75 be overemphasized, as it provides the benefit with benefits observed even with pressures as low 117
76 of the essential muscle strengthening stimulus, as 50 mmHg. The most commonly used pressure 118
77 without the threat of damaging the healing tis- is at 80% of arterial occlusion, which can be eas- 119
78 sues with high mechanical loads. ily measured with the use of a portable Doppler 120
ultrasound unit (commonly used for evaluation 121
of fetal sounds in the uterus) (see Fig. 37.1). 122
79 37.2.1 What Is BFR and How Does It Maximal occlusion pressure is reached when the 123
80 Work? sound emanating from posterior tibial artery is not 124
audible. Then, the pressure of the cuff is adjusted 125
81 BFR is applied with the use of inflatable cuffs at 80% of that maximal arterial occlusion pressure. 126
82 or elastic bands to the most proximal part of the
83 limb. The aim of this technique is to stop the
84 venous return from the muscles distal to the cuff 37.2.3 How Can It Be Used 127
85 and partially restrict the arterial inflow to those in Rehabilitation of Foot 128
86 muscles. The restriction in the normal blood flow and Ankle Injuries or Surgery? 129
87 creates a hypoxic environment which in turn trig-
88 gers various biochemical pathways that lead to BFR can be used in all stages of rehabilitation of 130
89 muscle protein synthesis. Various mechanisms an athlete. Loenneke et al. [7] proposed a staged 131
90 of BFR action have been proposed in the sci- model of BFR application. The first stage involves 132
91 entific literature; however, scientists still do not BFR during immobilization, the second stage 133
92 agree on the predominant mechanism. Proposed involves low-load aerobic activities like walk- 134
93 mechanisms include hormonal responses (i.e., ing and cycling with BFR, and in the third stage 135
94 increases in growth hormone), translation ini- BFR is utilized with low-load resistance exercise 136
95 tiation via intracellular pathways (mTORC1), to promote maximum strength and hypertrophy 137
96 metabolite accumulation (i.e., lactate), increased benefits. During periods of prolonged immobi- 138
97 fast glycolytic fiber type recruitment, increased lization, the cuff is inflated at 80% of maximal 139
98 satellite cell activity, and muscle cell swelling occlusion pressure for 5 min and then deflated 140
99 [5]. It appears that during the use of BFR without for 5 min for reperfusion to occur. This process 141
37 Advances in Rehabilitation Techniques 401
Fig. 37.1 Determining
maximal occlusion
pressure via Doppler US
device
Fig. 37.2 BFR use

during immobilization
period
142 is repeated five times during a session and it can dizing the injured ankle. An example of PWB 155
143 be repeated five times during the day (Fig. 37.2). exercise with BFR is seen in Fig. 37.4. 156
144 It has been demonstrated that BFR use during When weight-bearing exercises are allowed, 157
145 periods of complete immobilization can attenuate then BFR can be utilized in conjunction with 158
146 the loss of strength and muscle volume in postoper- walking (Fig. 37.5) or cycling and offer the 159
147 ative patients [8]. When the patient is allowed to use advantage of muscle strength and cardiovascu- 160
148 active ROM (either full, or partial), BFR can be used lar endurance gains for the recovering athlete. 161
149 with active movements of the ankle in all directions Twenty minutes of walking at 45% of maximum 162
150 until muscle fatigue ensues. Light elastic resistance heart rate has been found to increase both car- 163
151 can be added when appropriate (Fig. 37.3). diovascular fitness and offer small but substantial 164
152 In cases where partial weight-bearing (PWB) improvements in thigh muscle strength. These 165
153 activities are indicated and allowed, BFR can strength gains are not evident when such low- 166
154 offer substantial muscular load without jeopar- load activities are performed without BFR [9]. 167
Fig. 37.3 BFR with

light elastic resistance
Fig. 37.4 Partial
weight-bearing exercise
with BFR
168 When resistance exercise at low-loads is proposed with the following order of repeti- 176
169 allowed by the athlete’s condition, then BFR tions: 30, 15, 15, 15. Rest interval is set at 30 s 177
170 can offer its greatest advantages. Resistance and the cuff stays inflated in order to enhance 178
171 can either be applied by own bodyweight, elas- the effect of metabolite accumulation. In 179
172 tic resistance, or gym equipment (Fig. 37.6). healthy populations, 30% of 1 RM is the most 180
173 Scott et al. [3] provide a concise overview of common resistance load applied during BFR 181
174 the acute variables of BFR resistance training, exercise; however, in patient populations 1 RM 182
175 based on best available evidence. Four sets are testing may not be feasible or safe. In our insti- 183
Fig. 37.5 Walking on

