ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

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• ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY
• USE OF MEDIAL PORTALS
• IN ANKLE ARTHROSCOPY
• Francesco
  Allegra
• Casa di Cura Villa Silvana - Aprilia

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ANKLE JOINT PATHOLOGY

• Arthroscopic treatment
• Intarticular
• 1. anterior
• 2. medial
• 3. lateral
• 4. posterior
• Extrarticular
• 1. anterior
• 2. posterior

26th AANA Annual Meeting ICL ADVANCED ANKLE AND
SUBTALAR ARTHROSCOPY
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ANKLE JOINT ARTHOSCOPY

• Anterior side
• - accordance on possibility and utility of the
  arthroscopic
• treatment in all articular and para-articular
  pathologies

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SUBTALAR ARTHROSCOPY
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ANKLE JOINT ARTRHOSCOPY

• Anterior side
• - traditional supine assessment of the patient
• - small joint instrumentation set-up
• - anterior approach by two anteromedial and
  anterolateral
• portals
• - traction
• - joint distension

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ANKLE JOINT ARTRHOSCOPY

• Posterior side
• - lesser accordance on possibility and utility of
  the arthroscopic
• treatment because difficulties and risks of an
  hazardous area
• - possibility to reach posterior gutter from
  anterior if joint not stiff
• - some authors discourage use of posterolateral
  portal

Parisien JS, Vangsness T., CORR,1985 Operative
arthroscopy of the ankle. Three years experience
Faiwell LA, Frey C., Foot Ankle, 1993 Anatomic
study of arthroscopic portal of the ankle.
Ferkel RD et al. Arthroscopy,1996 Neurological
complications of ankle arthroscopy
...postero-medial portals are never used because
of their high potential for neurovascular injury.
26th AANA Annual Meeting ICL ADVANCED ANKLE AND
SUBTALAR ARTHROSCOPY
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ANKLE JOINT ARTRHOSCOPY

• Posterior side from anterior
• - if the distension of the ankle capsule is
  limited, the space
• available can make it difficult to work
• - surgery limitation by the shape of talus
• - the treatment is limited only to intrarticular
  pathology

...assessment of the posterior ankle joint is
possible but instrumentation from the front to
the back of the joint is difficult because of
the shape
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SUBTALAR ARTHROSCOPY
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WHAT IS THE POSTERIOR ANKLE JOINT?

• Posterior anatomic district
• ankle joint recess
• - posterior
• - medial
• - lateral
• subtalar joint recess
• - posterior
• rear foot extra articular region
• - proximal
• - distal

dilemma arthroscopic treatment or not?
26th AANA Annual Meeting ICL ADVANCED ANKLE AND
SUBTALAR ARTHROSCOPY
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ANKLE JOINT SURGERY

• Posterior side
• - open surgery to be considered in all cases
• - arthroscopic procedure is equal compared to
  open one but
• superior as invasivity and as surgical
  selectivity
• - arthroscopic surgeon must remember to adopt a
  different
• procedure in selected case if needed

Maquirriain J Jour Am Ac Orth Sur,
2005 Posterior ankle impingement syndrome
......endoscopic technique...may be a valid
alternative for treating a variety of
posterior ankle problems including etiologic
PAIS lesions.
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SUBTALAR ARTHROSCOPY
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ANKLE JOINT SURGERY

• Posterior side
• - tarsal syndrome
• - posterior cyst
• - big bony spurs (Haglunds disease)

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SUBTALAR ARTHROSCOPY
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ANKLE JOINT ARTRHOSCOPY

• Posterior side
• - discover of new therapeutic opportunities by
  Nijk Van Dijk
• - posterior portals in arthroscopic treatment of
  joint and extra
• joint pathology through a risk area

Van Dijk NC et al. Arthroscopy, 2000 A 2-portal
endoscopic approach for diagnosis and treatment
of posterior ankle pathology
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SUBTALAR ARTHROSCOPY
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ANKLE JOINT ARTRHOSCOPY

