Ankle and Foot Arthroscopy

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Arthroscopy for athletic foot and ankle injuries
Terrence M. Philbin, DOa,b, Thomas H. Lee, MDb, Gregory C. Berlet, MDa,b,*
Department of Orthopaedic Surgery, The Ohio State University, 370 West 9th Avenue, Columbus, OH, 43210, USA b Orthopedic Foot and Ankle Center, 6200 Cleveland Avenue, Columbus, OH 43231, USA
a

Arthroscopic and endoscopic techniques used today have a long history of development. The earliest efforts involved instruments to view the urinary bladder. Professor Kenji Takagi of Tokyo University in Japan first applied endoscopic techniques to the knee joint in 1918 [1 –4]. His initial goal was to diagnose and treat the stiffness of tuberculous arthritis, which caused serious social disabilities among Japanese citizens who were unable to kneel or squat. On July 6, 1932, he gave the first report of endoscopy of the knee to the Japanese Orthopedic Association [5]. Bircher, in 1921, placed the Jacobeus laparoscope into a knee and referred to the technique as ‘‘artho-endoscopy’’ [6,7]. Kreuscher published the first report describing arthroscopy in the US literature in 1925 [8]. He discussed the use of arthroscopy for the diagnosis and treatment of meniscal lesions. Unfortunately, World War II halted most of the advancements of arthroscopy until the 1950s. In 1955, Watanabe, a student of Professor Takagi, performed the first recorded arthroscopic surgical procedure [3,9,10]. During the late 1960s and 1970s, the teaching of arthroscopy grew rapidly in the United States. By the 1980s, arthroscopy was accepted as a minimally invasive diagnostic tool that was associated with few complications. This article describes recent arthroscopic techniques that are useful in diagnosing and treating athletic injuries of the foot and ankle.

Arthroscopy of the great toe In 1972, Watanabe described the first arthroscopy of the first metatarsophalangeal (MTP) joint [11]. Common indications for arthroscopy of the first
* Corresponding author. Orthopedic Foot and Ankle Center, 6200 Cleveland Avenue, Columbus, OH 43231. E-mail address: [email protected] (G.C. Berlet). 0278-5919/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0278-5919(03)00093-0

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Table 1 Indications for first MTP arthroscopy Authors Davis and Saxby [12] van Dijk et al [13] Borton et al [14] Indications bone cyst of the proxmial phalanx meniscoid-like lesion painful sesamoid bones bacterial arthritis pigmented villonodular synovitis

MTP joint include osteophytes, hallux rigidus, chondromalacia, osteochondral dissecans, loose bodies, arthrofibrosis, and synovitis (Table 1 [12 –14]). Dorsal osteophytes, hallux rigidus, and osteochondral lesions are common indications among athletes. Diagnostic first MTP arthroscopy may be indicated for patients who fail conservative treatment of recurrent edema, locking pain, and diminished range of motion [15]. Arthroscopic anatomy and portals The dorsal medial, dorsal lateral, and straight medial portals are used most commonly for arthroscopic evaluation and treatment of the first MTP joint (Fig. 1A,B). van Dijk et al reported that two portals are needed to visualize and treat disorders of the lateral sesamoid—one in the first web space and another 4 cm proximal to the joint line between the short abductor and the flexor halluces

Fig. 1. (A,B) The dorsal medial, dorsal lateral, and straight medial portals. (Illustrations created by Peter Maurus, MD, Resident, Department of Orthopaedic Surgery, The Ohio State University, Columbus, OH.)

