ANKLE ARTHROSCOPY

SummaryIntroduction . Ankle arthroscopy provides better visualization, less tissue trauma, faster recovery, shorter hospitalization and reduced treatment costs. Complication rates are lower in relation to the classic open approach. This study was aimed at presenting the surgical te -chnique, its advantages and limitations, complications as well as our experience. Material and Methods. We performed 31 ankle arthros copies in 23 male and 8 female patients in the period from October, 2007 to l September 2016. All surgeries were performed with tour niquet applied on the thigh, using standard arthroscopy portals, with the optic 4.0, 30 degrees. Anterior and posterior bony and soft tissue impingements were found in 23 patients, 4 patients had osteochondral defects of the talar dome, loose bodies were seen in 4 patients. The majority of patients were athletes and recreational sportspeople (29 cases). The average duration of surgery was 25 minutes. The avera ge stay in hospital was one day. Full weight-bearing was achieved 18 days after surgery on average (from 10 to 28 days). There were no infections. Transitory palsy of superficial peroneal nerve was recorded in three cases. Results. The average American Orthopedic Foot and Ankle Score value was 46 before surgery and 92 after surgery. According to Foot and Ankle Outcome Score there were improve ments in the postoperative range of motion, alleviation of pain, longer walking distance and improvement in daily living activities. Conclusion. Ankle arthroscopy resulted in a significant postoperative improvement in functional scores in our study sample.


Introduction
Ankle arthroscopy became important in the past decade. It is used as diagnostic and therapeutic procedure in acute and chronic cases, and it replaced open surgery [1]. Its application is getting wider because more and more people go in for sports which leads to increased trauma or overuse injuries of the ankle joint. The overall incidence of ankle and foot trauma is high, accounting up to 40% of all injuries in athletes. Of that number 20% to 30% will have some residual problems [2]. The main indications for ankle arthroscopy are ankle impingement, osteochondral and chondral defects, cartilage degeneration, joint instability and synovitis. Depending on the location of injury, anterior, posterior or combined approach can be used. There are differences in surgical technique used in the world: in Europe and Asia surgeons use the so called dorsiflexion method, while in the United States of America surgeons use non-invasive distraction technique [3][4][5]. It has taken a long time to establish ankle arthroscopy, and turn it from diagnostic to therapeutic procedure. The first article on ankle arthroscopy was published by Burmnan [6] in 1931. He said that the ankle joint was unsuitable for arthroscopy because of the anatomy. But only eight years later, in 1939, the first ankle arthroscopy was performed by Kenji Tagaki [7]. Watanabe reported a series of 28 ankle arthroscopies in 1972 [8]; and Chen published his work on a series of 67 patients in 1976 [9]. The shape of the articular surfaces and little joint laxity was the main reason for difficulty in performing ankle arthroscopy. In 1988 Guhl and Ferkel [3,10] introduced invasive distraction technique. It was later replaced with non-invasive distraction that produced less complications. Van Dijk and Scholte [11] introduced the dorsiflexion method in 1997. With foot in dorsiflexion, the complication rate was further decreased, and ankle arthroscopy became more popular among surgeons in Europe. Development in technology, such as video transmission, fibre optics, small instruments and cameras, computed tomography (CT) and magnetic resonance imaging (MRI) diagnostics are of the great influence in arthroscopy procedures, particularly the ankle arthroscopy.

Material and Methods
A retrospective study, which was conducted from October 2007 to September 2016, included 31 patients (23 males and 8 females) who had undergone ankle arthroscopy. Inclusion criteria were pain, reduced range of motion, swelling, and no response to physical therapy in the previous six months. Exclusion criteria were infection at the site of ankle and the radiographic signs of narrowing of the joint space that suggested the presence of ankle osteoarthritis. Anterior and posterior bony and soft tissue impingements were treated in 23 patients, osteochondral defects of the talar dome loose bodies were treated in 4 patients, each (Graph. 1).
The majority of patients were athletes and recreational sportspeople (29 cases). The follow-up period was 1 year on average (ranging from 1 month to 18 months). The average duration of surgery was 25 minutes. The average stay in hospital was one day. Full weight-bearing was achieved 18 days after surgery on average (from 10 to 28 days). There were no infections. Transitory palsy of superficial peroneal nerve was recorded in three cases. Prior to surgery, radiographs, CT or MRI diagnostic were performed. If bony impingement was seen on standard radiographs we did not use CT or MRI. Surgeries were performed with tourniquet applied on the thigh, using general or epidural anesthesia. The patients were placed in supine or prone position, depending on the pathology that had  to be treated. The affected limb was placed in a slight elevation and with the foot at the edge of the operating table, thus enabling the surgeon to manipulate with the foot and to dorsiflex it fully. The joint distraction was performed by an assistant. Standard anteromedial and anterolateral portals were used for anterior ankle arthroscopy (Figures 1 and 2), and posterolateral and posteromedial portals were used for posterior an-kle arthroscopy, as described by van Dijk [12] (Figures 3 and 4).
The arthroscope which we used was 4 mm wide at the angle of 30 degrees, without an arthropump. The landmarks were drawn on the skin prior to the skin incision. After surgery the wound was closed by single sutures, and an elastic bandage was applied running from the foot to the knee. The patients were discharged from hospital the day after surgery, they were allowed to walk on the crutches without weight-bearing for 3 days, and after that with progressive load.

Results
The results were assessed by means of two scoring systems. The American Orthopedic Foot and Ankle Society Score (AOFAS) [13] is one of the most widely used clinician-reporting tools for foot and ankle conditions. Developed in 1994, AOFAS is a clinicianbased score that measures outcomes for four different anatomic regions of the foot: the ankle-hindfoot, midfoot, metatarsophalangeal (MTP)-interphalangeal (IP) for the hallux, and MTP-IP for the lesser toes. The four anatomic regions of the AOFAS are all represented by a different version of the survey with each tool designed to be used independently. The questionnaire consists of nine items that are distributed over three categories: Pain (40 points), function (50 points) and alignment (10 points). These are all scored together for a total of 100 points. The average values of AOFAS score in our study was 46 before surgery and 92 after surgery.
Foot and Ankle Outcome Score (FAOS) [14] was developed to assess the patients' opinion about a variety of foot and ankle-related problems. FAOS consists of 5 subscales: pain, other symptoms, function in daily living (ADL), function in sport and recreation (Sport(Rec), and foot and ankle-related Quality of Life (QOL). The previous week has to be taken into consideration when answering the questionnaire. Standardized answer options are given and each question gets a score from 0 to 4. A normalized score (100 indicating no symptoms and 0 indicating extreme symptoms) is calculated for each subscale. In our study sample there were improvements in the postoperative range of motion, alleviation of pain, longer walking distance and improvement in daily living activities.

Conclusion
Ankle arthroscopy is one of the latest surgical procedures performed at our Department. Although we have a lot of experience in knee arthroscopy, the ankle arthroscopy is the field that we want to enter more rapidly. A limitation of the study is a small number of patients treated by ankle arthroscopy. However, in spite of a small sample we have achieved satisfactory results according to American Orthopedic Foot and Ankle Score and Foot and Ankle Outcome Score system. The first results have encouraged us to continue to improve our skills.