Arthroscopic findings and treatment of maisonneuve fracture complex

Background The Maisonneuve fracture complex (MFC) is a well-known lower leg injury. However, the optimal treatment is still not clear and there is limited data on concomitant injuries of cartilage. Therefore, the aim of our study was to report the incidence of incidental cartilage injuries and their management in arthroscopic treatment of MFC. Patients and methods Between February 2018 and February 2021 all patients presenting with MFC in our department were treated with diagnostic ankle arthroscopy and percutaneous syndesmotic screw or suture-endobutton fixation. In case of instable cartilage, it was debrided and according to the International Consensus Meeting on Cartilage Repair of the Ankle, in grade IV lesions < 10 mm or < 100 mm2 area the subchondral bone was microfractured. Results Eighteen patients, 16 male and two female, with a mean age of 48.1 years, were included. In all cases, instability of the distal tibiofibular articulation was confirmed arthroscopically. Injuries of the cartilage were found in 56% of the cases and in 31% of the patients surgical intervention was required. In three talar and one tibial lesion additional arthroscopic bone marrow stimulation with microfracture of the subchondral bone was performed. Conclusions Ankle arthroscopy is a helpful method to guide fibular reduction and to detect and address associated cartilage injuries. Due to the high rate of chondral lesions, addressing these arthroscopically may contribute to better postoperative results. Level of evidence IV

Impact of Early Weightbearing After Ankle Arthroscopy and Bone Marrow Stimulation for Osteochondral Lesions of the Talus

Background: Osteochondral lesion of the talus (OLT) may be caused by osteochondritis dissecans, osteochondral fractures, avascular necrosis, or focal arthritic changes. For certain focal cartilage defects, bone marrow stimulation (BMS) has been a widely used technique to restore a fibrocartilage substitute overlying the defect. There are various postoperative weightbearing protocols for this procedure, with no single gold standard method. Purpose: To retrospectively review the outcomes of patients undergoing ankle arthroscopy with concomitant BMS to determine outcomes based on postoperative weightbearing status. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively reviewed the records of patients who underwent ankle arthroscopy with BMS for OLTs between 2015 and 2018. Patients were placed into 2 cohorts based on postoperative immobilization status: the nonweightbearing (NWB) group and the weightbearing-as-tolerated (WBAT) group. Patient characteristics obtained included age, sex, comorbidities, and etiology of talar pathology. Outcomes included the pain visual analog scale (VAS), range of motion (ROM), complications, time to first weightbearing, and the method and length of immobilization. Patients who were lost to follow-up before 30 days were excluded. The chi-square test was used to compare categorical variables between cohorts, and the t test was used for continuous variables. Results: A total of 69 patients met the inclusion criteria for this study, 18 in the WBAT group and 51 in the NWB group. The mean lesion size was 9.48 × 9.21 mm (range, 3-15 mm × 2-20 mm) for the NWB group and 9.36 × 9.72 mm (range, 5-14 mm × 6-20 mm) for the WBAT group ( P > .05). The VAS scores improved from 4.40 to 0.67 for the WBAT group and from 6.33 to 2.55 for the NWB group, with the difference in final values reaching statistical significance ( P = .0002). Postoperative ROM was not significantly different between the groups. There were 4 repeat operations within the NWB cohort. Conclusion: The surgical management of OLTs can be challenging, and the postoperative weightbearing protocol can be an extra obstacle for the patient to navigate. We found no difference in pain, ROM, or complications when allowing immediate, full WBAT.

Use of an aiming drill guide and ankle arthroscopy for reduction of depressed articular surface in posterior malleolar fractures

Purpose We describe a novel technique that uses an aiming drill guide and ankle arthroscopy for direct visualization and reduction of the depressed articular surface located between the posterior tibia and the fractured posterior malleolus. This technique requires less soft tissue dissection to visualize and reduce the depressed articular surface. Methods Between June 2014 and May 2019, 126 patients were surgically treated for trimalleolar fractures. Among them, 11 had depressed articular fragment between the posterior tibia and the fractured posterior malleolus reduced using our novel technique. The study included six men and five women, with a mean age of 46.5 (range: 23–62) years. Results In eight (73%) cases, the articular surface was reduced, with the articular surface step-off being less than 2 mm, as noted on postoperative computed tomography (CT). Syndesmosis congruity within an anterior-to-posterior difference of less than 2 mm was confirmed in nine (82%) cases via postoperative CT. The mean 100-mm visual analog scale (VAS) and the mean Olerud-Molander ankle score at the final follow-up were 16.6 ± 14.5 and 87.7 ± 7.5, respectively. Conclusions The depressed articular fragment located between the posterior tibia and the fractured posterior malleolus can be treated using an aiming drill guide and ankle arthroscopy. Ankle arthroscopy is used for direct visualization of the depressed articular surface, and the aiming drill guide can guide the bone plunger precisely to the depressed articular surface for reduction. This technique requires less soft tissue dissection than conventional techniques to visualize and reduce the depressed articular surface.

ARTHROSCOPIC TREATMENT OF POSTERIOR ANKLE IMPINGEMENT IN PEDIATRIC ATHLETES AND ITS OUTCOMES - A PROSPECTIVE STUDY

Background: Posterior ankle impingement (PAI) is a known cause of posterior ankle pain in athletes performing repetitive plantarflexion motions, such as in soccer. Even though it is well-described in adults, literature on PAI in pediatric patients is scarce. Purpose: The purpose was to describe prospective outcomes after arthroscopic management of posterior ankle impingement in pediatric and adolescent patients. Methods: An IRB-approved prospective study was performed at a tertiary children’s hospital from 2016-2020. Patients <18 years of age who were diagnosed with posterior ankle impingement and underwent posterior ankle arthroscopy with minimum 3-month post-operative follow-up were included. Data collected included pre-operative demographics and sporting activities, clinical and radiologic findings. Visual Analogue Scale (VAS) scores, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were collected at the initial and follow-up visits. Results: A total of 50 patients (65 ankles; 28 females), were included with mean age 13.3 years. Football and soccer were the most commonly implicated sports. All patients underwent initial conservative management including relative rest, immobilization and/or physical therapy for an average period of 44 weeks. The indication for surgery was failure of conservative management to improve symptoms. All patients underwent posterior ankle arthroscopy with arthroscopic confirmation of impingement pathology followed by debridement. The pathology was predominantly bony (Os trigonum, Stieda process) in 54%, and predominantly soft tissue (low flexor hallucis longus belly, ganglion cyst in the ankle, hypertrophied posterior ankle ligaments) in 46%. All 50 patients (100%) returned to sports at an average 8.5 ± 4.1 weeks. 51 ankles had radiographs done at 1 years post-operatively which did not show recurrence or any new osseous abnormalities. At mean follow up of 26 months, there was a statistically significant improvement in VAS scores (7.0 to 0.53, p<0.05) and AOFAS scores (63.9 to 95.6, p<0.05) from pre- to post-operative final follow-up. Complications included numbness over lateral part of the heel (sural nerve distribution) in 1 patient. Conclusion: The first prospective study on pediatric PAI demonstrates that arthroscopic treatment, after failed conservative management, allowed patients to return to prior level of activity and sports, and resulted in improved pain relief and higher functional parameters. Complications associated with this procedure were minimal.