Ankle and Foot
Indications and Goals: Indications for ankle arthroscopy continue to evolve. They include loose body removal, synovectomy (to include removal of so-called meniscoid lesions), bone removal for tibiotalar impingement, debridement/microfracture of talar articular cartilage injuries, os trigonum excision, and a variety of other procedures.
Procedure and Technique: For most cases, the patient is placed supine with a commercially available traction device. For posterior lesions, such as os trigonum excision, the patient is placed prone. A standard 4 mm arthroscope can be used, but a small 2.7 mm scope is often necessary to address intra-articular pathology. Care must be taken when creating arthroscopic portals in the ankle. The anteromedial portal, made just medial to the tibialis anterior tendon, is located just lateral to the saphenous vein, and care must be taken not to injure this structure. The anterolateral portal is made just lateral to the peroneus tertius tendon, and superficial peroneal nerve branches can easily be injured when creating this portal. Posterior portals, if used, should be immediately adjacent to the Achilles tendon to avoid injury to the sural nerve laterally and the posterior tibial artery medially. The nick and spread method can help avoid injury by just incising the skin and then using a blunt hemostat to open the portal. A systematic and thorough inspection of the joint is performed before beginning the planned procedure.
Post-surgical Precautions/Rehabilitation: Rehabilitation interventions for ankle arthoscopically performed procedures vary accordingly to the type of procedure performed, the extent of tissue repair versus removal, age and activity level of the patient, and goals of the patient. Patients are typically kept non-weight-bearing for 4 to 6 weeks.
Expected Outcomes: There are numerous procedures that can be performed arthroscopically for the ankle joint. Outcomes are based upon the type and extent of the injury, the type of procedure performed, the amount (if any) of concomitant injuries, and the compliance of the patient.
Return to Play: Return to sports participation depends entirely upon the procedure performed. Treatment of osteochondral defects will require 6 weeks non-weight-bearing, while soft tissue or bony decompression procedures may require only 4 weeks non-weight-bearing. Return to play depends upon incision healing, restoration of range of motion, and control of swelling.
Golanó P, Vega J, Pérez-Carro L, Götzens V. Ankle anatomy for the arthroscopist. Part II: Role of the ankle ligaments in soft tissue impingement. Foot Ankle Clin. 2006;11(2):275-296, v-vi. Review.
Golanó P, Vega J, Pérez-Carro L, Götzens V. Ankle anatomy for the arthroscopist. Part I: The portals. Foot Ankle Clin. 2006;11(2):253-273, v. Review.
Lui TH. Arthroscopy and endoscopy of the foot and ankle: Indications for new techniques. Arthroscopy. 2007;23(8):889-902. Epub 2007 May 7. Review.
Niek van Dijk C. Anterior and posterior ankle impingement. Foot Ankle Clin. 2006;11(3):663-683. Review.
Philbin TM, Lee TH, Berlet GC. Arthroscopy for athletic foot and ankle injuries. Clin Sports Med. 2004;23(1):35-53, vi. Review
Tasto JP. Arthroscopy of the subtalar joint and arthroscopic subtalar arthrodesis. Instr Course Lect. 2006;55:555-564. Review.
Tibiotalar Impingement Decompression
Indications and Goals: Anterior impingement of the tibia and talus, also known as footballer’s ankle, occurs commonly in cutting and jumping athletes. Patients may present with anterior pain and lack of full dorsiflexion. The weight-bearing, maximal dorsiflexion lateral radiograph is most helpful in evaluating these patients. The procedure is not indicated for patients with global tibiotalar arthritis.
Procedure and Technique: The anterolateral and anteromedial portals are used for this procedure. The arthroscope and shaver/burr are introduced into opposite portals and the offending bone is removed from the tibia and talus. A thorough synovectomy is performed in conjunction with the bony decompression. Intra-operative fluoroscopy is helpful to ensure that all of the bone is removed.
Post-surgical Precautions/Rehabilitation: Rehabilitation following a tibiotalar decompression may require a short period of reduced weight bearing to allow for intra-articular bone healing based upon the type, amount, and location of the decompression. One of the main goals is to restore normal joint movement, which is accomplished through active and passive range-of-motion exercises as well as keeping pain and swelling to a minimum within the joint. Compression wraps may be of benefit to provide early post-operative joint compression and proprioceptive feedback.
