ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY USE OF MEDIAL PORTALS IN ANKLE ARTHROSCOPY Francesco Allegra Casa di Cura Villa Silvana - Aprilia

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY ANKLE JOINT PATHOLOGY Arthroscopic treatment Intarticular 1. anterior 2. medial 3. lateral 4. posterior Extrarticular 2. posterior 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

ANKLE JOINT ARTHOSCOPY Anterior side - accordance on possibility and utility of the arthroscopic treatment in all articular and para-articular pathologies 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

ANKLE JOINT ARTRHOSCOPY Anterior side - traditional supine assessment of the patient - small joint instrumentation set-up - anterior approach by two anteromedial and anterolateral portals - traction - joint distension 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

ANKLE JOINT ARTRHOSCOPY Posterior side - lesser accordance on possibility and utility of the arthroscopic treatment because difficulties and risks of an hazardous area - possibility to reach posterior gutter from anterior if joint not stiff - some authors discourage use of posterolateral portal Parisien JS, Vangsness T., CORR,1985 Operative arthroscopy of the ankle. Three years experience Faiwell LA, Frey C., Foot & Ankle, 1993 Anatomic study of arthroscopic portal of the ankle. Ferkel RD et al. Arthroscopy,1996 Neurological complications of ankle arthroscopy ...postero-medial portals are never used because of their high potential for neurovascular injury. 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

ANKLE JOINT ARTRHOSCOPY Posterior side from anterior - if the distension of the ankle capsule is limited, the space available can make it difficult to work - surgery limitation by the shape of talus - the treatment is limited only to intrarticular pathology ...assessment of the posterior ankle joint is possible but instrumentation from the front to the back of the joint is difficult because of the shape… 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

WHAT IS THE POSTERIOR ANKLE JOINT? Posterior anatomic district ankle joint recess - posterior - medial - lateral subtalar joint recess rear foot extra articular region - proximal - distal dilemma: arthroscopic treatment or not? 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY ANKLE JOINT SURGERY Posterior side - open surgery to be considered in all cases - arthroscopic procedure is equal compared to open one but superior as invasivity and as surgical selectivity - arthroscopic surgeon must remember to adopt a different procedure in selected case if needed Maquirriain J Jour Am Ac Orth Sur, 2005 Posterior ankle impingement syndrome ......endoscopic technique…...may be a valid alternative for treating a variety of posterior ankle problems including etiologic PAIS lesions. 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY ANKLE JOINT SURGERY Posterior side - tarsal syndrome - posterior cyst - big bony spurs (Haglund’s disease) 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

ANKLE JOINT ARTRHOSCOPY Posterior side - “discover” of new therapeutic opportunities by Nijk Van Dijk - posterior portals in arthroscopic treatment of joint and extra joint pathology through a risk area Van Dijk NC et al. Arthroscopy, 2000 A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

ANKLE JOINT ARTRHOSCOPY Posterior side - new prone assessment of the patient - same dedicated small instrumentation - posterior approach by triangulation through two posteromedial and posterolateral portals - no traction - no previous distension Van Dijk NC et al. Arthroscopy, 2000 A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY ANKLE JOINT ANATOMY Posterior side - validation of the proposed procedure by anatomic study - easiest way to reach the posterior gutter and to treat spotted joint pathology Ljoi F et al. Arthroscopy, 2003 Posterior approach to the ankle: an anatomic study Sitler DF, Amendola A, Bailey CS, Than LM, Spouge A. JBJS, 2002 Posterior ankle arthroscopy: an anatomic study 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY ANKLE JOINT ANATOMY Posterior side - new procedure by prone position recently proposed by Sim JA - new posteromedial portal placed just posterior to the posterior colliculus of the medial malleolus lifting anteriorly the posterior tibial tendon - less easy way to reach the posterior gutter compared to the former, but big idea Sim JA, Lee BK, Kwak JH Arthroscopy, 2006 New posteromedial portal for ankle arthroscopy courtesy Sim JA 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY ANKLE JOINT PATHOLOGY Posterior side - new proposed portals coaxial to the posterior malleolar line - authors consider this procedure easy and safe to reach the posterior tibiotalar recess - portals are equidistant to neurovascular structures compared to conventional portals - unclear the patient assessment Acevedo J, Bush MT, Ganey TM, Hutton WC, Ogden JA. Arthroscopy, 2000 Coaxial portals for posterior ankle arthroscopy: an Anatomic study with clinical correlation on 29 pts ...our clinical results suggest this technique for posteromedial and posterolateral portal is safe, effective and reproducible. 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