• Posterior side
• - new prone assessment of the patient
• - same dedicated small instrumentation
• - posterior approach by triangulation through two
  posteromedial
• and posterolateral portals
• - no traction
• - no previous distension

Van Dijk NC et al. Arthroscopy, 2000 A 2-portal
endoscopic approach for diagnosis and treatment
of posterior ankle pathology
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SUBTALAR ARTHROSCOPY
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ANKLE JOINT ANATOMY

• Posterior side
• - validation of the proposed procedure by
  anatomic study
• - easiest way to reach the posterior gutter and
  to treat spotted
• joint pathology

Ljoi F et al. Arthroscopy, 2003 Posterior
approach to the ankle an anatomic study
Sitler DF, Amendola A, Bailey CS, Than LM, Spouge
A. JBJS, 2002 Posterior ankle arthroscopy an
anatomic study
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SUBTALAR ARTHROSCOPY
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ANKLE JOINT ANATOMY

• Posterior side
• - new procedure by prone position recently
  proposed by Sim JA
• - new posteromedial portal placed just posterior
  to the posterior
• colliculus of the medial malleolus lifting
  anteriorly the posterior
• tibial tendon
• - less easy way to reach the posterior gutter
  compared to the
• former, but big idea

Sim JA, Lee BK, Kwak JH Arthroscopy, 2006 New
posteromedial portal for ankle arthroscopy
courtesy Sim JA
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SUBTALAR ARTHROSCOPY
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ANKLE JOINT PATHOLOGY

• Posterior side
• - new proposed portals coaxial to the posterior
  malleolar line
• - authors consider this procedure easy and safe
  to reach the
• posterior tibiotalar recess
• - portals are equidistant to neurovascular
  structures compared to
• conventional portals
• - unclear the patient assessment

Acevedo J, Bush MT, Ganey TM, Hutton WC, Ogden
JA. Arthroscopy, 2000 Coaxial portals for
posterior ankle arthroscopy an Anatomic study
with clinical correlation on 29 pts
...our clinical results suggest this technique
for posteromedial and posterolateral portal is
safe, effective and reproducible.
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SUBTALAR ARTHROSCOPY
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POSTERIOR ANKLE ARTROSCOPY

• - many portals described
• - few completed anatomic studies on safety and
  respect of
• neurovascular bundle
• - prone positioning of the patient
• - procedures need triangulation or previous
  protection of TP
• tendon sheath
• - usual anesthesia
• - instrumentation for small joints depending
  surgeons request

the sharper the respect of original procedure the
safest the surgery, avoiding lesions of risk
structures
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SUBTALAR ARTHROSCOPY
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POSTERIOR ANKLE ARTROSCOPY

• many portals described
• - postero-medial
• - postero-lateral
• - postero-lateral accessory
• - transachilleous
• anatomic risk areas
• - posterior tibial artery
• - posterior tibial nerve
• - FHL tendon
• - small saphenous vein
• - saphenous nerve
• Van Dijk portals
• - postero medial
• - postero lateral

courtesy Ferkel RD
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SUBTALAR ARTHROSCOPY
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Van Dijk arthroscopic procedure

• - only posterior recess treatment
• - prone patient assessment
• - possibility of traction pulling by a belt
  around the surgeons
• waist
• - selected anesthesia

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SUBTALAR ARTHROSCOPY
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Van Dijk arthroscopic procedure

• original procedure
• - towel under the leg to lift the foot out the
  border of table
• - portals and anatomic risk areas to be marked
• - no inflation needed
• - triangulation of instruments on transverse
  plane
• - wide accuracy in exploring posterior joint
  recess and extra
• capsular space

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Posterior pathology

• Anatomic districts affected by spotted problems
• 1. posterior ankle joint recess
• 2. posterior ankle extrarticular space
• 3. posterior subtalar joint recess
• 4. posterior rearfoot area
• 5. Achilles' tendon front region

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SUBTALAR ARTHROSCOPY
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Posterior arthroscopic treatment

• ANKLE JOINT SPACE
• 1. ankle joint posterior gutters (between talus
• tibial and peroneal malleolus)
• 2. posterior subtalar joint
• KIND OF PATHOLOGY
• 1. posterior chondral defects
• 2. loose bodies
• 3. lesions of the posterior ligaments complex

