The June 2023 Foot & Ankle Roundup³⁶⁰ looks at: Nail versus plate fixation for ankle fractures; Outcomes of first ray amputation in diabetic patients; Vascular calcification on plain radiographs of the ankle to diagnose diabetes mellitus; Elderly patients with ankle fracture: the case for early weight-bearing; Active treatment for Frieberg’s disease: does it work?; Survival of ankle arthroplasty; Complications following ankle arthroscopy.

Aims. This systematic review aimed to summarize the full range of complications reported following ankle arthroscopy and the frequency at which they occur. Methods. A computer-based search was performed in PubMed, Embase, Emcare, and ISI Web of Science. Two-stage title/abstract and full-text screening was performed independently by two reviewers. English-language original research studies reporting perioperative complications in a cohort of at least ten patients undergoing ankle arthroscopy were included. Complications were pooled across included studies in order to derive an overall complication rate. Quality assessment was performed using the Oxford Centre for Evidence-Based Medicine levels of evidence classification. Results. A total of 150 studies describing 7,942 cases of ankle arthroscopy in 7,777 patients were included. The overall pooled complication rate was 325/7,942 (4.09%). The most common complication was neurological injury, accounting for 180/325 (55.4%) of all complications. Of these, 59 (32.7%) affected the superficial peroneal nerve. Overall, 36/180 (20%) of all nerve injuries were permanent. The overall complication rate following anterior ankle arthroscopy was 205/4,709 (4.35%) compared to a rate of 35/528 (6.6%) following posterior arthroscopy. Neurological injury occurred in 52/1,998 (2.6%) of anterior cases using distraction, compared to 59/2,711 (2.2%) in cases with no distraction. The overall rate of major complications was 16/7,942 (0.2%), with the most common major complication – deep vein thrombosis – occurring in five cases. Conclusion. This comprehensive systematic review demonstrates that ankle arthroscopy is a safe procedure with a low overall complication rate. The majority of complications are minor, with potentially life-threatening complications reported in only 0.2% of patients. Cite this article: Bone Joint J 2023;105-B(3):239–246

Most posterior hindfoot procedures have been described with the patient positioned prone. This affords excellent access to posterior hindfoot structures but has several disadvantages for the management of the airway, the requirement for an endotracheal tube in all patients, difficulty with ventilation and an increased risk of pressure injuries, especially with regard to reduced ocular perfusion.

We describe use of the ‘recovery position’, which affords equivalent access to the posterior aspect of the ankle and hindfoot without the morbidity associated with the prone position. A laryngeal mask rather than endotracheal tube may be used in most patients. In this annotation we describe this technique, which offers a safe and simple alternative method of positioning patients for posterior hindfoot and ankle surgery.

Cite this article: Bone Joint J 2013;95-B:1317–19.

Total ankle arthroplasty is used as a treatment for end stage arthritis of the ankle. Surgical techniques highlight risk of injury to anterior neurovascular structures. No literature highlights injury risk to the posterior neurovascular structures in ankle replacement surgery. Current literature consists of cadaveric study in relation posterior ankle arthroscopy. A retrospective review was done of ankle MRI's, performed by the senior author in his practice. Studies were included in the study where there was no pathology of the posterior ankle present. Axial, coronal and sagital T1 weighted films were reviewed and measurements of the posterior neurovascular structures and tendons were made in relation to the posterior tibia and medial malleolus in relation to planned tibial and talar cutting planes. A total of seventy-eight MRI's were included in the study (ages ranged from 22 to 78 years). There were 40 females and 38 males. At the level of the tibial cut the tibial nerve and artery were between two to six millimeters from the posterior surface of the tibia. The flexor hallucis longus (FHL) is located in the midline between the medial malleolus and fibula, closely related to the posterior tibial surface. The flexor digitorum longus (FDL) tendon is located in the posterior medial corner of the ankle. There is a window approx ten millimeters wide between where the neurovascular structures lie between the FDL and FHL tendons. At the level of the talus cut the tibial nerve and artery were between five to 11 mm from the posterior body of the talus. A similar window is present at this level where the neurovascular structures lie between the FDL and FHL tendons. The neurovascular structures of the ankle are potentially at risk during the tibial and talar bone resection. They are most at risk with the transverse cut of the tibia. This may be decreased by preventing direct pressure over these structures during bone resection

Introduction: Arthroscopic management of posterior ankle impingement syndrome (PAIS) is now commonly practiced. Scanty information about the results of this procedure in a district hospitals is available.

