Pertinent Insights On Ankle Arthroscopy

Patrick DeHeer, DPM, FACFAS, and Corey Groh, DPM

   Even though ankle arthroscopy has a low morbidity and is a relatively safe surgical procedure, contraindications to this treatment modality still exist. Moderate to severe degenerative joint disease, decreased range of motion and a markedly reduced joint space will not allow surgeon to use or maneuver the instrumentation adequately in the joint space. Severe edema and questionable vascular status can cause wound healing complications, even with the small size of the incisions surgeons would use for ankle arthroscopy.

   Finally, soft tissue infection in the soft tissues overlying the operative ankle is an absolute contraindication to prevent inoculation of the ankle joint with bacteria, leading to a septic ankle joint.

   Possible complications of this procedure include: further damage to the articular surface, neuropraxia, neuritis, vessel injury, synovial fistula formation, hemarthrosis leading to joint fibrosis, subchondral plate collapse, osteoarthritis and deep vein thrombosis. It should be stated that as with most foot and ankle surgical procedures, the occurrence of deep vein thrombosis from ankle arthroscopy is very low and prophylaxis is rarely necessary unless the patient’s individual history warrants such action.

A Guide To Arthroscopy Portal Location

Cartilaginous tissue lacks nerve or blood supply, which lends itself to poor healing following injury. The cartilage within the ankle joint is typically 2 to 3 cm thick. Articular cartilage is composed of three layers: the superficial, tangential and vertical layers. The vertical layer is the thickest stratum of the three. The smooth joint contour cartilage is attached to the subchondral bone via a lock and key mechanism. It is this subchondral bone, specifically the zone of calcified cartilage, which provides some of the nourishment to the chondrocytes via its blood supply. The remainder of the nourishment for the cartilage derives from the synovial fluid.

   One can access the ankle joint from the anterior or posterior aspect of the joint. There are three chief incision locations or portals that are in use most often in ankle arthroscopy. Surgeons can strategically place these portals to gain access to the ankle joint with instrumentation while minimizing the risk of damage to anatomical structures
around the ankle, especially nerves and blood vessels.

   Locate the anteromedial portal by palpating the tibialis anterior tendon and make an incision just medial to this structure at the level of the joint line. This location ensures that the anterior tibial artery and the deep peroneal nerve will be safe from trauma during the procedure. This is the safest portal anatomically speaking.

   The anterolateral portal is another commonly used point to access the ankle joint. Make this portal at the level of the ankle joint line and just lateral to the peroneus tertius tendon. The dorsal cutaneous nerves are at risk of injury when one selects this portal. Surgeons can minimize injury to these structures by plantarflexing and inverting the foot. Inserting the camera in the anteromedial portal and using its light source to transilluminate the anterolateral portion of the ankle can often aid in visualizing the ankle.

   The third most regularly used portal in ankle arthroscopy is the posterolateral portal. This portal is located just lateral to the Achilles tendon overlying the joint line. The joint line is much more difficult to palpate when using this technique. The sural nerve should pass safely anterior to this portal.

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