26th AANA Annual Meeting ICL ADVANCED ANKLE AND
SUBTALAR ARTHROSCOPY
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Posterior arthroscopic treatment

• ANKLE JOINT SPACE
• 1. ankle joint posterior gutters (between talus
• tibial and peroneal malleolus)
• 2. posterior subtalar joint
• KIND OF PATHOLOGY
• 1. posterior chondral defects
• 2. loose bodies
• 3. lesions of the posterior ligaments complex

26th AANA Annual Meeting ICL ADVANCED ANKLE AND
SUBTALAR ARTHROSCOPY
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Posterior arthroscopic treatment

• ANKLE JOINT SPACE
• 1. ankle joint posterior gutters (between talus
• tibial and peroneal malleolus)
• 2. posterior subtalar joint
• KIND OF PATHOLOGY
• 1. posterior chondral defects
• 2. loose bodies
• 3. lesions of the posterior ligaments complex

26th AANA Annual Meeting ICL ADVANCED ANKLE AND
SUBTALAR ARTHROSCOPY
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Posterior arthroscopic treatment

• ANKLE JOINT SPACE
• 1. ankle joint posterior gutters (between talus
• tibial and peroneal malleolus)
• 2. posterior subtalar joint
• KIND OF PATHOLOGY
• 1. posterior chondral defects
• 2. loose bodies
• 3. lesions of the posterior ligaments complex

26th AANA Annual Meeting ICL ADVANCED ANKLE AND
SUBTALAR ARTHROSCOPY
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Posterior arthroscopic treatment

• ANKLE JOINT SPACE
• 1. ankle joint posterior gutters (between talus
• tibial and peroneal malleolus)
• 2. posterior subtalar joint
• KIND OF PATHOLOGY
• 1. posterior chondral defects
• 2. loose bodies
• 3. lesions of the posterior ligaments complex

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SUBTALAR ARTHROSCOPY
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Posterior arthroscopic treatment

• ANKLE EXTRARTICULAR SPACE
• 1. posterior extrarticular and extracapsular
• anatomic space
• - FHL tendon
• - symptomatic os trigonum
• - posterior adhesions with stiffness

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SUBTALAR ARTHROSCOPY
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Posterior arthroscopic treatment

• ANKLE EXTRARTICULAR SPACE
• 1. posterior extrarticular and extracapsular
• anatomic space
• - FHL tendon
• - symptomatic os trigonum
• - posterior adhesions with stiffness

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SUBTALAR ARTHROSCOPY
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Posterior arthroscopic treatment

• ANKLE EXTRARTICULAR SPACE
• 1. posterior extrarticular and extracapsular
• anatomic space
• - FHL tendon
• - symptomatic os trigonum
• - posterior adhesions with stiffness

26th AANA Annual Meeting ICL ADVANCED ANKLE AND
SUBTALAR ARTHROSCOPY
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Posterior arthroscopic treatment

• ANKLE EXTRARTICULAR SPACE
• 1. posterior extrarticular and extracapsular
• anatomic space
• - FHL tendon
• - os trigonum
• - posterior adhesions with stiffness

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SUBTALAR ARTHROSCOPY
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Posterior arthroscopic treatment

• ANKLE EXTRARTICULAR SPACE
• 2. rear extrarticular and iuxta tendon
• anatomic space Haglunds disease

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SUBTALAR ARTHROSCOPY
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Both compartments ankle pathology

• Anterior association with posterior recess or
  with rearfoot side
• What to do? Many questions on the table
• - which kind of solution must be adopted?
• - which kind of patient assessment has to be
  privileged?
• - has the surgeon change during surgery the pt.
  assessment?
• - at least, has the surgeon to propose the
  patient a two-time
• treatment?