treadmill with BFR use
184 tution, we propose that clinicians incrementally training stimuli while the injured ankle is spared 201
185 increase low loads until the athlete completes from overload. 202
186 the assigned set and repetitions and reports a
187 rate of perceived exertion of eight out of ten at
188 the end of each exercise. Multiple exercises can 37.2.4 Is Training with BFR Safe 203
189 be used at this stage; however, it is advised not for the Patients? 204
190 to exceed a total time of 30 min per session.
191 Five minutes of rest between BFR exercises has As with any form of exercise, BFR training has 205
192 been proposed in order to allow reperfusion to its limitations and contraindications. Patients 206
193 the leg muscles and enhance the hypertrophic with severe cardiovascular disease and peripheral 207
194 effect. vascular disease are not candidates for BFR train- 208
195 When the athlete is allowed to train with high ing. BFR training with low-loads elicits similar 209
196 loads, LL-BFR can be an excellent tool to assist hemodynamic responses to high-intensity resis- 210
197 in the appropriate management of training load tance training without BFR and should not be a 211
198 during the final stages of rehabilitation. By alter- concern for athletes who are regularly exposed 212
199 nating sessions of high resistance training with to this stress. Interestingly, BFR training with 213
200 LL-BFR, the athlete is exposed to beneficial low loads does not seem to induce muscle dam- 214
Fig. 37.6 Low-load
resistance exercise with
BFR on the leg press
215 age compared to high resistance training and is appropriately, it is a safe procedure and can 229
216 therefore a safe option for patients with concerns greatly enhance the efficacy of our rehabilitation 230
217 for muscle tissue function. However, caution is protocols. 231
218 needed with patients that have not been exposed
219 to any type of training for long periods of time
220 in order to avoid acute reactions of overtraining. 37.3 Assessment of Range 232
221 For an excellent review on safety consideration of Motion 233
222 of LL-BFR training, please refer to Loenneke in the Rehabilitation Setting: 234
223 et al. [10]. What’s New? 235
224 In summary, LL-BFR training is a recently
225 introduced modality in the rehabilitation setting Range of motion (ROM) of the ankle is of a 236
226 that can promote muscle strength and hyper- high importance in restoring its normal function 237
227 trophy of the lower limb while avoiding detri- as well as the whole body functionality such as 238
228 mental loads to the healing tissues. When used walking, running, and jumping and thus it is very 239
240 important to restore full ROM after an injury or end attached to the mounting plate vertically 285
241 surgery to allow the athlete to return to full sports to the inclined upper surface. This lower end 286
242 activity. Measuring ROM is not an easy task as serves to calibrate the rotating rod (vertical to the 287
243 we are used to utilize the traditional goniom- inclined upper surface). An inclinometer, such as 288
244 eter, whose reliability is clinician-dependent, as a digital inclinometer, angle sensor, or the like, 289
245 the landmarks used and positioning can change is secured to the upper end of the elongated rod 290
246 from one practitioner to another. On the other to measure the angular displacement of the elon- 291
247 hand, using the universal goniometer in a supine gated rod with respect to the inclined upper sur- 292
248 position doesn’t reflect the true actual ROM of face of the device. 293
249 the ankle due to unnecessary tensioning of some A retaining bar is secured to the elongated rod, 294
250 antagonists, but also due to the non-functionality adjacent to its upper end extending substantially 295
251 of the ankle in that position. orthogonal to it and adapted to be positioned 296
252 If the ankle ROM is measured in a func- adjacent to the leg and slidably mounted on the 297
253 tional manner, these measurements may then elongated rod to adjust its height in order fit with 298
254 best reflect the different ankle positioning situ- the mid-shaft of the leg, allowing the device to 299
255 ations and so the real ankle ROM during play- measure the ankle ROM in patients having vary- 300
256 ing. Unfortunately, this is missing in the literature ing heights and body types. 301
257 and nothing was found to respond to these needs
258 except the lunging position for ankle DF mea-
259 surement due to its mounting evidence of being a 37.5 Testing 302
260 risk factor for ankle sprains. Actually, while the
261 DF is being measured functionally with knee to The patient stands upright behind the device 303
262 wall position using a ribbon meter to take the big using one hand as support against a wall and 304
263 toe to wall distance or using an inclinometer at then places his uninjured foot in the foot retainer 305
264 the anterior side of the tibia shaft, the three other which is locked in the sagittal plane; once the foot 306
265 ankle ROM directions are forgotten and we don’t is secured to the retainer with straps, the mounted 307
266 know much about them yet. sliding plate (holding the rod) is moved to align 308
267 Recently, we developed a device that can mea- with talo-crural joint axis, the rotating rod is cali- 309