POSTERIOR ANKLE ARTROSCOPY - many portals described - few completed anatomic studies on safety and respect of neurovascular bundle - prone positioning of the patient - procedures need triangulation or previous protection of TP tendon sheath - usual anesthesia - instrumentation for small joints depending surgeon’s request the sharper the respect of original procedure the safest the surgery, avoiding lesions of risk structures 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

POSTERIOR ANKLE ARTROSCOPY many portals described - postero-medial - postero-lateral - postero-lateral accessory - transachilleous anatomic risk areas - posterior tibial artery - posterior tibial nerve - FHL tendon - small saphenous vein - saphenous nerve Van Dijk portals - postero medial - postero lateral courtesy Ferkel RD 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Van Dijk arthroscopic procedure - only posterior recess treatment - prone patient assessment - possibility of traction pulling by a belt around the surgeon’s waist - selected anesthesia 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Van Dijk arthroscopic procedure original procedure - towel under the leg to lift the foot out the border of table - portals and anatomic risk areas to be marked - no inflation needed - triangulation of instruments on transverse plane - wide accuracy in exploring posterior joint recess and extra capsular space 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY Posterior pathology Anatomic districts affected by spotted problems 1. posterior ankle joint recess 2. posterior ankle extrarticular space 3. posterior subtalar joint recess 4. posterior rearfoot area 5. Achilles' tendon front region 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Posterior arthroscopic treatment ANKLE JOINT SPACE 1. ankle joint posterior gutters (between talus tibial and peroneal malleolus) 2. posterior subtalar joint KIND OF PATHOLOGY 1. posterior chondral defects 2. loose bodies 3. lesions of the posterior ligaments complex 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Posterior arthroscopic treatment ANKLE JOINT SPACE 1. ankle joint posterior gutters (between talus tibial and peroneal malleolus) 2. posterior subtalar joint KIND OF PATHOLOGY 1. posterior chondral defects 2. loose bodies 3. lesions of the posterior ligaments complex 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Posterior arthroscopic treatment ANKLE JOINT SPACE 1. ankle joint posterior gutters (between talus tibial and peroneal malleolus) 2. posterior subtalar joint KIND OF PATHOLOGY 1. posterior chondral defects 2. loose bodies 3. lesions of the posterior ligaments complex 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Posterior arthroscopic treatment ANKLE JOINT SPACE 1. ankle joint posterior gutters (between talus tibial and peroneal malleolus) 2. posterior subtalar joint KIND OF PATHOLOGY 1. posterior chondral defects 2. loose bodies 3. lesions of the posterior ligaments complex 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Posterior arthroscopic treatment ANKLE JOINT SPACE 1. ankle joint posterior gutters (between talus tibial and peroneal malleolus) 2. posterior subtalar joint KIND OF PATHOLOGY 1. posterior chondral defects 2. loose bodies 3. lesions of the posterior ligaments complex 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Posterior arthroscopic treatment ANKLE EXTRARTICULAR SPACE 1. posterior extrarticular and extracapsular anatomic space - FHL tendon - symptomatic os trigonum - posterior adhesions with stiffness 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Posterior arthroscopic treatment ANKLE EXTRARTICULAR SPACE 1. posterior extrarticular and extracapsular anatomic space - FHL tendon - symptomatic os trigonum - posterior adhesions with stiffness 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Posterior arthroscopic treatment ANKLE EXTRARTICULAR SPACE 1. posterior extrarticular and extracapsular anatomic space - FHL tendon - symptomatic os trigonum - posterior adhesions with stiffness 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Posterior arthroscopic treatment ANKLE EXTRARTICULAR SPACE 1. posterior extrarticular and extracapsular anatomic space - FHL tendon - os trigonum - posterior adhesions with stiffness 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Posterior arthroscopic treatment ANKLE EXTRARTICULAR SPACE 2. rear extrarticular and iuxta tendon anatomic space: Haglund’s disease 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Both compartments ankle pathology Anterior association with posterior recess or with rearfoot side: What to do? Many questions on the table: - which kind of solution must be adopted? - which kind of patient assessment has to be privileged? - has the surgeon change during surgery the pt. assessment? - at least, has the surgeon to propose the patient a two-time treatment? 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Both compartments ankle pathology Solutions from the surgeon’s experience 1. double coaxial portals: use limited to joint pathology only 2. prone posterior ankle approach firstly, anterior approach secondly with the knee in flexion and up-side down visualization Acevedo J, Bush MT, Ganey TM, Hutton WC, Ogden JA. Arthroscopy, 2000 Coaxial portals for posterior ankle arthroscopy: an Anatomic study with clinical correlation on 29 pts Van Dijk NC et al. Arthroscopy, 2000 A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Both compartments ankle pathology Solutions from the surgeon’s experience 3. double posteromedial portals in supine assessment, after anterior treatment - mild external rotation of the leg - portals anterior and postero-medial to be marked - longitudinal triangulation of the instruments - possibility to treat anterior and posterior problems into the joint and in the outer space 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Both compartments ankle pathology Ankle joint simultaneous anterior and posterior (articular and extra articular) pathology - arthroscopic treatment of the anterior articular problems by standard anterior portals - scope access to the posterior joint recess or to the rearfoot area through two posteromedial portals - placement secondary to anatomic studies to validate the procedure 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Double posteromedial portal - placed in “risk” area because the neurovascular bundle - externally to FHL tendon well palpable under the skin - access long the anterior margin of Achilles’ tendon - presence of safe triangular area surrounded by calcanear tuberosity (inferior) FHL (anterior) Achilles’ tendon (posterior) - area wide almost 25-30 mm² courtesy Ferkel RD 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Double posteromedial portal ANATOMIC TRIANGULAR AREA Well delimited by easy palpable anatomic structures as: - upper calcanear tuberosity - posterior margin of FHL tendon which protects the tibial bundle - anterior margin of Achilles’ tendon 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

