Anatomic Study of Anterior and Posterior Ankle Portal Sites for Ankle Arthroscopy in Plantarflexion and Dorsiflexion: A Cadaveric Study in the Japanese Population

Arthroscopy is an important and minimally invasive diagnostic and therapeutic tool. However, the risk of injury to the neurovascular structures around the portals exists during arthroscopy of the ankle. In the present study, we measured the distance between each portal and the adjacent neurovascular structures with the foot in plantarflexion and dorsiflexion in the Japanese population. Standard anterolateral (AL), anteromedial, posterolateral (PL), and posteromedial portal positions were identified in 6 fresh adult cadaveric feet. The skin was dissected from the underlying tissue to visualize the adjacent neurovascular structures as noninvasively as possible. The superficial peroneal nerve was the structure closest to an anterior (i.e., AL) portal (3.2?±?4.2 and 8.3?±?3.9?mm in plantarflexion and 5.2?±?4.3 and 10.8?±?4.1?mm in dorsiflexion), followed by the saphenous nerve and great saphenous vein (SpV). The distance from the superficial peroneal nerve to the AL portal and from the saphenous nerve and great SpV to the anteromedial portal increased significantly with dorsiflexion and decreased significantly with plantarflexion. The sural nerve was the structure closest to the posterior (i.e., PL) portal (10.4?±?4.8?mm in plantarflexion and 8.5?±?3.9?mm in dorsiflexion), followed by the lesser SpV. The distance from the sural nerve, saphenous nerve, and lesser SpV to the PL portal and from flexor hallucis longus, posterior tibial artery, and tibial nerve to the posteromedial portal increased significantly in plantarflexion and decreased significantly in dorsiflexion. These findings could help to prevent damage to the neurovascular structures during ankle arthroscopy.     

Arthroscopy and Endoscopy of the Foot and Ankle: Indications for New Techniques

The scope of arthroscopy and endoscopy of the foot and ankle is expanding. New techniques are emerging to deal with diverse ankle pathology. Some of the conditions that can be dealt with arthroscopically are as follows: hallux valgus deformity, lesser toe deformity, first metatarsophalangeal instability, cock-up deformity of the big toe, peroneal tendon instability, lateral ankle and subtalar instability, hindfoot deformity or arthrosis, first metatarsocuneiform hypermobility, Lisfranc joint arthrosis, various stages of posterior tibial tendon insufficiency, foot and ankle arthrofibrosis, late complications after calcaneal fracture, acute and chronic Achilles tendon rupture, insertional Achilles tendinopathy, entrapment of the first branch of the lateral plantar nerve, Freiberg’s infarction, flexor digitorum longus tenosynovitis, flexor hallucis longus pathology, calcaneonavicular coalition or “too-long” anterior process of the calcaneus, and ganglions. With sound knowledge regarding the indications, merits, and potential risks of new techniques, they will be powerful tools in foot and ankle surgery.     

Association of Ankle Dorsiflexion With Plantar Fasciitis

This study aimed to compare the mean ankle dorsiflexion range between individuals with and without plantar fasciitis using passive ankle dorsiflexion with consistent pressure, and to identify the prevalence of an isolated gastrocnemius and gastrocnemius soleus complex contracture in 2 groups. 91 participants were prospectively classified into the plantar fasciitis group (45 subjects) and the control group (46 subjects). Ankle dorsiflexion was measured with the knee extended and with the knee flexed 90° using a standard orthopedic goniometer while a consistent force of 2 kg was applied under the plantar surface of the forefoot using a custom-made scale. Intraclass correlation coefficients (ICC) were calculated to determine the interobserver and intraobserver reliability of the current ankle dorsiflexion measurement. The current ankle dorsiflexion measurement revealed excellent interobserver and intraobserver reliability. The mean ankle dorsiflexion in the knee extended was -9.6° ± 8.1° and -11.2° ± 8.2° in the study and control groups, respectively (p = .353). The mean ankle dorsiflexion in the knee flexed was 7.8° ± 6.5° and 5.1° ± 7.4° in the study and control groups, respectively (p = .068). In the study and control groups, 68.9% and 65.2%, respectively, had an isolated gastrocnemius contracture and 24.4% and 30.4%, respectively, had a gastrocnemius-soleus complex contracture (p = .768). The present study demonstrated that there were no significant differences in passive ankle dorsiflexion and in the prevalence of an isolated gastrocnemius or gastrocnemius soleus complex contracture between individuals with and without plantar fasciitis.     