268 sure the main four ankle ROM positions (DF, PF, brated vertically to the inclined upper surface, 310
269 INV, EV) of the ankle in a realistic functional and the digital inclinometer is zeroed in this start- 311
270 manner mimicking playing situations such as ing position. The patient is then asked to perform 312
271 tackling, jumping, and changing directions. his maximum PF in the talo-crural axis by bring- 313
ing his body backward so that the leg is pulled 314
to its maximum tolerated position without losing 315
272 37.4 Device any plantar foot contact with the foot retainer. 316
When the patient reaches his maximum PF the 317
273 Our apparatus (QF-AROM) includes a base, a rod is rotated until the retaining bar touch the leg 318
274 pair of sidewalls, a 30° inclined upper surface and the angular displacement shown in the incli- 319
275 and a foot retainer 180° rotatable, secured to nometer is recorded as Full Functional PF ROM 320
276 the inclined upper surface and serves to receive (FF PF ROM). Next, the patient is asked to make 321
277 the patient’s foot. A sliding mounting plate is anterior lunge until maximum DF is obtained in 322
278 attached to one of the pair of sidewalls, such that a knee over toe technique (avoiding excessive 323
279 it is selectively moveable along a direction paral- pronation), while keeping the heel flat in the foot 324
280 lel to the inclined upper surface for proper posi- container, where angular displacement on the 325
281 tioning with respect to the patient’s foot being inclinometer is recorded for FF DF ROM. Once 326
282 measured. completed, the foot retainer is unlocked and 327
283 An elongated rod, having opposed upper and the patient is instructed to move to the side of 328
284 lower ends, is further provided, with the lower the device (next to one of the side-walls) rotat- 329
330 ing the foot retainer 90° with his foot until it is rehabilitation protocol and most probably reduce 362
331 aligned with the axial plane of the device where the re-injury rate. 363
332 it is locked. The patient then stands next to one
333 of the sidewalls in a position allowing measure-
334 ment of inversion. The patient is instructed not to References 364
335 lift the lateral border of the foot from the retainer
336 while stretching into inversion. The sliding plate 1. American College of Sports Medicine. American 365
337 is then repositioned to fit with the rotational axis College of Sports Medicine position stand. 366
Progression models in resistance training for healthy 367
338 of the foot. Once the inversion angle is recorded, adults. Med Sci Sports Exerc. 2009;41(3):687–708. 368
339 the patient moves to the opposite side for ever- 2. Loenneke JP, Thiebaud RS, Abe T. The application 369
340 sion measurement with instructions to keep his of blood flow restriction training into Western medi- 370
341 medial foot border completely adherent to the cine: isn’t it about time? J Altern Complement Med. 371
2013;19(10):843–4. 372
342 foot retainer. The technique is then completed for 3. Scott BR, et al. Exercise with blood flow restriction: an 373
343 all four measures on the injured side. updated evidence-based approach for enhanced mus- 374
cular development. Sports Med. 2015;45(3):313–25. 375
4. Pope ZK, Willardson JM, Schoenfeld BJ. Exercise 376
and blood flow restriction. J Strength Cond Res. 377
344 37.6 Conclusion 2013;27(10):2914–26. 378
5. Hwang P, Willoughby DS. Mechanisms behind blood 379
345 In our study on 87 male athletes with injured flow restricted training and its effect towards mus- 380
346 ankles who reached sports-specific stage of RTP cle growth. J Strength Cond Res. 2017; https://doi. 381
org/10.1519/JSC.0000000000002384. 382
347 and 25 healthy athletes we found Statistically 6. Loenneke JP, et al. The acute muscle swelling 383
348 significant reductions in range of motion with effects of blood flow restriction. Acta Physiol Hung. 384
349 moderate to large effect sizes for plantar flexion, 2012;99(4):400–10. 385
350 dorsiflexion, and inversion and not for eversion. 7. Loenneke JP, et al. Blood flow restriction: an evidence 386
based progressive model (Review). Acta Physiol 387
351 Plantar flexion had the largest reduction and ever- Hung. 2012;99(3):235–50. 388
352 sion had the smallest when comparing injured 8. Takarada Y, Takazawa H, Ishii N. Applications 389
353 to healthy group. Standard errors were 2.1° for of vascular occlusion diminish disuse atrophy of 390
354 PF and 4.1 for Ev. Good reliability was for DF knee extensor muscles. Med Sci Sports Exerc. 391
2000;32(12):2035–9. 392
355 (0.76–0.87) and Inv (0.75–0.86) and excellent 9. Shimizu R, et al. Low-intensity resistance train- 393
356 for PF (0.9–0.95), however it was fair with Ev ing with blood flow restriction improves vas- 394
357 (0.49–07). cular endothelial function and peripheral blood 395
358 This innovative device showed the ability to circulation in healthy elderly people. Eur J Appl 396
Physiol. 2016;116(4):749–57. 397
359 measure the functional ankle ROM as well as 10. Loenneke JP, et al. Potential safety issues with blood 398
360 highlights the reduction in PF ROM at time of flow restriction training. Scand J Med Sci Sports. 399
361 RTP which may help clinicians to improve their 2011;21(4):510–8. 400
1
2
Foot Orthotic Advances
for the Athlete
38
3 Craig Tanner and Pieter D’Hooghe
4 38.1 Background sports medicine. In order to appreciate why, it 26

