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Board Review Surgery

Ankle Arthroscopy - Therapeutic versus Diagnostic

Benjamin Overley, Jr, DPM

Benjamin Overley, Jr, DPM discusses the indications for ankle arthroscopy through video and intra-operative slides. Dr Overley discusses how ankle arthroscopy can be useful in your practice and how more research is needed to define its role in treating ankle pathology.

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Goals and Objectives
  1. Indications for ankle arthroscopy
  2. Contraindications for ankle arthroscopy
  3. Role of ankle arthroscopy in every day practice
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  • CPME (Credits: 0.75)

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    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Benjamin Overley, Jr, DPM

    Surgical Skills Committee
    Section Editor for Trauma-Journal of Foot and Ankle Surgery
    Foot and Ankle Specialist/PMSI Orthopedics
    Pottstown, PA

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  • Lecture Transcript
  • Male Speaker 1: Good job, Larry, I appreciate it. Our next speaker probably not as eloquent or as good, certainly not as handsome as Larry. He comes to us from the Pennsylvania country, treats a lot of Amish people with horse carriage and so forth. Ben Overley is a great friend of mine, extremely knowledgeable, extremely experienced in trauma, arthroscopy, et cetera. So Ben is going to spend a little bit of time talking about arthroscopy before our break. Again, here is one of your speakers that would love to engage in any conversation and don’t be afraid to ask questions. Please welcome a great friend of mine, great educator, Dr. Ben Overley.

    Ben Overley: Okay. So I’m going to get started here and I’m going to see if I can find a spot here to put my water. Okay. So when I think about arthroscopy in terms of my particular practice and what I do, I’d like to say that probably every week, I’m doing a scope on my patients. And I think the reason why I’ve sort of gravitated towards arthroscopy as a solution or a means to an end with a lot of these cases is because it actually works pretty well. How do I advance? Here we go. Okay. [Coughs] So what we’re going to talk about is we’re going to talk about some indications and again these are sort of loose indication, some of them are a little bit more firm. And then we’re going to over at the end of it what I think is, you know, kind of the primary roles for arthroscopy. So really break it down into three categories. And if you think about it, this is really what is going to all come down to. Is it going to be a survey? Are you going to end there and take a look around? Are you actually going to fix something when you’re in there? Or are you actually going to do something like a fusion which is more of, I believe, a type procedure? So, contraindications are the kind of the usual suspects. You know, PAD obviously is no one we’re going to do surgery on. You know, is there a possibility that there’s a tumor involved? Pain complex do very purely with arthroscopy. I think if you have a patient that you suspect has RSD, CRPS, this is probably somebody you do not want to do this type of procedure on. So from a reparative standpoint, you know, you can use this for septic washouts. If you suspect any kind of infection, I mean you can use it for heterotopic bone formation. If you got extra osseous tissues, they work really great. So I’d say in terms of what I do in my practice and what I use this for is basically for impingement syndromes. These are going to be soft tissue. There are going to be bone. And this is really what’s going to come down to in terms of sort of the most popular things and the most common things that I see. So these are sort of my testimony tools if you take a look there. How do we diagnose impingement syndromes? A lot of is just clinical. And if you think about it from that perspective and don’t get hang up with the testing, I think you’ll find that if you just kind of slow down and you take a look at your patient, really touch them, really palpate along that anterior joint line and then do dorsiflexion at the same time. That’s when you’re really going to get, sort of that positive exam that’s going to give you the information that you need and then you’re going to proceed with doing a scope base on those findings. I don’t treat studies so if I see something on MRI that’s suspicious for it, I’ll kind of hold off unless it really correlates with the clinical exam. And that’s a video. So you can see here, you know, you can have a hemorrhagic synovitis. You can see me sort of cleaning that up with the one. And just to show you that again. So we want to get rid of that bloody tissue that’s usually indicative of, you know, an acute type of reaction. And this is also going to be painful and it’s also going to lead deformation more chronic synovial tissue down the line. So these are really the three types of soft tissue lesions you’re going to see when you look in the ankle joint. You’re going to have this. And if you look at that central one, that plicated body, you see how it’s lifted up.

