Preoperative Patient Care
Operative Techniques

Preoperative Plan


Determine pathology


Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical Instrumentation

  • standard arthroscopy pump


Room setup and Equipment

  • standard OR table with leg holder


Patient Positioning

  • supine
  • leg holders

Ankle Distractor Placement


Check the instrumentation

  • inspect all instruments
  • confirm that all parts of the noninvasive external distractor are sterile on the operative field


Place the patient for placement of the ankle distractor

  • place the patient on the operative table supine
  • the foot should rest within 10 cm of the end of the bed
  • place a bump under the hip to internally rotate the leg so that the toes are pointing straight up
  • place a tourniquet on the calf below the level of the fibular head to prevent peroneal nerve impingement
  • flex the hip 60 degrees
  • place the posterior thigh on a well padded thigh holder
  • secure with straps
  • prep and drape the ankle with standard arthroscopic draping
  • the distal portion of the arthroscopy drape is pulled off the end of the foot to allow distractor placement
  • place the bed clamp as far distal on the bed as possible
  • the external distractor strap is placed with the foam portions over the posterior inferior heel and on the dorsal foot
  • after creating equal lengths on the medial and lateral sides of the foot pull the hook lop distally with manual distraction
  • once this is connected use the threaded rod to provide further distraction to the ankle

Anterior Portal Placement


Prepare the ankle

  • inject the ankle with 10 cc of sterile saline via the anteromedial ankle
  • this allows identification of the correct orientation and location for the anteromedial arthroscopy portal


Make incision

  • make a 5 mm longitudinal skin incision and spread the subcutaneous tissue down to and then through the capsule with a small hemostat
  • A small gush of fluid will confirm the intra-articular location


Enter the joint

  • use a blunt tip trocar with the arthroscopic cannula to enter the joint
  • insert the arthroscope and start the water flow


Start the water pressure

  • place the water pressure about 5 mmhg above the systolic pressure if possible but no higher than 120 mmhg
  • this will help reduce the bleeding which often obscures the view
  • unless there is severe arthrofibrotric tissue in the anterior ankle the anterolateral ankle should be easily visualized upon introducing the arthroscope


Make the anterolateral portal

  • introduce the 18 gauge needle from the anterolateral portal location
  • this serves 2 purposes
  • allows for water flow through the needle which allows better visualization
  • identifies the correct location of the portal incision in order to access the joint properly
  • inspect the joint
  • distraction allows for much greater joint inspection than otherwise possible
  • make the anterolateral portal in the same fashion to the anteromedial portal

Anteromedial Inferior Portal Placement


Place the portal

  • visualize the medial gutter with the arthroscope through the anteromedial portal


Place the 18 gauge needle

  • introduce an 18 gauge needle into the inferior medial gutter which is usually 10 mm inferior to the normal anteromedial portal location
  • once the needle is confirmed to be in the proper position a new portal is then made as described earlier
  • this portal in combination with the conventional anteromedial portal can be used to first inspect and then debride the far anteromedial ankle joint and deltoid insertion

Posterior Coaxial Portal Placement


Make the skin incision

  • with the arthroscope and inflow in the anterolateral portal make the posterolateral portal with a small vertical skin incision immediately posterior to the peroneal tendon sheath and 1.5 cm proximal to the tip of the fibula


Position the ankle

  • hold the ankle in neutral dorsiflexion


Place the trocar

  • insert the arthroscope sheath and blunt trocar anterior and slightly inferior on a plane parallel to the bimalleolar axis


Confirm placement

  • confirm intracapsular placement by briefly inserting the arthroscope


Place switching rod

  • insert a long switching rod through the cannula and direct it towards the medial malleolus
  • use the rod to palpate the posterior colliculus and penetrate just anterior to the posterior tibial tendon


Place the posteromedial portal

  • tent and incise the skin over the posteromedial ankle
  • pass a second cannula over the switching stick into the posterior ankle recess


Maneuver the arthroscope


Place the sheath and blunt trocar appropiately

  • insert the arthroscope sheat and blunt trocar anterior and slightly inferior on a plane parallel to the bimalleolar axis


Confirm placement

  • confirm intracapsular placement by briefly inserting the arthroscope
  • for synovectomies or posteromedial osteochondral lesions, place the arthroscope in the posterolateral cannula while the posteromedial cannula is used as the working portal

Anatomy Visualization


Visualize the ligaments


Test the lateral and medial ligament stability

  • apply gentle varus, valgus and anterior pull stress
  • evert and pronate the foot to test deltoid ligament stability
  • check lateral instability
  • check for talar tilting by supination stress of the foot

Wound Closure


Use 3-0 and 4-0 biosyn for closure


Apply steristrips


Cover with tegaderm and occlusive dressings

Postoperative Patient Care

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