is useful to understand the differences in com- 27
5 Foot orthoses are a well-established tool in the parison to the traditional process of design and 28
6 prevention and/or management of a wide range manufacture. 29
7 of sports injuries of the lower limb. The simple
8 act of inserting a molded insole into a shoe can
9 have a significant preventative effect on lower 38.2 Traditional Manufacture 30
10 limb injuries [1]. Foot orthoses are relatively of Custom Foot Orthoses 31
11 inexpensive and, if prefabricated, can provide
12 almost immediate benefit. In addition, the risks The manufacture of CFOs is a multistep proce- 32
13 of side effects are minimal as they can be easily dure. The whole process may be performed by 33
14 removed if a potential problem arises. the individual practitioner, but a substantial com- 34
15 Their use, however, lacks standardization. ponent is often undertaken by commercial foot 35
16 Foot orthotic therapy varies greatly around orthotic laboratories following a written prescrip- 36
17 the world in both theory and application. tion. Almost every stage is open to variability and 37
18 Practitioners that produce or prescribe orthoses individualization. 38
19 come from a range of professions and there can In order to capture the geometry of the foot, 39
20 be quite diverse approaches to the management foam impression boxes, plaster slipper casts, or 40
21 of the same pathology [2, 3]. vacuum bladders are some of the more common 41
22 Irrespective of the design rationale, the digiti- traditional methods utilized. All of these methods 42
23 zation of the design and manufacture of custom create a negative model, which may be manip- 43
24 foot orthoses (CFOs) at the practitioner level is ulated by the practitioner by having the foot 44
25 a significant recent advancement in lower limb weighted, unweighted, or semi-weighted. All of 45
these options will affect the shape differently. 46
From this, a positive model of the foot is 47
C. Tanner then constructed—most commonly with plas- 48
Aspetar Orthopaedic and Sports Medicine Hospital,
Doha, Qatar ter. In many instances, the model may not be 49
e-mail: craig.tanner@aspetar.com modified further and this is the extent of the 50
P. D’Hooghe (*) “customization.” 51