Expected Outcomes: Tibiotalar decompression for anterior impingement often yields good to excellent results as reported up to 4 years follow-up. It is recommended to wear supportive ankle braces or taping for those who have unstable ankle ligamentous structures and for those who plan to engage in activities with high risk of ankle sprains.
Return to Play: Return to sports participation may occur as early as 2 weeks post-operatively as no structural tissue repair is required. Activities may be resumed once the patient achieves complete healing of the arthroscopic portals, resolution of pain and swelling, and full restoration of range of motion.
Frigg A, Frigg R, Hintermann B, Barg A, Valderrabano V. The biomechanical influence of tibio-talar containment on stability of the ankle joint. Knee Surg Sports Traumatol Arthrosc. 2007;15(11):1355-1362. Epub 2007 Jul 13.
Mosier-La Clair SM, Monroe MT, Manoli A. Medial impingement syndrome of the anterior tibiotalar fascicle of the deltoid ligament on the talus. Foot Ankle Int. 2000;21(5):385-391.
Tol JL, van Dijk CN. Etiology of the anterior ankle impingement syndrome: A descriptive anatomical study. Foot Ankle Int. 2004;25(6):382-386.
Talar Articular Cartilage Procedures
Indications and Goals: Talar dome chondral injuries are relatively common. They usually exist in two locations: Medial and lateral. Medial lesions tend to be more chronic, are more posterior and are usually deeper. Lateral lesions tend to be more acute, more anterior, and more superficial.
Procedure and Technique: The most common procedure is drilling or microfracture. Like in the knee, the lesion is debrided back to stable borders and fibrous tissue and the calcified cartilage layer is removed with a curette. Subsequently, the base of the lesion is punctured with a K-wire or awl at 2 to 3 mm intervals. Trans-malleolar drilling is sometimes required for medial lesions. An ACL guide can be helpful in targeting the wire, and the foot is dorsi- and plantarflexed to create the holes at the base of the lesion. Osteochondral transfer has been popularized for refractory lesions. This usually requires a medial malleolar osteotomy to allow perpendicular access to these lesions. Osteochondral plugs are usually harvested from the ipsilateral knee to fill these defects.
Post-surgical Precautions/Rehabilitation: Following surgical intervention for the articular cartilage of the talus, patients typically require crutches for non-weight-bearing ambulation for 4 to 6 weeks. A protective splint is also worn, and gentle range-of-motion exercises can begin shortly after surgery. Pain and swelling reduction are goals immediately, especially since this is a gravity-dependent anatomical location. Gradually, strengthening exercises will begin, and will coincide with a progression to an increase in weight-bearing status during ambulation. Full return to weight-bearing activities may take a couple of months.
Expected Outcomes: Recent advances in osteochondral grafting have reported improved post-operative pain relief and function. It is not uncommon to have residual joint discomfort despite restoration of the articular surface. Long-term outcomes will also depend upon restoration of ankle stability.
Return to Play: Return to sports participation takes approximately 3 months. It is preferred to have complete mature filling or integration of grafts into the defect, full ROM, no effusion, and pain-free running for a complete and safe return.
Hunt SA, Sherman O. Arthroscopic treatment of osteochondral lesions of the talus with correlation of outcome scoring systems. Arthroscopy. 2003;19(4):360-367. Review.
Muir D, Saltzman CL, Tochigi Y, Amendola N. Talar dome access for osteochondral lesions. Am J Sports Med. 2006;34(9):1457-1463. Epub 2006 Apr 24.
Nelson SC, Haycock DM. Arthroscopy-assisted retrograde drilling of osteochondral lesions of the talar dome. J Am Podiatr Med Assoc. 2005;95(1):91-96.
Schachter AK, Chen AL, Reddy PD, Tejwani NC. Osteochondral lesions of the talus. J Am Acad Orthop Surg. 2005;13(3):152-158. Review.
Takao M, Ochi M, Naito K, Uchio Y, Kono T, Oae K. Arthroscopic drilling for chondral, subchondral, and combined chondralsubchondral lesions of the talar dome. Arthroscopy. 2003;19(5):524-530. Review.