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SUBTALAR ARTHROSCOPY
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Both compartments ankle pathology

• Solutions from the surgeons experience
• 1. double coaxial portals use
• limited to joint pathology only
• 2. prone posterior ankle approach firstly,
• anterior approach secondly with the knee
• in flexion and up-side down visualization

Acevedo J, Bush MT, Ganey TM, Hutton WC, Ogden
JA. Arthroscopy, 2000 Coaxial portals for
posterior ankle arthroscopy an Anatomic study
with clinical correlation on 29 pts
Van Dijk NC et al. Arthroscopy, 2000 A 2-portal
endoscopic approach for diagnosis and treatment
of posterior ankle pathology
26th AANA Annual Meeting ICL ADVANCED ANKLE AND
SUBTALAR ARTHROSCOPY
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Both compartments ankle pathology

• Solutions from the surgeons experience
• 3. double posteromedial portals in supine
  assessment, after
• anterior treatment
• - mild external rotation of the leg
• - portals anterior and postero-medial to be
  marked
• - longitudinal triangulation of the
  instruments
• - possibility to treat anterior and posterior
  problems into the
• joint and in the outer space

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SUBTALAR ARTHROSCOPY
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Both compartments ankle pathology

• Ankle joint simultaneous anterior and posterior
  (articular and
• extra articular) pathology
• - arthroscopic treatment of the anterior
  articular problems by
• standard anterior portals
• - scope access to the posterior joint recess or
  to the rearfoot
• area through two posteromedial portals
• - placement secondary to anatomic studies to
  validate the
• procedure

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Double posteromedial portal

• - placed in risk area because the neurovascular
  bundle
• - externally to FHL tendon well palpable under
  the skin
• - access long the anterior margin of Achilles
  tendon
• - presence of safe triangular area
• surrounded by calcanear
• tuberosity (inferior) FHL (anterior)
• Achilles tendon (posterior)
• - area wide almost 25-30 mm²

courtesy Ferkel RD
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Double posteromedial portal

• ANATOMIC TRIANGULAR AREA
• Well delimited by easy palpable anatomic
  structures as
• - upper calcanear tuberosity
• - posterior margin of FHL tendon which protects
  the tibial bundle
• - anterior margin of Achilles tendon

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Double posteromedial portal

• ANATOMIC TRIANGULAR AREA
• Around it lie some important anatomic path at
  risk
• - calcanear branch of posterior tibial nerve
  (motor and sensitive)
• - posterior tibial neurovascular
• bundle
• To avoid any unwished collision the
• surgeon must
• - gently move ahead the cannula from
• one of the portals to the peroneal
• compartment until touching
• - make a triangulation on longitudinal
• plane pushing the shaver from the
• second portal until seeing the tip

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SUBTALAR ARTHROSCOPY
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Surgical technique

• Supine assessment in mild leg external rotation
• - leg-holder with tourniquet
• - both anterior and posterior portals to be
  marked
• - possibility to keep the foot in traction
• - treatment of the ankle pathology in anterior
  compartment
• - external rotation of the surgical table

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Surgical technique

• - skin incision
• - from inferior portal the cannula is inserted
  along the superior
• calcaneal margin to peroneal malleolus
• - from superior portal the shaver proceeds to the
  same malleolus
• - on the posterior tibio -peroneal margin the
  instruments stop
• - triangulation of instruments on longitudinal
  plane
• - direct sight of tip of shaver
• - possibility to lead out surgery reversing the
  instruments

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SUBTALAR ARTHROSCOPY
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Surgical treatment

• - posterior ankle joint reachable
• - posterior margin exploration of lateral
  malleolus and talar dome
• - inferior margin of tibial plateau visible
• - posterior loose bodies removal
• - symptomatic os trigonum treatment
• - debridement of FHL tendon
• impingement
• - subtalar pathology assessment

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SUBTALAR ARTHROSCOPY
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Conclusions
low surgical morbidity
patient assessment not changed
both compartments one step treatment
anterior and postero-medial portals
safe reproducible procedure
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SUBTALAR ARTHROSCOPY
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THANK YOU FOR YOUR ATTENTION
26th AANA Annual Meeting ICL ADVANCED ANKLE AND
SUBTALAR ARTHROSCOPY