Complications in Ankle and Foot Arthroscopy
RICHARD D. FERKEL
MICHAEL J. CARLSON
Arthroscopy of the ankle and foot has progressed significantly since Burman first tried to perform arthroscopy on the ankle in 1931.1 As equipment and instrumentation have advanced, especially over the last two decades, newer techniques have been developed. As the number of arthroscopic procedures has increased and more demanding procedures have been developed, the opportunity for significant complications has also increased.
HISTORY
In Small’s 1988 prospective study in which 21 surgeons participated, the overall complication rate for all arthroscopy was 1.7%, and the complication rate for ankle arthroscopy was 0.7%.2 Guhl in 1988 reported on 131 cases with 13 complications for a rate of about 10%.3 In 1989, Martin and associates4 reported a long-term follow-up on a series of 101 ankles with a 15% complication rate; Barber and colleagues5 reported an incidence of 17% in 53 cases. Ferkel and Guhl reported on complications in the first 518 cases with an overall rate of 9.8%; the most common complication was neurologic.6 In 2011, Young et al. reported their complication rates following 294 consecutive ankle arthroscopies using noninvasive distraction technique. They found an overall complication rate of 6.8% with 80% of these neurologic in nature.7 Recently, Nickisch et al. reported an 8.5% complication rate after prone posterior hindfoot arthroscopy.8 These rates of 7% to 17% are significant and emphasize the extreme caution that must be used in performing arthroscopy of the ankle and foot.9
TYPES OF COMPLICATIONS
Various complications can be associated with arthroscopic surgery of the ankle and foot (Fig. 22-1A, B; Table 22-1): systemic, preoperative, and procedure related.10 Systemic complications include those related to illness, the stress of injury, anesthesia, and surgery. Atelectasis, pulmonary embolus, deep vein thrombosis, myocardial infarction and other cardiopulmonary events, loss of limb, and even loss of life are all potential systemic complications. Preoperative complications include lack of preoperative planning, failure to obtain appropriate preoperative studies, and operating for the wrong diagnosis. Most complications in the ankle and foot are procedure related.
Neurovascular Injury
Neurovascular structures can be injured by incorrect portal placement, careless distraction pin placement, prolonged or inappropriate distraction, or excessive tourniquet use. The most common complication in ankle and foot arthroscopy is neurologic. This usually involves a temporary paresthesia of the superficial nerves but occasionally can be associated with permanent paresthesia or paresis. Neuromas can also form from injury to the nerve during surgery. The antero-medial portal can be associated with injury to the greater saphenous vein or saphenous nerve. The anterocentral portal is not recommended because of potential injury to the dorsalis pedis artery and deep peroneal nerve (Fig. 22-2).
The anterolateral portal is associated with significant risk to the superficial peroneal nerve. Injury to this nerve is the most common neurologic complication. Variations in the superficial nerve were described in Chapter 5. Preoperatively, it is critical to try to identify the nerve and its branches to avoid injury. Prior to prepping the lower extremity, we routinely use a sterile marking pen to draw out the superficial peroneal nerve as it is more easily identified before the surgical prep is applied. However, in some patients, particularly those who are obese, the nerve may not be seen either directly or through transillumination. Occasionally, the nerve location can be determined by manual palpation.
Nerve damage may be minimized by vertically incising only the skin with the knife blade, followed by careful spreading of the subcutaneous tissues with the hemostat before penetrating the capsule. This method is called the “nick and spread” technique. Repeated passage of instruments through the portal site without the use of a protective cannula can increase the risk of neurovascular injury. An interchangeable cannula system is helpful to avoid repetitive soft tissue injury.