    [05:03]

    It’s really a wavy. It’s almost like a meniscus that you would see in a knee. And what that is going to do is it’s going to incarcerate or insinuate itself into the ankle joint itself during dorsiflexion. So these are the typical things that you see soft tissue wise. So looking along the anterior joint line and looking at that type of pathology, you can see, you know, where do we see these patients having anterior ankle impingement syndrome? Well, it can be gout. You could have a tophus in there. You can have a prior septic joint. You can have a lot of synovial tissue that builds up over time. And, you know, when you see these patients, it’s really remarkable and you examine them and you take a look at the different types of studies and you really put the two together which you end up with is. They’re getting some sort of blockade whether it’s soft tissue or bone or combination thereof. So if you can go in there and get that clean out and you can actually see that intraoperatively, you’re going to do really well with cleaning that tissue up and getting them some relief. And you can see right there, you know, taking a look at that slide, that synovial fringe, synovial curtain that hangs down, you say the tails and tibia should be there. But you don’t really see the plafond at all. What you see is that tissue overhanging. You can imagine when that patient dorsiflexes where that tissue is actually going to end up which is just insinuating itself into the ankle joint. I think there may be video there too. Let’s see. I guess it did not show it. But you can have chondrocalcinosis. These are free-floating bodies right here. And this kind of come out like a bag of marbles when you see them. They are one of the easiest things removed and also provide a great amount of relief when you do see them. I’ve already taken entire cup full. You can see there the amount that you can get out of just one little ankle joint. That’s, you know, being an impingement lesion. So anterolateral, the same thing but usually Bassett’s ligament is going to be involved in this. And why is Bassett’s ligament such a problem? Well, if you think about chronic sprains, typically the gestalt bond are the anterior inferior tib fib ligament is involved and that’s Basset’s ligament. You can see how thickened that is. Also if you have microtrauma, you see this, you know, with lot of ankle fractures. I’ve started going in with scopes at the time of surgery because a lot of times with the fractures, you have these osteochondral fractures that are also involved and you don’t want to leave these things behind. And there’s been a lot of studies coming out of Europe where this is sort of becoming standard of care to scope at the same time as doing an ORIF. And the reason for that is when patients have persistent pain afterwards, a lot of times, it’s because they have these incarcerated osteochondral fractures that are flipped up and they’re sort of getting impinged or trapped within the ankle joint. And you can see here, you know, when you look at gouty tophus, you can actually see those little white crystalline body, so those little tophi that are actually insinuated in this hypertrophic synovial tissues. You know, this is a lot of little razor blades hanging out in this little soft tissue bonds. And what you see here looking, this is a lateral view looking at the ankle. And you see the type of jamming that can occur and that’s me going in there and shaving and removing that distal lip or that distal spur of the distal tibia to allow for more free range emotion and especially in dorsiflexion. These patients are typically going to complain with pain going upstairs, pain on inclines. And that’s going to be their primary complain. Now, when you see them, they oftentimes come in with more vague symptomatology and then maybe anterior joint line or the anterolateral joint line. So you have to be careful. You’re going to get both of them if you go with the scope. You’re going to see everything and you’re going to be able to address both issues. But be careful about delineating this in your documentation. Make sure that you don’t put anterior joint line and then you come back later and say anterolateral. Clearly, it’s a really tough differentiation between the two. So fracture repair, you can see this is what I was alluding to earlier. You see that large defect and that’s in the distal tibia. So you can see me in there grabbing that and it take sometimes a little while and like the person videoing this doesn’t have the steadiest hand. So you want to leave that free piece laying around there. Think of it sort of like for this, you know, the golf and you take a divot and you kind of, you know, take that big chunk of grass. And I see you guys walk back and they throw it on the ground again. That’s dead, alright? So that’s why you sprinkle the seeds from there. Same thing here. You want to get new cartilage growing, leaving that behind and trying to sort of flip it up or put it under the carpet where no one can see it. It’s really not going to do anybody any good. You’re really better serve at that point. You do a microfracture, get some new cartilage growth ahead of time instead of trying to just like I said hide it away because it’s not going to hide away for very long. As soon as that patient begins to rehab and that ankle begins to move, that defect or that cartilaginous flap is going to come back into play again.

