Arthroscopy - ankle

Introduction

Arthroscopic surgery on the ankle is the third most common joint surgery performed, following surgery on the knee and shoulder. We employ the same arthroscopic tools with the ankle as we use for the other two joints. Surgical treatment is indicated for painful swollen or blocked ankle joints.

The anesthesia employed is also similar. We normally use general anesthesia. In some cases, spinal or epidural anesthesia or a blocking agent (lumbar or ischiofemoral) may be used. We operate bloodlessly, working with a pneumatic thigh tourniquet.

Position and Access Points

The patient lies supine, with the legs protruding outside the operating field or the lower leg hanging over the edge of the table (for anterior ankle arthroscopy), or else lies prone (if the focus is on the posterior ankle and heel area). We sometimes employ leg traction to increase the space within the articulatio talocruralis.

Two access points are used for the anterior ankle:

1. Anteromedial Access Point: This is located at the level of the joint aperture, medial to the m. tibialis anterior tendon. Initially, we locate the joint aperture with a needle, then fill it with approximately 20 ml of solution. Then, using a short incision and blunt dissection of the subcutaneous tissue, we introduce a trocar, followed by the optics. In doing so, we take care not to injure n.saphenus and v.saphena magna.
2. Anterolateral Access Point: This point is also located at the level of the joint aperture. We illuminate the skin using the optics and once again use a minor incision and dissection of subcutaneous tissue, then introduce the working instrument.

Access points for the posterior ankle:

1. Posterolateral Access Point: This is located at the level of the joint aperture above the heel bone, exterior to the Achilles tendon. We take care not to injure suralis n. or v. saphena parva.
2. Posteromedial Access Point: This point is located slightly proximal to (above) the level of the joint aperture, over the heel bone, medially from the Achilles tendon behind the medial ankle. Once again, we take care not to injure the nerve/capillary bundle.

Clinical Picture And Examination Methods

We examine the extent of joint movement, focusing on stability (inversion and eversion of the leg). We also take note of the condition of the joint lining, joint effusion and the overall configuration.

We most often employ x-ray examination and ultrasound, which provides us with a basic picture of the situation at the joint and its stability. A CT scan may also be indicated. This furnishes a 3D image of the joint's bony structures. To rule out soft tissue damage, we recommend an MRI examination.

Indications

• impingement syndrome
• osteochondrosis dissecans
• synovitis and osteoarthritis
• Haglund's deformity