- 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;
- 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;
- 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.
CK Yates.
Arthroscopy. Vol 4. 1988. p 103-105.
- 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 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 tendonn
- 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;
- references:
- Anatomic relations between ankle arthroscopic portal sites and the
superficial peroneal and
saphenous nerves.
A. Saito MD and S. Kikuchi. Foot and Ankle International. Vol 19.
No 11. Nov 1998. p 748.
- 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);