In recent years, arthroscopic surgery of the ankle has become a standard orthopedic and trauma care procedure and can be used to address a wide range of injuries and pathologies. Acute injuries such as joint fractures, syndesmosis ruptures, acute osteochondral fractures, and ligament ruptures as well as chronic pathologies like impingement, stiff joints, chronic ligament ruptures, and osteochondral lesions can now be treated with arthroscopic surgery or arthroscopy-assisted procedures.
Fractures of the ankle and the tarsus are common injuries that can result from a sports or work-related accident. The ankle joint is most commonly affected, though all parts of the ankle are at risk (outer ankle, inner ankle, rear edge of the tibia—sometimes called the Volkmann triangle). Depending on the type of fracture, patient’s age, and level of activity, a personalized treatment decision will be made either for conservative therapy via immobilization in a plaster cast or Walker boot, or surgical treatment via arthroscopy, open repositioning, and fixation using titanium screws or plates. It is not uncommon to encounter a combined injury with a ligament rupture or syndesmosis rupture, which can be stabilized with sutures or an anchor and a tight rope system in the same treatment session. In some instances, the magnitude of the impact can also affect the top of the ankle in a pilon fracture. Such fractures often involve badly shattered bones, which must be delicately reconstructed to prevent osteoarthritis from developing. A bone transplant using material from the patient’s own or donated bone matter, or bone substitute material, can often be necessary to provide a good support surface for the joint. In the case of cartilage defects, a chondrogenic matrix may be required to achieve regeneration. Fractures of the tarsal bones, such as the talus or heel bone, very often affect one or more joints and must be treated surgically, even if only slightly displaced, in order to avoid long-term consequences. Titanium screws are often used for this, and in some cases, such as complex calcaneal fractures, the bone must be reconstructed and firmly fixed by titanium plates. It is important to achieve a level of training stability that is sufficient to prevent post-traumatic joint stiffness. Metatarsal and toe fractures can often be treated conservatively. In some cases, however—for example when there is severe shortening, axial deviation, or rotational misalignment—screws and plates must be surgically implanted. A Jones fracture at the base of the fifth metatarsal is a special case. Due to the critical blood flow around the fracture area, conservative treatment cannot always guarantee adequate healing, and the subsequent development of pseudarthrosis is not uncommon. Accordingly, this type of fracture should be treated using screws.
After the bone has healed, the implants can be removed in a later operation if any mechanical irritation is present. However, removal is no longer the general recommendation, and cases must be considered on an individual basis.
Ankle ligament injuries are one of the most common injuries of all, especially in sports. Almost everyone has fallen and twisted their ankle at some point in their life. The vast majority of these injuries do not require surgery and can be successfully treated using conservative therapy.
While simple injuries such as strained ligaments often heal well without any specific therapy, higher-grade capsular ligament injuries must be treated with ankle orthotics and targeted physiotherapy to achieve the best possible recovery.
However, chronic ankle instability does develop in 20–40% of cases despite adequate treatment. After the initial trauma, patients often report repeated twisting, sometimes with brief acute swelling and often accompanied by feeling instable on uneven ground and pain resulting from strain. It is not uncommon for mobility to be restricted, either due to capsular scarring or osteophytes on the anterior tibia or talus. In the case of symptomatic chronic ankle instability with no improvement despite ongoing physiotherapy, surgical ligament reconstruction is indicated. Surgery can be open, arthroscopic, or arthroscopy-assisted. For modified Broström-Gould anatomic reconstruction, the native instable ligamentous structures are first detached, then shortened, and reaffixed with the correct tension using small suture anchors (usually on the anterior outer ankle), thus addressing mild rotational instability. If the residual native structures are insufficient for use, various ligament slings using grafts or plastic bands (ligament bracing) can be implemented both laterally and medially.
In the case of complex injuries involving tibiofibular syndesmosis or multiple ligament ruptures (three-ligament injuries) in physically active patients, immediate surgical therapy via arthroscopy and ligament suturing or ligament reconstruction may also be necessary.
Impingement and soccer ankle
Ankle impingement syndrome most often affects the anterior part of the upper ankle, but can also occur at the rear of the upper ankle and in the lower ankle. A distinction is made between soft tissue and bony impingement, although the two often occur in combination. In most cases, painful entrapment after recurrent ankle injuries occurs due to the presence of capsule and ligament scarring. The scars cause painful pinching between the bony structures when in dorsiflexion. Impingement can also arise following recurrent microtraumas of the ankle joint, which can lead to both soft tissue hypertrophy and the formation of bony spurs. Such symptoms often arise on the shooting leg in soccer players; thus the condition is sometimes dubbed “soccer ankle”. If impingement is suspected, a diagnostic exploration under local anesthesia can be carried out in conjunction with magnetic resonance imaging (MRI). Pain relief can, on the one hand, help confirm the diagnosis, and on the other, can simulate the result of ankle arthroscopy with impingement resection. After the operation, it is not necessary to immobilize or restrict exercise, and movement therapy is initiated at an early stage in order to maintain the improved mobility and prevent renewed scarring.
