Surgical Treatment Paradigms of Ankle Lateral Instability, Osteochondral Defects and Impingement

Abstract

Ankle sprain is amongst the most frequent musculoskeletal injuries, particularly during sports activities. Chronic ankle instability (CAI) resulting from an ankle sprain might have severe long-lasting consequences on the ankle joint. Despite the fact that most patients will respond favourably to appropriate conservative treatment, around 20% will develop symptomatic CAI with sense of giving away and recurrent sprains leading to functional impairment. "Classical" surgical repair by Brostrom-like surgery in one of its many modifications has achieved good results over the years. Recently, major advances in surgical techniques have enabled arthroscopic repair of ankle instability with favourable outcome while also enabling the treatment of other concomitant lesions: loose bodies, osteochondral defects (OCDs) or ankle impingement. Moreover, when the tissue remnant does not permit a repair technique, anatomic reconstruction by means of using a free graft has been developed. In many cases, OCDs occur as a consequence of CAI. However, traumatic and non-traumatic aetiologies have been described. There is no evidence favouring any surgical treatment over another concerning OCDs. Considering lower cost and limited aggression, microfracture is still the most frequent surgical approach. Herein, the authors describe their algorithm in the treatment of these conditions. Similarly, anterior or posterior impingement might be linked with CAI. These are clinical syndromes based on clinical diagnosis which are currently managed arthroscopically upon failure of conservative treatment.

Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for large medial talar osteochondral defects

“…4 A preoperative CT scan is used to measure the bony dimensions of the osteochondral defect (anteroposterior diameter, mediolateral diameter and depth) 4 The last part of the distal tibial osteotomy is done with a chisel to prevent thermal damage to the osteochondral unit 4 Both the distal tibial osteotomy and iliac crest autograft transplantation can be customized for every patient 4 In case a larger distal tibial osteotomy is indicated, an extra antiglide plate can be used to prevent rotation and proximal translation 4 Press-fit autograft transplantation allows for quick rehabilitation without need for intra-articular screw removal 4 Theoretically, an optimal graft to replace an osteochondral unit has the following characteristics: natural scaffold, good quality cells, and growth factors [36,41,42,48,53] Postoperative management…”

Implications of Classification of Os Trigonum: A Study Based on Computed Tomography Three-Dimensional Imaging

“…In the case of fracture of the neck of the talus, type III os trigonum could be used for the posterior approach screw implantation and internal fixation [7,12]. The measurement of the macro- and minor-axis, position relationship, and distance as the point of entry provided the basis for estimating the diameter of the bone tunnel and the length of screw [25–28], and it was more suitable for the general public.…”

Ankle instability – review and new trends

“…Nowadays, arthroscopy evaluation is considered the most important prognostic factor and, because of this, a thorough arthroscopic evaluation, as well as treatment of any intra-articular pathology, prior to ligament surgery, is recommended by most authors. 17,24 The treatment of concomitant injuries is beyond the scope of this review.…”

“…29,30 Given these concerns, 31 and the favourable outcome of anatomic techniques, the former are currently the first line of surgical treatment. 17,24,25 Anatomic open repair was first described in 1966 by Brostrom. 32 This technique respects the original anatomy by tightening the torn ATFL and CFL to the distal fibula.…”