Ankle Arthroscopy

IndicationAnkle Arthroscopy

 

Diagnostic

 

Pain / Stiffness / Locking

Instability

- exclude OCD

Assess syndesmosis

 

Therapeutic

 

Synovitis

Osseous lesions / Tibiotalar impingement spurs

Osteochondral defects

Anterolateral impingement lesions (soft tissue)

Loose bodies

 

Ankle Scope Loose BodyAnkle Scope Loose Body 2

 

 

Technique

 

Set up

 

Position

- supine on table

- tourniquet

 

Traction

A.  Assistant provide traction

B.  Foot traction halter

C.  Skeletal distracter

 

Ankle Arthroscopy Traction

 

Instrumentations

- standard knee scope or

- 2.7mm 30° scope

- small scope better for getting across joint line without chondral damage

 

Portals

 

Ankle distended first

- 20 ml syringe, normal saline

- anteromedial

- insert needle, move ankle

- if on bone and needle moves, on talus and need to redirect proximally

- if on bone and needle doesn't move, on tibia and need to redirect inferiorly

- insufflate with 15 mls to create anterior space

 

Portals

- usually want instrumentation on side of pathology

- exception is anterior spurs

- usually large osteophyte laterally so first portal insert medially

 

Ankle Scope Medial and Lateral PortalsAnkle Superficial Peroneal Nerve

 

Anterolateral

- lateral to peroneus tertius

- can then transilluminate and avoid saphenous nerve on AM portal

- structure at risk is branches SPN

- Just proximal to joint line

- incision in skin only

- blunt dissect down to capsule

- insert blunt trochar

- aim anterior to joint to create space

 

Anteromedial

- second portal

- medial to tibialis anterior

- structure at risk is G saphenous vein and saphenous nerve

- use transillumination to avoid

- insert and visualise needle

- skin incision, blunt dissection

- insert shaver, again anteriorly

- clear soft tisse until can visualise joint line

- beware anterior tendons and nerves

 

Technique

 

1.  Inspect anterior talus

- plantarflex foot

- look for chondral lesions

 

2.  Inspect distal tibia

- look for osteophytes

 

3.  Inspect gutters

 

A.  Medial

 

Ankle Arthroscopy Medial GutterAnkle Scope Medial GutterAnkle Scope Medial Gutter

 

B.  Lateral

- exclude meniscoid lesions

 

Ankle scope lateral gutterAnkle Scope Lateral Gutter

 

4.  Look across joint

- distract

- insert probe or shaver and use as level

- look at tibial plafond and syndesmosis

 

Ankle Arthroscopy Lateral GutterAnkle Scope Talar Dome

 

5.  Inspect syndesmosis

- probe and assess stability

 

Ankle scope syndesmosisAnkle scope syndesmosis 2

 

6.  Inspect posterior joint line

 

Ankle Scope Posteromedial CapsuleAnkle scope posterior capsule laterally

 

Posterior Ankle Arthroscopy

 

Posterior ankle arthroscopy

 

Posterolateral

- just lateral to tendo achilles

- medial to fibular

- 1.2-1.5cm above tip of fibula

- sural nerve & vein anterior

- remember joint 1cm higher at back

 

Subtalar Arthroscopy

 

Subtalar arthroscopy

 

Complications

 

Nerve Injury

 

Specific

 

Anterolateral portal - SPN

Anteromedial portal - Saphenous

Posterolateral portal - Sural

Anterocentral - Deep Peroneal

Posteromedial - Posterior Tibial

 

Minimise by

1.  Marking of skin prior to arthroscopy

2.  Transillumination to visualise nerves

3.  Feel nerve 

4.  Use of blunt dissection

 

Mechanism injury

- penetration

- neural structures close to capsule

- anterior penetration by chondrotome may injure DPN

- traction device

- pins in talus and calcaneus may injure sural nerve

 

Other

 

Compartment syndrome

- From extravasation of fluid into calf

 

Articular cartilage damage

 

Infection

 

Pseudoaneurysm

 

Pseudoaneurysm AngiographyPseudoaneurysm MRI