Department of Orthopaedic Surgeon, Aspetar Over the years, however, different philosophies 52
Orthopaedic and Sports Medicine Hospital, have emerged as practitioners have strived for 53
Doha, Qatar improved effectiveness. The positive model may 54
e-mail: pieter.dhooghe@aspetar.com
© ISAKOS 2019 407

https://doi.org/10.1007/978-3-662-58704-1_38
408 C. Tanner and P. D’Hooghe
55 be modified significantly to implement specific 38.3 Digital Manufacture 78

56 changes. A “prescription” may be applied involving
57 intrinsic posting, skiving, and shaping of the design Over the past 20 years the digitization of this pro- 79
58 based on the requirements defined by the practitio- cess has evolved. CADCAM (Computer Aided 80
59 ner [4–6]. Depending on the theoretical aim of the Design Computer Aided Manufacture) has been 81
60 device, the shape may be altered significantly from introduced and has completely changed how 82
61 the original model. Although the resultant orthoses orthoses may be produced. 83
62 may appear similar, these changes can have a sig- Due to the large initial investment being 84
63 nificant impact on how forces act across the foot. required, it was commercial laboratories that first 85
64 The orthosis is created by heating, mold- implemented this technology. A variety of scan- 86
65 ing, and shaping a material around this positive ning systems were used to digitize the traditional 87
66 model. A wide range of different materials may plaster casts or foam box impressions. There was 88
67 be used ranging from Ethyl Vinyl Acetate (EVA) no need for practitioners to change or invest in 89
68 or Polyurethane (PU) foams of various densities, new technology. 90
69 to harder shell materials such as polypropylene More recently, the technology has become 91
70 or carbon fiber composites. These materials may economical enough that many practitioners will 92
71 have varying stiffness properties through the have a scanner which allows direct capture of 93
72 availability of different thickness blanks. the foot shape. In addition to the obvious ben- 94
73 Following the molding, further modification is efits of being cleaner for both the practitioner and 95
74 required to remove excess material and allow the patient, it is a significantly faster process. The 96
75 orthosis to be fitted into a shoe. Finishing may speed of direct digital capture means that it is 97
76 also involve fixing additions such as stabilizers, feasible for multiple scans to be taken at once for 98
77 pads, and wedges as well as a final top cover. later reference if so desired. 99
Partial weight bearing scan

with 3D laser scanner
38 Foot Orthotic Advances for the Athlete 409
100 As with traditional capture methods, there are

101 many options as to how this can be taken. The
102 choice of technique used can obviously have
103 a significant impact on the shape of the final
104 orthosis.
Medial view of non-weight bearing scan—Foot is above

the surface of the scanner glass
106
Resultant digital scan from laser scanner (Partial Weight

Bearing Scan). Markers on central plantar heel, first and
fifth plantar MTPJ and point of medial arch apex
Medial view of non-weight bearing scan with practitioner

dorsiflexion of the first MPJ. The windlass mechanism
creates the highest medial longitudinal arch
107
Whether directly scanned or a scanned cast, 108

the digital master copy of the foot may be saved 109
Medial view of full weight bearing scan—Lowest medial indefinitely. This may be useful as a reference 110
longitudinal arch profile. Soft tissues distorted by the
point in future designs. In many traditional meth- 111
surface
105 ods, if a new design is indicated, a new physical 112
model must be produced by re-casting. 113
114
Medial view of partial weight bearing scan—Arch profile

unloaded and therefore higher, but soft tissue structures
distorted by the surface
115
Plantar View of four scanning conditions—From top, left to right, Full WB, Part WB, Non WB, Non WB with MTPJ
dorsiflexion. Clear differences in foot geometry can be seen
116 Digital design essentially bypasses the steps The creation of a physical orthoses from a digi- 129
117 involved in model manufacture and proceeds to tal design uses CAM software to create a toolpath 130
118 directly designing the finished orthosis. Many for a computer numeric controlled (CNC) carver 131
119 additions that would usually require changes to or router. This is known as “subtractive rapid pro- 132
120 a model can be applied directly to the digital totyping” as the design is created by carving, or 133
121 design. Importantly, this is can be performed in subtracting, material out of a solid block. 134
122 steps to create multiple designs with small varia- The hardware required for this is scalable. 135
123 tions. Until the last few years, this was the realm Large commercial laboratories are able to manu- 136
124 of laboratories only. Individual practitioners now facture dozens of pairs of orthoses at once. It is, 137
125 have access to CAD software that allows the full however, now also feasible for practitioners to do 138
126 design to be manipulated on a computer monitor the same on a much smaller scale. 139
127 in real time. As with traditional manufacturing, a variety 140
of materials with differing characteristics may 141
128 be used. Rather than different thickness blanks, a 142
shell type of orthosis may be machined by vary- 143
ing tool offsets to alter the thickness and there- 144
fore manipulate stiffness. Sections of the device 145
may also be modified discretely to provide more 146
flexible—or stiffer—areas with minimal weight 147
changes. 148
149
A foot orthosis designed to follow foot contours
The same foot, but now with an inversion modification.