Aim: We present the results of our series of patients treated with hindfoot arthroscopy for PAIS, and describe the complications encountered.

Patients and Method: Twenty procedures were performed on 19 patients (12 males, 7 females) between January 2006 and September 2008. Patients were followed up for an average of 7.9 months. Return to sport, patient satisfaction, relief of symptoms and the American Orthopaedic Foot and Ankle Society (AOFAS) hind-foot score were all assessed.

Results: Procedures performed included excision of an os trigonum, flexor hallucis longus decompression, and microfracture of the posterior talus. The average age of the patients was 35 years. Return to activity occurred at an average of 4 weeks. Four patients were dissatisfied, 1 was unsure and all the other patients were satisfied with their outcome. The average pre-operative AOFAS score was 73.8 and the post operative score was 84.5. There were no neurovascular injuries.

Conclusion: There was a significant incidence of dissatisfied patients in the absence of major complications. This might reflect technical difficulties early in the early learning curve for this procedure.

Introduction: When conservative treatment of posterior ankle impingement syndrome (PAIS) fails, operative intervention is indicated. Traditionally this involved an open approach. More recently posterior ankle arthroscopy has been employed. We report the first series of results from an exclusively elite athlete population. Method: We looked retrospectively at a prospectively compiled database of a consecutive series of elite professional soccer players on whom we have performed posterior ankle arthroscopy for both bony and soft tissue PAIS over the past 5 years. We reviewed our clinical and operative notes and those of the Football Association medical team. Statistical analysis was performed using MedCalc for Windows, version 9.6.4 (MedCalc software, Mariakerke, Belgium). Results: One player was lost to follow up leaving 27 out of 28 players in the study. The mean time to return to training post operatively was 34 days (24–54) and to playing was 41 days (29–72). Significant correlations were found between the length of symptoms and the number of pre operative injections (Spearman’s rank correlation coefficient = 0.806. p< 0.001) and the length of symptoms pre-operatively and return to training (Correlation coefficient = 0.383. p=0.048) and return to play (Correlation coefficient = 0.385. p=0.048). Return to training was significantly faster after soft tissue debridement with FHL release than after bony surgery (p=0.046 Kruskal-Wallis test). There was one surgical complication in the form of a persistent portal leakage. This was successfully treated by resting the ankle in a boot for 2 weeks. One patient had recurrent symptoms 3 months after surgery; this was successfully treated with an ultrasound guided injection. There were no infections and no neurovascular injuries. Conclusion: Posterior ankle arthroscopy is safe and effective in the treatment of posterior ankle impingement syndrome in the elite soccer player with return to training expected at an average of 5 weeks

Ankle arthroscopy is generally performed through anterior portals and provides good access to the anterior aspect of the ankle joint. However, the structure of the talus and the anatomical confines of the ankle joint limit access to posterior structures via this approach. Developments in the technique of posterior ankle arthroscopy have determined the appropriate site for portals with minimal risk of iatrogenic neurovascular injury. This facilitates treatment of conditions such as flexor hallucis longus (FHL) release, excision of os trigonum for posterior impingement, treatment of retro-calcaneal bursitis and treatment of ankle and subtalar joint pathology. Posterior ankle arthroscopy is a relatively new technique and has recently been adopted by the senior author. This study was performed to explore the benefits and limitations of this procedure and to identify early post operative results. We describe our experience of this technique in treating 9 patients with varied posterior ankle pathology. 2 patients had excision of os trigonum; 2 had FHL release; 1 had both excision of os trigonum and FHL release; 3 had curettage for posterior osteochondral defect (OCD) of the talus; and 1 had resection of Haglund’s deformity. The mean pre-operative AOFAS scores (Ankle-Hindfoot Scale) was 73 (range 47 to 85). The mean post operative AOFAS score at 3 months was 82 (range 75 to 87). 4 patients had recent surgery and await follow up. There were no complications. Two cases exposed the limitations of this procedure: Incomplete resection of (i) a Haglund’s deformity required conversion to an open excision and (ii) a posteromedial OCD lesion will require further anterior ankle arthroscopy due to inadequate exposure. We conclude that for the experienced arthroscopic surgeon this is a safe technique that facilitates treatment of a variety of ankle and hindfoot problems that would otherwise require open procedures

