1. Ankle problems/procedures and techniques

2. Ankle Arthroscopy

3. Indications Diagnostic Treatment Impingement Removal FB Stabilisation
OCD’s
Fusion procedures

4. Set up is everything Mark out important structures like peroneal nerve
Think about traction
Inflate ankle with saline

5. Portals Anteromedial Anterolateral Medial to tib ant
Either side of peroneal nerve
Incise through skin only, use clip to bluntly get into ankle joint after inflating

6. What to look for 8 point anterior examination
Will need to switch camera from medial to lateral portal to see everything

7. Ankle instability
Physio is important to work on proprioception and peroneal recruitment and resolves most cases
Seen in the NHS as a more chronic picture were ATFL +/- CFL stretched with resultant poor propriception peroneal recruitment

8. Anatomy of lateral ligament complex

9. Diagnosis of ligament injury

10. Surgery for modified Brostrum
Use longitudinal incision as also allows access to peroneal tendons
Try and place anchors in position of ATFL and CFL

11. Ankle fusion Can do anterior or lateral approach
If lateral remove fibula (and can replace this if you want)
Can use plate or screws
Aim for neutral alignment with heel 5 degrees valgus
Remove all cartillage. Make sure you have petallated bed of bleeding cancellous bone

12. Open lateral approach with fibula osteotomy I
Take off fibula just proximal to ankle
Open ankle joint with Hinterman retractors
Use lateral talar process as landmark for first wire and go distal to proximal

13. Open lateral approach with fibula osteotomy II
Once length measured drill wire more proximally out through medial skin and place first screw ( don’t spear yourself)
Check on AP and LAT

14. Post op for ankle fusion
Non weight bearing 6 weeks in plaster
Further 6 weeks weight bearing in aircast boot
Physio at 8 weeks
If smoker usually add on extra 4 weeks to above

15. Arthroscopic ankle fusion
Will need traction
Make sure cartillage removed and subchondral bone exposed to allow to bleed
Fix with 2 percutaneous screws

16. Syndesmosis Injury 5-10% of ankle sprains
Rupture of the interosseous ligaments between the tibia and fibula with or without fibular fracture
Medial malleolar fracture or deltoid ligament rupture
Persistent instability and gap in the joint after bimalleolar fixation

17. Syndesmosis Exam Squeeze Test Abduction-External Rotation Stress Test
Squeeze the syndesmosis above the anklepain
Abduction-External Rotation Stress Test
Further instability with external rotation (may be shown with x-ray)

18. Syndesmosis injuries AP/LAT/OBLIQUE ankle x-rays Syndesmotic widening
Medial joint space widening
Presence of fibula FX
External rotation stress x-rays
Severe pain associated with normal x-rays
Must get tib/fib x-rays to rule out high fibula fracture

19. Syndesmosis surgical management
Gently dorsiflex hindfoot
Internally rotate to align fibula with tibia
Consider using large clamp if unable to reduce and internally rotate the fibula and compressing it to the tibia
Perform medial arthrotomy if unable to reduce in order to debride medial ankle joint

20. How big, how long and where to put it?
1 or 2: 3.5 or 4.5 mm cortical screws (no absolute evidence)
3 or 4 cortices (no evidence)
Placed cm superior to ankle joint line parallel to ankle joint from the posterolateral fibula to the anteromedial tibia
Screws are not lagged!
Posterior

21. Tightrope for fixation
Potentially better reduction of syndesmosis
No need to remove
Earlier weight bearing