This shape of the device is the same apart from the point CADCAM EVA and Polypropylene foot orthoses. Same
of contact under the heel and lateral column. This tech- digital design, but machined out of different material
nique would traditionally involve replication of the arch
of the foot in plaster when the model is produced [4].
Research suggests that can be an effective way of apply- 150
ing an inversion force to the plantar foot [7]
151
The first consideration is the wide variety of 174

approaches used around the world with conflict- 175
ing terminology and definitions. As described pre- 176
viously, a custom foot orthosis can vary between 177
a device that is simply a soft insole that is molded 178
to shape of a foot, to a stiff material that has been 179
molded around an extensively modified model. 180
Yet researchers often do not make any distinction 181
between these approaches, defining all orthoses 182
that are based on a foot model as being custom. 183
In addition, there is significant conjecture as to 184
the theoretical basis and mechanism of action of 185
foot orthoses. The traditional view that they act 186
to support or align the lower limb has very little 187
evidence to support it [8, 9]. Extensive research 188
152
into potential mechanisms have found no single 189
answer. There is evidence that foot orthoses influ- 190
Previous design with examples of modifications. The ence kinematic variables such as rearfoot ever- 191
material is thinner overall which allows for flexibility, but
it is reinforced with an element that will maintain longitu- sion and tibial rotation as well as kinetic variables 192
dinal stiffness. The extrinsic heel stabilizer is smaller in such as loading rate and vertical impact forces 193
length which will decrease longitudinal stiffness. There is [10]. There is also good evidence of neuromotor 194
an accommodating flare added under the talo-navicular effects through EMG studies, suggesting a role 195
area
in altering muscle loading and function [10, 11]. 196
However, the most important recurrent obser- 197
153 CADCAM technology has improved effi- vation of all of this research is there is significant 198
154 ciency in every step of the process of manufac- variability in responses to the different orthoses 199
155 ture. Traditional methods require plaster to cure, tested. Applying the same intervention to differ- 200
156 and for material to heat and cool. Additionally, ent subjects often gives very different effects. A 201
157 there is significant labor involved. In realistic range of simple wedges applied to a pre-made 202
158 terms, a laboratory would allow at least 48 h for orthosis demonstrated inconsistent, subject- 203
159 this as a “rapid turnaround” service to produce specific responses which were also often contrary 204
160 a CFO. CADCAM design and manufacture can to what was expected [12–14]. A similar conclu- 205
161 produce a fully bespoke pair of foot orthoses in sion was noted in respect to center of pressure 206
162 less than 60 min. (COP) and knee joint moments [15]. Identical 207
163 The vastly improved efficiency of digital man- interventions can have substantially different 208
164 ufacture is fundamental as to why this is such an results for different subjects. 209
165 important advance in orthotic therapy applica- This observation is perhaps not so surprising 210
166 tion. In order to understand why, it is useful to when you consider the high level of variability 211
167 briefly review the research into foot orthoses and observed when foot motion is closely examined 212
168 their mechanism of action. [16, 17]. For this reason, traditional models that 213
suggest there is a measurable “normal” foot have 214
faced criticism [8, 9, 18, 19]. Newer paradigms 215
169 38.4 F
oot Orthoses: Implications may still approach orthotic design based on an 216
170 of Research individual cast or scan, but with tailored modi- 217
fications designed to alter load on structures by 218
171 Research into foot orthoses and their relation- shifting the application of forces on the plantar 219
172 ship to pathology is complicated for a number of surface of the foot [5, 20]. Orthoses that changes 220
173 reasons. kinetic variables have shown to be effective when 221
222 previous designs have failed. It should be noted The ability to make precise incremental 251
223 that even within these subjects the responses are adjustments to a CADCAM orthotic design 252
224 variable [7]. has allowed some exploration of the concept of 253
225 This variability impacts the relevance of some orthotic dosing. The efficiency and accuracy of 254
226 research into the effectiveness of foot orthoses in production allows many versions of a foot ortho- 255
227 injury management. The challenges of high-level sis to be manufactured from the same scan and 256
228 research design will lead to a standardized inter- then modified in steps. This has yielded some 257
229 vention protocol either through the use of prefab- linear relationships, but also much variability 258
230 ricated orthoses or through a predefined design [24, 25]. 259
231 of CFO. However, it should be expected that the The limitation even with this type of research 260
232 generic application of an orthotic intervention to is that it is only relevant to a certain prescriptive 261
233 a cohort of individuals will have variable effects approach. However, one significant advantage of 262
234 within the group. The most robust design studies CAD software is that it does not tie the practitio- 263
235 do not account for individualized interventions. ner to any particular approach, or to variables that 264
236 The response therefore is likely to significantly are defined by an external laboratory. It allows 265
237 milder that it could potentially be. Meta-analyses a practitioner to have the same level of design 266
238 on foot orthoses tend to be comprised of studies control as if they are making a solid model them- 267
239 like this may and therefore report small effects if selves. The only difference is that the model is on 268
240 any at all [21, 22]. the computer screen. 269
241 It is argued that this limits the relevance of This highlights why the use of CADCAM 270
242 such studies as they do not reflect usual clinical orthoses at the clinic level is such a significant 271
243 practice. There is a growing contention that foot advancement. A practitioner is able to make an 272
244 orthoses should be viewed in a similar way to individual design decision and then view the 273
245 drugs in the pharmaceutical industry whereby a resultant effect. The improved efficiency, repeat- 274
246 practitioner should be aiming for a “dose” which ability, and accuracy of the technology means that 275
247 is best for the individual [23]. Based on the evi- it is now viable to make specific design variations 276
248 dence mentioned above, this is not likely to be a directly based on clinical response. Adjustments 277
249 simple linear relationship, but rather a solution can be made almost immediately to a wide range 278
250 which is specific tailored to the individual. of parameters. 279
Left: 15I Inverted orthosis;

