Chapter 12 — Ankle Arthroscopy Chapter 12 Ankle Arthroscopy Introduction Arthroscopic surgery of the ankle and hindfoot i increasingly popular. Arthroscopy for visualization of joints was reported in cadavers in 1931, this included the ankle! The advantage of arthroscopic surgery i in having a technique that can assist with both diagnosis and treatment of pathologies inthe ankle and hindfoot, while minimizing the collateral damage tothe sof tissue envelope, The aim isto reduce the morbidity associated with the so tissue stripping, allowing early discharge from hospital, faster rchabilitation, improved healing, and fewer complications. Classically, arthroscopy is used for intra-articular pathologies, although its versatility has led to a more recent increase in its use for tendon and ligament abnormalities Initial Assessment Arthroscopy is a surgical tol. Itis only employed after meticulous assessment, both clinically and radiologically. es, and to counsel t The aim of clinical assessment isto establish a diagnosis, its functional impact, to record the patient's comorbid patient as tothe expected outcome of the arthroscopic intervention, Clinical assessment uses the systematic interview technique and features ff exemination outlined in Table 12.1 Table 12.1 The core elements of history and examination HistorySymptoms Soreness, tfness, swelling, stability, shape Function Mobility, work, activities of daily living, sport Examination Shope Coronal-sagital Swelling Soft issu-bony Gait Velocity sti; length: cadence Stance tests Ski stance dorsiflexion, double stance hee! ase, single stance heel raise, weightbearing supination, hoe! rock Tendemess Range of movement Active-passve Compensatory Stress tests Neurology Vaselarity Radiological examination should include a weightbearing AP view of the ankle, with an additional mortise view if deemed neces \weightbearing lateral view ofthe whole foot and ankle; a dorsoplantar weightbearing view ofthe foot; and an oblique view ofthe foo ‘Additional views may be of assistance, for example a limb alignment view for assessment of deformity, and an ankle anteromedial oblique impingement view is helpful for medial bony impingement from talar neck osteophyjes. Computed tomography scanning is useful to evaluate deformity, the presence of occult arthritis, tarsal coalitions, and occult fractures. The use of SPECT-CT scanning may be helpful in better localizing pathology. Magnetic resonance imaging ean provide useful ationalinformation regarding the Sof tissue envelope, particulary th ligaments and tendons, but also the presence of bone edema, infection, and «avascular necrosis (AVN), Ultrasound isa valuable dynamic tool, particularly in the assessment of pathology and trauma in tendons and ligaments. Image guided joint injections of local anesthetic and contrast medium also help in localization, Ankle Arthroscopy Avvatiety of techniques of positioning and joint distraction are availabe. The authors prefer a simple setup, with the patient placed supine in ‘a marginal head-down position. An ipsilateral bolster under the buttock is used to correct extersal rotation and align the aakle in neutral position, The lower legis placed on a thick cushion, flexing the knee to approximately 20°. Traction, if required, can be applied through an ankle strap, attached 10 a fixed arm atthe end ofthe table (Figure 12.1) The traction is increased and decreased not by any complex ‘mechanism, but by elevating or depressing the end of the table. The standard 30°, 4,0 mm arthroscope is the workhorse, but narrower diameters (2.7 mm "Panviston”) are preferable for smaller and tighter ankles, as well as for children, A reliable and stable fluid-management system with a relatively low-pressure setting is employed. A camera system should allow an adjustment of aperture and of focus. It shou ‘be routine to record pictures or videos. —— Figure 12.1 Shows the position to allow traction, with the knee slightly bent and the initial access achieved with a hypodermic needle. A4.0 ‘mm arthroscope is inserted in the anteromedial portalAn initial “examination under anesthe fare used regularly Figure 12.2) should be recorded, This should include stability in the sagittal and coronal planes. Three portals + the anteromedial, which is medial tothe tibialis anterior ‘the medial midline, between the tbi is anterior and extensor hallucis longus «+ the