    [10:00]

    So anterolateral ankle impingement, again, just for you residence that are in attendance, this is going to be the number one thing that is going to be your host sprain pathology. Number two is probably going to be a saddle syndesmosis. So when I say those two terms and I say saddle syndesmosis, what I’m referring to is what do we do to these patients that have had an ankle sprain and they’ve gone through rehab, maybe – and they’ve been braced or they’ve been booted and you get to two to three months down the line and these patient are still having a fair amount of pain in the ankle joint and you ask them and you’re like, "Well, what’s going on? You know, what are you feeling?" And they’ll say, "Well, you know, I’m really having trouble going up and downstairs and I’m having trouble with inclines and I’m having trouble with uneven surfaces." That really points to an anterolateral ankle impingement and most certainly points to a subtle syndesmosis. These things do need to be repaired and it’s amazing when you go in arthroscopically and you actually take a look at these patients and you see what the syndesmosis looks like distally and you see how loose they are. You can actually do this in the operating room and I wish I had video of it to show you. But you can actually sort of bounce the distal fibula away from the tibia. You can actually just by dorsiflexing with your scope in there, you can actually see it begin to migrate away. Well, what does that tell you? Every time that person takes a step, these two bones are trying to split apart and if they’re trying to split apart. And you’re – you can do that just with your hand in the operating room. Imagine what body weight is doing to that same, you know, junction. So again, go with meniscoid bodies, these are very common in the anterolateral ankle, very rarely that you see this in the directly anterior. They’re usually going to be sort of tapped-off to the side and they’re going to be right below or maybe even a part of Bassett’s ligament. So this is what can happen. This Bassett’s ligament or that AIFTL can tear and a portion of that can then flap down. And when it flaps down, it begins to again insinuate itself into that anterolateral ankle gutter and that’s what gives you your pain. And then you can see the Bassett’s ligament there and that’s relatively healthy-looking one. Well, what you don’t want to see is you’re going to see a lot of yellowish tissue but you can see, looking at that ligament, the things that standout to me, because there’s probably about two or three times the size that it probably should be or two or three times the caliber of width that it should be. And in addition, if you look at the fringe, look at the outside borders. You see it’s all furry and fuzzy looking. That is a pathologic Bassett’s ligament and that’s what it’s showing you. That should be nice and streamlined just like when you’re looking at a tendon and you’re doing a lateral ankle repair, you should see that. That should look like nice and smooth. If it looks frayed or it looks fuzzy like that, that’s pathologic. So you see when you’re taking down this tissue and I’ll typically use what I call spot suction, which is just to use my scope, flip it away from anything. I obviously don’t want to injure. But I’ll also, with my suction, go on and off, on and off, on and off. And what that’s doing is it’s pointing a tissue to me, instead of me trying to go to the tissue and then you start shooting up the whole bunch of things. You don’t want to leave your in somebody’s ankle joint. So the way to avoid doing that is to use sort of spot suction. You can see as I’m beginning to clean up, and you see that yellowish ligament and it’s sitting right behind my shaver right there and you can see what’s – how thickened that is and also by the color of it that it is probably pathologic and you can also see that it’s split in two and you see that invagination right in the middle with a band, there’s a superior and an inferior band that tells you it’s torn, and in addition, it’s also diseased. So arthrofibrosis is also, you know, this is sort of like you’re going to get an ankle replacement or an ankle fusion very soon. When you get to the point where you’re seeing arthrofibrosis and if you think, then I’ll just go pop back to that here in a second. So you can see it. Look at the overall condition of that ankle joint. It’s not a healthy ankle joint. And in time, I might buy that patient maybe three or four years, but it becomes sort of like when you get a knee replacement and you know, the orthopedic surgeon does, you know, Synvisc and cortisone and physical therapy and bracing and then it’s a series of two or three arthroscopies before you finally get to what you’re probably really needed in the first place, which is to get your knee replaced. So the same thing happens here with arthrofibrosis. Is it going to really give us a whole lot, probably not. So syndesmotic impingement is also very common and is associated with high ankle sprains. And the majority of ankle sprains, I would say fall under that category, very few ankle sprains. And think about it, high ankle sprain is really your plantar, that plantarflexion inversion sprain. The force transmission goes upward. It’s above the joint line. It’s not at the joint line. Very few people have their leg perfectly over their foot and roll it over while they’re at the 90 degree angle to the weight-bearing surface.