Ankle Arthroscopy: Correct Portals and Noninvasive Distraction

Noninvasive ankle distraction technique is the standard of care for ankle arthroscopic surgery. Noninvasive distraction can be performed safely and with fewer complications when compared side-by-side with the nondistraction dorsiflexion technique. Moreover, distraction techniques allow a single surgeon to operate in the most convenient supine position and in a “hands-free” manner, with adequate space to avoid iatrogenic chondral damage. In addition, distraction allows for dedicated inflow and outflow portals to sufficiently irrigate the joint. Although the nondistraction technique allows excellent visualization of the anterior joint, it fails to provide appropriate visualization of the entire joint, using both anterior and posterior portals. Pathology that is best accessed from the posterior portal includes posterior osteochondral lesions, loose bodies, tears of the transverse ligament, acute ankle fractures, posterior tibial osteophytes, and occasionally an os trigonum. Fortunately, noninvasive distraction techniques plantarflex the ankle, also providing optimal access to the talus through the anterior approach. With the added use of posterolateral and occasionally posteromedial portals, near-universal access to lesions about the ankle can be obtained. In this infographic, the authors present the current indications for noninvasive ankle distraction arthroscopy and illustrate the importance of proper portal placement in obtaining the access and visualization necessary to easily and safely address pathology throughout the entire ankle and subtalar joint.     

Ankle Arthroscopy: I. Technique and Complications

Arthroscopic surgery of the ankle allows the direct visualization of all intra-articular structures of the ankle without an arthrotomy or malleolar osteotomy. Technological advances and a thorough understanding of anatomy have resulted in an improved ability to perform diagnostic and operative arthroscopy of the ankle. The decreased morbidity and faster recovery times make it an appealing technique compared with open arthrotomy. A keen understanding of the anatomy of the foot and ankle is critical to safe performance of arthroscopic procedures and prevention of complications.     

Ankle Arthroscopy: II. Indications and Results

Diagnostic indications for the use of ankle arthroscopy include unexplained pain, swelling, stiffness, instability, hemarthrosis, and locking or popping, as well as a negative workup in a patient with significant ankle symptoms unresponsive to conservative care. Therapeutic indications include injuries of the articular cartilage and soft tissue, bone impingement, debridement of soft-tissue lesions, synovectomy and loose-body removal, arthrofibrosis, ankle fractures, and osteochondral defects. Ankle arthroscopy can also be used in ankle-stabilization procedures and arthrodesis, as well as for irrigation and debridement of septic arthritis. An algorithm has been developed to facilitate selection of the appropriate treatment for a patient with chronic ankle pain of unknown etiology. When used for the appropriate indications, ankle arthroscopy appears to give good results.     

New Posteromedial Portal for Ankle Arthroscopy

We describe a new posteromedial portal through the bed of the posterior tibial tendon. It can be made easily with a 0.5-inch posteromedial skin incision along the course of the posterior tibial tendon just behind the posterior colliculus of the medial malleolus. After the flexor retinaculum is incised and the posterior tibial tendon is retracted anteriorly, a small bulging area of capsule can be seen as a result of saline inflation. The new posteromedial portal can then be made easily through this inflated capsule. This portal allows good access to the posterior joint surface and has a minimal risk of injury to the medial neurovascular bundle.     

踝关节镜检查与镜下手术治疗

回顾性总结踝关节镜检查与镜下手术治疗的结果及经验体会，对38例44个关节的踝关节疾病患者施行踝关节镜检查与镜下手术。术后关节功能：优，31个踝（70.4％）；良，7个踝（15.9％）；一般，5个踝（11.4％）；差，1个踝（2.3％）。无血管及神经损伤并发症发生。踝关节镜手术的适应证广，经关节镜手术具有损伤小、恢复快、并发症少的优点。     

踝关节镜在踝关节骨折治疗中的价值

目的探讨踝关节镜在踝关节骨折治疗中的价值。方法 2009年12月～2011年7月26例踝关节骨折在踝关节镜下探查踝关节腔,清理撕裂韧带、水肿滑膜、损伤软骨,在踝关节镜辅助下复位、固定骨折,修复、重建损伤的韧带。结果软骨损伤部位同时累及胫骨远端关节面及距骨上关节面6例;累及距骨内侧面12例,其中5例同时合并内踝损伤,1例同时合并内、外踝损伤;同时合并外踝及距骨外侧面损伤8例,其中1例同时合并内踝及距骨体部损伤。关节镜下软骨碎片取出术11例,软骨复位固定9例,关节面修整、微骨折术6例;距下关节镜检查示软骨损伤及韧带松弛5例,距跟韧带断裂3例,均在关节镜辅助下行修复重建术。手术时间40～160 min,平均90 min;术中出血量10～300 ml,平均100 ml。术中均无神经、血管损伤,术后无感染病例,切口一期愈合。术后3个月采用改良McGuire评分系统评定临床疗效：优15例（81～100分）,良9例（71～80分）,可2例（65～70分）。26例随访3～24个月,平均9个月,骨折全部愈合。结论踝关节镜辅助治疗踝关节骨折能够精确解剖复位关节面,及时发现、处理软骨、韧带等合并损伤,创伤小,治疗效果满意。