Arthroscopic Treatment of Osteochondral Talar Defects

Transcription

1 Arthroscopic Treatment of Osteochondral Talar Defects Christiaan J.A. van Bergen, MD, Ruben Zwiers, MSc, and C. Niek van Dijk, MD, PhD Based on an original article: J Bone Joint Surg Am Mar 20;95(6): Introduction Arthroscopic debridement and bone marrow stimulation (i.e., drilling or microfracturing) is considered the primary surgical treatment of osteochondral defects of the talus 1-4. Advantages of this procedure are the relative simplicity of the technique, outpatient treatment, low costs, and early rehabilitation 1,2. Depending on its location, the osteochondral defect can be accessed through an anterior or posterior arthroscopic approach. The procedure is done in four stages: Step 1: Position the Patient For anterior ankle arthroscopy, position the patient supine; for posterior arthroscopy, position the patient prone. For anterior ankle arthroscopy (Fig. 1): Use either general or spinal anesthesia. Place a tourniquet around the thigh. Place the patient in the supine position. The heel of the affected foot rests on the very end of the operating table. This allows the surgeon to fully dorsiflex the ankle by leaning against the sole of the patient s foot. Elevate the ipsilateral buttock with a support. Prepare and drape the ankle. For posterior ankle arthroscopy (Fig. 2): Use either general or spinal anesthesia. Place a tourniquet around the thigh. Place the patient in the prone position. The end of the operating table is at the level of the distal part of the tibia. Place a small support under the lower leg, making it possible to move the ankle freely. Prepare and drape the ankle. Step 2: Arthroscopic Approach For anterior ankle arthroscopy, place the portals medial to the tibialis anterior tendon and lateral to the peroneus tertius tendon at the level of the ankle joint 5 ; for posterior arthroscopy, place the portals lateral and medial to the Achilles tendon just above the level of the tip of the lateral malleolus 6. For anterior ankle arthroscopy (see Appendix: Video 1): Make the anteromedial portal first. Identify the level of the ankle joint and the tibialis anterior tendon with the ankle fully dorsiflexed. Make a vertical skin incision just medial to the tibialis anterior tendon at the level of the ankle joint. Divide the subcutaneous layer and the joint capsule bluntly with a mosquito clamp. Introduce the arthroscope with the ankle in the dorsiflexed position. We routinely use a 4-mm, 30 -angle arthroscope or a 2.7-mm arthroscope with a 4.6-mm sheath (length, 11 cm). Introduce saline solution into the joint. Under arthroscopic control, start the anterolateral portal by inserting a spinal needle lateral to the peroneus tertius tendon while respecting the superficial peroneal nerve (Fig. 3). Incise the skin, and divide the subcutaneous layer and joint capsule with a mosquito clamp. Introduce instruments with the ankle dorsiflexed. Enter and inspect the ankle joint. If there is synovitis, perform a local synovectomy with the ankle dorsiflexed. doi: /JBJS.ST.M , 3(2):e10 1

2 For posterior ankle arthroscopy (see Appendix: Video 2): Make the posterolateral portal first. With the ankle in the neutral position, draw a line from the tip of the lateral malleolus to the Achilles tendon, parallel to the foot sole. The posterolateral portal is situated just above this line, in front of the Achilles tendon (Fig. 4). Make a vertical stab incision. Split the subcutaneous tissue with a mosquito clamp. Direct the mosquito clamp anteriorly, pointing it in the direction of the interdigital web space between the first and second toes. Introduce the instruments and arthroscope with the ankle in the slightly plantar flexed position. Exchange the clamp for a 4.0-mm arthroscope when the tip touches the bone. The direction of view is 30 to the lateral side. Make the posteromedial portal at the same level. Make a vertical stab incision in front of the medial aspect of the Achilles tendon. Introduce a mosquito clamp, directed toward the arthroscope shaft at a 90 angle. When the clamp touches the arthroscope, move it anteriorly in the direction of the ankle joint, all of the way down, touching the arthroscope shaft until it reaches the bone. Pull the arthroscope slightly backward until the tip of the mosquito clamp comes into view. Use the clamp to spread the extraarticular soft tissue in front of the tip of the lens. When scar tissue or adhesions are present, exchange the mosquito clamp for a 4.5-mm full-radius shaver. Push the shaver 1 to 2 cm anterior to the lateral side of the talus. This is the level of the posterolateral aspect of the subtalar joint. After removing the very thin joint capsule of the subtalar joint by a few turns of the shaver, visualize the posterior compartment of the subtalar joint. At the level of the ankle joint, identify the posterior tibiofibular and talofibular ligaments. Optionally, free the posterior talar process of scar tissue. Identify the flexor hallucis longus tendon (Fig. 5). This tendon is an important landmark to prevent damage to the medial neurovascular bundle. Always stay lateral to this tendon when treating an osteochondral defect. Move medially only when release of the neurovascular bundle is indicated (e.g., for tarsal tunnel syndrome). Remove the thin joint capsule of the ankle joint, and enter and inspect the joint. Step 3: Debridement and Bone Marrow Stimulation Fully debride the osteochondral defect and create multiple microfractures in the bottom of the defect. Identify the osteochondral defect with the ankle in the plantar flexed position (for anterior arthroscopy) or distracted position (for posterior arthroscopy) by palpating the cartilage with a probe or hook (Fig. 6-A). During this part of the procedure, soft-tissue distraction can be applied with a strap around the ankle that is attached to a strap around the surgeon s waist. If necessary, remove a small anterior rim of the tibial plafond with the shaver for adequate exposure during anterior arthroscopy. Remove all of the unstable cartilage and subchondral necrotic bone of the visible part of the defect with a full-radius shaver and/or curet. Subsequently, bring the instruments into the defect to treat the remainder (Fig. 6-B). Check every step in the debridement procedure by regularly switching portals (Fig. 6-C). After full debridement, penetrate the sclerotic zone several times to a depth of 3 to 4 mm with use of a microfracture awl or a Kirschner wire at intervals of approximately 3 mm (Figs. 6-D and 6-E) Step 4: Closure and Postoperative Care Prescribe partial weight-bearing for six weeks. Remove the instruments and close the incisions. Apply a pressure bandage for two days. Encourage active plantar flexion and dorsiflexion. Allow partial (i.e., eggshell-pressure) weightbearing as tolerated for six weeks. Permit running on even ground after twelve weeks. Full return to sports is usually possible after four to six months. 2013, 3(2):e10 2

