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Ankle

Upper Ankle Joint

Arthroscopical Debridement / Lavage

Scar formation after injuries of joint capsules, ligaments, fractures or simple ankle joint dislocations can lead to pain and limited mobility in the upper ankle. These scarred cords cause impingement syndroms especially, in the joint between the external ankle and the talus, but also between the inner ankle and the talus.

With an arthroscopic procedure and the help of fine rotating knives and pliers the scars can be removed easily without the need for larger skin incisions. Due the same procedure smaller cartilage damages can be treatened. This shortens the rehabiliation phase and enables a premature recovery of your professional, private and sporting activities. Additional arthrosis caused by limited mobility can be prevented.

Mediaclly speaking, an anterior impingement occurs when, in the course of years/decades, bone spurs in the lower leg front edge formate which are painfully disabling dorsal extensions (e.g. climbing stairs, walking uphill etc.) . Using small round drills the bone spurs can be smoothed arthroscopically so that pain free movement in the ankle gets restored.

Microfracturing

Cartilage damages in the ankle occur after injuries (e.g. fractures, ligament injuries etc.) but also by the cause of cartilage circulatory disorders (Osteochondrosis dissecans).
Without any treatment this kind of cartilage damages passes over to a complete ankle osteoarthrosis. Not only in the knee but also in the ankle joint small holes can be yielded into the bone with the help of pointed prickers beneith the absentee cartilage layer.

This results in bone bleeding. Stem cells adhere in the microfracturing zone (superclot). Through load-relief on the upper ankle joint ( 8 weeks) and restricted movement controlled with a motor split (CPM= continous passive motion) the stem cells then differentiate into fibrocartilage and refill the cartilage damage within several months. Under normal loading the patient can get pain free again.
In a prospective study, within 5 year examinations, an overall success rate of 90% was demonstrated. The cartilage damage shall not be larger than 1x1 cm.

Osteochondral Transplantation

If a microfracturing was performed without the desired success being achieved, there is the option of a osteochondral transplantation (cartilage-bone transplanation). In principle the indication for a osteochondral transplantation also exist by primary situations with cartilage lesions and cystic underground.

The disadvantage of the osteochondral transplantation is that the transplant shall be taken out of a healthy knee joint. This determines the risk of painful changes at the point of use area in the knee joint. Therefore, our philosophy is extreme restraint with knee joint cartilage removal.

In the light of the scientific evaluation there is still the problem of missing long term examinations ( longer than 2 years) for symptomatic complaints in the knee joint.
Because of our cartilage- cell and matrix transplanation and the outweight of the disadvantages we only see the need for this indication individually.

Chrondrocyte Transplantation

The chrondrocyte transplantation was designed by a Swedish research team. A piece of cartilage is arthroscopically taken from a less burdened region of the injuried joint. In a complex process the cartilage is freed of fibers and chondrocytes gained thereof can be cultured , which makes it possible to produce large numbers of multicellular spheroids. Approximately three to six weeks afterwards the cartilage damage will be sewed over due an open procedure and the spheroids are injected into the resultant pocket. Within a few months new cartilage is regenerated that largely corresponds to that of natural cartilage substance.
Only a few centers have experience with this method at the ankle.
The autologous chondrocyte transplanation (ACT) with a periosteal flap, known from the knee, had no success inside the ankle because of the anatomical structure. The talus cartilage is very thinn which is why the periosteal flap can not be stiched on.
Which is why we procede as one of the first clinics the application of a matrix induced chondrocyte transplantation. One can imagine this technique, as a carpet (Matrix) made of chondrocytes. This carpet can be put into the defect at the talus.
Since 2000 we use this method and since then the results are very good.
It should be noted that we are still in a development phase in which it is already clear that cartilage damages in the ankle or other joints show a high potential of therapeutic development.

Since 2007 we are also able (as the firsts world wide) to proceed a cartilage cell transplanation at the upper ankle purely arthroscopic. With Codon®-Spheroids cartilage cells are seeded into the damage. As this method is also in the development phase at this point, we only use it on young patients and professional athletes.

AMIC Procedure

Microfracturing and similar procedures come to an end depending on the size and location of the defect. In the last couple of years matrix transplanations gained increasing attention. They do not need autologeous chondrocyts impregnations anymore. The application of more than 300 AMIC procedures within the last 5 yeras show konstant success.
Due to the defect sealing with a matrixm the question arises wheter the indication could be used in the foot and ankle joint area in order to reconstruct cartilage.
The unique technique of the AMIC procedure includes a complete arthroscopic debridement. After that microfracturing is performed, cysts are cleared out and filled in with conditioned bone marrow aspirate. Finally the matrix is impregnated with growth factors, instructed and stabilised with fibrin. Overlapping parts are removed during normal movement in the past days.
Furthermore additional biosupplements such as „plated rich plasma“ were used in fractions with lower proportion of leucocytes. At the beginning the treatment of talus defecty where in the center of focus, but the focus was expanted onto the AMIC procedure in tibiaplafond lesions.

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Lower Ankle

Due to the development of arthroscopical tools for smaller joints and new arthroscopical surgery techniques major progress was made. The most common applications for lower ankle arthroscopies are conditions affected by talus and heel bone injuries which where overseen and led so stiffening and pain. In particular case of very stiff lower ankle joints, the removal of scars and adhesions due debridements and cartilage stimulations help to achieve a significant improvement of pain and movement. As a result stiffening can be prevented.
Another indicator is the so-called sinus tarsal sydrome. This appears after injuires such as associated sprain trauma
or ankle fractures which cause a lot of pain.. Normally we can not see any phatological changes with imaging techniques (e.g. x-ray, CT, MRI) . During a lower ankle arthroscopy ligament tears, capsule lacerations and cartilage damages can be found. We can therefore end patient´s ordeal with a surgical procedure.
These arthroscopical procedures are only performed by a few specialist.

Following surgeries can be performed arthroscopically:
-Depridement/Lavage
-Sinus Tarsal Resection (Sinus Tarsal Syndrome)
-Posterior Impingement (Os Trigonum Syndrome)
-Microfracturing with ChondroGide
-Arthroscopically assisted lower ankle joint Stiffening