Purpose: Posterior Ankle Arthroscopy (PAA) is a relatively new operative technique for a specific and under-recognized ankle problem, posterior ankle impingement. Prospective data on the old technique, posterior ankle arthrotomy, have shown an unacceptable high complication rate. Literature review on PAA found reports on surgical techniques and anatomical studies only. The purpose of this study was to perform a retrospective study, with short-term follow-up to determine the quality of life, function and clinical results after posterior ankle arthroscopy. Methods: Twenty-three patients underwent a PAA between 1998 and 2004 at our centre. Fifteen patients (16 PAA) were available for follow-up. They filled out the LEFS-score, the AOFAS clinical rating systems, the SF-12, 3 satisfaction scales and also underwent an examination of their ankle. Results: The mean follow-up time was 32 months (6–74 months). The mean age at time of surgery was 25 years (19–43 years). After surgery they spent on average two weeks on crutches needing pain medication for 1 week. The mean return to work was 1 month (0–3 months) and return to sport was 5 months (1–24 months). 94% of the patients returned to their preoperative level of sport. Complications included five patients with temporary numbness around their scar and one patient with temporary ankle stiffness. There were no permanent neurovascular injuries. The mean LEFS score at follow-up was 75 (65–80; best = 80). The mean AOFAS score was 91 (77–100: 100 = best). The mean SF-12 score was 51.80 PCS (30.77–60.53); 55,80 MCS (44.26–63.33). All reported they had improved after their surgery and would have the surgery again. Conclusions: Functional and clinical evaluations after a PAA revealed that all of the patients were very satisfied with the result and showed excellent quality of life. Posterior ankle impingement is an under-recognised clinical entity which now has an effective treatment available. Increased clinical focus on this condition may reveal a higher incidence associated with other diagnosis. We are currently evaluating patients pre and postoperative in a prospective study

CT arthrography and arthroscopy were used to assess tears of the rotator cuff in 259 shoulders. Tear size was determined in the frontal and sagittal planes according to the classification of the French Arthroscopy Society.

CT arthrography had a sensitivity of 99% and a specificity of 100% for the diagnosis of tears of supraspinatus. For infraspinatus these figures were 97.44% and 99.52%, respectively and, for subscapularis, 64.71% and 98.17%. For lesions of the long head of the biceps, the sensitivity was 45.76% and the specificity was 99.57%.

Our study showed an excellent correlation between CT arthrography and arthroscopy when assessing the extent of a rotator cuff tear. CT arthrography should, therefore, be an indispensable part of pre-operative assessment. It allows determination of whether a tear is reparable (retraction of the tendon and fatty degeneration of the corresponding muscle) and whether this is possible by arthroscopy (degree of tendon retraction and extension to subscapularis).

Purpose: Posterior arthroscopy is generally performed by alternating visual control using the optic introduced via one of the anterior portals which is slid into the slit via the contralaeral posterior compartment. These two “crossed” posterior portals provide access to the posterior part of the menisci and to the condyle but remain oblique. Any sagittal partition separating the posterior compartments limits visual and instrument access to the posterior part of the articular cavity. The purpose of this work was to describe a novel back-and-forth technique for posterior arthroscopy which allows posterior access to the central pivot. Material and methods: The conventional posteromedial access was used. The optic was introduced to visualise the posterior cruciate ligament and the posterior partition, and when in contact with it, to push it forward. The optic was then replaced by a round-headed instrument to perforate the partition above the posterior cruciate ligament and penetrate into the lateral compartment. The instrument was pushed against the posterolateral wall determining the point of the corresponding portal. A motorised knife was introduced into the end of the canula then brought into the medial compartment. The posterior partition was resected, creating a single posterior space which could be examined under direct visual control. During an anatomy study, we examined the relationship between the noble elements in the popliteal fossa and the different instruments used during this procedure. Fifteen patients with villonodular synovitis underwent exclusively arthroscopic synovectomy using this approach. Results: We did not have any case of vessel or nerve injury and had no recurrence at mid-term. Postoperatively, patient comfort was much better than after arthrotomy synovectomy. Discussion: This difficult method requires an excellent knowledge of the position of the different anatomic elements in the popliteal fossa close to the posterior part of the articulation. This combined posterior approach facilitates access to the posterior part of the articular cavity of the knee and offers a new approach to the posterior cruciate ligament as well as broader indications for arthroscopic synovectomy with more complete resection. It does not allow access to the submeniscal folds nor to the fibulotibial articulation