I didn't actually design this course, so I got assigned an interesting combination of anterior impingement, ostrigone, and FHL, and I'm going to try and not step too much on the feet of our next presenter, who was assigned posterior arthroscopy. So this is going to be a little bit of a whirlwind tour of impingement in the ankle, anteriorly and posteriorly. I have no industry conflicts. When we talk about soft tissue impingement, you know, our modern history goes way back to 1950 with a guy named Wolin from Chicago, and he really coined the term meniscoid lesion of the ankle when he looked at these impinging lesions in the lateral gutter. As arthroscopy began to be applied to the ankle in Japan and in the United States, these could be visualized arthroscopically, and again, early on, we used this term meniscoid lesion. From the standpoint of soft tissue impingement, I think we can look at this as more cases of generalized synovitis or localized synovitis, and what we're talking about is usually the localized synovitis, which can occur anterolaterally. It can occur syndesmotically or posteriorly. Post-traumatic, usually they happen after a sprain or fracture, some other type of trauma to the ankle joint, and it's suggested that, you know, there's a stage of these that occur with initial hemarthrosis and gradual scar formation in some instances, the reason for which are not well delineated, but they can result in masses of synovitis, which literally have a mass effect within the joint and cause pain and other symptoms, or sometimes fibrous bands such as those pictured here. From an evaluation point of view, it's a pretty nonspecific thing with localized tenderness sometimes, sometimes swelling within the joint. Again, we look for other things to rule out other entities on the differential diagnosis of a painful ankle, but these should have, in general, no objective evidence of joint laxity. X-rays are usually normal, barring some other thing going on. MRIs certainly may have some benefit in the modern evaluation because, especially with the higher testicle units and better experience, we can see abnormal synovial impingement lesions. But certainly one important thing to do in an evaluation for any of these patients is a differential injection of zylocaine because if there's an intraarticular soft tissue problem, the pain should go away. If the pain doesn't go away, you better step back and find another diagnosis and not just say I'm going to look inside the joint. Naturally, with this kind of thing, you're going to initially have a nonoperative treatment plan, but if there's persistent pain, treatment for a reasonable period of three months or more, and a positive response to intraarticular injection, then it's appropriate to do an arthroscopic examination of the ankle joint. I set these patients up in this fashion, supine position, a well-padded leg holder with the forces going on the thigh, not in the papateal fossa, and use noninvasive distraction such as this, and routine anteromedial, anterolateral, and I always put in a posterolateral portal for all my ankle cases. And again, this is an example of a synovial impingement lesion. I think this is the real deal. There's always some soft tissue in the syndesmosis area, but when they get this big, they can actually act as little soft tissue masses in there and are easily treated by taking them out however you want. All of this material can be taken out. It's not part of the syndesmotic ligaments, and whether you use BASCUS forceps, bipolar electrocautery or whatever, you can take these out and in some instances give patients some significant relief of those symptoms. Attention has been called to the inferior bundle of the anterior inferior tib-fib ligament, so-called BASCUS ligament. That when it is injured in hypertrophies can cause pain. It can be treated arthroscopically, and it is said that any of really the interarticular portion can be taken out without having a deleterious effect on the syndesmotic ligaments and causing a syndesmosis injury. You'd like to see some corresponding area, for instance, of chondromalacia on the talus to help support the diagnosis at the time of surgery. Finally, some other synovial impingement can occur anywhere in the joint, including the medial side, and you can see here a big hunk of scar tissue essentially in the medial aspect of the joint, and they can sometimes be associated with osteochondral lesions of the talus. There's numerous studies in the literature going back into the 90s, and I'm not going to go through all these because of the time constraints, but that document significant improvement in activities, including in elite athletes, including ballet dancers, after soft tissue impingement debridement. So the incidence is uncertain. We think it's usually post-traumatic and will respond to arthroscopic surgery with what the literature suggests, 80% to 90% excellent or good results. The other type of impingement that we get is bony impingement from osteophytes, and I'm not going to go through literature or anything on this, but there is in general good response after excision of these if there is no coexisting arthritic change in the joint. You can see here that one of the important things is to lift any attached soft tissues from the anterior edge of the osteophyte so as to gain exposure and to avoid injury to any of the neurovascular or tendon structures anterior to that so you can see it well. And then I generally take these out using a burr, a four millimeter round burr, although you can use an osteotome and take them out piecemeal. People always ask, how much do you take out? Well, I think you take it back to a level where you start seeing normal articular cartilage such as this, especially when you, and you have to view from both medial and lateral sides to make sure that you take out the whole thing. The failures will occur if either expected or unexpected, there's too much arthritis, or if you fail to take out the whole osteophyte. And I would say that Nick Van Dyke has also taught us that a lot of these osteophytes occur intermediately, routine lateral ankle x-rays may not show them, but this modified oblique view can show them. And I'm just showing this one. This is like the ginormous osteophyte