Anterior and posterior impingement with lateral ossicle

Impingement Lesions

Description of patient (type of occupation, indication of age, intensity of sport):

37 Years old male with low physical activity and BMI of 32.

History and previous treatment:

Anterior joint pain with loading. Swelling on the lateral side. The complains started 6 month ago, without trauma. After few days of rest the symptoms subside and recur with loading. History for high uric acid level, which is treated and normalized.

Current complaints:

Anterior pain and lateral swelling, after loading. No pain at rest.

Physical examination:

Light pain with palpation on medial and lateral anterior joint line and forced dorsal flection. Swelling over the ossicle, under the lateral malleolus. Positive posterior impingement test. Tenderness posterior to the lateral malleolus.


[Picture 1]
Osteophytes on the anterior margine of the tibia, presence of one larger ossicle under the lateral malleolus and smaller ossicles in the posterior compartment.

Additional investigation (CT/MRI):
[Picture 2]
Effusion. Stieda process. Bone edema. Suspicion for early stage AVN.


Case summary:

Young male, with pain in the anterior joint line, when loaded. Swelling over ossicle in the lateral side. Data for posterior impingement. Suspicion for AVN.

Question(s) to this case:

1. Would anterior arthroscopic debridement, open ossicle excision on first stage, and second stage posterior arthroscopy, be a good option?
2. What is the chance for AVN. Should some kind of revascularization be attempted?


Yes, combined anterior and posterior ankle arthroscopy would be a good option. I am worried about the subtalar joint. There is arthrosis of the subtalar joint with bone marrow edema in talus and calcaneus. I do not see bone marrow edema in the ankle joint. It could well be that after the cleaning of the ankle joint the complaints persist due to the subtalar joint. You should then perform a subtalar arthrodesis.