anterolateral, which is just lateral tothe extensor digitorum longus. ‘The level ofthe ankle joint is usually determined witha small hypodermic needle. The tibialis anterior, the extensor digitorum longus, and the lateral branch or trunk of the superficial peroneal nerve are marked if possible. A technique for identifying the superficial peroneal nerve in thinner patients isto hold the fourth te plantar flexed and invert the foot. The nerve can usually be seen and felt subcutaneously. Its important fo note that the structures ean shift horizontally when traction is appliedFigure 12.2 The commonly used anterior portals for ankle arthroscopy. Red: anteromedial; mauve: medial midline; yellow: anterolateral ‘The anteromedial and anterolateral portals are the most commonly used. The medial portal is established first, with a skin incision being made witha knife followed by deep dissection tothe joint with fine scissors. blunt trocar within the arthroscope sheath is then used to establish access, before introducing the arhroscope into the anterior recess ofthe ankle. While traction allows easy initial access to the joint, itis often necessary to release the traction before undertaking surgery inthe anterior recesses of the ankle, as the ligament distraction increases soft tissue tension and thereby increases the risk of neurovascular injury. Ifthe anteromedial poral is established first, the light can ‘be used to transilluminate the Iatral superficial structures and reduce the risk of damage tothe superficial peroneal nerve, Once the to portals are established the initial view may be limited by fat, synovitis, or scarring within the anterior gutter. This can be removed using a 3.5 power-assisted shaver with suction. Care should be taken to keep the esection device facing backward into the joint to prevent introgenic damage o the anterior neurovascular bundle. Once the anterior gutter is cleared, a systematic review of the ankle can be performed (Figure 12.3),Figure 12.3 The systematic review of the ankle joint. 1: tbiofibular syndesmoss; 2: tibial plafond; 3: talar dome; 4: posteromedial recess 5 anterior margin ofthe tibia,Systematic review of the joint starts on the opposite side of the joint to the primary portal. Thus we work from the anterior inferior tibiofibular ligament visualizing the tibiofibula syndesmoss, the articular surfaces of the lateral sides ofthe talus and the tibia the posterior recess ofthe inferior tibiofibular join, the posterior inferior tibiofbular ligament, andthe posterior transverse intermalleolar ligament. This leads you across tothe posteromedial comer. As one returns anteriorly, the superior pat of dhe medial gutter ean be inspected with the ‘medial surfaces of the joint, Once you have returned to the anterior recess the traction ean be temporarily removed and the deeper part of the ‘medial gutter and the deltoid ligament can be visualized. The anterior recess can be futher inspected ~ particulary the talar neck. This brings you back wo the lateral gutter allowing you to view the anterio:taloibular ligament, At this point its important to check the stability ‘of the inferior tibiofbular joint with the traction off, Atal stages, the joint surfaces ofboth the tibia and talus should be carefully reviewed. Posterior Ankle Arthroscopy Approaches to the posterior ankle joint and posterior subtalar joint can be performed with the patient in the prone postion? orth lateral position. No distraction is required, Posteromedial and posterolateral portals can be used adjacent to either side ofthe tendo Ackil, atthe level ofthe tp ofthe fibula. It is necessary to take care to avoid damage tothe sural nerve laterally and the posterior tibial nerve medially daring poral placement. Alternative poral placements may be helpful. Ifthe patient is inthe lateral postion the ankle ean be instrumented or visualized through two posterolateral incisions ~ one close tothe peroneal tendons and one close tothe tendo Acbillis. The arthroscape is introduced into the lateral portal A soft tissue resector is then introduced medially (Figure 12.4). The resector is tapped against the arthroscope and then, when localized, the esectoris used to clear a space inthe ft. Asa pocket is created the visualization improves and the FHL tendon comes into ‘view. Ibis critical to remain lateral (othe FHL tendon, until adequate visualization is obtained ~ this avoids inadvertent