CME OnDemand: AOFAS 2022 Pre-Meeting Course: Advanced Arthroscopic Treatments-Pre-Meeting Keynote Speaker: C. Niek van Dijk, MD, PhD - The Evolution of Arthroscopy in Foot and Ankle Surgery

Video Transcription

It's really an honor for me to introduce Nick Van Dyke from the University of Amsterdam to serve as our pre-meeting keynote speaker.  Everyone in the room is familiar with Dr. Van Dyke, most of you have probably met him. You know that he is really a leading authority and innovator in ankle arthroscopy and has  played a role in bringing arthroscopy to our subspecialty. He is currently emeritus professor at the AMC at the University of Amsterdam and most  of his work now is at FIFA Medical Centers of Excellence in Madrid, Porto, and Pisa where he spends time working with the athletes and the surgeons teaching the techniques that  he has developed and perfected over his career. So it's again an honor to invite Dr. Van Dyke to speak to us on the evolution of arthroscopy and foot and ankle surgery.  So Nick, come on up.  Bonjour Quebec, it's a great pleasure and honor to be here with you on this podium this morning.  These are my affiliations and disclosures, I'm the editor-in-chief of the journal Visekos and I'm happy to receive your submissions.  The evolution of ankle arthroscopy, in order to prepare for this lecture I did a systematic research of the review of the literature and in that search I came across a discussion  between Richard Fergal and Jordi Vega on a heated discussion on a broiling topic in our field, distraction versus dorsiflexion.  And it started with two editorial commentaries by Richard Fergal, distraction is the key to success.  Jordi Vega wrote an answer in the journal Arthroscopy, Dr. Fergal's editorial commentaries negatively influenced the progress and development of ankle arthroscopy.  The major publications in European journals that support the dorsiflexion technique are ignored.  In the USA ankle arthroscopy is performed with routine distraction whereas the no distraction and dorsiflexion technique is the commonest technique in almost the rest of the world.  The dorsiflexion technique for ankle arthroscopy allows for third generation procedures which cannot be performed with routine distraction. Fergal replied, they are that wrong.  They have not read my books and articles. The notion that my teaching is not third generation is ridiculous.  In our courses all techniques are taught and we are excited that Nick van Dyck is coming to Quebec this year. Well, slightly different.  And last year again non-invasive ankle distraction technique is the standard of care for ankle  arthroscopic surgery whereas the dorsiflexion technique is the commonest technique in almost the rest of the world. So let's consider the two methods.  The fixed distraction method on the right introduced by Gould and on the left the dorsiflexion  technique which makes use of these capsular attachments and if you put saline in the joint the anterior working area opens up.  The safety of both methods was determined in the lab of Pau Golano and in the dorsiflexion technique the nerves and vessels move away from the joint whereas in distraction they  move towards the joint. And this results in a twice times larger safety area for the dorsiflexion technique which  was confirmed in 2018, 3.7 millimeter distance with dorsiflexion versus 1.7, 1.4 for the  distraction. The dorsiflexion technique finds its name in the position in which you introduce the instruments and for working in the anterior compartment.  But at any time during the procedure you can apply distraction. And you see it in this video, you have to introduce the instrument in dorsiflexion and  then if you want distraction you do it. But if you introduce your instrument in distraction the nerves and vessels are tensed.  And if you hit them with your instrument they're easily breaking. So any instrument change, go back to the dorsiflexion and this is probably the main reason why you  have less complications with the dorsiflexion technique. But you can apply forced plantarflexion if needed.  You use the heel and the operating table as a fulcrum to plantarflex the ankle. And it was shown by this research paper by Hitler a few years ago that plantarflexion  significantly improves reachability of the talus and is equal to non-invasive distraction. Concerning complications, soft tissue distraction 9%, mainly nerve complications.  In the dorsiflexion method it's 3% and these are mainly nerve injuries which was confirmed in a systematic review two years ago. Let's consider the pathology that we can treat.  First osteophytes of the distal tibia and the talar osteophyte. It's clear that in the dorsiflexion these are much better accessible than in the distraction.  The gutters open up in dorsiflexion. On the right you see the medial gutter. It's not possible to reach the gutters in distraction.  And especially on the lateral side if you're going to do a ligament repair you cannot have the ankle in distraction. Syndesmotic assessment.  Di Giovanni's group assessed that you cannot judge laxity on the syndesmosis in distraction. Loose bodies.  If you see on the left it's easy to remove the loose bodies in a dorsiflexion technique. However in distraction, as you see on the right, the loose bodies fall easily to the  back of the joint. And even if you remove osteophytes, remnants of the bone of the osteophyte can easily gather as a sort of garbage bin in the back of the ankle.  Osteogondral defect obviously can very well be treated in distraction. However, as I've been showing you, with the dorsiflexion technique you can easily treat  those osteogondral defects by distraction, by hyper plantar flexion. Every patient has his optimal position. Concerning economics.  It's much easier to eat from your own plate rather than to sit on a table and eat from your neighbor's plate.  It is much better for your spine, for your neck, to eat from your own plate. And again, dorsiflexion when you work anterior, distraction to work centrally. Instrument breakage.  