Posterior ankle and hindfoot arthroscopy typically requires the use of a posterolateral and/or posteromedial portals9 (Fig. 22-3). The use of each of these portals is associated with the risk of neurovascular injury. The posterolateral portal is routinely used and places the lesser saphenous
vein and sural nerve at risk. Although not used as commonly except by those operating in the prone position, the posteromedial portal places the tibial nerve and vessels at risk (Fig. 22-3). The overall risk of neurologic injury from combined posterior portals is reported to be as high as 19.5%.11 However, anatomic studies have demonstrated that portal placement in posterior ankle and hindfoot arthroscopy is relatively safe.12, 13 Recent literature looking at postoperative complications after posterior ankle and hindfoot arthroscopy in 189 procedures demonstrated neurologic complication rate of only 3.7%. The most common neurologic complaint was plantar numbness in four patients followed by sural nerve dysesthesia in three patients.8
vein and sural nerve at risk. Although not used as commonly except by those operating in the prone position, the posteromedial portal places the tibial nerve and vessels at risk (Fig. 22-3). The overall risk of neurologic injury from combined posterior portals is reported to be as high as 19.5%.11 However, anatomic studies have demonstrated that portal placement in posterior ankle and hindfoot arthroscopy is relatively safe.12, 13 Recent literature looking at postoperative complications after posterior ankle and hindfoot arthroscopy in 189 procedures demonstrated neurologic complication rate of only 3.7%. The most common neurologic complaint was plantar numbness in four patients followed by sural nerve dysesthesia in three patients.8
 FIGURE 22-1. Arthroscopy complications. (A) Doing ankle arthroscopy is like walking through a minefield: the arthroscopic surgeon must maneuver carefully to avoid a complication (explosion). (B) Poor technique can lead to the most common complication in ankle arthroscopy, which is neurologic. (Illustration by Susan Brust, Copyright Richard D. Ferkel.) |
Table 22-1. Complications of Foot and Ankle Arthroscopy | |
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If paresthesia or pain develops after arthroscopy, its site and extent should be carefully documented. The patient should be informed about the problem and followed carefully. A positive Tinel sign that develops over the portal site may be due to nerve contusion or neurapraxia or to neuroma formation (Fig. 22-4). Rarely is additional surgery necessary to correct these problems.
 FIGURE 22-2. Anterior view of arthroscopic portals. Caution is necessary to avoid injury to the neurovascular structures (Illustration by Susan Brust.) |
The noninvasive distraction strap may compress the neurovascular structures, but this complication is rare. This has been seen more frequently with placing the forefoot strap too low on the dorsum of the foot where the nerves are more vulnerable. We have identified two cases postoperatively with diffuse numbness below the knee after using a noninvasive distraction technique over 2 hours. These complications occurred in obese individuals, and both of them resolved over time. Currently, after 1 hour of noninvasive distraction, we decrease the tension by one click on the noninvasive distraction device to lower the risk of traction injury.
Vascular injury can occur at the portal sites or through the use of the invasive pin distractor.14 A number of case reports of AV fistulas and pseudoaneurysm of the anterior tibial artery have been noted using standard anterior portals.15 The use of the anterocentral portal can be associated with injury to the dorsalis pedis artery or deep peroneal nerve (Fig. 22-5A, B). Placing the anterocentral portal through the extensor tendons helps prevent this complication. A pseudoaneurysm can also develop secondary to excessive shaving of the anterior capsule and nicking the dorsalis pedis or anterior tibial artery. The shaver blades should always be pointed away or at a 45° angle to the anterior capsule to avoid this complication (Fig. 22-6A, B).
Tourniquet
The pneumatic tourniquet facilitates arthroscopic surgery by providing improved visibility and a bloodless field. The complications associated with its use are well documented,
including paresthesias, paresis, thigh pain, and perhaps thrombophlebitis.16 Sherman and colleagues, in a study on knee arthroscopy complications, showed there was no increase in complications with tourniquet use unless the tourniquet time exceeded 60 minutes.17 We place the tourniquet high on a well-padded upper thigh and inflated it to between 250 and 275 mm Hg, for no longer than 2 hours. Anesthesia should notify the surgeon after 1 hour of tourniquet time and then every 15 minutes thereafter until 2 hours occurs. We do not routinely put the tourniquet back up if 2 hours is exceeded. Proper application, adequate padding, low tourniquet pressures, and reduction of tourniquet time can minimize problems related to the use of the tourniquet.