that ate New York. I've never seen one bigger than this in my practice. And this is a guy who actually had pretty minimal arthritis given the amount of osteophyte he had. But it shows the importance of the whole medial thing because here you can see the anterior part completely taking that out. But this humongous osteophyte goes way down medially, and if you don't take that out, you're not going to get relief. And this shows after you've taken that out all the way down to the tip of the medial malleolus basically, and you have to do that. You can see the degree of arthritis. It's there, but it's not probably as bad as you might expect from the size of the osteophyte. So again, use preoperative studies to know where they are, be certain to visualize the whole thing, and examine the tailor neck for kissing lesions. So we know that arthroscopic treatment is good for anterior impingement, but what about these problems? How are you going to handle a symptomatic osteogonim, flexor hallus as long as tenosynovitis that's unresponsive to conservative care, a cyst or osteochondral defect way posteriorly, or something like a Haglund's with retrocalcaneal bursitis? Now there's a guy named Rick Ferkel who really enjoys taking these out through a sub-tailor approach and says it's easy, but I'm not quite as talented as him, and it's not as easy for me. So posterior ankle arthroscopy allows access to what we consider to be a formerly inaccessible area only by open techniques. It's less invasive. I'd argue it has better visualization, lower morbidity, and faster return to activity. And we can credit Nick Van Dyke, really, as I think the teacher of all of us in this room, as to how to do a posterior scope. He's a very innovative guy. It's important to look at and be knowledgeable about the anatomy, and very quickly, this cross-sectional view taken at approximately the level of the sub-tailor joint shows the posterior talofibular ligament coming into the posterior process, or osteogonim if there is one. The flexor hallus, as long as it's starting to live in its groove going down into the foot. And the important part is the neurovascular bundles are all lateral, I'm sorry, medial to that. So the point is, as you're creating this visualization in here, the first goal is to look at that FHL and stay lateral to it, and you will be safe. So the way we do this is we do prone arthroscopy. The two portals adjacent to the Achilles tendon are placed at approximately the level of the distal tip of the fibula. And this is how you do it. I use a four millimeter scope, as Nick does. You insert the scope lateral and aim it towards the first web space, and then stick the shaver in perpendicular to the scope, hit the scope so you know where it is, walk it down to the end, and then create a space. And what you can see here is the type of view you have. So you get the shaver in there, and again, you're very careful taking out fat and the posterior capsule, which is very thin, and then find the flexor hallus as longest, and you can see it. So this is just a quick example of an FHL, tenosynovitis, that didn't get better with conservative treatment. You can see a basket forceps here. With perfect visualization, going down and releasing the fibroosseous tunnel here to decompress the FHL. In this case, the bad stuff is on the left side, and the ankle joint is on the right side. That's a quick look from an ostragonum resection. You can see here that for any ostragonum resection, no matter what the approach, you do have to take off the attachment of the posterior talofibular ligament. You can do that any way you want. You can use a little knife. You can use arthroscopic scissors, in this case a bipolar cautery. It doesn't matter how you do it. Just expose the thing. Do the minimal exposure necessary. This was a big ostragonum, and this came out piecemeal nicely. They tend to be a little softer because they're loose fragments. A nice, big pituitary ronger to grab as big a piece as you can, and then when you take out the whole thing, you can use the shaver, and this is what it looks like afterwards when you've removed it. That, if I can get the pointer up, there's the ankle joint that you can see, and in this one, the subtalar joint, you can barely see down here. When you wiggle it, you can see just a little bit of motion at the subtalar joint. That was kind of a tight one. The last thing I'll show you real quickly is a retrocalcaneal bursitis, Haglund's deformity, if you're going to take that off. It's actually pretty simple to do if you have just a little bit of patience. The portals are a little bit lower than the portals I described for the regular posterior arthroscopy, and if you're used to doing shoulder surgery, all you have to do is flip yourself on your head because this is just an upside-down acromioplasty, and basically what you're seeing here is the surface of the posterior calcaneus. The Achilles tendon is on this side, and you're basically taking this bump down. I think in general, when you take them down arthroscopically, you're probably not taking out quite as big a piece as you do when you do it open, but you can see from this last video, if it'll go up, that you get quite a nice decompression. You can see that the Achilles tendon's been completely decompressed back there on the left side, and there's postoperative care for all these things we talked about. Pretty easy. I always splint my patients for a week just to let the wounds heal. Weight-bearing is tolerated after that, and physical therapy as necessary. Again, with regard to posterior arthroscopy, we have ample literature now showing good results, improved results with lower morbidity. I believe there's a study by Nick is showing basically that the experience demonstrated that posterior ankle arthroscopy can be performed with a low rate of major postoperative complications, so I think that posterior ankle arthroscopy is a safe and reproducible technique. Careful attention to technical details is important with knowledge of the anatomy, and for me, it's the preferred approach to purely posterior pathology in the ankle and subtalar joints. Thank you.

ankle impingement

soft tissue impingement

localized synovitis

arthroscopic examination

posterior ankle arthroscopy