Like in hip arthroscopy, when you have a fixed situation, you can much more easily break your instruments. Complications.  Superficial peroneal nerve lesions twice as much in the fixed distraction. Twelve times more sural nerve lesions. Five times more saphenous nerve lesions.  So introduce your instruments always in dorsiflexion. That is the best method to prevent these nerve lesions. A narrative review.  Last year ankle distraction method was routinely used in the past.  However, nowadays, anterior arthroscopy is done in dorsiflexion, initially used as a diagnostic tool. Ankle arthroscopy is now used exclusively as a therapeutic tool.  The ankle fix distraction method should be abandoned. Anterior ankle impingement. The first prospective study we published with an 83% good result on the long term.  This year, systematic review of 28 articles confirmed an 80% success rate. What was interesting that in our first study, the osteophytes returned in 70% of the patients.  So if you have the osteophyte here on the picture, and you remove it, and you make an x-ray a few years later, the osteophyte has returned.  And this was confirmed by a study in 2014 by Walsh, 84% of patients show recurrence of the osteophytes.  So the development of osteophytes is an adaptive response to increase joint stability. And what is an interesting fact is this study in 2018.  670 cadaver ankles, age 20 to 40, that is the age in which you find anterior impingement patients, 20% had osteophytes, asymptomatic osteophytes.  So osteophytes in general are not pathologic, but 99.9999% of osteophytes are physiologic. And again, if you remove them, they will return. Then to osteogonal defect.  Osteogonal defect behaves different probably in the ankle than in an incongruent joint like the knee joint.  The pain comes from the bone, and the cartilage is just there to protect the bone. And the mechanism is that if there is a subchondral deficiency, then the content of the cartilage  being water, 75% is water, is compressed into the subchondral bone, leading to bone myelodema on the MRI, and eventually to cystic lesions.  You only find cystic lesions in congruent joints like the hip joint and the ankle joint, not in incongruent joints through this mechanism. Statman had the correct approach.  He approached the bone fracture, bone marrow stimulation. That was the correct approach for osteogonal defect 25 years ago. What have we accomplished in those 25 years?  And there has been a development of many methods concentrating on the cartilage. If you look at the two most recent reviews, review in 2018 and a recent review last month,  none of the intervention showed clinical superiority. Isn't that sad to realize that in 25 years, basically, looking at the literature, 55 studies,  none of the intervention showed clinical superiority. Bone marrow stimulation yielded the pooled success of 82%.  The pooled success rate of 82% suggest bone marrow stimulation as a fair treatment strategy for defects up till 150s per millimeter, which is, for example, 10 by 15 millimeter.  So what does the average surgeon do with defects of this size? DiGiovanni and others published this review last year, an international survey among 1,800  foot and ankle surgeons in 80 countries. And for these lesions, 80% of us, of you, perform bone marrow stimulation.  So from the literature, it's bone marrow stimulation, and that's also what apparently we all do. Question is, what is the long-term outcome of bone marrow stimulation?  Is there a critical size? Shall we not batter at cultured chondrocytes? What about post-operative weight-bearing, direct or not? What is the time to return to sport?  What about MRI for follow-up? First, the long-term outcome. We published the first long-term outcome study, 78% good, excellent results. Last year, three long-term outcome studies.  The first by Kaur and Raikin, 10 to 12-year follow-up, 93% survival rate. Jinbu Lee's group, also last year, 97% survival rate.  And a review of the literature confirmed that the results of bone marrow stimulation remain over time. Joint space narrowing in 4%. That's also what we found in our series in 2013.  By the way, you see this red line in most of my slides. Above the red line is where we came from. Below the red line is what is the current evidence. Is there a critical size?  You all are aware of these two studies, 2009-2008, by the Jinbu Lee group and the Cheuk-Pai Wong group, who determined that lesions up till 10  by 15 millimeter can be treated with bone marrow stimulation. For the larger lesions, you should perform a different approach.  Then came the review from the John Kennedy's group in 2017, who narrowed this to 107 square millimeter. Twenty-five studies narrowed it to 107 square millimeter,  which is 7 by 15 millimeter or 8 by 13 or 6 by 12. That's about the size. However, the evidence on which they based their conclusions is not very solid.  Twenty-four of the 25 studies had not good methodology. Twenty-two of the studies had a poor level of evidence.  Then came the study last year from Jinbu Lee, who determined that there was in his patients no difference in VAS and AOVAS between the larger and the smaller size lesions.  There was no difference between shoulder lesions and contained lesions. No difference between cystic lesions and non-cystic lesions. The smaller lesions had a survival rate of 97%.  The larger lesions of 83%. So what does the average surgeon do? Well, from the same survey that I mentioned before, also for these larger lesions,  bone marrow stimulation is performed most frequent. Shall we not better culture chondrocytes? You all are aware of the research by Brittberg and Peterson in 1994.  The group of Engelbretsen did this prospective study, ACI versus microfracture. And they could not find a difference in short-term, mid-term, and 2016, the long-term follow-up.  And even on long-term follow-up, there was twice as more total knees in the ACI group compared to microfracture. So what is the current situation for the ankle?  