Center: Same device with
15° 4 mm Medial heel
Skive; Right: Same with
25° 4 mm Medial Heel
Skive. All these
modifications should apply
a slightly different
inversion force around the
subtalar joint when applied
to the same foot
280 In simple terms, an individual practitioner can

281 design and modify an orthosis to their specific
282 requirements and know that the end result is a
283 reflection of this. Any subsequent modification of
284 the design will also be more specific and accurate.
285
Static assessment—Orthosis has an inverted modification.

Force on the medial heel applies an inversion moment
which decreases direct pressure on talo-navicular area, so
previous bulging is less evident
Left: 15° medial heel skive; R 25° medial heel skive. This is
the manufactured previous digital design. The flat area of the
heel applies a force in slightly different direction in relation
to the heel. The two devices are otherwise identical
Static assessment—Further increase in inversion through

medial heel skive modification now suggests less control.
Foot is being shifted laterally as evidenced by the small
gap to the medial heel cup edge. In this case, more is less
It is important to understand that when foot 286

Resting foot position orthoses are used as part of a management plan, 287
they need to be assessed as to whether they are 288
working as intended. The first step in the appli- 289
cation of orthotic therapy is establishing why an 290
orthosis may have a benefit and how it should 291
be designed to achieve this. Reviewing ortho- 292
ses should therefore assess whether the response 293
reflects the design aim. 294
Some outcomes such as resolution of pain 295
are obvious. The solution, however, must also be 296
comfortable and functional. This is even more 297
critical in high-level sports. The design versatil- 298
ity and manufacturing efficiency of CADCAM 299
orthoses allows this in a more predictable and 300
Static assessment of foot orthosis shows good fit, but
bulge in soft tissue under talo-navicular region may indi- repeatable manner. 301
cate increased load on the medial arch

302 Manufacturing efficiency allows additional References 342

303 orthoses to be produced with design adjustments
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Sports Injuries of the Foot and Ankle

Sports Injuries of the

ISBN 978-3-662-58703-4 ISBN 978-3-662-58704-1 (eBook)

