The double posteromedial portals endoscopy for posterior ankle impingement syndrome in athletes

The main result of the present study was the favourable clinical and functional outcomes at a mean follow-up of 26.7 months after the endoscopic procedure for the management of PAIS through a double posteromedial technique. PAIS is clinically characterised by posterior ankle pain as result of repetitive or acute forced plantar flexion [22], which has been extensively described in classical ballet dancers [23, 24], in soccer, basketball, and volleyball players, and in runners [25]. If nonoperative management fails to relieve symptoms, surgical excision of the causative impingement is the optimal treatment [14]. Common PAIS management procedures include open excision of the os trigonum through a posterolateral [14, 23, 24] or a posteromedial [26] approach, with a high risk of neurological complications and wound problems due to the open approach itself [26].

The major advantages in the use of an endoscopic compared with an open procedure for the management of PAIS include less tissue damage, a quicker recovery time, and less symptomatic scar formation, all of which are important for athletes [27, 28]. Various endoscopic techniques have been described. One of the most popular is the posterior hindfoot endoscopy described by van Dijk et al. [29], who reported one case of arthroscopic management of PAIS due to a symptomatic os trigonum, with excellent results achieved through a posteromedial and a posterolateral portal. The posterior approach with the patient prone and with two para-Achilles tendon portals, one medial and one lateral, has been in use for nearly two decades, and it has been shown to be safe and effective. Some authors have expressed concern about portal placement close to the posterior tibial neurovascular bundle and the effect of ankle dorsiflexion during endoscopy [30]. When the procedure is performed with the patient prone and using a single posteromedial and a single posterolateral portal, both immediately adjacent to the Achilles tendon, and with the ankle held at a neutral–neutral position with portals described by van Dijk, the greatest margin of safety from neurovascular structures is achieved. This is what was accomplished when we produced the distal posteromedial portal. As shown in our previous studies on the use of the double posteromedial portal, the proximal posteromedial portal is 45–50 mm proximal to the distal one and well in the safe area [16]. Indeed, in our setting, we have routinely used this approach for the past 15 years and have never encountered any neurovascular compromise.

The approach used in the present study is undertaken with the patient supine and involves two posteromedial para-Achilles tendon entry portals [31]. To our knowledge, this is the only investigation in which this technique was used systematically to approach the pathology at hand. The double posteromedial approach with the patient supine has several advantages. For example, positioning the patient is much easier, as the patient is supine instead of prone. Hence, if general anaesthesia is used, the patient needs to be intubated to secure the airways. Triangulation of the arthroscope and the working instrument is easily performed, and we have experienced no technical issues in undertaking the desired interventions.

The double posteromedial portal approach used in the present study [31] is safe and allows excellent vision of the posterior compartment without any neurovascular or tendon complications [16]. In addition, the patient is supine, and therefore the operating theatre setup is simpler and achieved faster than when positioning the patient prone. Also, monitoring is easier with the patient supine.

The mean time of return to sports was 10.6 ± 3.1 weeks (range 9 to 14), which compares favourably to published literature on a military population [18] and is better than for dancers [32]. Similar clinical outcomes were found for open and arthroscopic excision of a symptomatic os trigonum in a 41-case series [14], but, regarding the different complication rates, it was reported that the overall complication rate after endoscopic management was 4.8% (25 of 521 cases), with a neurological complication rate of 3.6% (19 of 521 cases), while the overall complication rate for open surgery was up to 14.7% [17]. In another relatively recent systematic review, the reported complication rate was 15.9% (23 cases) for open surgery and 7.3% (20 cases) for endoscopic surgery [33]. On the other hand, Nickisch et al. [34] found a complication rate of 8.5% in 186 patients managed with two-portal posterior ankle arthroscopy. This higher complication rate likely resulted from the population heterogeneity and a lack of differentiation between posterior ankle and hindfoot arthroscopy and endoscopy. Furthermore, Ribbans et al. reported an 80% rate of return to the pre-injury level of sport in both endoscopic and open surgery groups at an average of 8.9 weeks and 14.8 weeks, respectively [17].

Our study reported five patients (14.7%) with persistent swelling for 2 months and two patients (5.9%) with pain and tenderness for 3 months postoperatively, but no patient developed a superficial wound infection or venous thromboembolism. Our complications relate to findings present in almost any orthopaedic procedure in the lower limb and constitute minor issues that resolved spontaneously over time.

Jerosch [15] described the results of arthroscopic resection of a symptomatic os trigonum by two posterior portals in 10 patients, and Ahn et al. [35] compared the results of arthroscopic and endoscopic management of PAIS due to os trigonum, showing that both procedures were effective and safe [35]. However, they reported a failure rate of 12.5% in patients with a large os trigonum who underwent endoscopic excision [35].

In the present study, at last follow-up, none of the patients experienced pain during plantar flexion and all were able to return to sports with a good level of performance. To the best of our knowledge, this study reports one of the largest case series of athletes who were managed with a posterior ankle endoscopic technique for PAIS, and it is the first one where the procedure was performed with the patient supine using the double posteromedial portals. The major limitation of the present study was the absence of a control group: ideally, an appropriately powered randomised controlled trial where the traditional lateral and medial posterior para-Achilles portals are used with the patient prone would have been compared to the present approach with the patient supine and using the double posteromedial portal. This is the first study that reports results obtained using two posteromedial portals to manage PAIS in athletic patients and not only dancers or military personnel who underwent surgery. The low complication rate and relatively simple complications reported may be related to these two posteromedial portals, suggesting that being less aggressive on soft tissues could reduce adverse events such as haematoma.

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