Complications in foot and ankle arthroscopy.

Arthroscopy of the foot and ankle has become an important diagnostic and therapeutic tool for the orthopaedic surgeon. A thorough knowledge of foot and ankle anatomy and intraarticular anatomy is critical to avoid complications in foot and ankle arthroscopy. Numerous complications can occur in foot and ankle arthroscopy, such as neurologic, tendon, and ligament injuries, wound complications, infections, and instrument breakage. The most common complication is neurologic injury. The overall complication rate is 9%. Most complications associated with foot and ankle arthroscopy are transient and tend to resolve within 6 months. The only complication that persisted at 10 years followup was a neurologic injury, specifically, numbness at the incision site. Because the difficulty of procedures has increased, so has the complication rate. Knowledge of the more common complications in foot and ankle arthroscopy and improved techniques and instruments may reduce the overall complication rate.

Arthroscopic findings associated with the unstable ankle.

Before lateral ankle stabilization, arthroscopic surgery was performed on 54 patients (55 ankles) with chronic ankle instability. All patient charts, x-rays, operative reports, and surgical videotapes were reviewed. A detailed questionnaire was answered by all patients. The study population included 31 males and 23 females, with a mean age of 31 years (range, 14-64 years). The right ankle was involved in 64% of cases. Average follow-up was 9.6 months. Arthroscopic surgery was performed using small joint instrumentation including 30 degrees and 70 degrees 2.7-mm arthroscopes and a 30 degrees 1.9-mm arthroscope. At surgery, 51 ankles (93%) had intra-articular abnormalities including loose bodies (12), synovitis (38), osteochondral lesions of the talus (9), ossicles (14), osteophytes (6), adhesions (8), and chondromalacia (12). The most common arthroscopic procedures were synovectomy, removal of loose bodies and ossicles, excision and drilling of osteochondral lesions, debridement of the lateral gutter, excision of osteophytes, and removal of adhesions and scar tissue. There was a 25% incidence of chondral injuries, which differs considerably from the results of Taga et al., who found chondral injuries in 95% of ankles with lateral instability. Overall, there were excellent or good results in 96% of ankles. The incidence of excellent results was lower in the worker's compensation patients because of a greater incidence of complaints of pain with activity. There was no correlation between the presence of osteochondral lesions or amount of talar tilt and results.

Intraosseous ganglion cysts of the ankle: a report of three cases with long-term follow-up.

Three cases of intraosseous ganglion cysts of the ankle are presented with an average follow-up of 68 months (range, 48-78 months). Review of the literature revealed 251 cases of intraosseous ganglion cysts, with 75 located in the ankle and a recurrence rate of 6.1%. In the three cases presented, a satisfactory long-term result was obtained with bone graft and curettage in two cases and currettage alone in one case. No recurrences or complications occurred.

Subtalar arthroscopy: indications, technique, and results.

The purpose of this study was to present the indications, technique, and results for subtalar arthroscopy in 50 consecutive patients. In each case, ankle arthroscopy was performed concomitantly to assess the exact source of the patient's pain. Surgical indications included chronic pain, swelling, buckling, and/or locking that failed conservative treatment. Arthroscopy of the ankle and subtalar joints were performed using both 2.7- and 1.9-mm arthroscopes through standard and accessory portals; distraction was used in all cases. All patients were followed-up for an average of 48 months (range, 36 to 70 months). Group 1 included 21 patients (42%) with chronic lateral ankle pain following an inversion injury. In this group, the subtalar joints were completely normal and the pathology was found to be limited only to the ankle joint. In group 2, 29 patients (58%) had the following diagnoses at arthroscopy: synovitis, 7; degenerative joint disease, 5; subtalar dysfunction, 5; chondromalacia, 4; nonunion of os trigonum, 4; arthrofibrosis, 2; loose bodies, 1; and osteochondral lesions of the talus, 1. Overall, the results were 86% good-to-excellent in group 2.

The role of arthroscopy in ankle and subtalar degenerative joint disease.

Treatment options for degenerative joint disease of the ankle and subtalar joints are limited. When conservative management fails, the only effective procedure is arthrodesis. With the advent of the small arthroscope and the development of better instrumentation and distraction techniques, small joint arthroscopy has gained popularity as an important diagnostic and therapeutic tool in the treatment of ankle and subtalar disorders. Although the benefits of arthroscopic ankle arthrodesis are well established, and arthroscopic subtalar arthrodesis has been described recently, the role of arthroscopic debridement for degenerative joint disease of the ankle and subtalar joints remains controversial. Traditionally, operative arthroscopy for ankle arthritis has not met with great success; however, recent studies have shown that it can provide an interim alternative to arthrodesis in early arthritis with preserved range of motion. Lesions associated with arthritis, such as impinging osteophytes and loose bodies, can be treated effectively with arthroscopy.