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brevis muscle [13]. When making portals, care must be taken to avoid injuring the branches of the deep peroneal nerve laterally, branches of the superficial nerve medially, and branches of the saphenous around the medial aspect of the first MTP joint. Technique The patient is placed in a supine position on the operating table with the heels resting on the end of the table. After appropriate anesthesia is administered, apply an ankle or thigh tourniquet (usually not inflated unless needed during the procedure). Routine sterile skin preparation and draping are performed. The joint can be visualized using manual traction or a sterile finger trap. Palpate the joint line either side of the extensor halluces longus (EHL), insert a 22-gauge spinal needle into the joint medial to the EHL, and inject 5 ml of normal saline to distend the joint. Make a longitudinal skin incision with a #15 blade and use a hemostat to spread the subcutaneous tissue to avoid trauma to the surrounding neurovascular bundles. A blunt trocar is inserted into the joint followed by the arthroscope. A 1.7 mm [15], 1.9 mm [12], and 2.7 [13] mm scope have all been used for first MTP arthroscopy. The dorsal lateral portal can be started once the joint is visualized. The spinal needle is then inserted to assist with appropriate placement of the dorsal lateral and straight medial portals. A 13-point, systematic examination of the first MTP, as described by Ferkel, proceeds as follows [16]: 1. Lateral gutter 2. Lateral corner of the metatarsal head 3. Central portion of the metatarsal 4. Medial corner of the metatarsal head 5. Medial gutter 6. Medial capsular reflection 7. Central bare area 8. Lateral capsular reflection 9. Medial portion of the proximal phalanx 10. Central portion of the proximal phalanx 11. Lateral potion of the proximal phalanx 12. Medial sesamoid 13. Lateral sesamoid Davies and Saxby list 10 equipment requirements for first MTP arthroscopy with finger trap distraction [17]: Thigh tourniquet Shoulder holder Sterile Chinese finger trap 1.9 mm, 30° arthroscope Small joint shaver

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2 mm probe 2 mm curette Small joint grasper Two 23-gauge needles 10 cc syringe Postoperative care and rehabilitation The small portals are approximated with interrupted nylon sutures and a bulky compressive dressing is applied for 1 week. The patient should remain nonweight bearing for the first week. After 1 week, a low-tide walker boot can be used until pain and swelling resolve. Range-of-motion exercises can be started 2 weeks postoperatively. Results There is a paucity of literature on the clinical results of first MTP arthroscopy. Ferkel and Van Buecken reported the results of 22 patients whose ages ranged from 18 to 70 years (mean age 40), with a mean follow-up of 54 months [18]. They reported a good outcome in 73% of the cases, fair outcome in 13.5%, and poor outcome in 13.5%. All patients in the fair and poor categories had degenerative joint disease and required a fusion later. van Dijk et al reported on 23 patients who underwent first MTP arthroscopy [13]. The patients averaged 33 years of age (range, 16– 61 years) and the followup period averaged 2 years. They reported excellent or good results for 14 patients and fair or poor results for 9 patients. One patient experienced transient loss of medial hallux sensation and another experienced loss of lateral hallux sensation. The authors advocate sesamoid removal laterally with the scope but state that removing the medial sesamoid arthroscopically has not proven promising. Davies and Saxby performed first MTP arthroscopy on 11 patients ranging from 15 to 58 years of age (mean 30 years) with a mean follow-up of 19.3 months [17]. At the final follow-up, all the patients had no or minimal pain, decreased edema, and increased range of motion. One patient had a minor wound complication. Three patients required an arthrotomy during the surgery. In summary, first MTP arthroscopy is an evolving technique. The best indications are osteochondral lesions. Debridement of marked degenerative joint disease should be discouraged.

Subtalar arthroscopy In 1985, Parisien and Vangsness published the results of a cadaveric study of subtalar arthroscopy [19], followed by three case reports in 1988 [20]. The major potential advantages of the subtalar arthroscopy compared with subtalar arthrotomy include diminished morbidity and more rapid rehabilitation. Open subtalar arthrotomy often requires fat pad excision, extensor digitorum brevis

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detachment, and cervical ligament transection—all of which can be avoided with subtalar arthroscopy. The indications for arthroscopy of the subtalar joint include chondromalacia, osteophytes, arthrofibrosis, synovitis, loose bodies, osteochondritis dissecans, painful os trigonum syndrome [21], and arthroscopic-assisted reduction in calcaneal fractures [22,23]. Subtalar arthroscopic anatomy and portals The most common primary portals used for subtalar arthroscopy are the anterior lateral, middle, and posterior lateral portals (Figs. 2 –4). Cheng and Ferkel have described the accessory anterolateral and accessory posterolateral portals that are used for instrumentation [24]. Mekhail et al reported good subtalar joint visualization via a medial subtalar arthroscopic portal in a cadaveric study [25]. The bony anatomy and Achilles tendon should be outlined before surgery. The superficial peroneal nerve, sural nerve, and the dorsalis pedis neurovascular bundle should also be outlined. Establish the anterior lateral portal approximately 1 cm distal and 2 cm anterior to the tip of the fibula. The posterior lateral portal is positioned slightly proximal to the fibular tip and anterior to the Achilles tendon. Place the middle portal just anterior to the fibula and directly over the sinus tarsi. Frey et al reported the results of a cadaveric study evaluating subtalar arthroscopy portals and the structures at risk [26]. The posterior lateral portal posed the

Fig. 2. Sites are marked for creating the posterior lateral portal, middle portal, and anterolateral portal. (Courtesy of Christopher Hyer, MD, Columbus, OH.)