Ankle Stabilization Procedures
Indications and Goals: Ankle sprains are the most common injury in sports, yet rarely do they require operative intervention. Patients with recurrent sprains who have failed bracing, peroneal strengthening, and other non-operative measures with objective evidence of instability (stress radiographs) may be candidates for operative stabilization. Ankle sprains usually involve the anterior talofibular ligament (ATFL) which becomes attenuated with recurrent injury (inversion in plantarflexion). The calcaneofibular ligament (CFL) can also be attenuated with inversion injuries (in dorsiflexion). The anterior drawer and talar-tilt tests are helpful in making the diagnosis. “High” ankle sprains involve the syndesmosis and can be detected with a positive squeeze test (compressing the proximal syndesmosis causes ankle pain) and the external rotation test (external rotation of the foot causes pain in the syndesmosis region).
Procedure and Technique: A variety of procedures have been described to address ankle instability. Many of these utilize free tissue grafts (typically half of the peroneus brevis tendon) which is passed through tunnels. However, most surgeons favor the more anatomic Broström-Gould procedure. This procedure involves imbrication (pants-over-vest) of the ATFL and the CFL. The inferior extensor retinaculum is then incorporated to reinforce the repair and limit subtalar range of motion (the Gould modification). Patients who have generalized ligamentous laxity or those who have already failed the Broström-Gould procedure may require allograft augmentation to reconstruct the lateral ligaments.
Post-surgical Precautions/Rehabilitation: During the first 2 weeks post-operative patients are placed in a splint or short leg cast in slight eversion with no weight bearing. Primary goals during this phase include reducing both pain and local swelling. Between weeks 3 and 6, weight bearing in a walker boot is allowed, and supervised range-of-motion exercises are begun with the exception of inversion. Strengthening of the peroneals and restoration of dorsiflexion are critical to full rehabilitation of these patients. At week 7, weaning of the boot is begun, and gentle ankle inversion movement is initiated and proprioceptive exercises are implemented to facilitate balance and strength of the lower extremity.
Expected Outcomes: A high percentage of patients with lateral ankle instability have intra-articular pathology. Excellent results can be expected in patients with ankle instability who undergo arthroscopic treatment of associated intra-articular pathology and the modified Broström procedure, including a reduction in anterior drawer and talar-tilt laxity.
Return to Play: A full return to activities of daily living can occur within 12 weeks, and a return to sports-related full activity by 5 months post-operatively. Gradual advancement of cutting maneuvers is incorporated into physical therapy protocols, once peroneal strength and dorsiflexion is near symmetric to the contralateral extremity.
Baumhauer JF, O’Brien T. Surgical considerations in the treatment of ankle instability. J Athl Train. 2002;37(4):458-462.
Coughlin MJ, Schenck RC Jr, Grebing BR, Treme G. Comprehensive reconstruction of the lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int. 2004;25(4):231-241.
Ferkel RD, Chams RN. Chronic lateral instability: Arthroscopic findings and long-term results. Foot Ankle Int. 2007;28(1):24-31.
Janis LR, Kittleson RS, Cox DG. Chronic lateral ankle instability: Assessment of subjective outcomes following delayed primary repair and a new secondary reconstruction. J Foot Ankle Surg. 1998;37(5):369-375.
Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. 2007;18;(2):CD000380. Review.
Messer TM, Cummins CA, Ahn J, Kelikian AS. Outcome of the modified Broström procedure for chronic lateral ankle instability using suture anchors. Foot Ankle Int. 2000;21(12):996-1003.
Roos EM, Brandsson S, Karlsson J. Validation of the foot and ankle outcome score for ankle ligament reconstruction. Foot Ankle Int. 2001;22(10):788-794.
Wasserman LR, Saltzman CL, Amendola A. Minimally invasive ankle reconstruction: Current scope and indications. Orthop Clin North Am. 2004;35(2):247-253. Review.
