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
Table 22-1. Complications of Foot and Ankle Arthroscopy
FIGURE 22-2. Anterior view of arthroscopic portals. Caution is necessary to avoid injury to the neurovascular structures (Illustration by Susan Brust.)
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.
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.
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