Arthroscopy Of the Ankle Mr. T.D.Tennent FRCS(Orth)

Ankle Arthroscopy Anatomy Patient setup Portal placement Procedures Complications

Anatomy

Portals Anterior Anteromedial Anterolateral Anterocentral Posterior Posterolateral Posteromedial Transachilles Tendon

Portals Anterior Anteromedial medial to tibialis anterior saphenous nerve and vein are medial

Portals Anterior Anterolateral lateral to peroneus tertius between branches of superficial peroneal nerve (6.5cm prox to tib of fibula)

Portals Anterior Anterocentral between tendons of extensor digitorum communis dorsalis pedis artery and deep branch of peroneal nerve lie between tendons of EDC and EHL

Portals Accessory Anterior Portals Accessory anteromedial 1cm inferior and anterior to anterior border of medial malleolus Accessory anterolateral 1cm anterior and at or below tip of lateral malleolus

Anterior Portals

Portals Posterior Posterolateral adjacent to lateral edge of achilles tendon 1.2-2.5 cm above tip of fibula sural nerve and small saphenous vein

Portals Posterior Posteromedial medial to achilles tendon at the joint line posterior tibial artery and tibial nerve Tendons of FHL and FDL calcaneal nerve branches

Portals Posterior Transachilles Tendon at same level as the posteromedial but through center of achilles tendon

Portals Accessory Posterior Portals Accessory Posterolateral 1-1.5 cm lateral to posterolateral portal, slightly higher sural nerve and small saphenous vein

Portals Accessory Portals Transmalleolar Transtalar

Posterior Portals

Patient Setup

Making Portals

Normal Ankle Examination 21 Point examination (Ferkel) 8 anterior (anteromedial portal) 6 central (anteromedial portal) 7 posterior (posterolateral portal)

Normal Ankle Examination Anterior 1: Deep portion deltoid ligament 2: Medial gutter 3: Medial talar dome 4: Medial talus articulation with plafond sagittal groove

Normal Ankle Examination 5: Lateral talus 6: Talofibular articulation “trifurcation” distal lateral tibial plafond lateral talar dome fibula 7: Lateral gutter 8: Anterior gutter

Anterior Examination

Normal Ankle Examination Central 9: Medial dome of talus & corresponding plafond 10: Central portion of talus & plafond 11: Articulation lateral talar dome with tibia & fibula

Normal Ankle Examination Posterior 12: Posterior inferior tibiofibular ligament 13: Transverse tibiofibular ligament 14: Capsular reflection of FHL

Central Examination

Normal Ankle Examination Posterior (from posterolateral portal) 15: Deltoid ligament, posteromedial gutter 16: Posterior medial talar dome, tibial plafond 17: Central talus and distal tibia 18: Lateral talar dome, posterior tibia

Normal Ankle Examination 19: Posterior talofibular articulation 20: Lateral gutter 21: Posterior gutter

Posterior Examination

Procedures Arthrodesis Osteochondral Defects Instability Post Sprain Pain Anterior Impingement Meniscoid Lesions

Arthrodesis

Arthrodesis Zvijac (Arthroscopy Jan 2002) 21 patients Mean age 52.7 Av. FU 34 months 20/21 fusion Av. time to union 8.9 weeks

Arthrodesis 9 excellent: no pain, limp, or occupational restriction 11 good: mild pain, occasional limp 1 poor: failed union and pain extensive AVN approximately 50% talus

Arthrodesis Advantages: high fusion rate decreased time to fusion decreased cost No or mild angular deformity No AVN greater than 30% of the talus.

Arthrodesis Cameron (Arthroscopy Feb 2000) 15 cases FU 1-3 years 100% fusion Average of 11.5 weeks

Arthrodesis 5 patients required further surgical treatment 2/5: infections 2 required hardware removal 1 screws symptomatic subcutaneously 1 screw penetrated the subtalar joint

Osteochondral Defects Ogilvie-Harris (Arthroscopy Dec 1999) 33 patients duration of symptoms 2.3 years FU 7.4 years Osteocartilaginous fragment removed Defect debrided with a power shaver Base abraded

OCD 79% were able to return to unrestricted sports 3% (1 pt) was unable to return to any sport Minor degenerative changes in 2 cases

OCD Lahm (Arthroscopy April 2000) 42 patients 22 underwent percutaneous drilling 13 cancellous bone grafting 4 refixation 3 curettage

OCD 24 lateral talus all had trauma 11/18 lesions at the medial talus no evidence of trauma

OCD K-wire drilling reached an average of 87 points No significant difference in the lesions at the medial or lateral talus

Ankle instability Ogilvie-Harris (Arthroscopy Nov 1994) 19 patients Clinical features of disruption of the syndesmotic ligaments Positive external rotation stress test

Ankle instability Common triad: Disruption of the posterior inferior tibiofibular ligament Rupture of the interosseous ligament Chondral fracture of the posterolateral portion of the tibial plafond

Ankle instability Arthroscopic resection of the torn portion of the interosseous ligament and the chondral pathology Successfully relieved the symptoms in most of the patients

Post sprain pain Ogilvie-Harris (Arthroscopy Oct 1997) 100 patients Failed to respond to conservative treatment for at least 6 months

Post sprain pain 3 groups: Instabilities (lateral and syndesmotic) Impingements (anterior and anterolateral) Articular lesions (chondral and osteochondral).

Post sprain pain Significant improvements : Chondral fractures syndesmotic instability anterior and anterolateral impingement Chondral fractures stable ankle : 75% good unstable ankles: 33% good

Post sprain pain Arthroscopy offered little to the management of lateral instability Minimal improvements for the patients with nonspecific diagnoses

Anterior Impingement Anterior ankle pain ? aetiology

Meniscoid Lesion Persistent pain in the anterior part of the upper ankle Portions of hyalinized tissue following an inversion sprain of the ankle Trapping of this formation between the lateral cheek of the talus and the fibula is supposed to be responsible for pain

Meniscoid lesion Lahm (Arthroscopy Sept 1998) 59 arthroscopic procedures Meniscoid lesions were seen in 19 cases Only 1 of these 19 patients showed lateral and anterior instability

Osteoarthritis Ogilvie-Harris (Arthroscopy Aug 1995) 27 patients 4 years symptoms FU 45 months 17/27 patients improved only 2 ankles were restored to normal function

Osteoarthritis Statistically significant improvement in Pain Swelling Stiffness Limp Activity level Feeling of instability failed to reach significance

Outcomes Amendola (Arthroscopy Oct 1996) 79 arthroscopies minimum 2-year follow-up

Outcomes 21 OCD 14 post-ankle fracture scarring 11osteoarthritis and chondromalacia 14 anterior bony impingement 15 anterolateral soft tissue impingement or synovitis

Outcomes 63 of 79 patients benefited in some way Theraputic only: 36 of 44 (82%) of the patients benefited

Outcomes Best results: Localized osteochondral lesion of the talus Localized bony or soft tissue impingement Localized lateral plica

Outcomes Worse results: Osteoarthritis Posttraumatic chondromalacia Arthrofibrosis

Outcomes 3 significant neurological complications 2 partial deep peroneal nerve neuropraxia 1 superficial peroneal nerve irritation

Complications RD Ferkel (Arthroscopy 1996) 612 patients overall 9.0%, 27 neurological (4.4%) 15 superficial peroneal nerve 6 sural nerve 5 saphenous nerve 1 deep peroneal nerve

Complications Mariani (Arthroscopy April 2001) pseudoaneurysm

Summary Useful technique Advantages over open surgery in some cases Potential neurovascular complications Strict adherence to portal technique

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