Arthroscopic Management of Osteochondral Lesions of the Talus
Yoshiharu Shimozono
John G. Kennedy
Sterile Instruments/Equipment
Thigh tourniquet
Ankle distractor
Standard arthroscopic equipment
Irrigation system (pressure: 50-60 mm Hg, fluid flow: 0.5 L/min)
A 2.4/2.7-mm arthroscope with 30°/70° viewing angle
A 3.5/4.5-mm shaver for soft-tissue debridement
A small-size curette
Microfracture pics or a 2.0-mm Kirschner wire for bone marrow stimulation (BMS)
Positioning
The patient is positioned in the supine position with the ipsilateral hip flexed and supported by a well-padded leg holder (Figure 19-1).
A sterile ankle distraction strap is placed around the hindfoot and midfoot (Figure 19-2).
 Figure 19-1. A small bump can be additionally placed under the ipsilateral pelvis to facilitate the neutral alignment of the foot and ankle. |
 Figure 19-2. Ankle with sterile distraction strap. It is connected to a sterile bar using a band and allows the surgeon to achieve the desired degree of distraction of the ankle joint. |
Knowledge About Portals
Anteromedial, anterolateral, and, occasionally, posterolateral portals
Before any incision, mark anatomic landmarks including lateral malleolus, medial malleolus, peroneus tertius, anterior tibial tendon, and superficial peroneal nerve (Figure 19-3). The superficial peroneal nerve is identified with plantar flexion and inversion of the foot (Figure 19-4).
Figure 19-3. Anterior portals and landmarks. LM, lateral malleolus; MM, medial malleolus.
Figure 19-4. Marking the course of the superficial peroneal nerve is important before starting.
Anteromedial portal is 1 mm medial to the medial border of anterior tibial tendon.
Anterolateral portal is 1 mm lateral to the peroneus tertius. The location of the superficial peroneal nerve is found by flexing the fourth toe down. This can accentuate the subcutaneous course of the nerve.
Posterolateral portal is 1 mm anterior to the lateral border of the Achilles tendon at the level between the horizontal lines of medial malleolus and lateral malleolus tips. This portal is sometimes needed to approach the posterior aspect of the ankle joint. Care should be taken about the location of the sural nerve (Figure 19-5).
 Figure 19-5. Posterolateral portal is useful both for inflow and for posterior visualization. |
Operative Technique
Making the Portals
The portals are usually made in the following order: anteromedial portal, anterolateral portal, posterolateral portal.
A 22-gauge needle is inserted from the site of the previously marked anteromedial portal to the ankle joint and 10 mL saline is injected into the ankle joint (Figure 19-6). This allows to judge the joint orientation and to verify the correct portal position if saline is injected smoothly with overall ankle joint inflation.
Figure 19-6. The needle is used to locate the optimal position for the portal.
Skin cut using a #11 blade and subcutaneous blunt dissection using a mosquito clamp
A 2.7-mm arthroscope sleeve with trocar is carefully advanced into the ankle joint, and then switched out for a 2.7-mm arthroscope.
A 22-gauge needle is inserted from the site of the previously marked anterolateral portal to the ankle joint. Once needle is confirmed, skin cut and subcutaneous blunt dissection are performed. This can be done under direct arthroscopic visualization using the transillumination technique to avoid neurovascular injury.
Diagnostic Arthroscopy
An organized diagnostic arthroscopy is performed initially from the anteromedial portal. A probe is placed through the anterolateral portal to palpate the talar surface.
Cartilage lesions are examined by probing. Any loose, unstable, or degenerative cartilage needs to be removed and requires the microfracture technique.
In some lesions where the overlying cartilage appears normal, the retrograde drilling technique is applied to preserve the intact hyaline cartilage, while stimulating the subchondral bone revascularization.
The location of pathology guides surgical treatment strategies. A nine-zone grid of the articular cartilage based on magnetic resonance imaging allows for accurate descriptions of the location of osteochondral lesion (OCLs) (Figure 19-7).4Related posts:
Management of Metatarsalgia and Equinus Contracture: Gastrocnemius Recession, Percutaneous Tendoachilles Lengthening, and Diaphyseal Metatarsal Shortening Osteotomy
Management of Lesser Toe Deformity: PIP Arthroplasty and Extensor Lengthening
Medial Malleolar Stress Fractures
Talus Fractures
Achilles Tendinopathy
Metatarsal Neck Fractures
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