    [14:58]

    There are always plantarflex to their dorsiflex. Very rarely are the dorsiflex, most of the time, it’s at their plantarflex. So when they rollover, the force transmission which is going to up into that distal syndesmosis begins to split it apart. It also makes that area bleed. And what the result of that bleeding tissue is, is this syndesmotic impingement that we see. And there it is and that’s what it looks like. You can tell it’s got a lot of hemorrhagic tissue involvement. It looks sort of like, you know, kind of a cauliflowery appearance for lack of a better word. That’s sort of the surface of it. It sort looks like the surface of cauliflower. And if you can imagine that, this is actually pushing the two, your distal tibia and fibula away from each other. So with that resting or being in, you know, sort of incarcerated in there, the articulation of the ankle is not going to be very good. And you can sort of see that frayed cartilage right beneath that hemorrhagic tissue. You see how that sort of wavy, sort of see an enemy look. That also is diseased cartilage as result of injury. And there’s that cauliflower or, you know, type appearance and you can see how thickened that is and how it’s actually passed the – it’s now into the ankle joint. It’s no longer up. It’s actually put itself into the ankle joint. So if you run into this tissue and as part of your arthroscopic survey, clearly you must address this. Posterior ankle impingement is very simple. These are very rare. I can tell you or probably do, I don’t know, in years time, somewhere on the order of 80 to 100 ankle arthroscopies and I can tell you maybe two ever required me to go in the back door and actually try to get these things. This is not a comfortable scope to do. It requires a lot of positioning. It’s a lot of technical skill to get to address these things arthroscopically. So this is your os trigonum. Typically, these are going to be patients that are on-point dancers, ballet dancers, patients that do a lot of these tough motors or Spartan races and do a lot of downhill aggressive running, you know, that kind of thing. So they’re very, very rare and you’re probably better off just trying to address this in an open fashion and trying to get after. And arthroscopically, there’s a lot of things back there you really don’t want to get involved with while you have a shaver in there that may end up with leaving people with numb or dysvascular feet. So it’s better to be able to kind of see what you’re doing instead of just blindly racing in there and trying to get after these structures. So differentiation for posterior impingement is pretty easy. I will sometimes get a CAT scat just to see if there’s any break of the synchondrosis. That can be helpful. MRIs can be helpful, but maybe they give you a little bit too much information. And you know, what we want to see is, you know, this type of motion afterwards without any kind of discomfort. So, oh, sorry, this is – so we talked about a glazed over scoping a total ankle. So there’s very few people that do ankle replacement. And then actually to go in there with an arthroscope is somewhat of a sort of a scary notion to them. I really don’t have any problems with that but the things that I would stress to you is after almost 200 ankle replacements, I feel comfortable doing that and I’ve done more scopes than I can remember. But to combine the two is kind of a scary notion because if I go in there and start dinging up that poly and start with my shaver and I can’t use any radio frequency one while I’m in there, you can really end up damaging it or creating infection. You know, these pieces of plastic don’t like cut marks in them and they tend to harbor bacteria and then you end up with some sort of, you know, glycocalyx. It ends up being a problem and you have to pull it out. So you got to be really careful with these things. So this was a patient of mine, seven months post off, increased pain. He was doing great and then out of – and for whatever reason, just started having issues. So the ankle replacement in this individual should work like this and on the tibial side, it should be sort of an elliptical or a double elliptical type motion. But this is what it looked like intraoperatively. And you can see the poly is completely incarcerated on the superior surface in the tibial side. It’s basically stuck in place. And what I see when I go in and do this, is you get the sort of yawning effect that occurs. So just to show you that again and just to focus on what’s going on at top and not so much at the bottom, and you can see that top is not – that’s not moving anywhere. And the synovial tissue is so thickened in this instance that it actually had insinuated itself between the poly and its – and the tibial component. So really had it glued into place. So what you do then, well, you know, this is what you should be looking at the implant when we go and scope. And the minute I go in to scope in these ankle replacements. This is not something I do all the time, maybe two times a year I have to do this.