Fibular grooving for recurrent peroneal tendon subluxation.

Twelve ankles in 11 consecutive patients with recurrent peroneal tendon dislocations were studied after undergoing a fibular grooving procedure. The mean age of the patients was 25 years (range, 13 to 45). The mean time from initial injury to surgery was 18 months, and the mean follow-up time was 6 years. All patients had preoperative peroneal tenderness; 9 of 12 ankles had active peroneal tendon subluxation on examination. All patients had failed results from nonoperative treatments of rehabilitation and bracing. Before the fibular grooving procedure, 10 ankles were shown to have intraarticular pathologic changes on arthroscopic evaluation. Postoperatively, there were no resubluxations. Eleven ankles were pain-free, 10 had full and symmetric range of motion, and 1 patient lost 3 degrees of eversion. Ten patients were able to return to full unrestricted activities including all previous sports. Eleven ankles were rated as excellent results. Complications included suture abscesses in two patients and refractory pain in one patient who had multiple surgeries for subtalar pain but had no peroneal resubluxation. Recurrent peroneal tendon subluxation is an uncommon problem. An accurate diagnosis is essential. The fibular grooving procedure appears to reproducibly alleviate resubluxation of the peroneal tendons and diminish pain. It also allows for retainment of motion and subsequent return to work and sports with a high satisfaction rate.

Arthroscopic excision of the os trigonum: a new technique with preliminary clinical results.

Open excision of a painful os trigonum can be associated with prolonged recovery. An arthroscopic technique has been developed to decrease scarring, diminish surgical morbidity, and promote a faster recovery. Eleven patients were retrospectively evaluated after removal of the os trigonum after a mean follow-up of 35 months. Small joint arthroscopy equipment was utilized in a supine position with a distraction device. Average patient scores improved on the AOFAS Ankle/Hindfoot Scale from 45 to 86 points. All patients went home the same day, and no complications occurred during the procedure. All patients reached maximum recovery level within the first 3 months after surgery. Arthroscopic excision of a painful os trigonum yields good results with minimal surgical morbidity and shorter recovery time.

Neurological complications of ankle arthroscopy.

A retrospective review of the first 612 patients undergoing consecutive ankle arthroscopy in the practices of two experienced arthroscopists was under-taken. All inpatient records, outpatient charts, and operative reports were reviewed. Indications for surgery included pain, swelling, locking, and instability that failed to respond to nonoperative management. The results of our investigation revealed an overall complication rate of 9.0% (55 complications). There were 27 neurological complications (4.4% of all arthroscopies) accounting for 49.1% of the complications noted. Specifically, the superficial peroneal nerve was injured in 15 cases, the sural nerve in 6, the saphenous nerve in 5, and the deep peroneal nerve in 1. All nerve injuries occurred through direct injury by portal or distractor pin placement. No cases of neurological injury caused by tourniquet compression or compartment syndrome were seen. Also, 1 case of reflex sympathetic dystrophy was identified.

Arthroscopy of the foot and ankle.

Arthroscopic surgery of the foot and ankle represents a relatively new and exciting addition to the armamentarium of the orthopedic surgeon. Direct visualization of all intraarticular structures without extensive surgical approach, arthrotomy, or malleolar osteotomy is now possible. Laxity or incompetency of ligamentous structures can be demonstrated by intraoperative stress testing maneuvers.

Arthroscopic treatment of ankle injuries.

Arthroscopic examination of the ankle joint permits complete examination of the intra-articular structures. With recent advances in equipment and additional experience, numerous ankle problems can be handled arthroscopically. These problems include treatment of soft-tissue and bony impingement, osteochondral lesions of the talus, removal of loose bodies, treatment of acute and chronic fractures, lateral ankle stabilization, and arthroscopic fusion procedures.

Trephination of incomplete meniscal tears.

