Degenerative joint disease of the ankle and subtalar joint is a difficult orthopaedic problem. In the past, when conservative measures failed to relieve pain, arthrodesis and arthroplasty were the only treatment alternatives. However, with the growth of ankle arthroscopy, specific pathologies associated with degenerative joint disease have been treated successfully,2,3,5,12-15,17,18,23-25,27,30 whereas arthroscopic debridement for generalized degenerative disease remains less beneficial to patients.2,5,11,14 The literature on arthroscopic treatment of subtalar arthritis is scant and remains experimental.8,10,17,19 This paper presents a critical analysis of current indications for arthroscopy in the treatment of ankle and subtalar arthritis. The authors' method of treatment will be discussed and posttraumatic and degenerative pathologic conditions will be addressed, including osteophyte, synovitis, adhesions, loose bodies, chondromalacia, and chondral defects.
The impetus for arthroscopic treatment of ankle arthritis came from experience in the knee. In addition to playing a diagnostic role, knee arthroscopy has made possible treatment of specific lesions that has prolonged the patient's use of the knee before arthroplasty. A reasonable percentage of patients can obtain symptomatic relief after arthroscopic debridement if there is preservation of alignment and articular cartilage.1 Burks4 reported that 50% to 75% of patients with knee arthritis treated arthroscopically had significant improvement in the first or second post-operative years. Although the results tend to decline as time progresses, arthroscopic debridement seems to benefit a significant percentage of patients. Treatment of specific degenerative pathologic conditions improves the chance of a good result, although the more severe and widespread the degenerative changes are, the less likelihood of obtaining a prolonged benefit.1,4,22
Knowledge of this experience with the knee has influenced the indications and approach to the ankle. Ankle arthroscopy has a diagnostic and therapeutic role in treatment of degenerative disease. By offering direct visualization of all intraarticular and intracapsular structures, arthroscopy can be extremely valuable in defining the existence and extent of ankle disease. This is particularly useful in patients who have had unsuccessful conservative care and do not have extensive surface defects definable on routine imaging studies. In degenerative ankles, this indication applies primarily to those in the early stages of disease who have preserved joint space. Arthroscopy also is useful in patients with previous ankle fractures in whom an adequate reduction was performed and the patient has continued to have persistent pain and symptoms. Arthroscopic examination can assess the amount of degenerative change and treat these posttraumatic changes with minimal morbidity. In the majority of patients with arthritic ankles the disease is defined preoperatively and the patient undergoes arthroscopy in the hope of alleviating the symptoms. Arthroscopy has proven to be useful in the treatment of impinging osteophytes, synovitis, adhesions, loose bodies, ossicle, and some chondral defects.2,7,12-15,17,23-27,30 Debridement for generalized degenerative changes should be reserved for those in the early stages of disease with preserved range of motion(ROM).18 The efficacy of limited abrasion arthroplasty and transchondral drilling of large chondral defects remains to be proven.
Patients with degenerative arthritis of the ankle who should be excluded from arthroscopic intervention are those with advanced articular destruction, marked joint line narrowing, extensive fibrosis, and significant instability or deformity.
The surgical procedure is performed with the patient under general, spinal, or epidural anesthesia. The patient is placed in the supine position. A thigh tourniquet is used for all cases, and the leg is placed onto a well padded thigh support and positioned with the hip flexed 45° to 50°. Soft tissue distraction is used via a commercially manufactured strap linked to a sterile distraction device. Instruments for viewing consist of 2.7-mm 30° and 70° small joint arthroscopes. Small joint probes, graspers, basket forceps, knives, curettes, and rongeurs, and 2.9-mm and 3.5-mm short motorized shavers and burrs are used for the surgical procedure. Three portals are used to evaluate and treat all intraarticular lesions. Also, all arthroscopies are performed using a gravity drainage system. The anterolateral and anteromedial portals usually are used for viewing and instrumentation, whereas the posterolateral portal provides the inflow. However, all three portals can be used interchangeably to treat the disease. The anteromedial portal is established first by inserting an 18-gauge needle through the anteromedial site to infuse 10 cc of sterile Ringer's lactate solution and distend the ankle joint. A Number 11 scalpel blade is used to make an incision through the skin only, with the opposite hand palpating the tibialis anterior tendon. A hemostat is used to spread the subcutaneous tissue and penetrate the joint capsule. The 2.9-mm arthroscopic cannula is placed into the anteromedial portal and the joint is inspected while additional Ringer's lactate solution is infused into the joint. Under direct vision, an 18-gauge needle is used to locate the anterolateral portal. In a similar fashion, the skin is incised and the inflow cannula is inserted into the joint. The arthroscope is inserted and a sequential examination of the joint compartments and their structures is performed using the 21-point system that has been described previously9,25 (Table 1). Additional portals are established as necessary for better visualization or operative technique. The posterolateral portal is used routinely for inflow and visualization. In general, the 2.7-mm 30° arthroscope is used, although the 70° arthroscope is used to visualize the gutters. Postoperatively, the portals are closed with mattress nylon suture and a compressive dressing and splint applied for 1 week. Range of motion and strengthening exercises then are begun with progressively more weightbearing as tolerated and dependent on the procedure performed.
