Ankle Arthroscopy

Indications

Indications
- osteochondral lesions of the talus
- microfracture of OCD
- debridement of post-traumatic synovitis
- ATFL anterolateral impingement
- AITFL anterolateral impingement
- resection of anterior tibiotalar spurs
  - such as anterior bony impingement
- os trigonum excision
- removal of loose bodies
- cartilage debridement in conjunction with ankle fusions

Positioning and Scope insertion

Position
- patient placed supine
- leg over well padded bolster
Tourniquet
- place tourniquet and exsanguinate limb
Joint distention
- external traction device applied to distract tibiotalar joint
- can load joint with saline to distend joint
Scope insertion
- nick and spread method commonly utilized to access joint and minimize neurovascular injury

Portals

Anteromedial
- function
  - primary viewing portal
  - typically established first
  - access to anteromedial joint
- location and technique
  - medial to tibialis anterior and lateral to medial malleolus
  - make portal between tibialis anterior and saphenous vein
Anterolateral
- function
  - primary viewing portal
  - access to anterolateral joint
- location and technique
  - located just lateral to peroneus tertius and superficial peroneal nerve and medial to lateral malleolus
  - can trace out superficial peroneal nerve prior to incision
Anterocentral
- function
  - anterior viewing portal
- location and technique
  - not commonly utilized due to danger to dorsal pedis artery
  - medial to extensor digitorum communis and lateral to EHL
Posterolateral
- function
  - posterior viewing portal for access to os trigonum
- location and technique
  - located 2cm proximal to tip of lateral malleolus
  - medial to peroneal tendons and lateral to achilles tendon
Posteromedial
- function
  - posterior viewing portal for access to os trigonum
- location and technique
  - just medial to achilles tendon

Complications

Synovial cutaneous fistula
- avoid by immobilization to allow portal skin healing and closure
Neurovascular injury from portal placement
- Anterolateral portal
  - risks dorsal intermediate cutaneous branch of superficial peroneal nerve
    - most common neurovascular injury
- Anteromedial portal
  - risks saphenous nerve and vein
- Anterocentral portal
  - risks dorsalis pedis artery
- Posterolateral portal
  - risks sural nerve and small saphenous vein
- Posteromedial portal
  - risks posterior tibial artery

TAG

(OBQ08.241) Nerve injury is the most common complication of ankle arthroscopy. The Superficial peroneal nerve is at greatest risk of injury with which of the following portals shown in Figure A? Topic

Review Topic

FIGURES: A

1. Portal A
2. Portal B
3. Portal C
4. Portal D
5. Portal E

PREFERRED RESPONSE ▶

DISCUSSION: Nerve injury is the most common complication of ankle arthroscopy. The Superficial Peroneal Nerve is the most commonly injured nerve and is at risk with use of the anterolateral portal, shown as Portal A in the Figure.

Ferkel et al (1996). in a retrospective review looking at complications associated with ankle arthroscopy, found an overall complication rate of 9.0%, of these 4.4% were neurological complications. Of the 27 cases of nerve injury, the superficial peroneal nerve was injured in 15 cases, the sural nerve in 6, the saphenous nerve in 5, and the deep peroneal nerve in 1. All nerve injuries occurred through direct injury by portal or distractor pin placement.

Ferkel et al (2001) reviewed the complications associated with ankle arthroscopy and discusses strategies to prevent them. They again state that the overall complication rate is 9%. They report most complications associated with foot and ankle arthroscopy are transient and tend to resolve within 6 months.

Stephens et al describe a technique to identify the superficial peroneal subcutaneously that entails flexion of the fourth toe which accentuates the subcutaneous course of the cutaneous branches of the superficial peroneal nerve. They recommend this technique as a way of identifying the nerve to prevent injury during portal placement.

Illustration A shows the anterior portals used for ankle arthroscopy. Illustration B shows the posterior portals used in ankle arthroscopy.

Illustrations: A

REFERENCES:

1. Ferkel RD, Heath DD, Guhl JF: Neurologic complications of ankle arthroscopy. Arthroscopy 1996;12:200-208 PMID:8776998 (Link to Abstract)

2. Ferkel RD, Small HN, Gittins JE: Complications in foot and ankle arthroscopy. Clin Orthop Relat Res 2001;391:89-104 PMID:11603693 (Link to Abstract)

3. Stephens MM, Kelly PM. Fourth toe flexion sign: a new clinical sign for identification of the superficial peroneal nerve. Foot Ankle Int. 2000 Oct;21(10):860-3. Erratum in: Foot Ankle Int 2000 Dec;21(12):995. PubMed PMID: 11128019. PMID:11128019 (Link to Abstract)

Question Authors:

Derek Moore, Derek Moore, Patrick McCulloch MD,

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Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Ferkel RD, Heath DD, Guhl JF: Neurologic complications of ankle arthroscopy. Arthroscopy 1996;12:200-208 PMID:8776998 (Link to Abstract)
Ferkel RD, Small HN, Gittins JE: Complications in foot and ankle arthroscopy. Clin Orthop Relat Res 2001;391:89-104 PMID:11603693 (Link to Abstract)
Stephens MM, Kelly PM. Fourth toe flexion sign: a new clinical sign for identification of the superficial peroneal nerve. Foot Ankle Int. 2000 Oct;21(10):860-3. Erratum in: Foot Ankle Int 2000 Dec;21(12):995. PubMed PMID: 11128019. PMID:11128019 (Link to Abstract)

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