The meniscus performs several roles that are important to the function of the knee joint. In an effort to preserve these functions of the meniscus, methods to promote the healing of meniscal lesions have been investigated. One such method involves trephination or the creation of vascular access channels by removal of a core of tissue from the periphery of the meniscus to the tear, thus connecting a lesion in the avascular portion of the meniscus to the peripheral blood supply. The purpose of this study is to describe our experience with arthroscopic trephination of symptomatic incomplete meniscal tears in humans. This is a simple technique that avoids the risk associated with suture repair of the meniscal tissue, yet preserves the meniscus. Overall results were good or excellent in 90% of the cases. In conclusion, symptomatic incomplete meniscal tears can be treated by stimulation of vascular channels without the risk associated with suturing of this tissue, while preserving the important functions of the meniscus.

Arthroscopic-assisted anterior cruciate ligament reconstruction with the semitendinosus tendon: comparison of results with and without braided polypropylene augmentation.

Fifteen chronic anterior cruciate ligament-deficient knees were arthroscopically reconstructed with a semitendinosus tendon polypropylene (STP) augmented composite graft. A comparison group of 28 reconstructions with the semitendinosus tendon (ST) but without augmentation was simultaneously reviewed. The mean follow-up in the STP group was 31 months (range of 24-42 months) and in the ST group it was 34 months (range 26-54 months). Both patient groups had similar age, sex, preinjury functional sports level, injury-to-surgery interval, and associated meniscal pathology. Good-to-excellent subjective results were reported in 86% of STP patients and 78% of ST patients, whereas 86% of the STP patients and 88% of the ST patients returned to sports activity. Objective examination revealed 73% of the STP group and 82% of the ST group to have a negative or 1+ Lachman test result. A negative pivot shift was noted at follow-up in 80% of the STP group and in 82% of the ST group. KT-1000 testing revealed 60% of the STP patients and 61% of the ST patients to have less than or equal to 3 mm of side-to-side difference. In the STP group there was no evidence of graft breakage, deep infections, or sterile effusions. Overall subjective and functional results were uniformly better than objective results in both patient groups. Analysis of subjective, objective, and functional results reveal no difference in outcome between the STP and the ST patient groups.

Arthroscopic treatment of anterolateral impingement of the ankle.

We studied 31 patients (17 females, 14 males; average age, 34) with more than 2 years of followup who had chronic anterolateral ankle pain following inversion injury. All had failed to respond to at least 2 months of conservative treatment and had negative stress radiographs to rule out instability. On physical examination, tenderness was localized to the anterolateral corner of the talar dome. Magnetic resonance imaging was the most useful diagnostic screening test, showing synovial thickening consistent with impingement in the anterolateral gutter. At an average of 24 months after injury, all patients underwent ankle arthroscopy, which showed proliferative synovitis and fibrotic scar tissue in the lateral gutter, often with associated chondromalacia of the talus. Operative arthroscopic treatment consisted of partial synovectomy with debridement of scar tissue from the lateral gutter. Postoperatively, patients walked with crutches allowing weightbearing as tolerated. Average return to sports was 6 weeks. Histopathologic analysis performed on the resected tissue showed synovial changes consistent with chronic inflammation. Results of treatment after at least 2 year followup were 15 excellent, 11 good, 4 fair, and 1 poor. Since there are several distinct causes of chronic ankle pain, we prefer to call this problem "anterolateral impingement of the ankle" and believe the term "chronic sprain pain" should be discarded.

Magnetic resonance imaging of the foot and ankle: correlation of normal anatomy with pathologic conditions.

Abnormalities of the foot and ankle can be difficult to diagnose by conventional examination and x-rays. Recently, magnetic resonance imaging (MRI) has emerged as a diagnostic tool for soft tissue and bony imaging. One hundred and ten normal feet and ankles were studied to define normal MRI anatomy. An additional 150 MRI scans were performed to diagnose and characterize various abnormal conditions. MRI demonstrated excellent definition of normal structures and pathologic entities. Surgical correlation with the MRI was done in 42 patients. MRI appears to be a useful examination for patients with certain soft tissue and bony abnormalities. A special oblique view also has been developed to assist in the diagnosis of injuries to the tibialis posterior, flexor hallucis longus, and flexor digitorum longus tendons.

Osteonecrosis of the knee after arthroscopic surgery: diagnosis with MR imaging.