Achilles Tendon Surgery
Indications and Goals: Achilles tendinosis and Achilles tendon ruptures are common in running and jumping sports. Tendinosis, or degeneration of the tendon itself, is often the result of overuse. In tendinosis, the area of tenderness moves with the tendon during ankle plantar- and dorsiflexion. This is differentiated from peritenonitis, in which the area of tenderness does not move. Tendinosis is usually treated with rest, ice, stretching and NSAIDs. Occasionally, in refractory cases, they may require surgical debridement. Achilles tendon ruptures are usually a result of maximal forced plantarflexion during push off. It is common for the injured athlete to report a pop and a feeling of being shot or kicked in the back of the heel. Ruptures occur 2 to 6 cm from the Achilles insertion; this is believed to be because of a poor blood supply in this area. With complete ruptures, the Thompson test is positive (squeezing the calf with the patient prone usually results in plantarflexion of the foot, but it will not in cases of Achilles tendon rupture). Repair of complete ruptures results in a much lower recurrence rate, but at the risk of wound healing problems.
Procedure and Technique: Debridement of tendinosis involves excision of damaged tissue and repair of longitudinal tears. Repair of complete ruptures involves heavy non-absorbable “core” locking core sutures and smaller absorbable running suture on the exterior of the tendon. Chronic ruptures may require tendon augmentation with V-Y lengthening or central 1/3 turndown, with flexor hallucis longus transfer as necessary.
Post-surgical Precautions/Rehabilitation: A walking boot is applied for approximately 6 weeks, with the ankle in slight plantarflexion to reduce the stress on the repair. Scar management can be performed immediately, and supervised passive range of motion can begin between 4 and 6 weeks post-operatively. Early active ROM (restrict dorsiflexion to neutral for 6 weeks) with WBAT at 6 weeks post-operatively. Progressive resistive exercises are performed at week 6, and initial return to weight bearing.
Expected Outcomes: Surgical repair of a torn Achilles tendon yields a significant reduction in the risk of rerupture when compared with conservative treatment. Most individuals are able to return to pre-injury function within 1 year post-operatively.
Return to Play: Return to sports participation is usually around the 6-month timeframe. Early active ROM with restriction of dorsiflexion to neutral for 6 weeks is commonplace with avoidance of weight bearing until 6 weeks post-operatively. Recovery after more extensive reconstruction can be more unpredictable, but patients can be expected to resume activities of daily living, but may not be able to return to explosive jumping or cutting activities.
Bhandari M, Guyatt GH, Siddiqui F, Morrow F, Busse J, Leighton RK, Sprague S, Schemitsch EH. Treatment of acute Achilles tendon ruptures: A systematic overview and metaanalysis. Clin Orthop Relat Res. 2002;(400):190-200. Review.
Lynch RM. Achilles tendon rupture: Surgical versus non-surgical treatment. Accid Emerg Nurs. 2004;12(3):149-158. Review.
Rippstein PF, Jung M, Assal M. Surgical repair of acute Achilles tendon rupture using a “mini-open” technique. Foot Ankle Clin. 2002;7(3):611-619. Review.
Suchak AA, Spooner C, Reid DC, Jomha NM. Postoperative rehabilitation protocols for Achilles tendon ruptures: A meta-analysis. Clin Orthop Relat Res. 2006;445:216-221.
Wong J, Barrass V, Maffulli N. Quantitative review of operative and nonoperative management of achilles tendon ruptures. Am J Sports Med. 2002;30(4):565-575. Review.
Posterior Tibialis Tendon Surgery
Indications and Goals: Although this usually occurs in older athletes, it is a common cause of medial ankle pain. Like the Achilles, it involves a spectrum disease from tendinosis to rupture. It is caused by repeated stress of the tendon when the foot is pronated during weight-bearing activities. The location of tendinosis/rupture is just distal to the medial malleolus, where there is limited vascularity. If left untreated, this can result in an acquired flatfoot deformity. When observed from behind, these patients may exhibit a valgus hindfoot alignment, and the “too many toes sign.” Patients may also be unable to stand on their toes and have pain with resisted inversion. Initial treatment should be conservative with rest, ice, NSAIDs, activity modification, and arch supports. A brief period of immobilization may also be helpful. Failing this, debridement, repair, or tendon transfers may be necessary. Treatment can involve the Kidner procedure (removal of accessory navicular/advancement of tendon). The workhorse for treatment of tendinopathy is the flexor digitorum longus (FDL) transfer, as repair is rarely indicated or successful. Correction of valgus malalignment is necessary if deformity is present.