3 Results A systematic review of the literature identified eighteen studies on bone marrow stimulation that included a total of 388 patients 3. The study weighted success rate was 85% (range, 46% to 100%). Successful treatment was defined as an excellent or good result at the time of follow-up or, if the success rate was not reported in the original article, by the scoring system of Thompson and Loomer 7. In a recent long-term follow-up study, fifty patients with a primary osteochondral defect treated with arthroscopic debridement and bone marrow stimulation were evaluated at a mean of twelve years (range, eight to twenty years) 8. Forty-seven patients were treated with anterior arthroscopy, and three were treated with posterior arthroscopy. Clinical assessment measures included the Ogilvie-Harris score, Berndt and Harty outcome question, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and Short Form-36 (SF-36) as well as resumption of work and sports. Weight-bearing radiographs were compared with preoperative radiographs with use of an ankle osteoarthritis classification 9. The Ogilvie-Harris score was excellent for 20% of patients, good for 58%, fair for 22%, and poor in 0%. According to the Berndt and Harty outcome question, 74% of the patients rated the ankle as good; 20%, as fair; and 6%, as poor. The median AOFAS score was 88 (range, 64 to 100). Of the eight subscales of the SF- 36, six were comparable with population norms and two were superior in the study group. Ninety-four percent of patients had resumed work, and 88% had resumed sports. The radiographs indicated an osteoarthritis grade of 0 in 33% of the patients, I in 63%, II in 4%, and III in 0%. Compared with the preoperative osteoarthritis classification, the classification on the follow-up radiographs showed no progression in 67% of the patients and showed progression by one grade in 33%. What to Watch For Indications The best indication is a primary, symptomatic osteochondral defect smaller than 15 mm in an adult patient 1-3,10. The procedure may also be considered for defects larger than 15 mm, cystic defects, secondary defects, and defects in adolescents 1,2. Anterior ankle arthroscopy is the preferred approach for most defects 2. In general, the defect can be reached and treated with the ankle in full plantar flexion when the anterior border of the defect is in the anterior half of the talar dome and plantar flexion of the ankle is not limited 11. The posterior approach can be employed when the defect is more posterior. In doubtful cases, a computed tomography scan of the ankle in full plantar flexion can be obtained for preoperative planning of the arthroscopic approach 12. Contraindications Absolute Infection Relative Massive osteochondral defect Osteoarthritis of the ankle joint Malalignment Vascular disease Edema Pitfalls & Challenges Difficulty reaching the defect. Despite careful preoperative planning, accessibility of the defect is sometimes limited. In these cases, a soft-tissue distractor can be applied. In addition, a small rim of the tibial plafond or an osteophyte (if present) can be removed. The microfracture procedure may create small osseous fragments, which could act as loose bodies 13. Any such fragments should be removed. It is recommended that the joint be carefully inspected and lavaged at the end of the procedure. Damage to the superficial peroneal nerve has been reported as a complication associated with the anterolateral portal 14. The nerve consistently moves laterally when the ankle is maneuvered to the dorsiflexed position 15. It is therefore advisable to create the anterolateral portal medial from the preoperative course of the superficial peroneal nerve, if it is visible, in order to prevent iatrogenic damage. Clinical Comments What are the optimal depth and distance of the microfracture holes? Additional studies on optimization of the rehabilitation are encouraged. Randomized controlled trials comparing the technique with other treatment methods are warranted. More instructional videos can be found on , 3(2):e10 3