Tibiotalar osteophytes often occur secondary to trauma or degenerative changes and commonly are seen in the anterior lip of the distal tibia. Spurs also can occur anterolaterally between the talus and lateral malleolus,24 on the anterior aspect of the medial malleolus, and the posterior aspect of the distal tibia. With anterior spurs, the beaklike prominence of the distal tibia often is associated with a kissing lesion of the talar neck. Tibiotalar osteophytes can cause bony impingement, resulting in decreased ROM, pain, catching, and joint swelling(Fig 1). After a complete arthroscopic evaluation of the joint, attention is given to the anterior osteophytes. Preoperatively, the amount of bone to be resected can be judged by remembering the normal angle formed by lines tangential to the talar neck and the anterior tibia should be greater than 60°. The superior, anterior, and inferior borders of the osteophyte must be identified first by elevating the soft tissue using a small shaver and a freer dissector. Extreme caution must be taken not to turn the shaver blade dorsally into the soft tissue and neurovascular structures. A small burr is introduced to remove the osteophyte. Alternatively, a pituitary rongeur and small osteotome also can be used. Complete removal of the osteophyte usually requires that the instruments be used through the anteromedial and anterolateral portals. Once the tibial osteophyte has been resected, attention is given to the anterior talar neck to make sure it is smooth. Intraoperative radiographs are helpful to verify that resection is complete.
Synovitis and Adhesions
The synovium of the ankle joint can become inflamed and hypertrophied secondary to degenerative and posttraumatic changes. The synovectomy can be performed with a 2.9- or 3.5-mm full radius shaver and must be performed in a systematic manner. Posttraumatic adhesions can make visualization of the joint space difficult. The surgeon cannot always be certain that instruments are in the joint, and the only way to verify this is to place the cannulas through the anteromedial and anterolateral portals and triangulate the tips posteriorly. It is critical to verify that the arthroscopic instruments are intraarticular to prevent shaving of soft tissue such as the dorsal neurovascular bundle. The posterolateral portal is established by a spinal needle, and verified by seeing outflow through the needle. Once the joint space is visualized, the shaver then is introduced to remove all adhesions.
Loose Bodies and Ossicle
Chondral and osteochondral loose bodies often are present in degenerative and posttraumatic ankle joints. Loose bodies can cause locking, catching, swelling, pain, and decreased ROM as they float through the joint. It sometimes can be difficult to maneuver loose bodies out of the joint. The use of a 70° 2.7-mm arthroscope and accessory medial or lateral portals are helpful. With the arthroscope coming across the joint, a spinal needle can stabilize the loose body or ossicle while a dissecting instrument comes from the same side through the accessory portal. Often a large ossicle can be debrided with a rongeur or power shaver so as to make it easier to remove through a small portal.