And if you look at the current evidence, then you see that it is shifting towards no difference between microfracture with or without AMIC.  You see also Lou Schoen, who could not show in his failed biopsies, he showed only minimal evidence of type 2 hyaline cartilage formation.  In the recent systematic review, AMIC also concluded there is insufficient strength to conclude which approach is most beneficial.  So adding cultured chondrocytes from the literature does not help us very much. Early versus delayed weight-bearing. This meta-analysis included 232 patients.  No difference between early versus delayed weight-bearing. Time to return to sport after bone marrow stimulation, average 5 months, which is also my experience.  Then two interesting studies. Two interesting studies, 2017-2019. They looked at the results of bone marrow stimulation and they showed, and you see it  on the right, the FAS score, preoperative, 3 months, 6 months, up till 24 months improvement, also in the OFAS score, and then it leveled, it stayed stable at 24 months.  So these patients keep improving up till 2 years postoperative, which is important to know because if you have a patient at 1 year who still is slightly symptomatic, you can  tell him that he can expect his ankle to be better up till 2 years. The end result of bone marrow stimulation apparently is reached at 2 years. So how and why does it work?  Pain comes from the bone, the cartilage is there to protect the bone, ankle joint is the most congruent.  It's the edge of the defect which takes the load and I want to introduce to you this concept of edge loading.  So if you have a defect, you debride it, it fills with cells from the bone marrow, the subchondral bone plate restores and you have a good result.  In a larger defect, initially it happens the same. The defect will fill with fibrocartilage but now it's the edge of the defect which takes  the load, not the defect itself, because the defect itself has inferior load bearing capacity. So it's the edge which is now under attack.  This might result in pressure leading to new cystic lesions. Maybe this process continues, you will find lesions also on the medial side and this then can be the end result.  So we have to provide with our treatment a filling of the defect which is capable of offloading the edge of the defect.  So for example a metal implant or an OATS, that is how it works. It offloads the edge of the defect.  Ankle fractures, you all are aware of this study by Hinterman who raised our interest in 80% of ankle fractures have cartilage damage and that started that we were going  to do ankle arthroscopy in ankle fractures. However, the Kennedy's group showed recently that only 1% of ankle surgeons in US perform  an ankle fracture, they perform arthroscopy and even in this 1% there is no significant difference in re-operation rate between the ones who had arthroscopy and the ones who didn't.  And this was confirmed in a study last year. No difference in clinical outcome for a diagnostic arthroscopy in ankle fractures.  So apparently there is no added clinical value of a diagnostic arthroscopy in ankle fractures. What about instability?  The same group, Hinterman, 66% of ankle unstable patients have cartilage damage. However there is a similar re-operation rate between patients with or without additional  arthroscopy and I'm talking about a diagnostic arthroscopy, non-symptomatic lesions that are maybe diagnosed and treated with this arthroscopy.  So no added value of a scope in an asymptomatic patient who you treat for an instability, so without pain and we already published that in 1997.  No value for and no indication for a diagnostic arthroscopy because if you do a diagnostic arthroscopy and you see these tram track lesions, what do you tell your patient?  You make them extremely worried and for no reason because you will not do anything to it and better not know that there is this tram track lesion and even this asymptomatic  osteophyte, you might be tempted to remove it but it will return anyway and it is of no value if it is asymptomatic to recognize apparently also from the literature.  Concerning this 21 point examination, the Smith and Nephew technique guide proposes this. It doesn't make sense to do a diagnostic round in an ankle in which you are going to  treat a patient for an osteogondal defect, only deep ankle pain or taking away loose bodies. No indication for a diagnostic arthroscopy. Instability.  It's important to distinguish instability from laxity. Instability is a sign, it's objective, it's a positive anterior drawer and you can grade the positive anterior drawer.  Instability is a symptom, it is recurrent giving way and you can distinguish functional instability which is recurrent giving way, no laxity versus mechanical instability, recurrent  giving way in a lax ankle. We will consider open versus arthroscopic repair, is ATFL repair enough, do we need  a gold augmentation, internal brace, what if there is no ATFL remnant, diagnostic arthroscopy I already addressed. So first open versus arthroscopic.  The first meta-analysis by Kennedy and the second one, no difference in outcome between arthroscopic and open.  However the last two meta-analysis showed a difference and you can see the difference in AOFAS and FASCOR, lower wound complication while the ankles are similarly stable.  So arthroscopic repair from the literature, from the two recent meta-analysis gives better clinical outcomes. Is ATFL repair enough?  We published in 2005 our good long-term results of only ATFL repair and two years ago the study ATFL repair versus ATFL plus CFL, similar outcome.  I believe what's interesting to realize that if you do an ATFL arthroscopically that there is this connection between ATFL and CFL in almost all patients which means that if you  detach the ligament and you proximalize the insertion, you automatically also shorten the CFL and that's probably what you have to do in arthroscopic repair and in this way  you also do something to the CFL and not only the ATFL. Augmentation with a gold, three studies last year, no difference in outcome between augmentation versus no augmentation.  