A Pertinent Guide To Basic Ankle Arthroscopy
There are several lenses that are angled to varying degrees. The angles create obliquity within the field of vision. Once a surgeon is experienced with arthroscopy, altering the obliquity to gain vision of different areas within the joint is extremely helpful. The most common angle to use on the 4-mm arthroscope is 30 degrees.
Whether you place the camera within the medial or lateral portal will typically be dictated by the pathology you are treating. In general, placing the camera within the anteromedial portal will allow you to see the medial gutter, the anterior joint line and some portions of the lateral gutter. Placing the camera laterally will only emphasize the opposite structures.
Other Essential Pearls To Keep In Mind
It is important to remember that not all ankle joints will be easy to enter. In certain instances, debridement of hypertrophic synovium or adhesed capsule may be necessary to adequately maneuver within the joint. A common surgical error is not fully entering the ankle joint and assuming that hypertrophic tissue is obscuring the view. This leads to debridement of healthy capsule and allows fluid within the joint to spread into the subcutaneous tissues.
Once you are inside the joint, you should first orient yourself and then routinely check for synovitis, instability and cartilage derangement. One may also evaluate numerous other intraarticular problems based on the patient’s particular pathology. Using distraction devices, both invasive and noninvasive, can enhance access to different areas of the ankle joints. However, be aware that these devices can increase complications associated with this procedure as well.4
When employing the two-portal technique, you may need to exchange the camera between portals to evaluate the joint completely.
Hand instruments include varying forceps, probes and knives. Surgeons often use power instruments in arthroscopic ankle procedures with the most common instrument being a shaver. A shaver can significantly reduce the amount of time needed to thoroughly debride an inflamed joint.
Closure of the incisions is based on preference. Often, one may not suture one portal, leaving it open or steri-stripped in order to allow drainage of excess fluid.
Post-op care following ankle arthroscopy is based on the type of pathology you are treating. In simple diagnostic procedures with debridement, I usually allow full weightbearing and encourage active range of motion. In more extensive procedures, including chondroplasty or cartilage transfer, non-weightbearing is vitally important to the surgical success.
Although arthroscopy may have lower complication rates than comparable open procedures, there are potential problems that you should keep in mind. Neurovascular, tendinous and cartilaginous damage have all been reported as well as infections, painful scarring and broken equipment.5,6,7 My own complication rate seems to increase when I use invasive distraction devices.
Ankle arthroscopy is a versatile surgical tool for both diagnosis and treatment of articular disorders. When it is used effectively, it can provide many patients with a quicker recovery and less perioperative morbidity than many traditional surgical approaches.
Dr. Burks is a Fellow of the American College of Foot And Ankle Surgeons, and is board-certified in foot and ankle surgery. Dr. Burks practices in Little Rock, Ark.
Editor’s Note: For previous “Surgical Pearls” columns, check out the archives at www.podiatrytoday.com.
1. Mintz DN, Tashjian GS, Connell DA, Deland JT, O’Malley M, Potter HO: Osteochondral lesions of the talus: a new magnetic resonance grading system with arthroscopic correlation. Arthroscopy 19(4): 353-359, 2003.
2. Seeber PW, Staschiak VJ: Diagnosis and treatment of ankle pain with the use of arthroscopy. Clin Pod Med Surg 19(4): 509-517, 2002.
3. Wharbach GP, Stewart JD, Lambert EW, Anderson C: Arthroscopy in the lateral decubitus position. Foot Ankle Int 24(8): 597-599, 2003.
4. Waseem M, Barrie JL: A new distraction method in difficult ankle arthroscopy. J Foot Ankle Surg 41(6): 412-413, 2002.