SLR - August 2021 - Zachary J. Lubek

Open Versus Endoscopic Surgical Treatment of Posterior Ankle Impingement: A Meta-analysis 

Reference: Zwiers R, Miedema T, Wiegerinck J, Blankevoort L, Niek van Dijk, C. Open Versus Endoscopic Surgical Treatment of Posterior Ankle Impingement: A Meta-analysis. The American Journal of Sports Medicine. May 2021. doi:10.1177/03635465211004977

Level of Evidence: Level 1 – Meta Analysis

Scientific Literature Review

Reviewed By: Zachary J. Lubek, DPM 
Residency Program: Regions Hospital / Health Partners Institute – St. Paul, MN
Podiatric Relevance: Posterior ankle impingement is a relatively common condition treated by foot and ankle specialists, especially in the active population requiring repetitive plantarflexion which we commonly see in athletes and dancers. When conservative efforts fail, surgery may be indicated. Surgical treatment of posterior ankle impingement has historically been performed with open techniques yielding good results. However, recently there have been advancements in endoscopic techniques with attributed benefits. This study seeks to determine whether endoscopic surgery for posterior ankle impingement was superior to open surgery in terms of functional outcomes, with a secondary aim to evaluate differences in return to activity, patient satisfaction, and complications.

Methods: Data collection was performed by two reviewers to identify all literature available on surgical treatment of posterior ankle impingement – MEDLINE, EMBASE and CINAHL databases were searched. With established inclusion and exclusion criteria, the publication and patient characteristics, surgical techniques, AOFAS scores, return to activity, patient satisfaction and complications were extracted. AOFAS scores were the primary outcome measure. Pooled data was analyzed using a random-effects inverse variance method, and sub-analysis was performed according to the Downs and Black score. 

Results: There were 2,331 titles initially identified, with a total of 32 studies included in the review. There was no statistically significant difference in postoperative AOFAS scores between open surgery (88.0) and endoscopic surgery (94.0). There was no difference in the proportion of patients who rated their satisfaction ‘good’ or ‘excellent’ (0.91 vs 0.86 respectively between groups). No significant difference in time to return to full activity (10.8 weeks vs. 8.9 weeks). Pooled proportions of patients with post-operative complications were 0.15 for open surgery vs 0.08 for endoscopic, which was statistically significant for both total and minor complications.  

Conclusions: The authors found no statistically significant difference in post-operative AOFAS scores, patient satisfaction, and return to activity between open and endoscopic techniques. The only statistically significant finding was that of postoperative complications, of which the proportion was significantly lower in the endoscopic group. While they acknowledge limitations of this study, the authors conclude it provides evidence for good clinical outcomes for the surgical treatment of patients with posterior ankle impingement. Endoscopic approaches yield similar clinical and functional outcomes with lower complication rates and shorter recover time when compared with open techniques. When considering these findings, I feel that shorter recovery time and quicker return to activity is an important consideration for a majority of individuals, especially younger athletes and dancers. Having the ability and confidence to preform these endoscopic procedures may become increasingly useful as minimally invasive surgical techniques continue to evolve. As foot and ankle surgeons, I think we should all strive to be getting our patients back to their desired level of activity as quick as possible while minimizing complications, and without compromising functional and clinical outcomes.

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