Treatment of Soft Tissue Impingement Lesions

After a thorough diagnostic arthroscopy, anterolateral impingement lesions can be removed with the aid of the arthroscope. Bassett lesions have been found in normal ankles but can become symptomatic in the setting of inversion ankle injuries. This distal

Figure 67-7 Ankle in maximal dorsiflexion without distraction. (From Van Dijk CN, Tol JL, Verheyen CC: A prospective study of the prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement. Am J Sports Med 1997;24:737-745. Copyright 1997 American Orthopaedic Society for Sports Medicine.)

Figure 67-7 Ankle in maximal dorsiflexion without distraction. (From Van Dijk CN, Tol JL, Verheyen CC: A prospective study of the prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement. Am J Sports Med 1997;24:737-745. Copyright 1997 American Orthopaedic Society for Sports Medicine.)

fascicle will be separate from the anteroinferior tibiofibular ligament by a fibrofatty septum and can be removed without compromising the stability of the syndesmosis. The articular cartilage should be carefully evaluated once the accessory ligament is removed. All abnormal synovium and scar tissue should be removed, and any fraying of the anterior syndesmosis or anterior talofibular ligament should be débrided.

Posteromedial impingement lesions may be difficult to visualize and treat with arthroscopic techniques using standard anterior portals. Prone posterior ankle arthroscopy may have a role in treatment of this lesion but has not been described. An open technique has been described in which the tendon sheath of the tibialis posterior tendon is opened, the tendon is retracted anteriorly, and the bed of the tendon sheath is opened to gain access to the posteromedial aspect of the joint. The pathologic tissue tends to "erupt through this incision" and is removed. The incision in the bed of the tendon sheath is left open, and the superficial sheath incision and skin are closed.7

Arthroscopic Treatment of Chondral and Osteochondral Lesions of the Talus

Lesions confined to the cartilage alone can be treated arthro-scopically with a simple chondroplasty to smooth the articular surface and débride back to normal healthy cartilage (Fig.

67-8). As stated earlier, strong consideration should be given to stabilizing ankles with lateral ligament instability in the setting of a chondral lesion.1

Treating osteochondral lesions with arthroscopic techniques requires a systematic approach based on the arthroscopic appearance of the lesion. There are numerous techniques available, and the surgeon should be familiar with the advantages and disadvantages of each type of treatment to optimize treatment of a given lesion. Arthroscopy provides excellent visualization of the joint, but some far posteromedial lesions may be difficult to visualize. Therefore, the surgeon should be prepared to convert to an open procedure if necessary.

Stage I lesions appear as an area of softened articular cartilage without a definable fragment. If this lesion is symptomatic, then the main treatment decision is whether the articular cartilage should be violated to try to stimulate the lesion to heal. Drilling of an intact lesion can be performed by drilling a 0.062-inch Kirschner wire through the intact cartilage and into the base of the lesion. It is believed that the drill holes stimulate revascularization of the avascular fragment. Anterolateral lesions can usually be easily drilled through the anterolateral portal. Pos-teromedial lesions can be more difficult to access because of their location. With the arthroscope in the anterolateral portal, the ankle is placed in maximal plantarflexion. If the area of softened cartilage can be visualized, then drilling can be performed through the anteromedial portal. If this is unsuccessful, then transmalleolar drilling can be considered. A small joint drill guide is placed over the lesion, and the Kirschner wire is drilled through the medial malleolus and into the lesion (Fig. 67-9).2 These techniques have the advantage of decreased operative morbidity compared to open techniques but injure articular cartilage. An alternative approach allows grafting behind an intact lesion without violating the integrity of the articular cartilage. A small joint drill guide is placed over the lesion, and a guide wire is placed in the sinus tarsi. Retrograde transtalar drilling is then performed under direct arthroscopic visualization (Fig. 67-10).2,8 The tunnel is expanded with a small reamer, and the lesion is grafted with local or distal tibia cancellous bone graft.

Stage II lesions have a breach in the articular cartilage, but the fragment is not displaceable. Once the overlying cartilage has been debrided, the underlying bone bed can be addressed. It is important to remove any sclerotic or nonviable bone until bleeding subchondral bone is seen at the base of the lesion.14 Drilling can be performed as described for stage I lesions, or the microfracture technique may be used. The microfracture technique uses specialized awls, and multiple perforations are made in the subchondral plate approximately 3 mm apart.17 Both drilling and microfracture stimulate the release of growth factors and mesenchymal stem cells, which result in filling of the defect with fibrocartilage.16 The advantages of these techniques are decreased operative morbidity compared to open procedures and filling of the defects with fibrocartilage. Two of the potential shortcomings of these techniques are that they are not able to reconstitute significant loss of subchondral bone and long-term durability of fibrocartilage on the talus is not known.

Stage III lesions have a breach in the articular cartilage with a displaceable fragment. The size and viability of the fragment as well as the condition of the overlying articular cartilage should be carefully assessed. Some acute traumatic lesions may be candidates for internal fixation (discussed later in chapter). If the lesion is loose and not amenable to internal fixation, then it

Visual Fissure Caries

Figure 67-8 A, Partial-thickness chondral lesion of the talar dome viewed arthroscopically. B, Motorized shaver debriding the lesion. C, Articular surface of the talus after debridement.

should be removed and the subchondral bed treated as discussed for stage II lesions. Loose lesions will often have a flap of articular cartilage attached to the lesion. In the past, there has been some question about what to do with this cartilage. A recent report has shown that leaving this remaining cartilage in place may obstruct regeneration of healing tissue and that the removal of all degenerative cartilage improves results.9

Stage IV lesions are loose bodies in the ankle joint. Unlike stage I through III lesions, loose bodies are treated surgically as soon as the diagnosis is made. Once again, acute traumatic lesions can be assessed for internal fixation. If the lesion is chronic, nonviable, less than 1 cm in size, or has poor overlying articular cartilage, it is removed.8,14 The site of loose body displacement is debrided, and the subchondral bone bed is treated like stage II and III lesions.

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