Library of Congress Control Number: 2019935194

Torino, Italy Gian Luigi Canata

Part I Ligament Injuries

1 Acute Ankle Ligament Injuries������������������������������������������������������ 3

9 Cartilage Techniques for Osteochondral Lesions

Part III Bone and Joint Injuries

15 Ankle Fractures�������������������������������������������������������������������������������� 161

22 Jones Fractures�������������������������������������������������������������������������������� 249

Part IV Tendons and Biology

27 Biologics in the Foot and Ankle������������������������������������������������������ 305

Part V Special Considerations

Queries Details Required Author's Response

3 1.1 Introduction department admissions [1]. By other estimates, 26

Deltoid ligament Posterior talotibeal

First dorsal cuneonavicular

Medial cuneonavicular ligament

Anterior talofibular ligament

Interrosseous talocalcaneal ligament

Dorsal talonavicular ligament

Calcaneonavicular part ligament

Long plantar ligament Dorsal intermetatarsal ligament

407 1.10 Treatment it is important to consider potential risks of each 450

3 2.1 Introduction dissection of the extra-articular structures of the 30

59 2.3 Surgical Anatomy Area B corresponds with the part comprised 86

Fig. 2.3 Arthroscopic anatomy. Layered sections of the different areas

2.4 Technique 140

2.4.1 Setup 141

A tourniquet is placed above the knee, so as to take 142

1 the supine position with a cushion under the prone 144

6. Brandes CB, Smith RW. Characterization of patients 352

6 3.1 Introduction with retensioning and direct suturing of the 27

Fig. 3.1 Standard tools

56 technique can be performed with different types

59 3.2.1 Patient Positioning

60 Two installations are possible: in a prone position

74 Three portals are usually created to perform the 3.2.3 S

Fig. 3.3 Portal 2 by transillumination

is then peeled off from its malleolar origin (as 130

Fig. 3.7 Lasso loop on the ATFL

area around the IER. In this way, the cutaneous 160

Fig. 3.8 Preparation of the working area for IER dissection

Fig. 3.9 Suture in the IER

to avoid swelling and pain. Rehabilitation is 197

3.3 Discussion 201

Arthroscopy is gradually moving to a central 202

4.2.2.1 Step 1: Making Portals 49

a 4.2.2.2 Step 2: Insert a Suture Anchor 79

b the thread slides. 88

4.2.2.3 Step 3: Suture Relay Technique 89

Fig. 4.3 Position. (a) In arthroscopic repair. The position is

154 4.2.3 Postoperative Management 4.3 Arthroscopic Reconstruction 162

167 Ligament of the ankle” [9]. There are three types

15mm 15mm 15mm 15mm 15mm 15mm 15mm 15mm 15mm

Into the talar Into the fibular Into the calcaneal

4.3.2 Postoperative Management the strength of biological bonding and becomes

Guide wire for

3. Valderrabano V, Hintermann B, Horisberger M, Fung

6 Abbreviations Three-quarters of the ankle injuries comprise 23

Fig. 5.1 Anatomy of the ankle

Fig. 5.2 (a, b) Positive Talar Tilt test

97 are considered positive. The anterior drawer test

Full Book Sports Injuries in F& A

Full Book Sports Injuries in F& A

Torino, Italy Gian Luigi Canata

Part I Ligament Injuries

1 Acute Ankle Ligament Injuries�� 3

9 Cartilage Techniques for Osteochondral Lesions

Part III Bone and Joint Injuries

15 Ankle Fractures�� 161

22 Jones Fractures�� 249

Part IV Tendons and Biology

27 Biologics in the Foot and Ankle�� 305

Part V Special Considerations

3 1.1 Introduction department admissions [1]. By other estimates, 26

407 1.10 Treatment it is important to consider potential risks of each 450

3 2.1 Introduction dissection of the extra-articular structures of the 30

59 2.3 Surgical Anatomy Area B corresponds with the part comprised 86

2.4 Technique 140

2.4.1 Setup 141

6 3.1 Introduction with retensioning and direct suturing of the 27

59 3.2.1 Patient Positioning

3.3 Discussion 201

4.2.2.1 Step 1: Making Portals 49

a 4.2.2.2 Step 2: Insert a Suture Anchor 79

4.2.2.3 Step 3: Suture Relay Technique 89

154 4.2.3 Postoperative Management 4.3 Arthroscopic Reconstruction 162

4.3.2 Postoperative Management the strength of biological bonding and becomes

253 id-substance repair of the ATFL in 1966. In

3 6.1 Introduction externally and moves posteriorly and laterally. 28

60 6.2 Anatomy disrupted with joint space widening or frank 107

6.9 Return to Play 925

5 7.1 Anatomy which connects the anterior margin of the susten- 24

7.5 Surgical Technique 296

325 7.6 Surgical Technique

6 8.1 Introduction potentially career-ending for the athlete, as they 30

626 Wound Closure 8.9 Postoperative Complications 671

6 9.1 Introduction microfracture [4]. Replacement procedures 25

124 offers better articular cartilage repair than large-

134 9.2.4 Particulated Juvenile

189 9.3 Autologous Osteochondral

191 9.3.1 Indications

484 9.6 Scaffolds

554 9.7.1 Platelet-Rich Plasma 9.7.2 C

6 10.1 Introduction lesions (OCLs) of the talus; nevertheless a gold 27

J. J. Berkowitz 11.1 Patient Selection 55

112 11.5 Surgical Procedure

3 12.1 Introduction incidence of these lesions in patients with acute 14

6 13.1 Introduction (BMS) procedure can be carried out. However, 22