damage tothe posterior tibial artery and nerve (Figure 12.5). Once the posterior ankle capsule and fa are removed, the transverse tibiofbular and {ulofibular ligaments, the posterior ankle joint, and the subtalar joint can be viewed,Figure 12.4 The set up for posterior ankle and subtalar arthroscopy, The “bad” leg is down, The enkle (superior) and subtalar portals are marked,Figure 12.5 The erthroscope is introduced toward the second toe, The shaver i introduced medially, and loceted initially by tapping it ‘agains the arthroscope, Soft Tissue Pathology ‘The pathologies affecting the synovium and sof tissues are numerous and are outlined in Table 12.2. A common indication for arthroscopy is persistent anterior ankle pain, with or without instability following an ankle “sprain.” The patient usually presents with anterolateral pain, fiom synovitis, Abrosi, o searing, which impinges on ankle dorsiflexion’. The impingement i from a mas of fibrotic tissue, which builds ‘up in the anterolateral ankle and resembles the meniscus ofthe knee ~ a “meniscoid lesion” (Figure 12.6a). Arthroscopic resection is easily undertaken with a soft tissue shaver, Such surgery has 2 90% rate of success with purely soft tissue lesions“ but the success rate is lower if there is articular surface damage or arthrosis. It is important to also asses the syadesmosis®, and deltoid ligament, Impingement lesions can also occur anteromedislly or posteriorly. On occasions the inferior margin of the anterior inferior tbiofibular ligament ean impinge on the ltr ala dome — in this as its known as asset's igament Figure 12.60), Artrosepie esestion ofthe prominent ligament i Aective Table 12.2 The soft tissue pathologies seen during ankle arthroscopy Soft tissue and synovial pathologyInfection Inflammation: | inflammatory arthropathy crystal arthropathy, hemophilia Neoplasia: | pigmented villonodular synovitis, synovial osteochondromatosis Degenerative: | post-traumatic, degenerative Trauma: fibrosis, ligament injures, scarring, impingeme: Figure 12.6(a) A meniscoid lesion,(©) A Bassett’s ligament (arrow) that was impinging on the tala dome Bony Pathology Anterior bony impingement ofthe ankle is a common indication for arthroscopy. The usual sites are an anterolateral tibial or a medial tear ‘neck osteophyte. Osteophytes also occur on the anterior edges, as well as the tips, ofthe medial and lateral malleli. They may also be seen fon the lateral shoulder ofthe neck ofthe talus. Removal of an anterior tibial osteophyte is performed using a 3.5 mm barrel bur, introduced ‘through the anterolateral portal. The normal tibia above the osteophyticshel(is identified and the osteophyte is resected to a level flush with the anterior face ofthe tibia. Adequate resection is also marked when the articular cartilage returns to normal. Repeated dorsiflexion of the ankle helps identify adequate clearance ofthe impingement. The areas that are easily missed include the extreme anterolateral corner of the tibia, and the front of the medial malleolus. Results suggest 90% of patients are improved following surgery although this is reduced 10 5 if the joint space is narrowed on preoperative radiographs" Ithas also been shown that ossicles that ate symptomatic and enhance on MRI scanning respond well to arthroseapic excision!” [As well as anterior impingement, posterior ankle impingement syndrome is increasingly recognized in ballet dancers and athletes, The typical history is of posterior, or posteromedial, ankle pain worsened by plantar flexion, Posterior ankle impingement is thought to arise ‘fom osseous impingement between the posterior process ofthe tals, or anos trigomum, and the tibia, Secondary inflammation may occur in the mobile ankle, leading to mechanical entrapment of the FHL tendon, This typically oceurs asthe FHL runs posterior tothe talus, ‘between the medial und lateral talar tubercles, In about 7% of the population an os trigonum lying just posterior tothe lateral tubercle, wich is the more prominent of the two tubercles, is present. In some individuals the lateral tubercle is long, in which case itis called a Stieda’s process. Theos trigonum or Stieda’s process can be excised with a posterior ankle arthroscopy (Figure 12.7), and provides 80% good or ‘excellent results a two to five years’ follow-up!"Figure © space posterior tothe ankle is cleared of ft, staying lateral to the FHL. An