Abstract
The use of arthroscopy in the management of acute traumatic conditions of the foot and ankle has increased in recent years, primarily because of an appreciation of fracture morphology and the utility of reducing the surgical footprint. This article presents an overview of the use of this modality in foot and ankle trauma and presents an anatomical survey of the various fractures where arthroscopic assistance can be of benefit. In addition, a discussion of the seminal articles on this subject is included.
Level of Evidence: Therapeutic Level IV: Review
Keywords: arthroscopy; foot; ankle trauma
Introduction
Since ankle arthroscopy was first described in 1972 by Watanabe1 as a diagnostic tool, the utility of this modality has increased substantially. It has been used to treat various pathologies, including osteochondral lesions, arthrofibrosis, and ankle impingement.2,3 Arthroscopy has also been used in the treatment of subtalar joint pathology.4-8
Although the role of arthroscopy is expanding, its use in the setting of acute trauma, with the exception of the knee, is mostly undefined.9,10 There are numerous reports of arthroscopic-assisted treatment of acute foot and ankle trauma,11-24 but there is no universal agreement with regard to specific indications in this arena.
The use of percutaneous techniques and limited exposure during repair of acute trauma is appealing because of the potential reduction in surgical exposure and morbidity. The benefits of a less-invasive approach include earlier mobilization and rehabilitation, fewer wound complications, and reduction in postoperative morbidity.25 The application of arthroscopy for operative reduction is referred to as arthroscopic reduction and internal fixation (ARIF). The ability to clearly evaluate the extent of chondral injury and achieve anatomical reduction without formal arthrotomy has intuitive benefits, yet the impact on definitive functional outcomes has not been formally established.17 The purpose of this article is to survey the literature regarding the adjunct use of arthroscopy in the treatment of traumatic foot and ankle injuries and related posttraumatic conditions.
General Technique
The ankle and subtalar joint can be accessed with standard arthroscopic techniques that are well described in the literature.2,3,26-28 In most cases, a standard 2-portal (anteromedial and anterolateral) approach can be used in ankle trauma.20 However, initial portal placement can be difficult because of soft-tissue swelling and may also compromise the ability to identify the intermediate dorsal cutaneous nerve.29,30 Earlier personal experience with ankle arthroscopy showed a tendency to make the portals too proximal, which can result in suboptimal visualization of the joint surface and reduce the capacity for intraoperative manipulation of the anatomy. Distraction is rarely required in the anterior approach and infrequently in the posterior approach; if necessary, manual distraction can provide adequate visualization.28 An accessory ankle portal, particularly with the posterior approach, may be useful for better global visualization and improved fluid flow.31 Hintermann et al32 have also described the use of a single anterocentral portal for global visualization of the distal tibial plafond; however, the deep peroneal nerve and dorsalis pedis artery are more at risk with this approach. Gravity flow instead of a pump will minimize extravasation of fluid into already swollen soft tissues. Epinephrine, 1 mg/L, in the inflow solution is also helpful in minimizing bleeding and may preclude the use of a tourniquet.28,33 Often, there is synovial tissue from old injury or preexisting arthritic changes that needs to be resected to visualize the intraarticular fracture lines. Once adequate visualization of the intra-articular injury has been obtained, the fracture sites are freed of interposed hematoma prior to any attempt at reduction. A 4-mm, 70° scope is preferable for optimal visualization of the joint surfaces and fracture lines.
Acute Ankle Fractures
The use of ankle arthroscopy for treatment of acute malleolar fractures has been described for a wide variety of situations. However, the precise indications have yet to be defined, primarily because of the lack of correlation with better clinical outcome17; the use of arthroscopy can help identify concomitant pathology or treat intraarticular damage that would otherwise be undetected, which in turn should lessen long-term morbidity such as posttraumatic arthritis.2,5,32 In addition to damage to the chondral surfaces, the integrity of the ligaments and the quality of syndesmotic reduction can also be assessed.34,35
Specific Pathological Entities
Acute Osteochondral Lesions. Occult chondral injury at the time of ankle injury may be responsible for residual symptoms after ankle trauma.20,36,37 Even lateral ligament injuries from ankle sprains have a high rate of associated chondral lesions, ranging from 89% in acute to 95% in chronic injuries.38 The overall incidence of chondral lesions associated with acute ankle fractures varies with the severity of injury but has been reported to be as high as 79%.32 In a series of 288 ankle fractures treated with arthroscopic assistance, Hintermann et al32 noted an increase in osteochondral lesion incidence and severity in Weber-B and Weber-C fracture patterns. Active treatment of these lesions occurred in 20% of patients and consisted of frayed cartilage removal and, rarely, pinning of a loose osteochondral fragment. There are numerous other reports regarding the arthroscopic identification of osteochondral damage that occur consequent to an ankle fracture.16,37-41 These reports advocated active treatment of these lesions, ranging from excision to microfracture. The effect of treating these chondral lesions at the time of ankle fracture fixation on the functional outcome is still unknown. There is only supposition that standard treatment of these lesions is actually effective in reducing symptoms. Furthermore, there is little evidence that links the latent discovery of osteochondral damage to previous ankle fracture, especially given the high incidence of lesions in acute ankle sprains. Our personal experience in the management of more than 3000 acute ankle fractures confirms an extremely low incidence of latent presentation of osteochondral lesions (Figure 1)...
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John M. Schuberth, DPM, has extensive experience in Complex Foot and Ankle Surgery. Throughout his 40 year career, he has performed over 25,000 surgical cases and over 1,500 ankle replacements. He has published extensively on a wide variety of subject involving foot and ankle surgery (128 publications) and lectured all over the world on Foot and Ankle surgery. Please refer to his most recent CV for details. Dr. Schuberth provides expert witness services to attorneys representing plaintiff and defense. His services include medical record review, thorough reporting, depositions, and trial testimony as needed. He has been deposed/testified over 20 times since 2020.
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