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Fig. 3. The arthroscope is placed in the anterior lateral portal and the shaver is placed in the middle portal. (Courtesy of Christopher Hyer, MD, Columbus, OH.)

greatest risk of nerve or vessel damage in the study. The sural nerve and lesser saphenous vein are at risk during posterior lateral portal placement. The middle portal was found to be without risk to the surrounding structures. The study showed that the dorsal intermediate cutaneous branch of the superficial nerve and a small branch of the lesser saphenous vein are at most risk with anterior lateral portal placement. Frey et al reported that the best portal combination for posterior facet visualization was placing the arthroscope in the anterior lateral portal and the instrumentation in the posterior lateral portal [26]. Technique The patient is placed in a lateral decubitus position with the operative extremity upward. After appropriate anesthesia is administered, a thigh tourniquet should be applied, as should a noninvasive distraction strap to assist with visualization. Following routine skin preparation and draping, the joint can be distracted by placing an 18-gauge needle into the anterior lateral portal, with the needle positioned away from the sinus tarsi upon entry to help prevent injury to the articular surface. Once the needle is in proper position, the joint is distended with fluid, and free backflow of fluid is used to help confirm intra-articular placement. The 2.7 mm arthroscope is then inserted into the joint and an outflow cannula is established with an 18-gauge needle in the posterior lateral portal. Care should be taken to avoid making the posterior lateral portal too proximal, which

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Fig. 4. The arthroscope is placed in the anterior lateral portal and the shaver is placed in the posterior lateral portal. (Courtesy of Christopher Hyer, MD, Columbus, OH.)

can prevent entering the posterior ankle joint. Visualization of the intra-articular needle helps to confirm proper positioning. The posterior lateral portal can be used for joint inspection or placement of instrumentation. Ferkel has recommended the following 13-point diagnostic subtalar exam [16]: 1. Deep interosseous ligament 2. Superficial interosseous ligament 3. Anterior posterior talocalcaneal joint 4. Anterolateral corner 5. Lateral talocalcaneal ligament 6. Calcaneofibular ligament 7. Central talocalcaneal joint 8. Posterolateral gutter 9. Posterolateral recess 10. Posterior gutter 11. Posteromedial recess 12. Posteromedial corner 13. Posterior talocalcaneal joint Numbers 1 through 8 should be visualized through the anterior lateral portal and numbers 9 through 13 can be seen through the posterior lateral portal.

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The authors recommend the following equipment for subtalar arthroscopy: 1.9 mm or 2.7 mm arthroscope Small joint shaver 18-gauge spinal needles Small joint probe and grasper Ring curets Small joint picks K-wires Noninvasive joint distracter Rarely, an ankle arthroscopy and subtalar arthroscopy may be required at the same operative setting. Should this occur, it is recommended that the subtalar arthroscopy be performed first, because after ankle arthroscopy, the fluid extravasation can prevent proper subtalar portal placement. Postoperative care and rehabilitation Following surgery, the small portals are approximated with interrupted nylon suture. The extremity is placed into a bulky dressing with a posterior splint. For the first week, patients are instructed to be non-weight bearing. At 1 week postoperatively, the extremity can be placed in a low-tide boot and walking may begin as pain and swelling allow. Range-of-motion exercises are commenced when wound healing is complete. Results There are few published reports of the results of arthroscopy of the subtalar joint. In 1994, Williams and Ferkel reported the results on 29 patients who had subtalar arthroscopy [27]. All the patients in the study underwent ankle arthroscopy followed by subtalar arthroscopy. With an average 32-month follow-up, 86% of the results were good-to-excellent and there were no major complications. Goldberger and Conti presented the clinical outcomes of 12 patients after subtalar arthroscopy [28]. Their mean age was 41 years and follow-up averaged 17.5 months. The mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale Score was 60, which improved to 71 postoperatively. Three patients improved their score by 10 or more points. Three of the 4 patients whose scores decreased scores later required subtalar fusion. The authors found subtalar arthroscopy to be a more accurate method of diagnosing subtalar articular injury than radiographs, bone scan, and magnetic resonance imaging. The therapeutic benefit in the treatment of early degenerative joint disease with subtalar arthroscopy was thought to be limited. Frey et al reported a retrospective study on 49 subtalar arthroscopies [29]. The average patient age was 35 years and the follow-up period averaged 54 months. Excellent-to-good results were achieved in 94% of the cases. The

