Clinical Study Of Ankle Arthroscopy In The Treatment Of Common Foot And Ankle Diseases

BackgroundAnkle arthroscopy has become more popular as a method of diagnosis and treatment.It is a safe and effective method with few complications.It can improve the ankle function quickly after surgery.Many ankle problems can be treated under arthroscopy,including joint pain,swelling,stiffness and instability of the ankle.End-stage ankle arthritis is very common in clinical practice.The pathogeny includes systemic and local biomechanical factors.For patients with end-stage ankle arthritis,ankle arthrodesis is one of the most important surgical methods,which can relieve ankle pain,correct ankle deformity and restore joint stability.Traditional open surgery has many disadvantages,such as severe soft tissue trauma,slow improvement of functional activity and more complications.Schneider reported arthroscopic ankle arthrodesis firstly in 1983,and then a large number of scholars have applied it.It has a similar fusion rate compared with open surgery,with shorter fusion time,smaller blood loss,lower rate of complications and faster function improvement.In clinical,there are many patients with end-stage arthritis who have severe varus or valgus deformity of ankle joint.There is still controversy about whether such patients can undergo arthroscopic ankle arthrodesis.Microfracture technique is a minimally invasive method guided by arthroscopy.Subchondral bones are drilled,so the bone marrow stem cells and growth factors can effusion from the hole to the fusion surface,which can promote bone fusion and reduce unnecessary bone graft.Osteochondral lesions of talus is one of the important causes of recurrent ankle pain.The exact etiology and pathogenesis are still unclear.Osteochondral lesions of talus involve articular cartilage and subchondral bone.There is no vascular distribution on the surface of cartilage,so it lacks of self-repair ability.Bone marrow stimulation especially the microfracture technique is recommended for first-line options.It is suitable for small lesions with no large cystic defects of talus.It has the advantages of low cost,high efficiency,simple operation,low complications and less postoperative pain.The purpose of the microfracture technique is to penetrate the subchondral bone by various methods(drilling or microfracture cone).Mesenchymal stem cells can migrate into the lesion site for fibrocartilage repair.Many studies demonstrated the short-and midterm clinical outcomes were good,but the long-term result was controversial.In clinical practice,we observed that there are still some patients complain ankle pain after the application of this method.Extracorporeal shock wave therapy(ESWT)was firstly introduced in 1980 s and proved to be a safe,non-invasive and effective treatment in chronic patellar tendon disease.Compared with surgical operation,ESWT has the advantages of non-invasive,simple method and less complications.The risk of the treatment is lower than that of surgical operation and relatively lower cost.ESWT is based on the principle of energy conversion and transmission.The shock waves are conducted through the device into the target site.The mechanical energy occurs at the interface of different density tissues.The effects will release the soft-tissues,promote microcirculation and elastic deformation,induce neovascularization and increase expression of osteogenesis-related growth factors.Thus,ESWT can control the inflammatory courses and activate bone reparative process.Purpose1.To investigate the clinical outcomes of microfracture technique in arthroscopic ankle arthrodesis for end-stage ankle arthritis in our department,especially with obvious deformity of the ankle.To explore whether the fusion rate can be improved by microfracture technique and avoid bone graft.2.The effect of ankle arthroscopic surgery on talus osteochondral lesions was satisfactory,but there were still some patients complain about ankle pain postoperative.To evaluate the clinical effect of extracorporeal shock wave therapy on pain relief after arthroscopy for osteochondral lesions of the talus.MethodsPart 1.Microfracture technique in arthroscopic ankle arthrodesis for severe ankle arthritisA total of 48 patients underwent arthroscopic ankle arthrodesis in our department from Jan 1,2011 to Dec 31,2017 were followed up.There are 20 males and 28 females,aged 57.7 to 10.2 years(30 to 76 years old).There were 18 cases in left side,30 cases in right side,all received unilateral surgery.The deformity was measured on weight-bearing radiographs of the ankle.The patients with varus or valgus deformity between 10° and 20° were termed as group A and those within 10° were termed as group B.Arthroscopic ankle arthrodesis was performed routinely.Microfracture technique was