So it is apparently from the literature not needed. Internal brace, there was a systematic review last year, seven clinical trials, no difference in outcome.  Internal brace is not needed, it's just a cover up for bad surgery. These are two interesting studies and worrisome maybe, I don't know, two studies in which  there were no remnants of the ATFL and they still did a type of repair, they just grabbed the tissue which was there and they had good results.  So apparently it doesn't matter so much what we do. Just take the tissue which is available, I put a question mark in it, I just show you the results from the literature.  Then a hot topic, micro instability. Micro instability, the concept was introduced by Vega, patient with anterolateral pain,  no abnormal laxity, changes to the ATFL, patient had functional instability and he called it micro instability.  Then in 2020 he wrote an editorial in the Keista journal, Enkartos be the wave that is coming.  And if we see his publication one year later, I understand what he is meaning because in four years time he treated 230 patients with micro instability.  I believe in my whole career I did not treat so many patients with a frank instability. And now the definition has changed, it's now a subtle anterior translation and there is  now, he called it mechanical laxity. So basically it is micro laxity. But is it laxity? Because up till 2mm is physiologic, it's the normal anatomy.  Most patients have subtle anterior drawer. So basically what he is talking about is functional instability with morphologic changes to the ATFL. And we have a lot of them.  Because in US alone, 10,000 lateral ligament ruptures per day, 30% persisting complaints means 1 million a year that you can perform ligament repair.  If that's the wave that is coming, we are certainly on the right track. These are patients who are functionally unstable and they should be treated with conservative treatment.  Because if you shorten a normal ligament, you induce a plantar flexion limitation. Maybe in case of persisting complaints you can do a synovectomy.  Multimodal laxity or inside ligament repair. And you can find the technique on the Ankle Platform website.  For longstanding laxity, still my preferred technique is an open repair and I will do a Brunel suture through the ATFL, a Brunel suture through the CFL and then I will shorten  it to the fibula. Ankle arthrodesis. Meyerson published the first study on open versus arthroscopic.  There has been two meta-analyses last year and they showed higher fusion rate, similar blood loss, less complication for the ankle arthrodesis.  You can also do it from the back, we published it from posterior. But it's interesting then to see what does the average surgeon reach with an arthroscopic arthrodesis.  And from the Swedish registry you can see here that in the arthroscopic screw placement there is 14% re-arthrodesis while open surgery has almost 8.6% and with a plate even less.  So screw placement is key. So it doesn't have a higher fusion rate in the hands of the average surgeon. Maybe we have to go from the back because we get fusion in all our patients.  For the subtalar arthrodesis, first described by Testo with the lateral approach, we published  it with the 3-portal approach and last year there was a review, excellent union rate in most patients in 8 weeks.  Then to the 2-portal hind foot approach, now accepted as one of the approaches to the ankle joint.  Meta-analysis last year showed better results than open. Return to sport, 12 weeks versus 7 in the scopic. Excellent results in ballet dancers and in athletes.  Percentage of complications 2.3 initially. In the most recent review of the literature, 3% complications which is less than anterior arthroscopy.  Of course we're always afraid of the tibial nerve, but you can also take it to your advantage  and if you have a tarsal tunnel syndrome, 4 studies on endoscopic tarsal tunnel release, 95% success rate, no complications. Then to the endoscopic calcaneoplasty.  Endoscopic calcaneoplasty we published in 2001. High patient satisfaction and good functional outcome.  What you do is that you take away the redundant bone, on the x-ray it will look like this.  Systematic review, 38 studies, better clinical functional outcome, lower complication rate, less failures and a shorter recovery time compared to open calcaneoplasty for retro  calcaneobursitis. Long term outcome we published last year, high patient satisfaction and good long term functional results.  So to conclude, the evolution of ankle arthroscopy, we started with skeletal distraction, we went  to fixed soft tissue distraction and we are now performing it with the dorsiflexion method. Anterior ankle impingement, average of 81% good excellent results.  For Taylor OCD the highest success rate is for bone marrow stimulation with a 10-20 year survival rate of 97% and it's a treatment of choice for 80% of surgeons.  Chronic ankle instability, arthroscopic repair is probably the best option currently, although for growth instability I perform and prefer the open.  Micro instability should be called functional instability with morphologic changes to the ATFL and the treatment should be conservative for at least one year.  Arthroscopic ankle arthrodesis has several advantages but screw placement is key. Sub-Taylor arthrodesis 96% union rate at an average of 8 weeks.  The two potter hind foot approach for a variety of indications is better than open and the scopical calcaneoplasty is better than open, same for achilles tendinopathy treatment.  No fiction distraction, no diagnostic arthroscopy, no 21 point methodological examination. Treat the patient, not the MRI. Listen to the patient, the patient is always right.  Listen to the patient, the patient will tell you the diagnosis. I thank you for your attention.

