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Foot and Ankle Arthroscopy

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1 Foot and Ankle Arthroscopy
Practical Aspects and Indications RJ Stillwell, MS4

2 Arthroscopy Advantages
Minimal soft tissue dissection Small capsular incisions Decreased postoperative pain Decreased stiffness Early return to function

3 Practical Aspects of Arthroscopy
Arthroscopes 4.0-mm / 2.7-mm 30 deg / 70 deg arthrodesis

4 Practical Aspects of Arthroscopy
Hand Instruments Picks / Osteotomes arthrodesis

5 Practical Aspects of Arthroscopy
Hand Instruments Probes Marked for use as a measuring device. 1-mm to 2-mm increments.

6 Practical Aspects of Arthroscopy
Hand Instruments Curettes – cupped / ring Marked for use as a measuring device. 1-mm to 2-mm increments.

7 Practical Aspects of Arthroscopy
Power Instruments Cutters / Shavers / Burrs / Abraders Thermoablation – RF wands / YAG laser Aspiration when attached to suction Aspiration pulls tissue towards instrument, closer to cutting edge.

8 Practical Aspects of Arthroscopy
Power Instruments Shavers – side-cutting / open-ended / full-radius Smooth / single incisor / double incisor The side-cutting shaver has a small window that does not allow exposure to the blade’s distal tip. These are the least aggressive of the power instruments. The open-ended shaver is the most aggressive and has the distal tip of the blade exposed. Probably the most commonly used is a combination of the 2 types, which is called a full-radius shaver. It has only partial exposure of the tip of the blade and the side-cutting window Teeth on barrel and on the blade

9 Practical Aspects of Arthroscopy
Patient positioning Supine / stirrup / distraction Lateral decubitus for STJ Anesthesia Hemostasis Tourniquet / epi Supine Ipsilateral hip bump Knee flexed? Hang foot over edge of table?

10 For 1st MTPJ – fingertrap or mini-rail

11 Draw anatomical landmarks prior to exsanguination.
Distend joint with mL saline. Can use 1%lido/epi to insufflate. Hang lactated ringers in 3L bags. Can inject epi into the 1st bag. Tourniquet also for visualization

12 Antero-medial portal The course of the superficial peroneal nerve in relation to the ankle position: anatomical study with ankle arthroscopic implications Peter A. J. de Leeuw,1 Pau Golanó,2 Inger N. Sierevelt,3 and C. Niek van Dijk3 Despite the fact that the superficial peroneal nerve is the only nerve in the human body that can be made visible; iatrogenic damage to this nerve is the most frequently reported complication in anterior ankle arthroscopy. One of the methods to visualize the nerve is combined ankle plantar flexion and inversion. In the majority of cases, the superficial peroneal nerve can be made visible. The portals for anterior ankle arthroscopy are however created with the ankle in the neutral or slightly dorsiflexed position and not in combined plantar flexion and inversion.  The mean superficial peroneal nerve movement was 2.4 mm to the lateral side when the ankle was moved from 10° plantar flexion and inversion to the neutral ankle position and 3.6 mm to the lateral side from 10° plantar flexion and inversion to 5° dorsiflexion. Both displacements were significant (P < 0.01). In a series of 612 patients presented by Ferkel et al,89 the overall complication rate was 9.8%, or 51 complications in the group. The most common complication was neurologic (49%), primarily involving the superficial peroneal nerve (56%), saphenous nerve (24%), and sural nerve (20%). Other complications include superficial infection, deep infection, adhesions, fractures, instrument failure, ligament injury, and incisional pain (Fig ).

13 ANTERO-LATERAL PORTAL

14 Anatomy Topographic Foot Ankle Int. 2000 Oct;21(10): Fourth toe flexion sign: a new clinical sign for identification of the superficial peroneal nerve. Stephens MM, Kelly PM.

15 Anatomy Topographic The course of the superficial peroneal nerve in relation to the ankle position: anatomical study with ankle arthroscopic implications. Peter A. J. de Leeuw,1 Pau Golanó,2 Inger N. Sierevelt,3 and C. Niek van Dijk3 The course of the superficial peroneal nerve in relation to the ankle position: anatomical study with ankle arthroscopic implications Peter A. J. de Leeuw,1 Pau Golanó,2 Inger N. Sierevelt,3 and C. Niek van Dijk3 Despite the fact that the superficial peroneal nerve is the only nerve in the human body that can be made visible; iatrogenic damage to this nerve is the most frequently reported complication in anterior ankle arthroscopy. The mean superficial peroneal nerve movement was 2.4 mm to the lateral side when the ankle was moved from 10° plantar flexion and inversion to the neutral ankle position and 3.6 mm to the lateral side from 10° plantar flexion and inversion to 5° dorsiflexion. Both displacements were significant (P < 0.01).

16 DIAGNOSTIC ARTHROSCOPY?
Imaging inconclusive? Diagnostic injections? Conservative treatment exhausted? Diagnostic? Direct visualization is often the most reliable way to see chondromalacia or the extent of another diagnosis that one may or may not appreciate on MRI. When a patient has persistent ankle pain that is relieved by a diagnostic injection yet demonstrates negative findings on X-ray, CT or MRI, he or she is a good candidate for a diagnostic ankle arthroscopy. In these cases, one must ensure the patient has a proper understanding (and has given his or her consent) that the purpose of the surgery is to attempt to diagnose a problem, not necessarily fix the idiopathic pain. In this scenario, ankle arthroscopy can be a last option. Surgeons should first attempt conservative treatments including physical therapy, custom orthotics or ankle foot orthosis, and perhaps an occasional soluble cortisone injection

17 ANKLE WASHOUT? Cochrane Database Syst Rev. 2010 May 12;(5):CD007320.
Joint lavage for osteoarthritis of the knee. CONCLUSIONS: Joint lavage does not result in a relevant benefit for patients with knee osteoarthritis in terms of pain relief or improvement of function. N Engl J Med. 2002 Jul 11;347(2):81-8. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. Sham-controlled - outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure. Diagnostic? Direct visualization is often the most reliable way to see chondromalacia or the extent of another diagnosis that one may or may not appreciate on MRI. When a patient has persistent ankle pain that is relieved by a diagnostic injection yet demonstrates negative findings on X-ray, CT or MRI, he or she is a good candidate for a diagnostic ankle arthroscopy. In these cases, one must ensure the patient has a proper understanding (and has given his or her consent) that the purpose of the surgery is to attempt to diagnose a problem, not necessarily fix the idiopathic pain. In this scenario, ankle arthroscopy can be a last option. Surgeons should first attempt conservative treatments including physical therapy, custom orthotics or ankle foot orthosis, and perhaps an occasional soluble cortisone injection

18 Arthroscopy Dec;25(12): Evidence-based indications for ankle arthroscopy. Glazebrook MA, Ganapathy V, Bridge MA, Stone JW, Allard JP.

19 Scranton PE Jr, McDermott JE. Anterior tibiotalar spurs: A
comparison of open versus arthroscopic debridement. Foot Ankle. 1992;13: Shorter recovery time with arthroscopy The bigger the spur, the longer the recovery

20 Kim SH, Ha KI. Arthroscopic treatment for impingement of the anterolateral soft tissues of the ankle. J Bone Joint Surg Br 2000;82: Anterolateral impingement of the ankle should be considered in a patient with chronic anterolateral pain after an injury, regardless of the stability of the ankle.

21 It has been noted that early resection of impinging synovium inhibits the progression of the cascade to chronic synovitis and scar-tissue formation. Meislin RJ, Rose DJ, Parisien JS, et al. Arthroscopic treatment of synovial impingement of the ankle. Am J Sports Med 1993;21:186–9.

22 Bassett FH, Gates HS, Billys JB, et al
Bassett FH, Gates HS, Billys JB, et al. Talar impingement by the anteroinferior tibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain. J Bone Joint Surg Am 1990;72:55–9.

23 Osteochondral Lesions

24 Osteochondral Lesions

25 Osteochondral Lesions
Perpendicular edges provide a circumferential barrier to hold the fibrocartilage plug in place during the healing process. Promote bleeding of the trabecular bone beneath the subchondral bone plate to facilitate fibrocartilage formation.

26 Osteochondral Lesions

27 Osteochondral Lesions
Ferkel RD, Zanotti RM, Komenda GA, et al. Arthroscopic treatment of chronic osteochondral lesions of the talus: long-term results. Am J Sports Med 2008; 36(90):1750–62.

28 Osteochondral Lesions
For arthroscopic debridement of OCD lesions associated with any technique of subchondral bone penetration (curettage, drilling, or microfracture) in lesions under 15 mm in diameter, there is no evidence that one technique is superior to another.

29 Osteochondral Lesions
Parisien JS. Arthroscopic treatment of osteochondral lesions of the talus. Am J Sports Med 1986;14: Compared 10 patients who were non–weight bearing for 6 weeks with 8 patients who were allowed to bear weight as tolerated after an arthroscopic debridement and curettage or drilling. There was no difference in outcomes, with good results in nearly 90% of patients in both groups.

30 Ankle Arthrodesis Myerson and Quill published the first comparative study between open and arthroscopic ankle arthrodesis. They noted a similar fusion rate (94% v 100%), but significant shorter time to fusion in the arthroscopic group (8.7 weeks) compared with the open group (14.5 weeks). Myerson MS, Quill G. Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment. Clin Orthop Relat Res 1991:84-95.

31 Ankle Arthrodesis Gougoulias NE, Agathangelidis FG, Parsons SW. Arthroscopic ankle arthrodesis. Foot Ankle Int 2007;28: Gougoulias compared patients with arthroscopic ankle fusions that had minor deformity before surgery with patients who had varus or valgus deformity of more than 15° (maximum, 45°). There was 1 nonunion in each group, and the mean time to union was similar (13.1 and 11.6 weeks, respectively). Outcomes were similar, with good results in 79% and 80%, respectively. The authors suggested that contrary to the generally accepted opinion that deformity over 15° is a contraindication to arthroscopic ankle fusion, a good correction and fusion rate could be achieved with arthroscopic ankle arthrodesis in those patients.

32 Ankle Arthrodesis

33 Ankle Arthrodesis

34 LESS EVIDENCE Loose bodies Arthrofibrosis Fractures Septic arthritis
OA? Two questions are arising: Does this procedure put to a good purpose and is it of benefit in each case? Which are the risks and complications having to be exspected? The availability of non-invasive diagnosis has to be taken into consideration answering these questions. The relatively high number of neurologic complications was especially striking, in 16 cases we found a temporary neurologic deficit. In order to avoid injuries of the neurovasular structures the joint is distended by a lavage solution. In 116 patients we performed an arthroscopy of the ankle joint. 87 patients were followed up to a mean period of 38.4 months after arthroscopy (SD:21.35). The patients age ranged from 10 to 70 years (mean age: 33 y.). The indications are presented in Fig % of the patients had suffered from trauma, 4 patients had applied for retirement preoperatively. In opposition to other authors (Tab. 1) we feel that severe degeneration and unclear preoperative diagnosis are contraindications for arthroscopy.

35 Subtalar Arthroscopy Sinus Tarsi Syndrome
Interosseous ligament / cervical ligament Arthrofibrosis / synovitis Soft tissue impingement Os trigonum Arthrodesis

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40 First MTPJ Arthroscopy
Osteochondral lesions Synovitis Loose bodies Arthrofibrosis Osteophytes limiting dorsiflexion Sesamoid pathology Excision of gouty tophi

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43 Tendoscopy Peroneus Longus / Brevis FHL Tibialis Posterior
Achilles Tendon

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