Cartilage therapy / Osteochondral lesions
Cartilage lesions on the ankle can occur on any joint surface. In ankle injuries from recreational or sports accidents, the cartilage is often crushed or sheared off. Not infrequently, the subchondral bone is also torn off (osteochondral flake fracture). If the diagnosis is made early enough, the sheared piece of cartilage can often be repositioned using arthroscopy or open surgery and firmly affixed with the help of special absorbable nails or sutures, allowing it to heal back in place. Various surgical options are available for instances when the sheared fragments are unsuitable for refixation or if chronic cartilage damage is observed, depending on the size and depth of the damage. Bone marrow stimulation techniques can be used in case of small, flat defects, often with good results. After removing the unstable cartilage at the base of the defect, the bone surface is milled and drilled with special instruments to release the bone marrow. The stem cells and growth factors in the bone marrow are then able to grow and become new replacement cartilage at the site of the defect. This effect can be supported by the injection of hyaluronic acid or collagen matrix to bind any leaked blood, stem cells, and growth factors at the site and give the cells sufficient space to develop (autologous matrix-induced chondrogenesis—AMIC). Bone defects can be seamlessly filled with a bone cylinder from the iliac crest and mechanically stablized during the operation. For surgical cartilage therapy to truly succeed, however, all accompanying pathologies must also be addressed. Above all, ligament instability and mechanical overload resulting from axial misalignment must be eliminated during the operation using appropriate procedures.
The significance of a patient’s mechanical leg axis in the development of cartilage damage—even leading to arthritic joints—has been known for some time. Before joint prosthetics became more widespread, osteoarthritis of the knee and ankle was most commonly treated by surgical correction of the mechanical leg axis. Misalignments involving an increased valgus or varus in the ankle can be congenital or arise after a fracture. The changed weight-bearing on the inside or outside of the joint can damage cartilage and lead to the development of osteochondral lesions, which, if left untreated, can then result in ankle arthrosis. To investigate a misalignment and overstressing, imaging (MRI and CT) must be performed for the entire standing leg, and sometime layered images are also required for a detailed analysis and planning of the correction. The angle of the joint must first be determined to ascertain in which bone (thigh, shin) the deviation is present and whether an opening (additive), a closing (subtractive), or a torsion correction is needed. If the misalignment is in the distal lower leg, a supramalleolar osteotomy is indicated. In complex cases, various corrections must be combined in order to restore correct weight-bearing. According to the treatment plan, the operation then corrects the defect with millimeter precision, and the result is secured with a plate. With the modern plate fixators now available, full weight-bearing is usually possible after four weeks, thus enabling a quick return to everyday life. After the osteotomy has healed, the patient is often able to achieve good athletic performance. All other necessary interventions such as ligament reconstruction or treatment of (osteo-) chondral lesions can be performed arthroscopically prior to the osteotomy. The relief this achieves allows damaged cartilage to regenerate and protects reconstructed ligaments. In the case of misalignment around the rear foot area with an increased valgus (rolling flat foot) or increased varus (high arches), heel bone osteotomy can effectively correct the misalignment. Any necessary tendon transplants can be performed in the same session to reinforce chronically insufficient tendons.
Tendon injury and stress, plantar fasciitis, heel spurs
Runners and ballgame athletes often experience pain in their Achilles tendon or the plantar fascia, especially in connection with changes in training (e.g., preparation for an event such as a marathon). The two closely related structures can cause severe pain, both under stress and at rest. Pain is often greatest when taking the first steps in the morning after getting out of bed. Affected patients often describe a “tearing” sensation. In most cases, both pathologies arise from a shortening of the calf muscles, which then chronically overloads the Achilles tendon and/or plantar fascia. In some cases, chronic ankle instability can aggravate this strain. With the Achilles tendon, a distinction is made between the middle area and the site of attachment. A tender, spindle-shaped thickening often occurs in the middle area. The transition from chronic (para-)tendinopathy to an intratendinous partial rupture is fluid, and it is not possible to achieve an accurate clinical or radiological assessment of tendon stability. Chronic tendinopathy at the site of attachment can also lead to calcification of the tendon and the formation of a dorsal heel spur. Thickening of the tendon causes impingement, which can aggravate the pain. Another cause of pain around the Achilles tendon insertion is intrinsic impingement due to an enlarged heel bone (Haglund bump), which occurs when a raised heel bone presses the tendon from the inside. Chronic stress of the plantar fascia due to shortened calf muscles can also irritate the fibers at the base, leading to calcification and a plantar heel spur. The fundamental therapy for these pathologies is consistent physiotherapy with stretching exercises and extrinsic training of the calf muscles. A relatively new but very effective approach is Heavy Slow Resistance Training, which puts a heavy load on the tendon to stimulate the healing process. Fascia therapy can be very useful as well. Focused shock wave therapy can be applied to the Achilles tendon attachment area to activate regenerative processes. ACP therapy has also proven useful as a supplement to chronic plantar fasciitis treatment. If conservative therapy is unsuccessful, various surgical options are available for chronic tendinopathy of the Achilles tendon. In chronic mid-range (para)-tendinopathy, tendoscopy with decompression and synovectomy of the tendon can result in rapid improvement. If a Haglund bump is painful, endoscopic synovectomy and exostosis removal can decompress the tendon without compromising stability. In the case of chronic attachment tendinopathy with a dorsal heel spur, open surgery to remove the spur and resect tendinopathic parts is necessary if conservative treatment is unsuccessful. Depending on the size of the spur, it may be necessary to detach a larger section of tendon from the bone. In this case, the tendon must be reaffixed with bone anchors, and a walker must be used for six weeks following the operation to ensure that the tendon heals properly.
Ankle joint replacement / arthrodesis
For advanced painful arthrosis of the upper ankle joint, if all conservative therapeutic approaches have been exhausted, and depending on the age and activity level of the patient, the upper and lower ankle joint can be stiffened///reinforced? or a full prosthetic upper ankle joint can be implanted. Since the two procedures have comparable results in older patients, an individualized care decision must be made on a case-by-case basis. For younger patients with a high level of activity, ankle arthrodesis is often preferable, as function and resilience are high once healed and no subsequent operations are necessary.
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