Spontaneous osteonecrosis about the knee typically is a disease of the elderly characterized by an acute onset of pain. The exact cause of this condition has long been debated, although a causative relationship between meniscal tears and spontaneous osteonecrosis about the knee has been postulated. Seven patients with knee pain, meniscal tears, and chondromalacia without initial evidence of osteonecrosis at magnetic resonance (MR) imaging underwent arthroscopic surgery with meniscal recontouring or repair and cartilage shaving. These patients returned within 2-14 months with recurrent pain in the treated knee. MR imaging then demonstrated abnormalities consistent with osteonecrosis. Osteonecrosis of the femoral condyle or tibial plateau may be a late sequela of meniscal injury in association with chondromalacia and arthroscopic surgery. This diagnosis should be suspected in patients with recurrent knee pain after arthroscopic repair of meniscal tears. The precise relationship of this pattern of osteonecrosis to that previously described as spontaneous requires further investigation.

Accuracy of diagnoses from magnetic resonance imaging of the knee. A multi-center analysis of one thousand and fourteen patients.

Magnetic resonance images of the knee were made for 1014 patients, and the diagnosis was subsequently confirmed arthroscopically. The accuracy of the diagnoses from the imaging was 89 per cent for the medial meniscus, 88 per cent for the lateral meniscus, 93 per cent for the anterior cruciate ligament, and 99 per cent for the posterior cruciate ligament. The magnetic resonance examinations were done at several centers, and the results varied substantially among centers. The accuracy ranged from 64 to 95 per cent for the medial meniscus, from 83 to 94 per cent for the lateral meniscus, and from 78 to 97 per cent for the anterior cruciate ligament. The results from different magnetic-resonance units were also compared, and the findings suggested increased accuracy for the units that had a stronger magnetic field. Of the menisci for which the magnetic resonance signal was reported to be Grade II (a linear intrameniscal signal not extending to the superior or inferior meniscal surface), 17 per cent were found to be torn at arthroscopy.

Partial thickness rotator cuff tears: results of arthroscopic treatment.

Thirty-one patients with arthroscopically documented partial thickness rotator cuff tears treated by arthroscopic debridement of the lesion were retrospectively reviewed. The patients had had symptoms for an average of 20.5 months prior to surgery. Twenty-two of these 31 shoulders also had bursoscopy, with 18 having arthroscopic subacromial decompression. The results were graded by both the UCLA Shoulder Rating Scale and Neer's criteria. Twenty-six (84%) of the patients had satisfactory results with the remaining 5 (16%) patients having unsatisfactory results. A classification system for the size and location of partial thickness rotator cuff tears is presented. The lesion size did not affect the result. Repeat arthroscopy in three patients demonstrated no further deterioration of their rotator cuff. The results with and without subacromial decompression were similar. The need for subacromial decompression is best determined by the arthroscopic finding of a bursal side tear.

Acute anterior cruciate ligament reconstruction. Analysis of complications.

One hundred fifty-six patients treated with intraarticular anterior cruciate ligament (ACL) reconstruction were analyzed to determine the incidence of complications. The study group of 31 patients (Group I) was treated with repair or reconstruction of an acute ACL injury. A comparison group of 125 patients had reconstruction for chronic ACL instability (Group II). The patients were evaluated clinically and by roentgenograms. The average follow-up time for the study group was 52.2 months. In Group I, 35% developed fibroarthrosis postoperatively that required arthroscopic lysis of adhesions and manipulation to restore motion. In Group II, only 12% developed this complication. However, developing this complication did not affect a patient's long-term clinical result when properly recognized and promptly treated.

Evaluation of patients with persistent symptoms after lateral retinacular release by kinematic magnetic resonance imaging of the patellofemoral joint.

The arthroscopic lateral retinacular release is typically performed to treat patellar pain and instability. This procedure was previously considered to be relatively benign with a low associated complication rate. However, a high incidence of medial subluxation of the patella was recently reported in patients with persistent symptoms after lateral retinacular release. Because the use of physical examination criteria may not always be sufficient to assess patellar alignment, 40 patients (43 knees) were evaluated by the newly developed technique of kinematic magnetic resonance imaging of the patellofemoral joint. One (2%) patellofemoral joint had normal patellar alignment, 10 (23%) had lateral subluxation of the patella, 1 (2%) had excessive lateral pressure syndrome, 27 (63%) had medial subluxation of the patella, and 4 (9%) had lateral-to-medial subluxation of the patella. Seventeen of 40 patients (43%) with unilateral arthroscopic lateral retinacular releases had medially subluxated patellae on the unoperated joints. Because patellar malalignment commonly affects bilateral joints, medial subluxation of the patella may have been present before the lateral retinacular release but was not recognized in these patients.