Chapter 36: Arthroscopy

Ankle Arthroscopy
 ARTHROSCOPY
The most important indication for an arthroscopic procedure is less disability
than an open joint procedure. The advantages of arthroscopy are its use as a
diagnostic tool to see the pathology present when there is pain or disability in
the absence of a positive on MRI or CT, and ability to simultaneously correct
the condition. Hence it is a diagnostic and therapeutic procedure
Ankle Joint Arthroscopy
1. History:
a. Takagi (1918): First use in cadaveric knee- Tokyo, Japan
b. Bircher (1921): First arthroscopic knee examination (meniscus)
c. Burman (1931): First use in the USA (a cadaveric knee)
d. Takagi (1939): First successful ankle arthroscopy
e. Watanabe and Takagi: First operative procedure
f. Watanabe (1945): Developed smaller scopes to be used in joints
g. Heller and Vogler (1982): Podiatric applications of ankle arthroscopy

2. Patient evaluation and selection: Arthroscopy of the foot and ankle

should only be done after all conservative measures have been exhausted
a. Diagnostic indications:
i. Unexplained pain
ii. Swelling
iii. Stiffness
iv. Instability
v. Hemarthrosis
vi. "Popping"
b. Therapeutic indications:
i. Debridement of osseous bodies
ii. Repair of the ATFL iii. Irrigation
iv. Septic joint (flush out bacteria)
v. Osteochondral defects
vi. Soft tissue impingement
vii. Synovitis
viii. Arthrofibrosis
ix. Arthrodesis
c. Contraindications:
i. Cellulitis and local infections
ii. Fused joint
iii. Moderate DJD with restricted range of motion
iv. Severe edema
v. High risk medical patients

3. Instrumentation:
a. Arthroscopes: 2.7 mm, 4.0 mm with 30° viewing
b. Trochars, canulas and obturators
c. Accessory instruments (biopsy forceps, scissors, grasping forceps, suction
punch, meniscal knives, cutter, shavers, probes, suture delivery systems)
d. Irrigation system (normal saline, Ringer's lactate or acetate)
e. Other: Electrosurgical units, lasers, distraction devices (noninvasive or
invasive)

4. Ankle portals:
a. Anteromedial:
i. Medial to the anterior tibial tendon, saphenous nerve and vein
ii. Visualization of the medial gutter, medial transchondral bone margins
b. Anterolateral:
i. Lateral to the peroneus tertius and EDL
ii. Care must be taken to preserve the superficial peroneal nerve
iii. Visualization of the lateral gutter
c. Anterocentral:
i. Lateral to the EHL
ii. Care must be taken to preserve the anterior tibial artery and deep
peroneal nerve
d. Posterolateral:
i. Patient is usually prone
ii. Incision is lateral to the Achilles tendon
iii. Care must be taken to preserve the sural nerve and lesser saphenous
vein
e. Posteromedial:
i. Medial to the Achilles tendon
ii. Care must be taken to preserve the posterior tibial artery and nerve
iii. Visulalization to the posterior process of the talus and transchondral
lesions to the back of the talus
f. Accessory portals

5. Anatomy:
a. Anterior joint pouch:
i. Medial gutter:
• Medial malleolus
• Adjacent talar medial articular surface
• Anterior tibiotalar ligament (floor of the gutter)
• Posterior tibiotalar ligament (with valgus stress)
a. Anterior ankle (continued):
i. Medial bend
• Anterior tibial lip
• Medial talar shoulder
• Tibial plafond
a. Anterior ankle (continued):
i. Anterior joint line
• Sagittal groove of the talus
• Synovial recess (tibia)
• Capsular reflection (tibia)
a. Anterior ankle (continued):
i. Lateral talar shoulder
• Tbiofibular synovial recess
• Tibiofibular synovial fringe
• Anterior inferior tibiofibular ligament

b. Anterior ankle (continued):

i. Lateral gutter
• Mdial fibular articular surface
• Anterior talofibular ligament
• Posterior talofibular ligament (with varus stress deep in the lateral
gutter)

b. Posterior ankle:
i. Posterior joint pouch:
• Posterior tibial lip
• Posterior talar dome
• Sagittal groove of the talus
• Psterior tibiofibular ligament
• Labrum of the posterior tibiofibular ligament
• Medial bend
• Medial malleolus
• Posterior tibiotalar ligament
b. Posterior ankle (continued):
i. Posterior ankle via an anterior view
• Posterior tibiofibular ligament
• Posterior capsule wall
• Medial bend
• Medial gutter
• Posterior dome of the talus

6. Ankle Pathology:
a. Soft tissue:
i. Synovitis
ii. Fibrous bands
iii. Meniscoid bodies
• Wollins lesion
iv. Adhesive capsulitis
b. Cartilage:
i. Subchondral erosions
ii. Chondromalacia:
• Collins classification:
Grade 1 : Fraying
Grade 2: Fibrillation, fissuring
Grade 3: Extensive fissuring
Grade 4: Cartilage loss
• Goodfellows classification (superficial degeneration):
Type 1 : Superficial erosion
Type 2: Loss of superficial layer
Type 3: Exposed subchondral bone
Type 4: Deep matrix exposed
• Goodfellows classification (basal degeneration):
Stage 1 : Cartilage softening
Stage 2: Blister formation
Stage 3: Exposed matrix
Stage 4: Bone exposed
iii. Chondral lesions:
• Bauer and Jackson classification:
Type 1: Linear crack
Type 2: Stellate lesion
Type 3: Cartilage flap
Type 4: Avulsed with exposed bone
Type 5: Fibrillation
Type 6: Fibrillation plus subchondral erosion
c. Osseous pathology:
i. Osteochondral bodies
ii. Subchondral bone cysts

7. Specific ankle joint pathology:

a. Osteochondral lesions
b. Avulsion fractures of the ankle:
i. Anterior/posterior tibial lips
ii. Ligamentous insertions

c. Medial impingement lesions

d. Transchondral ankle fractures:
i. Berndt and Harty classification:
Stage 1: Compression
Stage 2: Partially detached
Stage 3: Totally detached
Stage 4: Avulsed
e. Tibial lip fractures
f. Impingement exostosis

8. Specific procedures done arthroscopically:

a. Ankle arthrodesis
b. Lateral ankle stabilization

9. Post-operative care and rehabilitation:

a. With exploration and general debridement: compressive dressing and
immediate weightbearing
b. With ligamentous repair: range of motion within 24 hours, patient in an
aircast 6 weeks post-weightbearing
c. With debridement for chondral defect: non-weightbearing 8 weeks with
active range of motion
d. With arthroscopic arthrodesis: 8 weeks in hard non-weightbearing cast
followed by 2 weeks in weightbearing splint

10. Complications of ankle arthroscopy:

a. Scope breakage
b. Infection
c. Cartilage injury or creation of multiple small bodies
d. Hemarthrosis due to trochar damage
e. Compartment syndrome
f. Polyneuritis of the ankle
g. Venous laceration
h. Painful scar
i. Nerve laceration
j. Recurrence of symptoms