Pertinent Insights On The Evolution Of The Ankle Arthroscopy
- Jeffrey Bowman DPM MS
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Arthroscopy in the ankle began in the 1920s with limited visualization. Initially, practitioners used 4.0 mm scopes until Takagi developed a 2.7 mm scope and implemented distraction techniques.1 Today, a 2.5 mm scope, distraction techniques and irrigation systems improve the ease and efficacy of ankle joint arthroscopy. Indications for ankle arthroscopy include diagnostic evaluation, synovitis, capsulitis, tibial/talar exostosis, ankle arthritis or osteochondral defects/fragments.
Traditionally, surgeons perform incisions through anterior portals but I prefer to use the anteromedial and anterolateral portals for the insertion of instrumentation. I make the medial incision at the level of the ankle joint immediately medial to the tibialis anterior tendon. Using the light from the camera subcutaneously to identify the proper position of the lateral portal and underlying neurovascular anatomy, I utilize a trocar and cannula to penetrate the capsule. Make the anterolateral portal just lateral to the peroneus tertius tendon in order to avoid the dorsal lateral branch of the peroneal nerve.
What the surgeon is trying to examine determines which portal to use for the camera versus the portal one would use for instrumentation. From the anteromedial portal, you can visualize the deltoid ligaments, medial malleolus, medial gutter, talar dome, anterior gutter and tibiofibular joint including the anterior talofibular ligament. In my experience, resection of joint pathology is effective with suction burr, curettage or handheld rasp instrumentation.
Mosey outlines the most common debatable topic regarding arthroscopy in the New England Journal of Medicine.2 He conducted a controlled trial of arthroscopic surgery for osteoarthritis of the knee. The study found the outcome after arthroscopic lavage or arthroscopic debridement was no better than the outcome after placebo. Further suggestions state that the simple joint distension and lavage are sufficient for pain relief. I obviously believe that surgical debridement is required in the presence of true pathology (OCD, excessive synovitis or exostosis).
I often allow immediate weight bearing postoperatively. However, some recommend partial weight bearing with ambulation for the first two weeks. I encourage range of motion ankle exercises as soon as possible. Sutures should remain in place for the standard 10 to 14 days.
Ray Allen of the Boston Celtics missed 20 games during the 2011-2012 regular season because of multiple bone spurs in his ankle joint. As a professional basketball player, he must work that joint tirelessly. In June 2012, the 36-year-old player had ankle arthroscopy to remove the spurs in the hope of extending his career. The procedure was successful and he came off the bench in the first game of the season to score 19 points with his new team, the Miami Heat.
Ankle arthroscopy has improved by leaps and bounds over the last 50 years, and will continue to do so with an increase in surgeon competency and education. Conservatively, physicians can recommend steroid injections and physical therapy for those who wish to avoid surgical intervention. However, ankle arthroscopy can provide a less invasive alternative to ankle arthrodesis or arthroplasty for chronic ankle arthritis.
For further information regarding ankle joint arthroscopy and its implementation in your practice, visit www.houstonfootspecialists.com .
1. Takagi K. The classic arthroscope. J Jap Orthop Assn. 1939;167:6-8.
2. Moseley JB, O’Malley K, Peterson NJ, et al. A controlled trial of arthroscopic surgery for osteo arthritis of the knee. N Engl J Med. 2002; 347(2):81-88
3. Canale ST. Ankle arthroscopy. In: Campbell’s Operative Orthopedics. 9th ed. Mosby Year Book, Mosby/Elsevier, Philadelphia; 1998:1542-50.
4. Lundeen GW. Historical perspectives of ankle arthroscopy. J Foot Surg. 1987;26(1):3-7.
5. Burman MS. Arthroscopy, a direct visualization of joints: an experimental study. J Bone Joint Surg Am. 1931;13(4):669-695.