Patients may be anesthetized with general anesthesia, popliteal blocks, regional ankle blocks, or a combination of these. With a popliteal block, dense general sedation is needed if a thigh tourniquet is to be inflated, as the block does not provide sufficient proximal pain control. Our preference is to bolster the hip and place a high thigh tourniquet, which can be inflated at the beginning of the case or if intra-articular bleeding is encountered later in the case (Fig. 14-1). The foot should be even with the edge of
the bed distally. Leg holders that brace the thigh and hold the hip and knee in flexion are also a viable option for positioning. A calf tourniquet can be used in lieu of a thigh tourniquet, but this compresses the leg muscles, shortening tendons traversing the ankle joint and preventing joint distraction. This represents a significant impediment to ankle arthroscopy under regional anesthesia. A tourniquet can often be avoided as long as a high-flow cannula is used and synovial debridement is kept to a minimum.

Distraction can help open the ankle joint for viewing and allow safe passage of instruments without damaging the articular cartilage. Static invasive distractors may be placed with threaded pins through the calcaneus and the tibia, or with a less invasive sling around the heel and midfoot that is tensioned at the end of the operative table. Our preference is to use dynamic distraction with an elasticized bandage tied around the foot, just below the malleoli, and then around the operative surgeon’s waist (Fig. 14-2). This allows for relaxation and distraction when needed, as well as the ability to dorsiflex and plantarflex the ankle with pressure on the sole of the foot from the operative surgeon’s abdomen (Fig. 14-3). It carries the added benefit of avoiding prolonged, persistent traction, which may result in skin necrosis or possibly nerve injury. Ergonomically, the surgeon has good control over the position of the foot and comfortable hand position when working through the anteromedial and anterolateral portals (Fig. 14-4). Supine dynamic distraction also allows the surgeon to abduct the ankle over the edge of the table and access the posterior portals by dropping the surgeon’s hands posteriorly below the mid-coronal line of the ankle (Fig. 14-5).

The prone position is usually more uncomfortable for the awake patient, and also makes access to the airway harder for the anesthesiologist. This combination of factors favors general anesthesia in the prone patient. Gel rolls or rolled blankets are placed longitudinally along the chest wall to elevate it from the table. Alternately, a prone positioning table such as a Wilson frame table can be used (Fig. 14-6). The sterile field should extend to the knee, but not above it. A thigh tourniquet is typically used. Surgeon hand positioning is similar to supine positioning (Fig. 14-7). Distraction may or may not be used with posterior ankle arthroscopy.