including paresthesias, paresis, thigh pain, and perhaps thrombophlebitis.16 Sherman and colleagues, in a study on knee arthroscopy complications, showed there was no increase in complications with tourniquet use unless the tourniquet time exceeded 60 minutes.17 We place the tourniquet high on a well-padded upper thigh and inflated it to between 250 and 275 mm Hg, for no longer than 2 hours. Anesthesia should notify the surgeon after 1 hour of tourniquet time and then every 15 minutes thereafter until 2 hours occurs. We do not routinely put the tourniquet back up if 2 hours is exceeded. Proper application, adequate padding, low tourniquet pressures, and reduction of tourniquet time can minimize problems related to the use of the tourniquet.
 FIGURE 22-3. Posterior arthroscopic portals. Usually, only the posterolateral portal is used with care taken to avoid injury to the sural nerve and small saphenous vein. (Illustration by Susan Brust.) |
Tendon Injuries
Numerous tendons traverse the ankle and foot, and they can be injured by careless portal placement or distraction pin insertion. Use of the trans-Achilles portal has been abandoned because of the increased potential for injury and possible rupture that can occur with instrumentation of the Achilles tendon. When invasive distraction is required, a blunt-tipped cannula should be inserted through the subcutaneous skin down to the tibia and calcaneus to avoid winding tendons or neurovascular structures when the pins are inserted. The flexor hallucis longus and posterior neurovascular structures can also be injured if extreme caution is not used when removing a painful os trigonum via subtalar arthroscopy (see Chap. 15). Recently, Phisitkul and Amendola have reported on the peroneocalcaneus internus muscle or so-called false FHL. They described how this normal variant imitated the flexor hallucis longus, which can lead to potential injury to the posterior tibial nerve and vessels in posterior hindfoot endoscopy18 (Fig. 22-7A, B).
 FIGURE 22-4. Neuroma of the sural nerve excised after prolonged symptoms. |
Ligament Injuries
Injury to the ligamentous structures of the ankle and foot can occur through improper portal placement, excessive debridement, and inappropriate distraction techniques. The use of accessory anteromedial and anterolateral portals can lead to injury of the deltoid or the anterior talofibular ligament. Injudicious use of the shaver and burrs can lead to injury to the ligamentous structures as well. Ankle distraction techniques also place the ligaments at risk; this risk can be minimized by the use of appropriate distraction forces for no more than 1.5 to 2.0 hours. In addition, periodic relaxation of the distraction is helpful. Because of the viscoelastic property of ligaments, adequate distraction can be maintained with less force after the first half-hour of the procedure. When general anesthesia is used, the
patient should be “paralyzed” to facilitate distraction while minimizing distraction forces. Also, the use of small pins with invasive distraction can prevent ligament injury by permitting pin bending before ligament failure.
patient should be “paralyzed” to facilitate distraction while minimizing distraction forces. Also, the use of small pins with invasive distraction can prevent ligament injury by permitting pin bending before ligament failure.
 FIGURE 22-5. Aneurysm formation. (A) Lateral arteriogram of a patient who underwent ankle arthroscopic arthrodesis with pin fixation. Note the aneurysm of the dorsalis pedis artery just above the joint line. (B) Intraoperative picture demonstrating aneurysm before resection. Aneurysm was formed by injury to the dorsalis pedis artery while using the anterocentral portal.
Related posts: Correlative Surgical Anatomy
 Regional Anesthesia for Foot and Ankle Arthroscopy
 Subtalar Arthroscopy: Anatomy, Setup, and Normal Exam
 Arthroscopic and Open Approaches to Ankle Instability
 Radiofrequency Use in Ankle and Foot Arthroscopy
 Endoscopic Plantar Fascia Release, Gastrocnemius Recession, and Intermetatarsal Nerve Decompression
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