Chondromalacia and Chondral Defect
Debridement for chondromalacia consists of removing the loose fragments of articular cartilage, and smoothing the dome of the talus and tibial plafond using a motorized shaver. The articular cartilage is left intact if it were found to be stable by probing. Chondral defects are approached similarly to such lesions in the knee. Full thickness lesions are debrided and the sclerotic bony base drilled in the hope of stimulating a blood supply and the formation of fibrocartilaginous cover.16 Small motorized full radius resectors and curettes can be used to trim loose cartilage pieces. Drilling of the bony base of these lesions is performed with smooth Kirschner (K) wires. Anterior lesions can be approached either anterolaterally or anteromedially by plantar flexing the ankle. For more posterior lesions, a transmalleolar technique can be used. The senior author has developed a drill guide (Mini-vector, Smith & Nephew Dyonics, Andover, MA) to direct accurately the K wire from a small incision over the medial distal tibia or fibula to lesions in the talus (Fig 2). Then by dorsiflexing or plantar flexing the ankle, multiple holes can be placed through the lesion using a single drill tract. Postoperatively, patients who had transosseous drilling to stimulate fibrocartilage development are kept nonweightbearing for 4 to 8 weeks, depending on the size of the lesion.
There are many potential complications associated with arthroscopy. The senior author and his coworkers8 have reported an overall complication rate of 9% in a series of 612 cases. The most common complication was neurologic (49%), primarily involving the superficial branch of the peroneal nerve (15/27 or 56%), sural nerve (6/27 or 22%), saphenous nerve (5/27 or 18%), and the deep peroneal nerve (1/27 or 4%). Other complications included two cases each of superficial infection, adhesions, fractures, and deep infections. The majority of complications associated with ankle arthroscopy are transient and minor, but serious complications can occur. Arthroscopic cannulas should be used to minimize soft tissue trauma around the portals. The portals should be sutured closed to minimize wound problems, and prophylactic antibiotics should be administered for all cases. Careful preoperative planning, knowledge of surface anatomy, and use of appropriate distraction and instrumentation will help avoid these complications.
The literature regarding arthroscopic treatment of arthritic ankle is sparse and the followup short.2,5,7,11,13,14,18,19,25,26,30 In general, arthroscopic treatment of ankle arthritis involves the removal of loose bodies and impinging osteophytes, which often are found anteriorly, and the debridement of chondral lesions. Limited abrasion arthroplasty and transchondral drilling is performed for Grade IV chondral defects and cysts, and any area of synovitis is debrided. The long term durability of these procedures remains to be proven.2,5,7,11,13,14,18,21,25,26,30 Parisien and Vangsness21 reported on five patients with 14 months followup and had four good results and one fair result. They defined the fair category as having no clinical signs of painful ROM, tenderness, or swelling but positive radiographic changes. Ferkel and Fischer7 observed 12 patients with a diagnosis of degenerative joint disease and six with a diagnosis of loose bodies and found 83% had significant improvement in pain at an average of 13 months postoperatively. A recent study of arthroscopic debridement of 27 osteoarthritic ankles found that ⅔ of patients reported symptomatic relief at an average followup of 45 months.18 In this study, arthroscopy served as a temporizing procedure to improve pain level in those patients with arthritis who had a reasonable ROM. The author found no correlation between results of debridement and the severity of arthritis as seen on plain radiographs. However, it seems that the patients with Grade 3 arthritic changes seen arthroscopically, generally had worse results than those patients with Grade 1 or Grade 2 changes.
Other authors have found debridement for arthritis not to be helpful.2,5,13,14 Martin et al14 in a review of 58 ankle arthroscopies have found 57% of good and excellent results in patients with osteophytes or loose bodies but only 12% good and excellent results in patients with degenerative joint disease. Forty-three percent of these patients had a subsequent fusion, and an additional 25% were awaiting fusion.14 Ammendola et al2 in an outcome study of ankle arthroscopies using a subjective questionnaire and visual analog scales, found uniformly poor results with arthroscopic debridement in 11 patients with arthritic ankles. Guhl11 stated that patients with advanced destruction, marked jointline narrowing, extensive fibrosis, or significant degrees of instability or deformity should be excluded from arthroscopic intervention. He also thinks that although limited abrasion may be useful in the treatment of arthritis, extensive abrasion is not recommended.
