28 Ankle Arthroscopy

10.1055/b-0040-174151

28 Ankle Arthroscopy

C. Lucas Myerson, Jimmy J. Chan, and Ettore Vulcano

Summary

The origins of arthroscopy can be traced back to Kenji Tagaki, who is considered the father of arthroscopy. ¹ Burman was the first to use arthroscopy in the ankle in 1931. Today, arthroscopy can be used to perform a variety of procedures including debridement, synovectomy, loose body removal, cartilage modification, and biopsy. The procedure offers a minimally invasive approach that allows for the direct visualization of joint anatomy. Success of this procedure varies according to the type of pathology encountered and the modalities pursued, once the portals have been established. As always, the understanding of local anatomy is the key to success with arthroscopy.

28.1 Portal Anatomy

Anteromedial portal. Medial to tibialis anterior tendon, lateral to the medial malleolus at the level of the ankle joint ² (▶Fig. 28.1)

Take care to avoid the long saphenous vein and nerve, located medially to this portal.
Anterolateral portal. Lateral to the extensor digitorum longus tendon, medial to lateral malleolus, at level of or just proximal to joint line (▶Fig. 28.1)

Note that this portal lies near a branch of the superficial peroneal nerve. The superficial peroneal nerve is the most commonly injured nerve in ankle arthroscopy.
Posterolateral portal. Posterior to peroneus longus tendon, anterior to Achilles tendon, at the level of the bimalleolar axis
- This portal lies in close proximity anterior to the sural nerve.
- Typically, a combination of the anterolateral, anteromedial and posterolateral portals is sufficient to adequately visualize the entire joint.
Posteromedial portal. Posterior to posterior colliculus of medial malleolus and anterior to posterior tibial tendon, at the level of the bimalleolar axis

**Fig. 28.1** The image demonstrates the location of the standard anteromedial (AM) and anterolateral (AL) ankle portals.

Caution not to injure the posterior tibial neurovascular bundle, which lies posterior to the portal.

28.2 Preop

Location of the pathology should guide the approach, distraction technique, and instrumentation utilized.
Diagnostic anesthetic injections can locate the site of pathology. ³
Imaging may also be used to determine ideal portal type. Standard anterior portals are used to address pathologies of the anterior and central tibiotalar joint. Posterior portals may be utilized to address posterior lesions of the talus or the posterior capsule.
Surgical table. Standard operating table
Patient positioning. Supine, with towel roll placed under ankle and the foot resting within 10 cm of the edge of the bed. Place a towel under the ipsilateral hip to internally rotate the leg such that the foot is perpendicular to the table.
Place either a thigh tourniquet or a calf tourniquet. If a calf tourniquet is used, make sure to place it below the level of the fibular head.
Flex the ipsilateral hip to 45–60 degrees and place the posterior thigh in a padded thigh holder or multiple blankets. Secure the thigh with straps if using a holder. Avoid compression of the popliteal fossa by ensuring that the thigh rests in the holder ² (▶Fig. 28.2).
Identify and mark the superficial peroneal nerve, which can be identified running a course anterior and inferior to the lateral malleolus. Plantar flex and invert the foot to facilitate identification.
Prep and drape the operative field in the usual fashion.