Άρθρα - Συνεντεύξεις

ARTHROSCOPY IN THE TREATMENT OF ANKLE OSTEOARTHRITIS

Thanos Badekas MD, Foot and Ankle Clinic, Metropolitan Hospital, Athens, Greece

Panayotis Symeonidis MD

Unlike the knee and hip joints, primary osteoarthritis of the ankle joint is rare. (Demetriades, Koepp) The true incidence the disease is difficult to determine mainly because of the variation between degenerative change and clinical correlation. (Daniels) Is is estimated however that approximately 6% to 13% of all cases of osteoarthritis involve the ankle joint. (Glazebrook 2) There is a significant impact of the disease on pain, function and health related quality of life of patients suffering from end stage ankle arthritis which is comparable, if not worse, to patients suffering from hip arthritis. (Agel, Glazebrook 1)

The ankle joint seems to be one of the most arthritis-resistant joints in the human body. (Staufer). The most common causes of degenerative changes are trauma and/or abnormal ankle biomechanics. (Thomas) In their study with over 300 ankle fractures, Lindsjo reported a 14%  incidence of post traumatic ankle arthritis. Less common causes are inflammatory arthropathies, hemochromatosis, infection, neuropathic arthropathy, or tumor.

The majority of the patient population have osteoarthtritis, secondary to a history of repetitive trauma or fracture in the region. On the other hand, a specific type of osteoarthritis which usually involves the anterior part of the joint is commonly encountered in the ankle joint. It is characterised by osteophyte formation in the anterior lip of the tibia with respective kissing osteophytes in the advanced stages of the disease in the talar neck, stiffness and pain anteriorly. This condition has been termed ankle impingement and can be either bony or caused by soft tissues.

Currently, ankle arthroscopy is considered a routinely performed minimally invasive technique which allows visualisation of all intra-articular structures. The role of arthroscopy on the treatment of ankle arthritis is multiple. A better understanding of the regional anatomy and pathology, along with advances in the equipment and arthroscopic techniques, have expanded the indications and applications of the method. Depending on the type, location and stage of ankle arthritis, a variety of arthroscopic or arthroscopically assisted procedures are being performed. These include arthroscopic synovectomy, debridement, removal of loose bodies, resection of anterior osteophytes and arthroscopically assisted ankle fusion.

Bony impingement – Osteophyte resection

The term “ankle impingement” encompasses an array of different pathological entities. It has been introduced to replace previous relevant terms, such as the “footballer’s ankle”. The impingement can be caused either by soft tissue, which usually is excessive synovium or scar tissue or by osteophyte formation, usually over the anterior lip of the tibia and the opposite talar neck region. In the latter case, the presence of osteophytes, painful joint stiffness and local tenderness, even in the absence of true joint space narrowing, can justify the inclusion of the bony impingement syndrome to the arthritides of the ankle joint.

In the original work of Scranton and McDermott, 43 patients with anterior bony impingement were treated either open or arthroscopically with osteophyte resection. In this study, a new classification system was introduced for the impingement syndrome was introduced and gradually became established in the relevant literature. Interestingly, the study also showed a faster recovery in the patients were an arthroscopic resection was performed. Many authors have confirmed the favorable results of arthroscopic osteophyte resection in an umber of well designed studies (Branca, Jerosh, Nihal, Reynart,  Ogilvie-Harris1,  Rasmussen, Tol, vanDijk 1 and 2).  Most of these  studies report rates of good and excellent patient outcomes over 80%, regardless of the outcome measurement tool used .  Although there is a trend toward improved postoperative results in patients with soft-tissue impingement compared with those with bony impingement, a prospective cohort study comparing the results of these two groups found no such difference (Baums).

Currently, bony impingement is one of the main indications for ankle arthroscopy. The removal of the anterior osteophytes is performed either with arthroscopic osteotomes or with burrs. The objective is to create a smooth edge on the anterior surface of the tibia in order to increase the range of motion and improve the anterior joint line pain.

Osteoarthritis

The results of arthroscopic debridement in the presence of degenerative joint disease have been mixed. According to previously published reports, symptomatic improvement can be achieved in certain cases. In a large case series (Oglivie-Harris 2) which included 27 patients with ankle arhtritis, approximately two-thirds showed improvement after ankle arthroscopy. However, only two patients were restored to normal function. Amendola et al, in a mixed series of ankle arthroscopy with a minimum of two years follow up, report in general poor results in the subgroup of 11 patients with osteoarthritits and osteomalacia. Similar results have been reported by others, who reported less favourable results of ankle arthroscopy in the presence of advanced degenerative changes (Arøen, Biedert, Cerulli, Loong, Martin).

Despite the improvement of instrumentation and techniques, during the last decade there has been a paucity in reporting results for the use of arthroscopy in the treatment of advanced ankle arthritis. This also reflects to the reluctance of arthroscopists to perform an arthroscopy in arthritic ankles. However, older reviews include  degenerative joint disease in the indications for ankle arthroscopy. (Baker, Ferkel) Candidates for ankle arthroscopy can be patients with limited ankle motion due to capsulitis; a minimal to moderate degree of fibroarthrosis; the presence of osteophytes, chondral defects, or loose bodies; or only a minimal degree of instability. However, in the presence of advanced destruction, marked joint-line narrowing, extensive fibrosis, and a significant degree of instability or deformity ankle arthroscopy is contraindicated (Fitzgibbons, Stetson). In a prospective study of the results of arthroscopic treatment of post-fracture ankle pain, vanDijk et al showed poorer results in patients with pre-existing osteoarthrtritis of the ankle compared to those with impingement alone.  Recently, in a relevant evidence-based review, the diagnosis of osteoarthritis was not considered a good indication for the method. (Glazebrook 1)

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Διεύθυνση 1: Λαζαράκη 10, 16675 Γλυφάδα
Διεύθυνση 2: Νοσοκομείο ΕΡΡΙΚΟΣ ΝΤΥΝΑΝ Μεσογείων 117, 115126 Αθήνα
 

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