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

2. Ankle Arthroscopy Anatomy Patient setup Portal placement Procedures
Complications

3. Anatomy

4. Portals Anterior Anteromedial Anterolateral Anterocentral Posterior
Posterolateral
Posteromedial
Transachilles Tendon

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

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

7. 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

8. 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

9. Anterior Portals

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

11. 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

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

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

14. Portals
Accessory Portals
Transmalleolar
Transtalar

15. Posterior Portals

16. Patient Setup

19. Making Portals

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

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

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

28. Anterior Examination

29. 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

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

31. Central Examination

32. 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

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

34. Posterior Examination

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

36. Arthrodesis

37. 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

38. 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

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

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

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

42. 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

43. 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

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

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

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

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

48. 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

49. 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

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

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

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

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

54. Anterior Impingement
Anterior ankle pain
? aetiology

57. 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

58. 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

59. 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

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

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

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

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

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

65. Outcomes Worse results: Osteoarthritis Posttraumatic chondromalacia
Arthrofibrosis

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

67. 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

68. Complications
Mariani (Arthroscopy April 2001)
pseudoaneurysm

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

70. Thank You