Summary

This systematic review reports good clinical results of arthroscopic debridement for chronic ankle anterolateral impingement but all papers had a low level of evidence and intraoperative observation of the ATFL and documentation of residual instability after surgery was lacking.

Abstract

Background

Chronic anterolateral pain is a frequent complaint after an inversion ankle sprain and soft tissue anterolateral impingement (ALI) of the ankle can be the cause of this symptom. Arthroscopic debridement is a common surgical treatment for patients with ALI of the ankle. This procedure is widely accepted, however, some cases with residual feeling of instability or new inversion injury after surgery have also been reported. Although a history of ankle sprain is commonplace, information regarding the role of ankle instability in ALI is limited. The aims of this review were to 1) assess the clinical outcomes of arthroscopic surgical treatment for ALI of the ankle and 2) review the data regarding anterior talofibular ligament (ATFL) injury and lateral ankle instability in patients who underwent arthroscopic surgery for ALI.

Method

A literature search of Pubmed and EMBASE were performed. Studies that met the following inclusion criteria were reviewed by two independent investigators: (1) human clinical studies investigating patients who underwent arthroscopic surgery for ALI; (2) results with at least one scoring system with minimum follow-up of six months. Exclusion criteria were: (1) review articles or case reports; (2) not written in English; (3) included patients with objective ankle instability; (4) included patients with previous injuries other than ankle sprains in the ipsilateral ankle. The quality of each study was evaluated using the Oxford CEBM tool to assess the level of evidence and the grade of recommendation. The data of patient characteristics, follow-up period, intra-operative findings of ATFL and anterior inferior tibiofibular ligament (AITFL) and clinical outcomes were extracted.

Results

The electronic database search yielded 192 studies. Of these, 8 articles were included in this systematic review, all of which were graded level 4 with grade C recommendation. In total, 203 patients with a mean age of 32 years (ranging from 11 to 74) were analysed. The mean follow-up period was 36 months (range, 12 - 152 months). AOFAS score was used in 6 studies and scored 90.1 on average at follow-up. Two other studies used original scores. One study reported arthroscopic findings of the ATFL with damage to the ATFL observed in 20 out of 24 cases. AITFL impingement was mentioned in 3 studies, with the rate of AITFL impingement reported from 19.5-25.0%. Another study reported residual instability after surgery in 2 out of 31 patients. New ankle sprains during follow-up period were reported in 8.3-20.0% of patients in 4 studies.

Conclusion

This review showed good clinical results of arthroscopic debridement for ALI but all papers were graded level 4 with grade C recommendation. Reports regarding arthroscopic observation of the ATFL and residual instability after surgery were lacking. Further investigation of what is frequently termed “ALI” should be made with higher level of evidence focusing more on ATFL injury and its effect on clinical outcomes.