Procedure and Technique: Debridement involves removing the scar tissue and inflamed and damaged tissues. Primary repair (to the navicular tuberosity) is indicated for the rare case of acute avulsion. FDL transfers may be helpful in complete midsubstance injuries. In patients with long-standing diseases, a medial displacement calcaneal osteotomy, or lateral column lengthening may be required. Correction of malalignment is critical to reduce pressure on the transferred FDL tendon and maximize the chance of sustained benefit from the reconstruction.
Post-surgical Precautions/Rehabilitation: The ultimate goal of the surgery is to place the foot in a stable position and decrease the pain of the region. Post-operatively, if only a decompression has been performed, a below the knee non-weight-bearing cast can be applied for 3 weeks, followed by a brace for another 3 weeks. More extensive procedures, such as the FDL transfer, will require casting in a plantarflexed and inverted position for 4 weeks, followed by an additional 2 weeks in neutral position. Upon removal of the casts, supervised active and passive range of motion can be performed, followed by strengthening and proprioceptive exercises. Weight-bearing status is determined by the procedure performed and surgeon preference based upon stability and healing requirements of the tissue. Calcaneal osteotomies require 6 weeks non-weight-bearing post-operatively.
Expected Outcomes: Current outcomes appear to be favorable, though pre-activity levels are not reached for all patients depending upon required stresses involved with activity goals.
Return to Play: This injury typically occurs in older athletes, and return to competitive sports may not be possible. Patients should be kept nonweight bearing for 6 weeks post-operatively, to allow for the calcaneal osteotomy and tendon transfer to heal.
Ceccarelli F, Faldini C, Pagkrati S, Giannini S. Rupture of the tibialis posterior tendon in a closed ankle fracture: A case report. Chir Organi Mov. 2008;91(3):167-170. Epub 2008 May 21.
Duffield P, Sinha U. Tibialis posterior tendon rupture. Early diagnosis can prevent long-term problems. Adv Nurse Pract. 1997;5(8):39-40, 78. Review.
Marcus RE, Goodfellow DB, Pfister ME. The difficult diagnosis of posterior tibialis tendon rupture in sports injuries. Orthopedics. 1995;18(8):715-721.
Peroneal Tendon Surgery
Indications and Goals: Rupture of the peroneal tendons is extremely rare. Tendinosis and subluxation/dislocation of these tendons are more common. Tendinosis is a result of overuse and is treated conservatively with rest, ice, NSAIDs, and arch supports. Subluxation or dislocation is a result of a violent contraction of these muscles in an everted, dorsiflexed foot. This results in tearing or attenuation of the superior peroneal retinaculum. It most commonly occurs in skiers and football players. Tenderness and visualization of the tendon subluxing with active eversion confirms the diagnosis. Conservative treatment includes a short leg non-weight-bearing cast in slight plantarflexion and eversion for 5 to 6 weeks. Failing this, stabilization may be required.
Procedure and Technique: Tenolysis should be performed by opening the tendon sheath at the location of tenderness. In some cases, normal superior peroneal retinacular anatomy can be restored by repairing the avulsed fibrocartilaginous rim to the fibula. Peroneal groove deepening may also be required if the posterior fibula is flat or convex. Associated longitudinal tears in the peroneus brevis are common and should be repaired with running sutures. Tears involving greater than 50% of the tendon may require tenodesis to the remaining peroneal tendon or allograft reconstruction. Low-lying brevis muscle belly or peroneus quartus should be excised if present.
Post-surgical Precautions/Rehabilitation: Most repairs are immobilized in a cast for 4 to 6 weeks before beginning any range of motion. Once the cast is removed, active, active-assisted, and passive range of motion can be initiated with extra caution placed upon active and passive inversions, and active eversion movements. Weight bearing is gradually increased as tolerated, with crutches utilized during the casting period and immediately after the cast is removed. Resistive ankle exercises can progress emphasizing low weight and early repetitions to restore ankle musculature endurance. Balance and proprioceptive exercises can also begin once the cast is removed and slowly progress to more difficult activities.