Current Concepts In Ankle Arthroscopy

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By Catherine Cheung, DPM

   Ankle arthroscopy is an extremely useful skill for a foot and ankle surgeon. Foot and ankle surgeons use ankle arthroscopies to treat a variety of problems, including osteochondral defects, loose osteochondral fragments, ankle impingement, post-traumatic fibrous bands, synovitis and ligamentous/capsular injuries.

   Ankle arthroscopy has several advantages over an open ankle procedure. The surgery is minimally invasive and has a low complication rate. One can perform this on an outpatient basis and it facilitates a relatively easy postoperative recovery period. In contrast to an open ankle technique, arthroscopy allows complete ankle joint visualization and does not result in intraarticular scar tissue formation. Proficiency with ankle arthroscopy develops with good training and experience.

There is a learning curve with ankle arthroscopy that surgeons cannot overcome simply by enrolling in a weekend learning course. It is important to master the instrumentation and develop the skills necessary to visualize three dimensionally. Much of the difficulty lies in being able to move and triangulate the instruments appropriately without actually looking at one’s hands, which is counterintuitive for a surgeon. Utilizing cadaver labs and assisting other surgeons in ankle arthroscopy are the most helpful ways to improve one’s skills.

A Guide To Planning And Preparation

   Preparation for ankle arthroscopy is very important. When scheduling the case, be sure to allow a few minutes of extra time for set-up. The typical operative time for simple arthroscopies ranges from 45 minutes to an hour and a half.

   Request a general anesthetic so the patient and the ankle joint are completely relaxed. One can use a thigh holder so the patient’s knee is bent during surgery and the ankle is hanging downward. This helps to distend the joint. Another technique is to have the patient supine on the bed with the patient as far down on the bed as possible. The surgeon can use his or her own body during the surgery to dorsiflex the ankle by leaning onto the plantar foot. A hip roll can internally rotate the operative leg so the foot and ankle are pointing toward the ceiling. This facilitates the use of the instruments in the portals.

   Typically, an anteromedial portal and anterolateral portal are enough to visualize the joint. Make these incisions from caudal to distal. The incisions should be about 1 cm in length at the level of the ankle joint. Blunt dissection down to the capsular layer is important to minimize neurovascular damage. While standard placement of these incisions is discussed in other publications, one should mark these incisions preoperatively before ankle joint insufflation since anatomical landmarks are more difficult to see when the joint is distended. The patient can also help identify landmarks by contracting the tibialis anterior for the anterior medial portal and extensor digitorum brevis muscle for the anterior lateral portal for marking in the preoperative holding area.

   Position the monitor in a direct visual line to yourself and typically fairly close to the anesthesiologist. One can use a 2.7 mm or 4.0 mm arthroscope with a 30-degree angle for most cases. However, when it comes to smaller patients, a 2.7 mm arthroscope is easier to use and can minimize iatrogenic damage to the cartilage. Surgeons can use a gravity-assisted lactated ringer’s solution or a pump machine, depending upon one’s preference. As a precaution, you may want place a thigh tourniquet on the patient although it is not always necessary in every case. Judicious preoperative use of 1% lidocaine with epinephrine can insufflate the joint and minimize bleeding. The surgeon can also inject epinephrine into the bag of lactated ringers to help control bleeding during the case.

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