Video Summary

In this video, Dr. Nick Van Dyke from the University of Amsterdam discusses the evolution of ankle arthroscopy and foot and ankle surgery. He is a leading authority and innovator in ankle arthroscopy and has worked extensively in this field. He begins by addressing a heated discussion in the field regarding distraction versus dorsiflexion techniques in ankle arthroscopy. He explains that both techniques have their advantages and discusses how the dorsiflexion technique allows for third-generation procedures that cannot be performed with routine distraction.<br /><br />Dr. Van Dyke then discusses the safety, complications, and effectiveness of both techniques in the treatment of various pathologies such as osteophytes, loose bodies, and osteochondral defects. He also addresses the use of bone marrow stimulation for the treatment of osteochondral defects and highlights the long-term outcomes of this approach.<br /><br />The video also covers other topics such as ankle fractures, instability, ankle arthrodesis, subtalar arthrodesis, tarsal tunnel release, and calcaneoplasty. Dr. Van Dyke provides insights and recommendations based on his experience and the current literature. He emphasizes the importance of patient-centered care, listening to patient symptoms, and tailoring treatment accordingly.<br /><br />Overall, this video provides a comprehensive overview of the evolution, techniques, and outcomes of ankle arthroscopy and foot and ankle surgery. It offers valuable insights for healthcare professionals in this field.

Asset Subtitle

Pre-Meeting Keynote Speaker: C. Niek van Dijk, MD, PhD
The Evolution of Arthroscopy in Foot and Ankle Surgery

Dr. Niek van Dijk is a leading authority for arthroscopic surgery of the ankle. As the founder of the Amsterdam Foot & Ankle School, his operative techniques have spread throughout the world and have benefited national and international athletes as well as non-athletes with ankle problems. He is also the founding editor of JISAKOS, the journal of the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine (ISAKOS).

Keywords

ankle arthroscopy

foot and ankle surgery

evolution

distraction technique

dorsiflexion technique

osteochondral defects

patient-centered care