os trigonum (OT) and the subtalar joint (STI) areJoint Surface Pathology Joint surface lesions include chondral lesions, osteochondral lesions, cysts, and arthritis. All ofthese lesions produce persistent deep-seated, pain, etching, locking, and instability, with swelling from the associated synovitis. Following ankle injury these deep symptoms are ‘differentiated {rom sof tissue pain or impingement, which tend to cause anterior joint line pain [Even ifthe MRI does not show an articular surface lesion, arthroscopy may well reveal joint laxity, ligament damage, synovitis, fibrosis, a _meniscoid lesion, chondral damage'”, and loose bodies. Tibial and talarosteophytes may be identified and treated, ‘The Bemat and Hardy radiological classification of osteochondral lesions ofthe talar dome has been updated to an MRI classification, as ‘only about 50% of osteochondral defects are visible on plain radiographs, The MRI classification is: + Stage I: Aricular cartilage injury only ‘+ Stage IIA: Cartilage injury with bony fracture and edema ‘Stage IB: Stage IIA without bony edema + ‘Stage Ill: Detached but undisplaced bony fragment ‘Stage IV: Detached and displaced fragment + ‘Stage V: Subchondeal eyst formation Lesions ofthe lateral talar dome ate said to be superficial with choxdral flaps (Figure 12.8a). Posteromedial lesions are said to be typically deeper and associated with osteochondral cysts. There isa range of treatments including microfracture, osteochondral grafting, chondrocyte implanation, and even the implantation of particulsted juvenile articular cartilage. Microftacture, with the creation of holes inthe subchondral plate 3 to 4 mam apart (Figure 12.8b) stimulate the bone maerow to produce fibrocertlaginous cover, has been reported as ‘ving good results in 80 to 85% of lesions that ae less than 15 mm in diameter, However, poorer outcomes, with less thaa 50% good results, are seen in eystic lesions", and lesions larger than 15 mm'®, There is evidence that bone grafting can produce comparable results to ‘microfracture. Early weight bearing following microstacture gives equal results to non-weightbearing™™ Figure 12.8(9) A lage talar dome flap will always have exposed bone underneath it(©) A medial lesion, which has been debrided and microfractured Success has been reported with repeat arthroscopic surgery"”-'8, when the firs arthroscopic operation fails. Nevertheless, in treating larger cystic lesions and those cases where microfracture has failed a Variety of techniques can be used. Cylindrical osteochondral autografing, or _mossicplasty, has been reported as having 87% excelent or good results, althougls concerns remain about the knes, from which the graft is ‘often harvested. Osteochandral allografts have also been reported to give satisfactory results ‘An alternative is autologous chondrocyte implantation (ACD, which can be embedded within a matrix (MACD. This is a two-stage procedure. In the first stage, the chondrocytes are harvested. They ae then cultured. The cultured chondrocytes are then reintroduced, eit ‘embedded in a matrix (MACD, or not (ACD. The results of these techniques appear comparable. A meta-analysis of AC inthe talus showed ‘an overall clinical sucess rate of 89.99%”, Isolated lesions ofthe distal tibia are much rarer than tala lesions; nevertheless, the success rate of arthroscopic treatment appears to be similar to that for talar dome lesions? Arthritis Ankle arthroscopy can be used in two ways forthe treatment of ankle arthritis: firstly, to debrde the joint; and, secondly, to fuse the joint. The value of arthroscopic debridement ofthe arthritic ankle is open to debate, Although the removal of flaps and loose bodies ean be of assistance with mechanical symptoms, it should be noted that 90% of patients without joint space narrowing have good or excellent results after excision of the anterior tibial osteophyte, whereas only 50% of patents with joint space narrowing on preoperative weightbearing radiographs had good or excellent results. Furthermore pain relict at two years aftr surgery was significantly improved in the pure enterior impingement group, but not the group with joint space narrowing”. Care should also be taken in those cases where the joint is clearly starting to sublux inthe sagittal plane. In chose patients with end-stage arthritis the roe of arthroscopic surgery lies with arthroscopic ankle arthrodesis,