One subset of patients with degenerative joint ankle changes do well with arthroscopic treatment. These patients have anterior tibiotalar osteophytes that cause impingement with dorsiflexion.12,17,24 The spurs are common and usually asymptomatic, being found in as much as 45% of football players and 59% of dancers.12 These are also one of the earliest radiographic changes in ankle osteoarthritis and can be a source of loose bodies. If conservative treatment of symptomatic osteophytes fails, arthroscopic debridement can be successful. Hawkins12 described complete resolution of symptoms after arthroscopic debridement in three patients. Biedert3 reported satisfactory results in 2/3 of 21 patients at an average of 18 months postoperatively. He found that the patients who did poorly were those with more degenerative changes and stated that the results in the treatment of degenerative joint changes are not encouraging. Scranton and McDermont24 reported on 22 patients with an average of 15 months followup. Their patients were graded on the severity of radiographic degenerative changes present and compared with a similar group treated with open debridement. The arthroscopically treated group achieved a full recovery approximately 3 weeks faster than the openly debrided group, and Scranton and McDermont found a direct correlation between the time to full recovery and the amount of degenerative changes present. Arthroscopic loose bodies removal was found to be uniformly successful by numerous authors.2,5,13 In a recent multicenter study of 245 ankle arthroscopies,30 88% of patients had good and excellent results after loose body removal.
Arthroscopic debridement does not offer a cure for all forms of degenerative joint disease of the ankle. However, it does alleviate the symptoms of many patients and seems to resolve symptoms permanently in some cases of degenerative arthritis. Similarly to the experience in the knee, the more advanced the patient's degenerative changes, the less the long term benefit that is likely to result. Although the arthroscope is not going to supplant the traditional indications for arthrodesis, it may delay the arrival at that decision and gives the orthopaedic surgeon a useful tool for the treatment of osteochondral disease in the degenerative ankle.
Although there had been many clinical and experimental reports on ankle arthroscopy, subtalar arthroscopy is still in its early stages of development.6,10,19,20,31 Subtalar arthroscopy has been advocated for the diagnosis and treatment of articular lesions in cases of chronic pain, adhesion, osteochondral lesions, loose bodies, and degenerative arthritis. The literature on arthroscopic treatment of degenerative arthritis remain scant.6,19,31 In a series of 50 subtalar arthroscopies described by Williams and Ferkel,31 34% of cases were for treatment of various stages of degenerative joint disease. Arthroscopic subtalar arthrodesis recently has been described with excellent results.29 However, the indications for arthroscopic debridement of arthritic subtalar joints is evolving and must be considered experimental at this time.
Subtalar arthroscopy is performed in a similar position and manner to ankle arthroscopy. A 2.7-mm 30° or 70° small joint arthroscope and occasionally a 1.9-mm 30° oblique arthroscope is used in particularly tight joints. The arthroscopic portals are located on the lateral hind foot. It is important to outline pertinent bony and soft tissue anatomy before subtalar arthroscopy. The superficial and deep peroneal nerve, lesser saphenous vein, and the dorsalis pedis artery should be marked with a pen. The tip of the fibula and Achilles tendon serve as the anatomic landmarks for the subtalar portals. The posterolateral portal is made at or slightly above the tip of the fibula, just lateral to the Achilles tendon. The anterolateral portal is approximately 2 cm anterior and 1 cm distal to the tip of the fibula tip (Fig 3). The anterolateral portal is used first as a viewing portal, whereas the posterolateral portal provides the outflow. Care must be taken when placing the posterolateral portal to avoid inadvertent entry into the ankle joint. The accessory anterolateral and posterolateral portals are used as needed for instrumentation or visualization. The portals are established in an atraumatic fashion similar to ankle arthroscopy. The senior author recommends a systemic 13-point arthroscopic evaluation to document all intraarticular pathologies.6 Once the diagnostic portion of the procedure is completed, the lesions observed are treated as needed. After completion of the surgery, the portals are closed with simple nylon sutures and the limb is immobilized in a soft, bulky short leg compressive dressing supported by a posterior splint.
In the only published series of subtalar arthroscopy to date,31 15 patients with degenerative joint disease were treated with an overall 83% good to excellent result at an average 32-month followup. However, the role of arthroscopic debridement in subtalar joint remains investigational. It is hoped that with additional studies in the future, the role of arthroscopic debridement of subtalar degenerative joint disease can be better defined.
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