Peter A. J. de Leeuw

Anatomy of the ankle ligaments: a pictorial essay

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.

Arthroscopy and endoscopy of the ankle and hindfoot.

Ankle arthroscopy provides the surgeon with a minimally invasive treatment option for a wide variety of indications such as impingement, osteochondral defects, loose bodies, ossicles, synovitis, adhesions, and instability. Posterior ankle pathology can be treated using endoscopic hindfoot portals. These posteromedial and lateral hindfoot portals provide excellent access to the posterior aspect of the ankle and subtalar joint. Also extra-articular structures in the hindfoot, for instance recurrent peroneal tendon dislocation, can be treated by creating an additional portal. The endoscopic hindfoot portals are safe and reliable, both anatomically and clinically. It compares favorably to open surgery with regard to less morbidity and a quicker recovery.

Delayed operative treatment of syndesmotic instability. Current concepts review.

OBJECTIVE To review the literature concerning articles evaluating the delayed operative treatment of isolated syndesmotic instability. MATERIAL AND METHODS The main databases Pubmed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, Current Controlled Trials and Embase were searched from 1988 to September 2008 to identify studies relating to the late reconstruction of the distal tibiofibular syndesmosis after isolated syndesmotic injury. The level of evidence of the included articles was scored. RESULTS Fifteen articles were identified, involving 94 ankles with a delayed reconstruction for isolated syndesmotic instability. CONCLUSION In subacute (6 weeks to 6 months) total ruptures the focus is to restore the normal anatomy by repair of the ruptured ligament with placement of a syndesmotic screw. On base of the literature in combination with experience in clinical practice some guidelines are formulated. If inadequate remnants of the anterior inferior tibiofibular ligament (AITFL) are present, a tendon graft can be used. The insertion of the AITFL on the tibia can be medialised with a bone block and fixed with a screw. For the treatment of persistent widening and late instability these reconstruction techniques have to be used combined with debridement and placement of a syndesmotic screw to protect the reconstruction. Most adequate treatment for chronic syndesmotic instability (>6 months) is the creation of a synostosis to stabilise the distal tibiofibular joint. Late repairs give satisfactory but less favourable outcome as compared to properly treated acute injuries. It is not easy to regain complete stability by means of these secondary procedures.

Potential pitfall in the microfracturing technique during the arthroscopic treatment of an osteochondral lesion

Debridement and bone marrow stimulation of the subchondral bone is currently considered to be the primary surgical treatment of most osteochondral lesions of the talus. Different methods of bone marrow stimulation are used, including drilling, abrasion, and microfracturing. The latter has gained recent popularity. In this technical note we describe a potential pitfall in the microfracturing technique. The microfracture awl can easily create small bony particles on retrieval of the probe that may stay behind in the joint. It is emphasized that the joint should be carefully inspected and flushed at the end of each procedure, in order to prevent leaving behind any loose bony particles.

Fixed distraction is not necessary for anterior ankle arthroscopy

We have read the article ‘‘Treatment of anterolateral impingements of the ankle joint by arthroscopy’’ by A.-H.M. Hassan with interest, care and appreciation [1]. One of the questions in this publication is whether anterior ankle arthroscopy can routinely be performed without joint distraction. He states that in patients with anterior ankle soft tissue impingement, distraction will result in tightening of the joint capsule thereby decreasing the anterior working area [1]. These findings are similar to ours [2]. With ankle distraction multiple anatomic structures are pulled tight. The ankle joint capsule has a characteristic difference in comparison with other joint capsules; the anterior capsular insertion in the tibia and talus is located at some distance from the cartilaginous layer. This peculiarity determines the existence of a substantial anterior capsular recess, which creates and allows an anterior working area. The dimension of this working area depends, however, on the position of the foot and ankle. Ankle distraction will reduce the working area, while ankle dorsiflexion creates an anterior capsular recess with subsequent working area [2]. Especially in anterior ankle impingement, the anterior ankle arthroscopic procedure can better and more effectively be performed with the foot and ankle in dorsiflexion, since the created working area will improve visibility and accessibility of this pathology [2–5]. However, later on Hassan argues that with forced plantar flexion the anterior working area opens up [1]. With forced ankle plantar flexion, traction is generated to the anterior ankle joint capsule, which will be pulled tightly, resulting in a reduced anterior working area. For arthroscopic treatment of talar osteochondral defects forced plantar flexion can bring the defect into the anterior working area [2, 6]. Treatment of osteochondral defects is not the topic of this paper. We assume therefore, that Hassan has mixed up the foot and ankle position with the arthroscopic treatment of osteochondral defects with that for the treatment of anterior ankle soft tissue impingement lesions. In conclusion, patients with an anterior ankle impingement lesion should be treated with the ankle in a dorsiflex position and not with routine distraction. This dorsiflex position will allow a better and more effective assessment of the pathology. Distraction or a plantar flexed position will close the anterior working area and will make it more difficult to perform the anterior ankle arthroscopic procedure.

Ankle Ligament Lesions

This chapter describes injury to the ankle ligaments, including the lateral ankle ligaments, the syndesmotic ligaments and the deltoid ligaments. All aspects on diagnosis, clinical appearances and therapeutic treatment options are highlighted, specified if possible for the footballer.

Surgical anatomy of the foot and ankle

Any operative intervention consists of two elements: the approach and the actual procedure itself. The actual procedure can be practised on sawbones or joint models [8], but the approach is mostly practised on patients. The learning curve for the approach is steep. In the past, surgeons made wide exposures and thus practised their anatomical skills on a day-to-day basis. With the introduction of minimally invasive and arthroscopic surgery, we learned to avoid the anatomy. We go straight to the bone and feel comfortable once inside a joint. Our incisions for open procedures get smaller and smaller. The patients like it if their surgical scars are very small, and there is some evidence that minimally invasive approaches can lead to shorter stays in hospital and to more rapid restoration of function, but our knowledge of the anatomy thus gets more and more forgotten. Our knowledge dates from anatomy books, which are, however, not specifically designed for surgical approaches.

A soccer player with idiopathic osteonecrosis of the complete lateral talar dome: a case report

We report a 13-year-old soccer player with osteonecrosis of the talus and a large carticular fragment. The defect was revitalized with curettage and drilling and filled with autologous bone graft followed by the fixation of the carticular fragment with two conventional lag screws. Screw placement was such that they could be removed arthroscopically. Healing was uneventful. Eighteen months postoperative hardware was indeed removed arthroscopically. He returned to his former competitive level without restrictions or complaints.

Subtalar Arthroscopic Arthrodesis

This chapter provides an overview of the main indications for subtalar joint arthrodesis with a detailed description of the minimally invasive surgical technique, which is based on the two-portal posterior ankle arthroscopic approach for the hindfoot.