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group had 90% good to excellent results. The authors believe that sinus tarsi syndrome is an inaccurate term and that subtalar arthroscopy is the proper tool to assist with accurate diagnosis of subtalar etiologies (14 of the patients had the preoperative diagnosis of sinus tarsi syndrome). After subtalar arthroscopy, all the diagnoses were changed. There were five minor complications resolved with nonoperative treatment; transient neuropraxia was the most common complication [29].

Anterior ankle impingement Anterior ankle impingement exostoses (footballer’s ankle) can decrease ankle dorsiflexion, cause anterior ankle pain, and can compromise ankle proprioception [30,31]. Anterior impingement lesions occur most commonly in the athletic population, particularly dancers and soccer players. Many etiological theories have been proposed, including anterior ankle capsular strain from forced plantarflexion with resultant calcific deposits along capsular lines, or repetitive dorsiflexion resulting in subchondral injury and new bone formation [31 – 33]. These spurs can occur coincidentally with degenerative joint disease, although there is no conclusive evidence that chronic ankle instability leads to degenerative joint disease [34]. Capsular strain likely represents the mechanism of anterior impingement lesions, which are found commonly in the chronically unstable ankle. Impingement can be classified according to the stages of Scranton and McDermott: Stage I—anterior tibial osteophytes less than 3 mm, Stage II— osteophytes greater than 3 mm with osteochondral reaction, and Stage III—tibial and talar kissing lesions [35]. These lesions can be confirmed and staged with weight-bearing lateral radiographs in forced dorsiflexion. Using CT scanning for assessment of the axial malleolar distance, the mortise configuration has been proposed to influence the development of these spurs, as a more posteriorly positioned fibula increases the risk of lateral ankle instability and subsequent anterior impingement [36]. Berberian et al have shown that the talar spur peak lies medial to the midline, the tibial spur lies lateral to the midline, and the spurs typically do not overlap each other [37]. They also found that the tibial spur is wider than the talar spur, and the talar spur usually protrudes medially off the medial edge of the talar neck. The tibial spurs of impingement are anterior, whereas the degenerative spurs are more global [35]. Treatment considerations must include the association of lateral ankle instability and mechanical axis deviation as comorbid factors to the patient’s disability. Anterior ankle spurs can be removed arthroscopically or via open arthrotomy. It is the authors’ experience that arthroscopic intervention is successful in most cases, although the portals may need to be enlarged to accommodate large bony fragments. The spurs are best visualized with no distraction applied to the foot, because distraction tends to draw the anterior capsule close to the anterior bony structures. A 4.0 mm burr facilitates both the

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removal of the spur and adequate fluid flow to preserve visualization. A burr run on reverse has less potential for overly aggressive resection and can be useful for final smoothing or for less experienced arthroscopists. Degenerative spurs should be approached with caution, because the patient’s pain can be increased with improved ankle motion.

