Ankle Arthroscopy

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- See: Ankle Arthroscopy by Dr. Schneider et. al.

- Discussion:
    - indicated for symptomatic soft tissue impingement, synovitis:
    - specific lesions amenable to arthroscopic debridement include:
          - osteochondral lesions;
          - meniscoid lesion in anterolateral gutter;
                 - mass of fibrocartilagenous tissue arising from the tibio-fibular joint will protrude into the joint;
                 - patients will note anterolateral ankle pain, popping, and giving way;
          - anterior impingement snydrome of the ankle
                 - thickening of antero-inferior tibiofibular ligament;
          - arthrofibrosis following ankle fracture;

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- Technical Considerations:
    - use 30 deg wide angle - 2.7 mm arthroscope (if not available, then use 4 mm scope);
    - consider use of a pump set for a pressure of 50 mm;
    - use 3.5 mm shaver;
    - mechanical distraction:
          - some sort of mechanical distraction device is useful;
          - typically the kit will contain sterile straps which are applied to a sterile metal bar after the leg is prepped;
          - usually a sterile strap is wrapped over the dorsum of the foot and heel;
          - usually about 25 lbs of distraction force is required, which gives between 1 to 1.5 mm of distraction;
          - cautions:
                  - distraction of more than 30 lbs for more than 1 hour is associated with reversible nerve conduction changes;
                  - excssive use of force for prolonged periods of time may cause bothersome paresthesias in the superficial peroneal nerve;

             

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- Position:
    - patient is supine with leg placed in a arthroscopic leg holder (as for knee scopes);
    - leg hangs free so that knee is flexed to about 90 deg;
    - a sterile kerlex cloth band is wraped in figure of 8 fashio around the foot and ankle, with the free end tied into a loop which is then positioned just above the floor;
           - surgeon's foot is placed in the kerlex loop and is used to distract the ankle joint;
           - ref: A simple distraction technique technique for ankle arthroscopy.  

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- Portals:
    - use a 15 blade to carefully incise thru skin only;
    - anteromedial:
          - initial arthroscopy is performed with the scope in the anteromedial portal, but for the majority of case, this portal will be used for instrumentation;
          - located at the level of the ankle joint, just medial to the tibialis anterior tendon, and located about 5 mm proximal to the medial malleolus;
          - 18 gauge syringe is used to infuse saline into the joint;
          - greater saphenous nerve and vein are at risk w/ this portal, lying 7-9 mm medial to the portal;
    - anterolateral:
          - once joint is distended w/ saline, use 18 gauge needle to mark location of anterolateral  portal which should lie just lateral to peroneus tertius tendon;
                 - staying lateral to the peroneus tertius, helps avoid injury to the dorsal lateral branch of the peroneal nerve;
          - use the scope to transilluminate the anterolateral skin, inorder to look for underlying cutaneous nerves;
          - scope can then be driven forward (elevating the synovium and skin) which further assists with placement of this portal;
          - make small incision and then spread w/ hemostat;
          - be aware that the intermediate branch of the superficial peroneal nerve is about 5-6 mm from this portal;
    - reference:
          - Anatomic relations between ankle arthroscopic portal sites and the superficial peroneal and saphenous nerves.

                 

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- Sequential Examination:
    - visualization from the anteromedial portal:
          - deltoid ligament;
          - medial malleolus;
          - medial gutter (medial talomalleolar joint);
          - talar dome (osteochondral lesions)
          - anterior gutter;
          - tibiofibular joint:
                 - synovitis, fibrocartilagenous protrusion;
                 - posterior tib-fib ligament;
                 - anterior tib-fib ligament;
                 - anterior talofibular ligament (arising from the tip of the fibula)
         

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Current Concepts Review. Arthroscopy of the Ankle and Foot.

Diagnostic and operative arthroscopy of the ankle. An experimental approach.

Arthroscopic treatment of synovial impingement of the ankle. 

Arthroscopic treatment of anterolateral impingement of the ankle.

Noninvasive ankle distraction: relationship between force magnitude of distraction, and nerve conduction abnormalities.

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Original Text by Clifford R. Wheeless, III, MD.