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Figure 8-3. Identify the peroneus tertius and the extensor digitorum longus
muscles, and incise down to bone lateral to them in the upper half of the wound.
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Figure 8-4. Retract the extensor musculature medially to expose the anterior
aspect of the distal tibia and ankle joint. Identify the origin of the extensor
digitorum brevis.
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Figure 8-5. The extensor digitorum brevis has been detached from its origin
and reflected distally. The fat pad covering the sinus tarsi has been detached
and reflected downward. Incise the joint capsules that have been exposed.
Dangers
The deep peroneal nerve and anterior tibial artery cross the front of the
ankle joint. They are vulnerable if dissection is not carried out as close to
the bone as possible (see Fig. 10-5).
Try to avoid creating large skin flaps to avoid skin necrosis. This is done
by using full-thickness flaps and by not undermining these flaps. The
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extensor digitorum brevis muscle, its fascia, subcutaneous fat, and skin
should be a single block of tissue.
How to Enlarge the Approach
Extensile Measures
The approach can be extended proximally to explore structures in the
anterior compartment of the leg. Continue the incision over the
compartment and incise the thick deep fascia in line with the skin incision.
The approach also can be extended distally to expose the tarsometatarsal
joint on the lateral half of the foot. Continue the incision over the fourth
metatarsal and expose the subcutaneous tarsometatarsal joints.
REFERENCE
1. Buckley R, Moran C, Apivatthakakul T. Hindfoot—calcaneus and talus.
In: AO Principles of Fracture Management. 3rd ed. Vol 2. Thieme;
2017.
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9
Ankle Arthroscopy
Position of the Patient
Incision and Landmarks
Surgical Dissection
Dangers
Nerves
Vessels
Introduction
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Ankle arthroscopy has become much more popular in the past 20
years, with more than 1,300 original papers published. The
development of noninvasive distractors and smaller arthroscopes has
greatly increased the indications and scope for ankle arthroscopy. The
technique was originally used only for diagnostic purposes and
removal of loose bodies. More recently, a variety of arthroscopic
surgical procedures have become possible. This chapter will describe
only the two most commonly used arthroscopic portals: anteromedial
and anterolateral. Surgeons wishing to carry out more complex
procedures should refer to the original journal articles describing them.
Indications include the following1:
Removal of loose bodies or osteochondral fragments
Synovectomy
Removal of soft tissue and osteophytes in case of impingement
syndrome
Treatment of osteochondritis dissecans
Microfracture
Ankle arthroscopy has also been used in fracture surgery, both for
the removal of chondral loose bodies and for assessing the accuracy of
reduction of talar and ankle fractures. Three vital structures pass down
over the anterior aspect of the ankle: the superficial peroneal nerve;
the anterior neurovascular bundle, consisting of the anterior tibial
artery and deep peroneal nerve; and the saphenous nerve. Damage to
these vital structures should be avoided at all costs. A precise
knowledge of their anatomic position is vital in planning incisions
used for arthroscopic portals (see Fig. 10-5). A meticulous surgical
technique consisting of a skin incision followed by blunt dissection
down to the joint capsule is also advised, since the exact position of
the structures is subject to anatomic variability.
The ankle joint is essentially a hinge joint (ginglymus). The shape
of the medial and lateral malleoli together with the strong collateral
ligaments allows movement of the ankle in the flexion–extension
plane only. The space available within the joint is limited. Distraction
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of the joint both by external traction and injection of fluid into the
joint is therefore necessary for safe insertion of the arthroscope.
Position of the Patient
Place the patient supine on the operating table. Palpate the anterior
neurovascular bundle as it runs across the anterior aspect of the ankle joint,
just lateral to the tendon of the extensor hallucis longus, and mark its
position on the skin. Exsanguinate the limb using a soft rubber bandage,
then inflate a mid-thigh tourniquet.
Apply a noninvasive distractor to the dorsum of the foot. Distractors
usually consist of a calcaneal component and a dorsal containment strap. If
possible, ensure that the calcaneal strap of the distractor is placed so that the
foot is elevated. This ensures that you will be able to get access to the
posterolateral aspect of the ankle, if required, during the procedure (Fig. 9-
1). Drop the foot of the table 30 degrees to aid access to the anterior aspect
of the ankle joint.
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Figure 9-1. Apply a noninvasive distractor to the dorsum of the foot. Distractors
usually consist of a calcaneal component and a dorsal containment strap.
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Incision and Landmarks
The position of the anterior neurovascular bundle should have already been
marked prior to inflation of the tourniquet. Identify the tendon of the tibialis
anterior as it runs across the anteromedial aspect of the ankle joint. Finally,
flex and extend the ankle to allow you to palpate the joint line with your
thumb.
Insert an 18-gauge needle into the ankle joint, just medial to the tendon
of the tibialis anterior, at the level of the joint line. Distend the joint with 8
to 10 mL of normal saline. Take care not to inject the saline until you are
sure that you are in the joint. Injection of saline external to the joint capsule
will render arthroscopy difficult, if not impossible. Do not overdistend the
joint.
Make a 6- to 8-mm longitudinal incision just medial to the tendon of
tibialis anterior, at the level of the joint line. Take care to incise the skin
only.
Surgical Dissection
Carefully dissect down to the ankle joint capsule using blunt dissection with
a pair of mosquito forceps. Although the saphenous nerve should be well
medial to this approach, its position is variable; using this technique will
allow you to identify the nerve and preserve it if it is in an abnormal
position (Fig. 9-2).
Dorsiflex the foot to place it in the neutral position. This will bring the
talar dome away from the distal tibia and open up the anterior aspect of the
joint. Enter the ankle joint using a trocar. Ensure that the trocar is angled
laterally by approximately 60 degrees. Insert the arthroscope. Working from
medial to lateral, identify the following structures (see Figs. 9-2 and 9-3):
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Figure 9-2. Carefully dissect down to the ankle joint capsule using blunt
dissection with a pair of mosquito forceps. Although the saphenous nerve
should be well medial to this approach, its position is variable; using this
technique will allow you to identify the nerve and preserve it if it is in an
abnormal position.
1. Deep deltoid ligament
2. Medial gutter
3. Anterior tibiotalar joint
4. Anterior talar sulcus
5. Anterior talofibular ligament
6. Anterior tibiofibular ligament
7. Lateral gutter
Next, insert an 18-gauge needle into the joint on the anterolateral aspect
of the ankle. Confirm the position of the needle in the joint using the
arthroscope and make a 6- to 8-mm longitudinal skin incision at the site of
needle puncture. As with the anteromedial portal, take care to incise the
skin only. Deepen the incision down to the joint capsule using blunt
dissection with a pair of mosquito forceps (see Fig. 9-3). Be aware that
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