First, the ankle is anesthetized. Using approximately 5 cc of lidocaine (plain or with epinephrine) anesthetize the traditional portal areas. Then insert an 18 gauge needle through one of the portals past the ankle joint capsule and inject approximately 5–6 cc of local anesthetic. This will provide both anesthesia and distention of the ankle joint. An additional 15 cc of normal saline is then injected for further distention of the joint. If general anesthesia is used, a thigh tourniquet can be utilized and inflated to 350–400 mmHg. When local anesthesia is used, a high ankle tourniquet can be applied and inflated to 250–300 mmHg.4 Some surgeons prefer not to place local anesthetic within the joint pre-operatively, but rather, anesthetize the joint ­proximally. This is due to the fact some prefer not to use a tourniquet in order to verify bleeding during marrow stimulation techniques, i.e., microfracture. An arthroscopic “Dual Wave^TM” pump (Arthrex, Inc, Naples, FL USA) is preferred to maintain joint ­distraction (usually at 35 mmHg) and is an alternative to a tourniquet.

Using a noninvasive technique, distract the ankle joint.21,22 The first portal is anterior at the ankle level, lateral to the anterior lip of the medial malleolus, and medial to the tibialis anterior. It should be made midway between these two structures (Fig. 16.4). Make a 6-mm incision right at the anterior aspect of the joint and use a mosquito hemostat to bluntly dissect down to the capsule. The subcutaneous tissue is examined for neurovascular structures. Seeing none, the incision is deepened through the capsule and immediately fluid should be noted. Next insert the obturator and cannula (Fig. 16.5). At this time the obturator is removed, and the arthroscope is inserted through the cannula and connected to irrigation (ingress). Keeping the foot dorsiflexed while inserting instruments during anterior arthroscopy helps protect the articular surfaces. One should have a constant ingress and egress of fluid (often through another portal or attached to a shaver to allow for suction) to ensure the joint is distracted at all times while the arthroscope is in place; this will avoid damage to the cartilage surfaces, while allowing clearing of debris.4,5,23 Then we rotate the arthroscope laterally at the anterior aspect of the joint until visualization is made of the two branches of the superficial peroneal nerve, the intermediate dorsal cutaneous nerve, and the medial dorsal cutaneous nerve (Fig. 16.6). With the light shining from beneath (transillumination), a lateral incision is made between the two branches, which should be just lateral to the extensor digitorum longus tendon but medial to the anterior lip of the fibular malleolus right at the ankle level (Fig. 16.6). Next a 6-mm incision is made here and deepened using blunt dissection with a hemostat. The area is examined for any possibility of neurovascular structures which might be damaged when inserting the cannula. Next, an obturator and cannula are inserted until fluid return is noted after puncturing the synovial membrane. The arthroscope is then removed from the medial portal leaving cannula intact. The arthroscope is now inserted laterally, and examination of the joint can proceed (Fig. 16.7). At this stage, it is important to examine the area in front first which is the lateral shoulder and gutter (Fig. 16.8). Next, we focus our attention medially, going across the joint into the medial shoulder and then the medial gutter (Fig. 16.9). For better visualization, the arthroscope is now removed with the cannula left intact laterally and the arthroscope is now inserted into the medial cannula and examination of the medial gutter and then the posterior aspect of the joint can take place (Fig. 16.10). Once the arthroscope is in position and proper ingress and egress of fluid is established, use the full radius 3.5-mm shaver to clear away any hypertrophic synovium to get a better view of the talar defect. The lesion can then be treated via subchondral drilling, microfracture, curettage, or abrading the base.4,24

A technique to access difficult-to-visualize (and instrument) lesions was described by Grady and Hughes.25 If the defect is noted to be located within the posterior medial half of the talar dome and cannot be adequately accessed, a Micro Vector drill guide can be used to create an additional portal through the medial malleolus.25 (Fig. 16.11) The guide is made up of two curved articulating arms at 170° with constant alignment of the probe and guide regardless of the arm position. A 0.45, 0.62, or 0.125 k-wire guide is available with serrated tip to maintain bone position. The trephine used is 5.1 mm. Simply align the probe through existing medial portal and line up the adjustable end of the guide to the medial malleolus. The guide arms intersect (Fig. 16.12). Once the position is established, lock the hinge, and insert the 0.62 k-wire through the guide into the defect. Leaving the k-wire in place, remove the guide and bluntly dissect around the k-wire down to the medial malleolus. Next, a 5.1 mm trephine is placed over the k-wire and a core of bone is removed to access the ankle joint (Fig. 16.13). The defect should now be accessible for subchondral drilling using a 0.62 k-wire. This technique is designed to avoid potential “overheating” of bone which can occur during trans-malleolar and talar drilling (Fig. 16.14). Once completed, simply reinsert bony plug back into medial malleolus and repair periosteum using 3–0 vicryl. Next, release the joint distractor and suture the portal sites. The postoperative course should consist of a non-weight- bearing cast immobilization for 6–8 weeks if any windowing was performed. If the lesion was accessible via traditional portals, it is important to establish range-of-motion as soon as possible to prevent any adhesions from occurring and immediate weight-bearing is encouraged.23,26,27 More detail on treatment of talar defects is found in Chap. 8 in the Sports Medicine section of this text.

The first description of the ankle joint arthrodesis by Albert is dated back to 1879. Since then, an ankle fusion technique has been evolving from external to internal fixation including numerous implanted devices and cancellous screws. The latter increased the number of successful fusions and diminished the rate of complications such as infections and pseudoarthroses.31 More recently, advancement in arthroscopic technique has enabled surgeons to directly visualize the articular surface of joints which facilitated the debridement as well as subchondral bone resection techniques. The pioneer of the arthroscopic ankle arthrodesis was Schneider who was the first to describe the procedure in his video journal report in 1983.32Since then, the arthroscopic technique introduced many benefits over traditional open procedures.