    [19:58]

    But, you know, you should go in there and you say, well, I should be looking at the implant but I don’t see the implant at all. This is what I see. And you see this large amount of curtain that’s covering and it can be really, really disorienting when you’re looking at this intraoperatively, because you have all this metallic reflective surface and then you’re shining a light at it. So, it is again, you know, sort of a high-end technical thing to do. And then at the same time, you have to make sure your not nicking or cutting or scuffing up any the surfaces. So it really is sort of a pick and peel kind of maneuver. We have to grab the tissue and we must pull it away and then get rid of it and shave it out. And you can see what it looks like. So, there’s the anteromedial side, and you can see, you know, I’m beginning to do that pick and peel maneuver where I’m grabbing and I’m pulling it out. I’m trying to get it out of where it was. And that’s what it look like in the lateral side after I done my debridement. And you can see on that slide on the medial side, the tissue is not been addressed yet. This is not something you’re going to just rip in and go. You got to really take your time with this and I typically will do the lateral side first and then come back medially. And this is the medial side post-debridement, and you can see where everything is been remove and that ankle is going to function again. So, real quick, always test [indecipherable] [21:15] sort to look at roughly 70 some patients that he saw in his clinic. Did the exam. I talk about with dorsiflexion pressing on the interior joint line and also corroborating with MRI studies. And everyone in this case has said that there was something that was impinging. So this was his findings after scoping these 73 ankles. 41 were positive, we can read the slide, but they take home point here is and I don’t know why that’s up, but it should say 30 negative at the bottom. So, 32 out of the 73 really didn’t have anything going on. So, that’s a little bit less than half. So, be really weary of what you get information wise. So literally in this study 40 to 45% of these individuals really didn’t have an impingement. So, in the end you got to make sure before you proceed with anything, just to you the best of your ability, you know, should you proceed with it? So, let’s take a look at quick the evident, that we’ll take a quick look at evidence based medicine here. Since this is a educational course and we want to keep things real. You can see here, this is how we break things down when we’re doing studies and we try to say is there enough data. And I will tell you if somebody has written both chapters on ankle arthroscopy, that there’s paucity of data out there on ankle arthroscopy, is being good for anything. So, it begs the question, you know, should we be doing it. And I would tell you from my own personal standpoint, this is one of the kind, my go to procedure. So I have significant relieve that I’d obtained from my patients by doing ankle arthroscopy, based on the fact that I can skip the more open procedures anterior cheilectomy which are open and scar and they take forever to get better. This is something easy. It’s also a sexier sound to your patient that your going to have a little portal here, a little incision here and a little incision there instead of, you know, I’m going to open you up and take a look in and see what’s going on. So, from that perspective it’s also really nice. And in addition, unless you’re doing a microfracture where you really want to fill new cartilage, you can get these patients into rehab and moving very, very quickly. That’s also another good bonus point and getting them walking faster. So, synovitis and, you know, does this treat it? Insufficient data. We don’t know. You know, is it, does it wrong going in if you just suspects synovitis. Probably not, and there’s not data to say it’s going to do anything. Arthrofibrosis, poor evidence. And, again there’s just not enough out there that’s been done in terms of studies to take a look at these individuals and say what we’re doing is actually working or it’s not. Posterior impingement, we’ve talked about, again, poor evidence. Interior, so there’s fair evidence, because there’s enough information out there that can support either doing it or not doing it. But again, it’s still only a grade B recommendation. So, in the end, you know, really there was only really one thing that we were able to get any kind of a rating whatsoever and that was for impingement. And that is what you’re going to probably use this for mostly, which is what I do. Just real quick, OCD lesions, using MRIs, they’re very, it’s very useful in diagnosing these things. Be really careful. If I’m debating whether I’m going to go in and do a back fill procedure versus, I’m going to and do micro fracture, remember the upper limits for you residence, because you maybe get ask this is some point.

