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Is There Still a Place for Diagnostic Ankle Arthroscopy?
the time he used gas inflation (CO
2
) in order to avoid soft-tissue Figure 7: This Arthroscopic Image Shows a Deep Lesion
complications.
20
Acute (osteo)chondral lesions have been thought to
on the Talus as a Result of an Ankle Fracture
play an important role in the development of osteoarthritis after
anatomically reduced and fixated ankle fractures, but these lesions
cannot be visualised directly in undislocated ankle fractures, nor with
conventional radiography. Cartilage lesions were found in 228 ankles
(79.2%), more often on the talus (69.4%) than on the distal tibia
(45.8%), the fibula (45.1%) or the medial malleolus (41.3%). The
frequency and severity of the lesions increased from type B to type C
fractures (p<0.05). The findings showed that there are many
associated intra-articular lesions in acute fractures of the ankle
20
(see Figure 7). Leontaritis et al. confirmed the correlation between
severity of an acute ankle fracture and an increased number of
intra-articular chondral lesions. In the 283 patients studied by
Leontaritis et al., chondral lesions were found in 61 patients (73%).
This retrospective study demonstrated that the number of intra-
articular chondral lesions associated with the more severe ankle
fracture patterns (pronation–external rotation and supination–
external rotation type IV fractures) was greater than the number
associated with the less severe ankle fracture patterns.
21
Arthroscopy has also revealed that after a severe ankle sprain the
incidence of residual complaints, particularly on the medial side of the
joint, is high. van Dijk et al. studied a consecutive series of 30 patients
who had operative repair of acute ruptures of lateral ligaments.
22
New
Image reproduced with kind permission of Professor Beat Hintermann.
at the time was arthroscopic examination during operation, which
revealed a fresh injury to the articular cartilage in 20 ankles (66.7%).
Table 1: The Berndt and Harty Classification of
Osteochondral Lesions
26
These lesions had not been seen before with conventional
radiographic imaging. They provided evidence for the hypothesis that
Stage I A small compression fracture
in patients with a rupture of one or more of the lateral ankle ligaments
Stage II Incomplete avulsion of a fragment
after an inversion injury, an impingement occurs between the medial Stage III Complete avulsion of a fragment without displacement
malleolus and the medial facet of the talus. Important knowledge for Stage IV Displaced fragment
the prognosis was that a high-velocity injury had a higher incidence of
macroscopic cartilage damage (p<0.01), medially located pressure (40.3%) osteochondral lesions were seen, 13 patients (18%) had
pain (p=0.06) and medially located complaints at one-year follow-up symptomatic os subfibulare, three patients (4.2%) had anterior
(p=0.02) than those with low-velocity injury.
22
impingement exostosis and three patients (4.2%) had impingement
due to abnormally fibrous bands. The authors suggest that
Diagnostic Arthroscopy in arthroscopy can diagnose the cause of residual pain after an ankle
Chronic Ligamentous Laxity sprain in the cases that are otherwise undiagnosable by clinical
In cases in which a pre-operative ankle arthroscopy has been examination and radiographic imaging.
25
performed before lateral ligament reconstruction, the arthroscopy
has revealed essential information about chronic ankle instability Diagnostic Arthroscopy for
that would otherwise have gone undetected. In these cases a Chronic Osteochondral Lesions
diagnostic arthroscopy is still valuable. The purpose of several A lesion involving articular cartilage and subchondral bone has been
studies was to evaluate the intra-articular findings in patients with given several names, but is best known as an osteochondral defect in
chronic ligamentous instability of the ankle joint.
23–25
Schafer and the acute setting or osteochondritis dissecans (OCD) mostly in a
colleagues studied 110 patients: cartilage lesions of the talus were chronic setting. In the 1950s, the cause of osteochondral lesions of the
seen in 54% of the joints. Interestingly, cartilage damage was found talus was unknown. Berndt and Harty pioneered in this field and
independently of the lateral ligament injuries. Cartilage injury of the presented a four-stage classification scheme (see Table 1).
26
Talar OCDs
talus was seen in all complete ruptures of the deltoid ligament. are usually located posteomedial or anterolateral. Preceding trauma is
Medial instability was found arthroscopically in 23 ankle joints.
23
common in 93% of lateral lesions and 61% of medial lesions.
27
In a study
Another study of 148 patients with symptomatic chronic ankle of 31 ankles with osteochondral lesions, Canale et al. found that lateral
instability that had lasted six months or more showed that a lesions were shallow and wafer-shaped, and were more likely to scatter
persistent rupture or elongation of the anterior talofibular ligament loose bony bodies and hence to result in persistent symptoms. Medial
can be seen in 86% of ankles, of the calcaneofibular ligament in 64% lesions were deep and cup-shaped, and less symptomatic. In the long
and of the deltoid ligament in 40%.
24
In the same study, cartilage term, degenerative radiological changes in the ankle joint were
damage was noted in 66% of ankles with lateral ligament injuries, common: 50%, regardless of the type of treatment.
28
Parisien et al.
whereas 98% of the ankles with deltoid ligament injuries had showed that optimum visualisation of a lesion was obtained when the
cartilage damage.
24
Also, Takao has investigated 72 patients with arthroscope was placed on the same side as the lesion. Lesions on the
residual ankle disability after lateral ligament injury: in 29 patients posterior aspect of the talar dome and within the posterior talar pouch
EUROPEAN MUSCULOSKELETAL REVIEW 93
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