Posterior ankle arthroscopy Ankle arthroscopy has traditionally been performed using anterior ankle portals. At times, however, posterior pathology cannot be accessed through anterior portals. To facilitate posterior access, posterolateral, posteromedial, and transAchilles tendon portals can be used [38,39]. Pathology that may require posterior arthroscopic visualization includes posteromedial and posterolateral talar osteochondritis dissecans lesions, flexor halluces longus stenosing tenosynovitis, posterior ankle impingement, displaced fracture of the os trigonum, insertional Achilles tendinitis, and retrocalcaneal bursitis. Technique Although there are three portals described for posterior ankle arthroscopy, the majority of clinical research has focused on the posterolateral portal. The paraAchilles posterolateral portal is made at the level of or slightly above the tip of the lateral malleolus just lateral to the Achilles tendon. The portal is established by introducing a spinal needle at the posterolateral site, injecting the posterior ankle joint with saline to confirm placement, and then making a small vertical skin incision. Blunt dissection is carried down until bone is encountered and then a 30°, 4.5 mm arthroscope shaft with a blunt trocar is introduced into the ankle joint. A coaxial portal placed directly posterior to the peroneal tendons can also be used. The para-Achilles portal should be created with the patient in the prone position, whereas the portal directly posterior to the peroneal tendons can be performed with the patient in the supine position. Results Drez et al reviewed 56 arthroscopies performed with a combination of anterior and posterior portals [40]. They found that the posterolateral portal allowed for a comprehensive view of the posterior recess and that the posteromedial portal was rarely needed. Ferkel et al likewise recommend the use of a posterolateral portal in routine ankle arthroscopy to confirm a complete visualization of the ankle joint [41]. The structures at risk with the posterolateral portal include the sural nerve and small saphenous vein. Sitler et al, in a cadaveric dissection study of the para-Achilles posterolateral portal, showed the average distance between the posterolateral portal and the sural nerve to be 3.2 mm and the average distance between the small saphenous vein and the portal to be 4.8 mm [39].

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Ferkel et al reported a neurological complication rate, using combination anterior and posterolateral portals, of 4.4% [41]. The posteromedial portal has been described being made in a para-Achilles location or in a true posteromedial location coursing between the posterior tibial tendon and flexor digitorum tendons [42 – 44]. The Achilles tendon posteromedial portal is made just medial to the Achilles tendon in the horizontal plane, at the same level as the posterolateral portal. A needle is inserted through the skin at the appropriate location, oriented toward the lateral aspect of the joint to ensure placement lateral to the flexor halluces longus tendon. The appropriate positioning of the needle can be confirmed via the arthroscope in the posterolateral portal before the posteromedial portal is created. The posteromedial portal is then established, with a short skin incision and blunt dissection to the posterior ankle joint following the course of the previous needle. The alternative posteromedial portal is made by developing the interval between the posterior tibial tendon and the flexor digitorum longus behind the medial malleolus. The blunt dissection is carried to the posterior ankle joint and the arthroscope introduced into the joint. Structures at risk with the posteromedial portal include the flexor halluces longus tendon and the posteromedial neurovascular bundle. Using the para-Achilles posteromedial portal, the average distance between the portal and the flexor halluces longus tendon was 2.7 mm, the average distance to the tibial nerve was 6.4 mm, and to the tibial artery 9.6 mm [39]. Using a posteromedial portal directly behind the medial malleolus adjacent to the posterior tibial tendon, the average distance from the cannula to the posterior tibial nerve was 5.7 mm and 6.4 mm to the tibial artery. The para-Achilles posteromedial portal is best used with the patient in the prone position, whereas the posteromedial portal may be used with the patient in the standard supine position.

Endoscopic calcaneal prominence resection The retrocalcaneal bursa and Achilles tendon can become compressed and irritated by a posterior-superior calcaneal prominence. When nonoperative treatment fails, the condition can be treated by open calcaneal resection, retrocalcaneal bursectomy, and Achilles debridement with repair when necessary. Recently, endoscopic calcaneoplasty has been described. The procedure is performed with the patient in a prone position, and posterior medial and posterior lateral portals are used. The portals are placed just medial and lateral to the Achilles tendon and just proximal to the superior aspect of the calcaneus. A 2.7 mm arthroscope and small joint equipment are recommended. To the authors’ knowledge, clinical results are yet to be published on endoscopic calcaneal resection. Extra-articular endoscopic decompression of the retrocalcaneal space can be useful for treating retrocalcaneal bursitis, Haglund’s spur, and impingement. The arthroscopic approach may decrease postoperative recovery time and incisional complications. Using lateral and accessory medial portals, Leitze et al showed

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at an average of 22 months postoperatively, a comparable result to open retrocalcaneal decompression as measured by the AOFAS Ankle-Hindfoot Scale [45]. The study authors believe this technique is useful in minimizing wound complications and decreasing the postoperative recovery time.

