Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Oct 18, 2016; 7(10): 657-663
Published online Oct 18, 2016. doi: 10.5312/wjo.v7.i10.657
Posterior ankle impingement syndrome: A systematic four-stage approach
Youichi Yasui, Charles P Hannon, Eoghan Hurley, John G Kennedy
Youichi Yasui, Department of Orthopaedic Surgery, 2nd Teikyo University School of Medicine, Tokyo 173-8606, Japan
Youichi Yasui, Charles P Hannon, Eoghan Hurley, John G Kennedy, Hospital for Special Surgery, New York, NY 10021, United States
Charles P Hannon, 2nd Department of Orthopaedic Surgery, Rush University Medical Center (C.P.H.), Chicago, IL 60612, United States
Eoghan Hurley, 2nd Royal College of Surgeons in Ireland, Dublin, Ireland
Author contributions: All authors equally contributed to this paper with conception and design of the study, literature review and analysis, drafting and critical revision and editing, and final approval of the final version.
Conflict-of-interest statement: Kennedy JG is a consultant for Arteriocyte, Inc.; has received research support from the Ohnell Family Foundation, Mr. and Mrs. Michael J Levitt, and Arteriocyte Inc.; is a board member for the European Society of Sports Traumatology, Knee Surgery, and Arthroscopy, International Society for Cartilage Repair of the Ankle, American Orthopaedic Foot and Ankle Society Awards and Scholarships Committee, International Cartilage Repair Society finance board.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: John G Kennedy, MD, MCh, MMSc, FRCS (Orth), Hospital for Special Surgery, 523 East 72nd Street, Suite 507, New York, NY 10021, United States.
Telephone: +1-646-7978880 Fax: +1-646-7978966
Received: May 18, 2016
Peer-review started: May 19, 2016
First decision: July 5, 2016
Revised: July 15, 2016
Accepted: July 29, 2016
Article in press: August 1, 2016
Published online: October 18, 2016

Posterior ankle impingement syndrome (PAIS) is a common injury in athletes engaging in repetitive plantarflexion, particularly ballet dancers and soccer players. Despite the increase in popularity of the posterior two-portal hindfoot approach, concerns with the technique remain, including; the technical difficulty, relatively steep learning curve, and difficulty performing simultaneous anterior ankle arthroscopy. The purpose of the current literature review is to provide comprehensive knowledge about PAIS, and to describe a systematic four-stage approach of the posterior two-portal arthroscopy. The etiology, clinical presentation, diagnostic strategies are first introduced followed by options in conservative and surgical management. A detailed systematic approach to posterior hindfoot arthroscopy is then described. This technique allows for systematic review of the anatomic structures and treatment of the bony and/or soft tissue lesions in four regions of interest in the hindfoot (superolateral, superomedial, inferomedial, and inferolateral). The review then discusses biological adjuncts and postoperative rehabilitation and ends with a discussion on the most recent clinical outcomes after posterior hindfoot arthroscopy for PAIS. Although clinical evidence suggests high success rates following posterior hindfoot arthroscopy in the short- and mid-term it may be limited in the pathology that can be addressed due to the technical skills required, but the systematic four-stage approach of the posterior two-portal arthroscopy may improve upon this problem.

Keywords: Posterior ankle impingement syndrome, Arthroscopy, Endoscopy, Review, Os trigonum

Core tip: A systematic four-stage approach was developed to standardize technical variety of posterior two-portal hindfoot arthroscopy for the treatment of posterior ankle impingement syndrome (PAIS). After making two-portals using the “nick and spread” technique, hindfoot strictures are divided into 4 regions of interest (superolateral, superomedial, inferomedial, and inferolateral) based on the intermalleolar ligament. In each region, anatomical structures are systematically reviewed and treated in regards to the presence of mechanical impingement and inflammation. Clinical evidence suggests high success rates following arthroscopic approach in short- and mid- term follow-up. This technique can help the surgeons optimize the outcomes following two-portal hindfoot arthroscopy for PAIS.