Double posteromedial portal ANATOMIC TRIANGULAR AREA Around it lie some important anatomic path at risk : - calcanear branch of posterior tibial nerve (motor and sensitive) - posterior tibial neurovascular bundle To avoid any unwished collision the surgeon must: - gently move ahead the cannula from one of the portals to the peroneal compartment until touching - make a triangulation on longitudinal plane pushing the shaver from the second portal until seeing the tip 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY Surgical technique Supine assessment in mild leg external rotation - leg-holder with tourniquet - both anterior and posterior portals to be marked - possibility to keep the foot in traction - treatment of the ankle pathology in anterior compartment - external rotation of the surgical table 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY Surgical technique - skin incision - from inferior portal the cannula is inserted along the superior calcaneal margin to peroneal malleolus - from superior portal the shaver proceeds to the same malleolus - on the posterior tibio -peroneal margin the instruments stop - triangulation of instruments on longitudinal plane - direct sight of tip of shaver - possibility to lead out surgery reversing the instruments 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY Surgical treatment - posterior ankle joint reachable - posterior margin exploration of lateral malleolus and talar dome - inferior margin of tibial plateau visible - posterior loose bodies removal - symptomatic os trigonum treatment - debridement of FHL tendon impingement - subtalar pathology assessment 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY Conclusions low surgical morbidity patient assessment not changed both compartments one step treatment anterior and postero-medial portals safe reproducible procedure 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY THANK YOU FOR YOUR ATTENTION 26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY