Ankle problems/procedures and techniques

Ankle Arthroscopy

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

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

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

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

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

Anatomy of lateral ligament complex

Diagnosis of ligament injury

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

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

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

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

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

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

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

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)

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

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

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 1.5-2.0 cm superior to ankle joint line parallel to ankle joint from the posterolateral fibula to the anteromedial tibia Screws are not lagged! Posterior

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