    [24:59]

    The upper limits from micro fracture according to the literature is roughly 1.1 centimeters. So once you get over that threshold and you attempt to microfracture, and there’s guys out there, they’ll say, oh, I’ll take a one or 2.5 centimeter thing and see how it goes. And if I have to get back and do another microfracture. Even if I get 50% of it to fill in with fiber cartilage, I’ll go back and do the rest later. It’s kind of a tough cell for people. You know, hey, we’re going to go in and solve half of your problem then come back and solve the other half of your problem later. And you’re waiting to figure out whether these things are really helping or not. So be really careful with that stuff, you know, the microfracturing and also the back fills. That’s for the osteochondral defects but they are very nicely addressed with ankle arthroscopy but you have to be very careful about the information that you’re getting in terms or MRIs and CT scans. Because MRIs, like I said, sometimes, you know, you look at that slide right there and you got, what will you do with that. And you know, you can see its superior lesion. It’s sort of on the shoulder, you know, is that something that you’re going to back fill. It looks kind of like it’s loose or fracture or depressed. And you know, before you start taking on these lesion and you know, you’ve become as depressed as the lesion, so does your patient. Make sure that you know what you’re doing in there because if it’s not going to get the job done with the microfracture then you better have the other things available. Now, you can see there, that’s an intact cartilage cap up top but look medially. So cartilage in the surface looks good. This is probably somebody that you could do a back fill. It’s a nice big lesion. We know that that bone is diseased. And we also know that [coughs] that it isn’t just the bone’s disease but what is happening in that lesion -- is if you think about cartilage, cartilage is like skin. It’s a living, breathing viable thing. And its have its cells with basement membranes. So they do allow for transport across that surface. Just like a nitro patch works on an arm. Same thing happens here. The joint flow is actually leaking through the cartilage and it’s expanding that lesion at a very slow rate and that is actually where the pain is coming from. There’s a lot of new literature becoming out in the knee for these types of defects which are right on the tibial plateau and going in instead the knee replacement or doing do scope. Isolate the defect and do an anti-grade filling or retrograde filling of that defect. Support it. Lift that cartilage back up again. Allow that area to settle and then heal and then avoid the replacement altogether. Well, that’s something I would be interested in rather than having a knee replaced. So, you know, this is the type of thing that you’re going to see more as we move along. So real quick, so we’re down about three minutes here. You can see these types of defects. If you’re going to do a back fill, it only works with medial and central lesions. You cannot do these on anterolateral lesions. And the reason why is because they’re out of the joint more than they’re in the joint and they tend to sheer and it’s also the shape of the lesion itself. And lend itself very well. They’re more waffery. They’re not that really thick. That really a circular sort of defect that you can go after and fill up. And you see something like this and you go, you know, does that anything worth addressing and then you look at it there? Some of these are very easy to spot on, you know, like you would look at that ankle. There’s nothing going on there till you do that. So, you have to be really, really conscientious of these things. What you’re going to do, have a plan. Make sure that if you do decide you’re going to do some sort of a back fill that you have the instrumentation. That you have the material that you’re going to use and that it’s based in reality what you’re trying to accomplish. Because if the lesion is just too big, you’re probably going to end up having to do a cut down which is something like this and get in there. Fix it and then go ahead and screw that medial malleolus back on there again. So apply the procedures real quick. The end of my last minute and a half. You know, you can see, that’s an arthroscopic knee prodigation again. This is sort of an end-stage procedure. I was probably doing an ankle scopes for three years before I attempted my first arthroscopic ankle fusion and they can be probably the most infuriating, unnerving procedures to do. And you look at these X-rays, three or four months later and you’re like still see this wide open joint space. And you’re thinking, why did I ever do this. Sometimes you have to. Sometimes the soft tissue doesn’t lend itself to a formal open procedure that you’re going to fuse. It’s a good option for patients that you’re really, you know, they need something done but you’re really don’t want to do a cheilectomy on them and get in there and you know, and make this huge wide expand to incision and they might have tissue healing issues. So, you know, keep that in mind when you’re doing this stuff that this is, you know, there are different options for doing ankle fusions.

    [30:03]

    I typically do it two screw construct. I think that tends to work best. But again, you look at these x-rays down the line and you have to be patient because you know, you look at them and you say, well, this thing should definitely be more filled in. And they do fill in. It’s just you don’t really get that smack together, look that you get when you can go in there and really fenestrate and put those to fusion platforms together. And so you have to be kind of prepared for looking at, you know, doing a peek and treat on your x-rays for the, you know, first three months coming out of the gate. So that’s it. So the summary was just basically, we just shot right off there but here we go. [Laughs] The summary is gone. So, really, the summary for my standpoint is it just not enough information out there. It’s a great procedure and I definitely advocate, you know, using it whenever possible versus open procedures. Thanks for your time. Appreciate it.