4 Appendix Videos demonstrating anterior and posterior arthroscopic treatment of osteochondral defects of the talar dome are available with the online version of this article as a data supplement at jbjs.org. Christiaan J.A. van Bergen, MD Ruben Zwiers, MSc C. Niek van Dijk, MD, PhD Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. address for C.J.A. van Bergen: c.j.vanbergen@amc.nl. address for R. Zwiers: r.zwiers@amc.nl. address for C.N. van Dijk: c.n.vandijk@amc.nl Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article. References 1. van Bergen CJ, de Leeuw PA, van Dijk CN. Treatment of osteochondral defects of the talus. Rev Chir Orthop Repar Appar Mot Dec;94(8)(Suppl): Epub 2008 Nov van Dijk CN, van Bergen CJ. Advancements in ankle arthroscopy. J Am Acad Orthop Surg Nov;16(11): Zengerink M, Struijs PA, Tol JL, van Dijk CN. Treatment of osteochondral lesions of the talus: a systematic review. Knee Surg Sports Traumatol Arthrosc Feb;18(2): Epub 2009 Oct van Dijk CN, Reilingh ML, Zengerink M, van Bergen CJ. Osteochondral defects in the ankle: why painful? Knee Surg Sports Traumatol Arthrosc May;18(5): Epub 2010 Feb van Dijk CN, Scholte D. Arthroscopy of the ankle joint. Arthroscopy Feb;13(1): van Dijk CN, Scholten PE, Krips R. A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthroscopy Nov;16(8): Thompson JP, Loomer RL. Osteochondral lesions of the talus in a sports medicine clinic. A new radiographic technique and surgical approach. Am J Sports Med Nov-Dec;12(6): van Bergen CJ, Kox LS, Maas M, Sierevelt IN, Kerkhoffs GM, van Dijk CN. Arthroscopic treatment of osteochondral defects of the talus: outcomes at 8 to 20 years of follow-up. J Bone Joint Surg Am Mar 20;95(6): van Dijk CN, Verhagen RA, Tol JL. Arthroscopy for problems after ankle fracture. J Bone Joint Surg Br Mar;79(2): Chuckpaiwong B, Berkson EM, Theodore GH. Microfracture for osteochondral lesions of the ankle: outcome analysis and outcome predictors of 105 cases. Arthroscopy Jan;24(1): Epub 2007 Nov van Bergen CJ, Tuijthof GJ, Maas M, Sierevelt IN, van Dijk CN. Arthroscopic accessibility of the talus quantified by computed tomography simulation. Am J Sports Med Oct;40(10): Epub 2012 Aug van Bergen CJ, Tuijthof GJ, Blankevoort L, Maas M, Kerkhoffs GM, van Dijk CN. Computed tomography of the ankle in full plantar flexion: a reliable method for preoperative planning of arthroscopic access to osteochondral defects of the talus. Arthroscopy Jul;28(7): Epub 2012 Feb van Bergen CJ, de Leeuw PA, van Dijk CN. Potential pitfall in the microfracturing technique during the arthroscopic treatment of an osteochondral lesion. Knee Surg Sports Traumatol Arthrosc Feb;17(2): Epub 2008 Sep Ferkel RD, Small HN, Gittins JE. Complications in foot and ankle arthroscopy. Clin Orthop Relat Res Oct;(391): de Leeuw PA, Golanó P, Sierevelt IN, van Dijk CN. The course of the superficial peroneal nerve in relation to the ankle position: anatomical study with ankle arthroscopic implications. Knee Surg Sports Traumatol Arthrosc May;18(5): Epub 2010 Mar , 3(2):e10 4

5 Figures Fig. 1 Patient positioning for anterior ankle arthroscopy. Fig. 2 Patient positioning for posterior ankle arthroscopy. Fig. 3 With the arthroscope in the anteromedial portal, start the anterolateral portal by inserting a spinal needle lateral to the peroneus tertius tendon. Fig. 4 The posterolateral portal is situated just above the line parallel to the foot sole from the tip of the lateral malleolus to the Achilles tendon, in front of the Achilles tendon, with the ankle in the neutral position. The posteromedial portal is made at the same level. The arrowheads point to the posterolateral (left) and posteromedial (right) portals. Fig. 5 The flexor hallucis longus (FHL) tendon is an important landmark to prevent damage to the medial neurovascular bundle. The arrowhead points to the level of the ankle joint. Fig. 6-A Identification of the osteochondral defect with the ankle in the plantar flexed position by palpating the cartilage with a probe. Fig. 6-B Debridement of the defect. Fig. 6-C Arthroscopic view after full debridement. Fig. 6-D Microfracture. Fig. 6-E Final view of the treated defect. Fig. 1 Fig , 3(2):e10 5

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7 Fig. 6-A Fig. 6-B Fig. 6-C Fig. 6-D Fig. 6-E 2013, 3(2):e10 7