Osteochondral lesions of the talus Osteochondral lesions of the talus (OLT) are most commonly attributed to trauma [46 – 54], and lateral talar dome lesions have a traumatic etiology more often than medial lesions [52,53]. The results of several biomechanical studies indicate that a repetitive overuse syndrome may be responsible for medial lesions, and support the belief that acute trauma causes lateral lesions [55 – 58]. The mechanism of injury of lateral lesions is inversion and dorsiflexion, in which the anterolateral aspect of the talus impacts the fibula. Medial lesions result from combined inversion, plantar flexion, and external rotational forces. The medial lesion is typically deep and cup-shaped, caused by the posteromedial talar dome impacting the tibial articular surface. Radiographic evaluation with the ankle in plantarflexion can show posteromedial lesions, and dorsiflexion can reveal anterolateral lesions. Magnetic resonance imaging is helpful in identifying injuries of the subchondral bone and cartilage. When an OLT is diagnosed, staging should follow according to one of several staging systems published previously [16,59 – 63]; however, studies correlating the stage of the lesion and outcome following treatment are lacking [49]. Treatment Arthroscopic treatment of OLT involves three principles: removing loose bodies, securing the OLT to the talar dome, and stimulating development of hyaline cartilage. Using a wide-angle, 2.7 mm arthroscope may provide more mobility than a 4 mm arthroscope, and noninvasive joint distraction enables visualization of the entire talar dome Microfracture The microfracture technique is relatively new in treating osteochondral defects of the talus, although the technique has been successful in treating chondral defects in the knee for several years [64,65]. Using awls, microfractures (perforations) are made approximately 3 mm to 4 mm apart in the subchondral bone while maintaining the integrity of the bone plate. The microfracture technique promotes new tissue formation by releasing substances such as mesenchymal stem cells, growth factors, and healing proteins [64]. Ultimately, cartilage-like cells form and fill the original defect. Steadman et al performed the microfracture technique in the knees of 25 professional football players between 1986 and 1997

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[66]. Players returning to the sport averaged 4.6 subsequent seasons of participation, and 9 players continued to play at the time of writing this article (April 2003). Thermann et al reported that early results show the technique is successful in improving function and restoring cartilage (as determined by MRI) in the talus [67].

Osteochondral autologous transfer system and mosaicplasty Osteochondral autologous transfer system (OATS) and mosaicplasty transplant either a single, large osteochondral plug into the talar defect, or multiple small plugs to cover the defect. The grafts are taken from the femoral trochlea or condyle. An advantage of the single-plug method is that fibrocartilage ingrowth is minimal, but a disadvantage is possible donor-site morbidity because of the large graft size. Mosaicplasty may reduce donor-site morbidity, but a disadvantage is that 20% to 40% of the defect can be filled with fibrocartilage because of the small size of the grafts [68]. Hangody et al [69] reported the results of mosaicplasty for ‘‘large or unstable’’ osteochondral lesions ( > 10 mm in diameter) in 36 patients. They used an average of three plugs, ranging from 3.5 mm to 6.5 mm. With follow-up ranging from 2 to 7 years, 94% of the patients had good-to-excellent results. There was no long-term ipsilateral knee donor site morbidity [69]. More recently, Hangody and Fules reported the results of autologous osteochondral mosaicplasty in 831 patients [70]. They reported good-to-excellent results in 94% of patients treated with talar procedures. Autologous chondrocyte implantation (ACI or Carticel, Genzyme Biosurgery, Cambridge, Massachusetts) is a process that grows the patient’s own cartilage cells, which are then implanted beneath a patch into the site of the defect. In one report of ACI in the knee, 79% of patients showed improvement 5 years postoperatively [71]. The researchers reported that ACI patients enjoyed greater improvement and higher levels of functioning than a control group treated with drilling, abrasionplasty, or microfracture techniques [71].

Arthroscopic repair of chronic ankle instability Ankle sprains are common injuries, occurring in an estimated 1/10,000 persons per day [72]. Although the majority of acute ankle sprains heal with physical therapy/ankle rehabilitation, approximately 29% to 42% of patients experience chronic functional ankle instability [73]. The anterior talofibular ligament (ATFL) is the most commonly injured ligament during ankle sprains. It serves as the primary restraint to inversion and translation at all angles of ankle flexion [74,75]. During an inversion ankle sprain, the anterolateral capsule is typically injured first, followed by the ATFL, calcaneal fibular ligament (CFL), and posterior talofibular ligament (PTFL).