performed on the articular surface guided by arthroscopy.Statistical analysis was performed for the difference in bone fusion time and AOFAS scores between the two groups.Part 2.Extracorporeal shock wave therapy for pain-relief after arthroscopic treatment of osteochondral lesions of talusThe clinical outcomes of patients with OLT who underwent arthroscopic treatment and microfracture between March 2013 and April 2017 were retrospectively evaluated.The minority of patients who complained pain of ankle and restriction of weightbearing activities 3 months postoperatively were treated with ESWT.Totally 15 patients(12 males and 3 females)were included.The mean age of the patients at the time of operation was 35.1?1.3(18~51 years old).Visual Analogue Scale(VAS),American Orthopaedic Foot and Ankle Society(AOFAS)ankle-hindfoot scale and Magnetic Resonance Imaging(MRI)of ankle were evaluated before and after treatment.All the data were processed by Microsoft Excel,SPSS software.Continuous variables were expressed as mean ? standard deviation,and 95% confidence intervals were determined.The data were tested by normal distribution,and t-test was used to compare the data in accordance with normal distribution.Wilcoxon rank sum test was used to compare the data which did not accord with normal distribution.P value < 0.05 was considered as statistically significant.ResultsPart 1.Microfracture technique in arthroscopic ankle arthrodesis for severe ankle arthritis1.A total of 48 cases were included.Nineteen patients with varus or valgus angle between 10° and 20° were termed as group A.Twenty-nine patients with varus or valgus angle within 10° were termed as group B.There was no significant difference in age,sied of the affected ankle,operation time,length of hospital stays and follow-up period between the two groups(P>0.05).There was a significant difference in the angle of deformity between the two groups(P<0.001).In group B,there were 2 cases of dorsolateral numbness of foot,which were relieved at 6 weeks,and recovered at 3 months after surgery.Complications such as incision infection,poor healing and deep venous thrombosis were not observed in both groups.2.All 48 patients were followed up with 25.60?7.87 months.At the latest follow-up,the AOFAS scores of the two groups were significantly higher than those before the operation,and there was a significant difference between the two groups(P<0.05),but there was no significant difference in AOFAS at the corresponding time point(P>0.05).Bone fusion was achieved in both groups,but the time of bone fusion in group A was longer than that in group B(P<0.05).At the latest follow-up,there were 2 cases of mild degeneration of subtalar joint and 1 case of severe degeneration in group A;three cases of mild degeneration of subtalar joint and 2 cases of moderate degeneration of subtalar joint in group B(P>0.05).Part 2.Extracorporeal shock wave therapy for pain-relief after arthroscopic treatment of osteochondral lesions of talusAll 15 patients were followed up for 27.8?15.2 months(12 to 48 months).During the whole follow-up period,no complications such as infection and thrombus were observed.After shock wave treatment,one patient developed dorsolateral numbness of the foot,and the numbness symptoms returned to normal 3 months later.Except for one patient who complained of ankle joint pain after treatment,significant improvement was observed in the remaining 14 patients after therapeutic intervention.At 6 weeks,12 weeks and the latest follow-up after ESWT,the VAS score dropped significantly and there was statistical difference compared with that before treatment(P<0.01),but the mean improvement between 12 weeks and the latest follow-up was not statistically significant(P>0.05).At 6 weeks,12 weeks and the latest follow-up after ESWT,the AOFAS score were gradually improved,and there was statistical difference compared with that before treatment(P<0.01).At latest follow-up,the area of abnormal signal of talus osteochondral injury in MRI sagittal position was significantly smaller compared with that of preoperative MRI(P<0.001).Conclusion1.The microfracture is an effective technique to improve ankle fusion without bone graft in arthroscopic arthrodesis for the end-stage ankle arthritis,especially for the patients with varus and valgus deformities ranged 10°~20°.However,as the deformity become obvious,the bone fusion is time-delayed.2.The blood supply of the lesions can be enhanced for neovascularization by arthroscopic debridement and microfracture techniques.ESWT,as an innovative technology,applied after arthroscopy can promote bone osteogenesis and accelerate the repair process of cartilage.Combinations of the two treatment methods can promote a complementary and more significant clinical results in the treatment of OLT.