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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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 mm²
courtesy Ferkel RD
26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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