Ankle Arthroscopy - Foot & Ankle

Indications

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 EDC 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
- neuropraxia most common complication
- Anterolateral portal
  - risks superficial peroneal nerve
    - most common neurovascular injury
    - specifically, the dorsal intermediate cutaneous branch
- Anteromedial portal
  - risks saphenous nerve and vein
  - risk of tibialis anterior tendon injury
- Anterocentral portal
  - risks dorsalis pedis artery
- Posterolateral portal
  - risks sural nerve and short saphenous vein
- Posteromedial portal
  - risks posterior tibial artery