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Thermal-assisted capsular modification Thermal-assisted capsular modification for chronic lateral ankle instability was introduced recently [76,77]. This technique has been successful in treating shoulder instability and early results in the ankle are encouraging. The concept is based on the fact that thermal energy between 65°C and 70°C shrinks collagen, which comprises more than 90% of joint capsules, ligaments, and tendons (TACS). Factors such as tissue properties themselves, variables related to the laser include the density, application time, and concentration area determine the amount of energy delivered to the tissue [78]. Pulsing the laser (alternating the beam on and off) can minimize tissue damage and control depth of penetration Our decision to use thermal capsular modification for lateral ligament reconstruction is influenced by the patient’s body habitus, activity pattern, and degree of ligament injury. Indications include patients with moderate build, intraligament stretching (not avulsed from bone), generalized ligamentous laxity with functional ankle instability, a commitment to adhere to the postoperative rehabilitation protocol, and no previous ankle ligament reconstructive surgery. Contraindications include muscle weakness, tendon tears and instability, proprioceptive disorders, subtalar instability, and tibiofibular joint instability. Preoperatively, each patient undergoes a focused physical examination assessing ankle instability, muscle weakness, tendon tears and tendon instability, proprioceptive disorders, subtalar instability, and tibiofibular joint instability. Radiographs of the affected ankle are obtained and MRI should be performed if peroneal tears and chondral injuries of the talus are suspected. Technique Following sterile preparation and drape of the ankle, a noninvasive ankle distractor strap is applied (Arthrex, Naples, Florida). Anteromedial and anterolateral portals are established. The surgeon should then perform a complete arthroscopic examination and treat any pathology encountered (eg, synovitis, osteochondral defects) accordingly. Impingement lesions in the anterolateral gutter are encountered frequently and should be debrided aggressively with an arthroscopic trimmer to allow adequate exposure of the anterolateral gutter. Once visualization of the anterolateral capsule and distal fibula is confirmed, introduce a thermal control wand through the lateral portal and release the distraction device when the thermal wand is in position. The anterior talofibular ligament can be identified consistently [79]. With maximum temperature set at 65°C, the tissue of the anterolateral capsule (just distal and anterior to the distal fibula) and ATFL can be treated with the thermal wand by using a painting technique, starting deep in the lateral gutter and working anteriorly, avoiding repetitive treatment of a specific location. Thermal treatment is below the equator of the lateral arthroscopy portal to avoid creating an iatrogenic impingement lesion. The treated capsule will show a blushing following treatment. Surgeons familiar

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with shoulder thermal modification will note that there is a visual contraction of the shoulder capsule that occurs while working in the inferior glenohumeral pouch. There is much less visual confirmation of contraction in the ankle. Following adequate exposure to the thermal effects of the wand, the arthroscopic instrumentation can be removed. The ankle should be held in slight dorsiflexion and eversion as the portals are closed with suture and a well-padded posterior/ gutter splint (with cooling pack) is applied to the operative extremity. Results Between February 1999 and December 2001, the authors performed 42 arthroscopic thermal assisted capsular modifications of the anterolateral capsule and the ATFL [80]. The AOFAS hindfoot scores improved significantly: scores averaged 29.57 preoperatively (SD 15.6) and improved to 55.36 (SD 13.56) at an average follow-up of 14.1 months (P <.001). One patient had skin breakdown over the calf where the ankle distracter strap had been, which resolved with conservative wound care. There were no infections. Postoperatively, patients undergo physical examinations at 3-week intervals. Patients wear a non-weight bearing cast for the first 3 weeks, followed by a weight-bearing cast for 3 weeks, and then a weight-bearing boot walker for 3 weeks. Physical therapy ankle rehabilitation begins 9 weeks postoperatively. Favorable outcomes using thermal stabilization have been reported; however, no prospective studies have been published reporting the use of thermal modification for ankle instability [2,76,80 –82]. The authors believe that select patients with chronic lateral instability who have failed a course of conservative treatment are good candidates for arthroscopic thermal capsular and ATFL shrinkage. Greater follow-up will be necessary to determine whether the ankle will remain stable over time. Longer-term followup will determine how the outcomes compare with traditional surgical methods (ie, modified Brostrom repair).

Acknowledgments Editorial assistance was provided by Janet L. Tremaine, Tremaine Medical Communications, Dublin, Ohio.

References
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