Arthroscopy Of theAnkle

Arthroscopy Of theAnkle

Mr. T.D.Tennent FRCS(Orth) Mr. T.D.Tennent FRCS(Orth)

Ankle Arthroscopy

AnatomyPatient setupPortal placementProceduresComplications

Anatomy

Portals

AnteriorAnteromedialAnterolateralAnterocentral

PosteriorPosterolateralPosteromedialTransachilles Tendon

Portals

AnteriorAnteromedial

medial to tibialis anterior

saphenous nerve and vein are medial

Portals

AnteriorAnterolateral

lateral to peroneus tertius

between branches of superficial peroneal nerve (6.5cm prox to tib of fibula)

Portals

AnteriorAnterocentral

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 PortalsAccessory anteromedial

1cm inferior and anterior to anterior border of medial malleolus

Accessory anterolateral1cm anterior and at or below tip of lateral malleolus

Anterior Portals

Portals

PosteriorPosterolateral

adjacent to lateral edge of achilles tendon 1.2-2.5 cm above tip of fibula

sural nerve and small saphenous vein

Portals

PosteriorPosteromedial

medial to achilles tendon at the joint line

posterior tibial artery and tibial nerveTendons of FHL and FDLcalcaneal nerve branches

Portals

PosteriorTransachilles Tendon

at same level as the posteromedial but through center of achilles tendon

Portals

Accessory Posterior PortalsAccessory Posterolateral

1-1.5 cm lateral to posterolateral portal, slightly higher

sural nerve and small saphenous vein

Portals

Accessory PortalsTransmalleolar 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

Anterior1: Deep portion deltoid ligament2: Medial gutter3: Medial talar dome4: Medial talus articulation with

plafondsagittal groove

Normal Ankle Examination

5: Lateral talus 6: Talofibular articulation

“trifurcation”distal lateral tibial plafondlateral talar domefibula

7: Lateral gutter8: Anterior gutter

Anterior Examination

Normal Ankle Examination

Central9: Medial dome of talus &

corresponding plafond

10: Central portion of talus & plafond

11: Articulation lateral talar dome with tibia & fibula

Normal Ankle Examination

Posterior12: Posterior inferior tibiofibular

ligament13: Transverse tibiofibular ligament14: 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 tibia18: Lateral talar dome, posterior tibia

Normal Ankle Examination

19: Posterior talofibular articulation20: Lateral gutter21: Posterior gutter

Posterior Examination

Procedures

ArthrodesisOsteochondral DefectsInstabilityPost Sprain PainAnterior ImpingementMeniscoid Lesions

Arthrodesis

Arthrodesis

Zvijac (Arthroscopy Jan 2002)

21 patients Mean age 52.7 Av. FU 34 months20/21 fusionAv. time to union 8.9 weeks

Arthrodesis

9 excellent: no pain, limp, or occupational restriction

11 good: mild pain, occasional limp1 poor: failed union and pain

extensive AVN approximately 50% talus

Arthrodesis

Advantages: high fusion ratedecreased time to fusiondecreased cost

No or mild angular deformityNo AVN greater than 30% of the talus.

Arthrodesis

Cameron (Arthroscopy Feb 2000) 15 cases FU 1-3 years100% 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 removedDefect debrided with a power shaverBase 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 drilling13 cancellous bone grafting4 refixation3 curettage

OCD

24 lateral talusall had trauma

11/18 lesions at the medial talusno 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 :– 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 symptomsFU 45 months17/27 patients improvedonly 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 chondromalacia14 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 nerve6 sural nerve5 saphenous nerve1 deep peroneal nerve

Complications

Mariani (Arthroscopy April 2001)

pseudoaneurysm

Summary

Useful techniqueAdvantages over open surgery in

some casesPotential neurovascular

complicationsStrict adherence to portal technique

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