ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY USE OF MEDIAL PORTALS IN ANKLE ARTHROSCOPY Francesco Allegra...

ADVANCED ANKLE AND SUBTALAR ARTHROSCOPYADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

USE OF MEDIAL PORTALS USE OF MEDIAL PORTALS IN ANKLE ARTHROSCOPYIN ANKLE ARTHROSCOPY

Francesco Allegra Francesco Allegra

Casa di Cura Villa Silvana - ApriliaCasa di Cura Villa Silvana - Aprilia

ANKLE JOINT PATHOLOGYANKLE JOINT PATHOLOGYArthroscopic treatment Arthroscopic treatment

Intarticular Intarticular 1. anterior 1. anterior 2. medial 2. medial 3. lateral3. lateral4. posterior4. posterior

ExtrarticularExtrarticular1. anterior1. anterior2. posterior2. posterior

26th AANA Annual Meeting ICL ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY

ANKLE JOINT ARTHOSCOPYANKLE JOINT ARTHOSCOPYAnterior side Anterior side - accordance on possibility and utility of the arthroscopic- accordance on possibility and utility of the arthroscopic treatment in all articular and para-articular pathologiestreatment in all articular and para-articular pathologies


ANKLE JOINT ARTRHOSCOPYANKLE JOINT ARTRHOSCOPYAnterior side Anterior side - traditional supine assessment of the patient- traditional supine assessment of the patient- small joint instrumentation set-up- small joint instrumentation set-up- anterior approach by two anteromedial and anterolateral- anterior approach by two anteromedial and anterolateral portals portals - traction - traction - joint distension- joint distension


ANKLE JOINT ARTRHOSCOPYANKLE JOINT ARTRHOSCOPYPosterior side Posterior side - lesser accordance on possibility and utility of the arthroscopic- lesser accordance on possibility and utility of the arthroscopic treatment because difficulties and risks of an hazardous areatreatment because difficulties and risks of an hazardous area- possibility to reach posterior gutter from anterior if joint not stiff- possibility to reach posterior gutter from anterior if joint not stiff- - some authorssome authors discouragediscourage use of posterolateral portaluse of posterolateral portal


Ferkel RD Ferkel RD et al. Arthroscopy,1996et al. Arthroscopy,1996Neurological complications of ankle arthroscopyNeurological complications of ankle arthroscopy

......postero-medial portals arepostero-medial portals arenever never used because of their high used because of their high potential for neurovascular injury.potential for neurovascular injury.

Parisien JS, Vangsness T.,Parisien JS, Vangsness T., CORR,1985 CORR,1985Operative arthroscopy of the ankle. Operative arthroscopy of the ankle. Three years experienceThree years experience

Faiwell LA, Frey C.,Faiwell LA, Frey C., Foot & AnkleFoot & Ankle, 1993, 1993Anatomic study of arthroscopic portal of the ankle. Anatomic study of arthroscopic portal of the ankle.

ANKLE JOINT ARTRHOSCOPYANKLE JOINT ARTRHOSCOPYPosterior side from anteriorPosterior side from anterior- if the distension of the ankle capsule is limited, the space - if the distension of the ankle capsule is limited, the space available can make it difficult to workavailable can make it difficult to work- surgery limitation by the shape of talus- surgery limitation by the shape of talus- the treatment is limited only to intrarticular pathology- the treatment is limited only to intrarticular pathology


...assessment of the posterior ankle...assessment of the posterior anklejoint is possible but instrumentationjoint is possible but instrumentationfrom the front to the back of the joint from the front to the back of the joint is difficult because of the shape…is difficult because of the shape…

WHAT IS THE POSTERIOR ANKLE JOINT?WHAT IS THE POSTERIOR ANKLE JOINT?Posterior anatomic districtPosterior anatomic districtankle joint recessankle joint recess - posterior- posterior - medial - medial - lateral- lateralsubtalar joint recesssubtalar joint recess - posterior- posteriorrear foot extra articular regionrear foot extra articular region - proximal- proximal - distal- distal


dilemma: arthroscopic treatment or not?dilemma: arthroscopic treatment or not?

ANKLE JOINT SURGERYANKLE JOINT SURGERYPosterior sidePosterior side- open surgery to be considered in all cases- open surgery to be considered in all cases- arthroscopic procedure is equal compared to open one but- arthroscopic procedure is equal compared to open one but superior as invasivity and as surgical selectivity superior as invasivity and as surgical selectivity - arthroscopic surgeon must remember to adopt a different - arthroscopic surgeon must remember to adopt a different procedure in selected case if neededprocedure in selected case if needed


Maquirriain J Maquirriain J Jour Am Ac Orth Sur, 2005 Jour Am Ac Orth Sur, 2005Posterior ankle impingement syndromePosterior ankle impingement syndrome

......endoscopic technique…...may ......endoscopic technique…...may be a valid alternative for treating a be a valid alternative for treating a variety of posterior ankle problems variety of posterior ankle problems including etiologic PAIS lesions.including etiologic PAIS lesions.

ANKLE JOINT SURGERYANKLE JOINT SURGERYPosterior sidePosterior side- tarsal syndrome- tarsal syndromeposterior cyst- posterior cyst- big bony spurs (Haglund’s disease)- big bony spurs (Haglund’s disease)


ANKLE JOINT ARTRHOSCOPYANKLE JOINT ARTRHOSCOPYPosterior sidePosterior side- “discover” of new therapeutic opportunities by Nijk Van Dijk- “discover” of new therapeutic opportunities by Nijk Van Dijk- posterior portals in arthroscopic treatment of joint and extra - posterior portals in arthroscopic treatment of joint and extra joint pathology through a risk areajoint pathology through a risk area


Van Dijk NC Van Dijk NC et al. Arthroscopy, 2000et al. Arthroscopy, 2000A 2-portal endoscopic approach for diagnosis andA 2-portal endoscopic approach for diagnosis andtreatment of posterior ankle pathologytreatment of posterior ankle pathology

ANKLE JOINT ARTRHOSCOPYANKLE JOINT ARTRHOSCOPYPosterior side Posterior side - new prone assessment of the patient- new prone assessment of the patient- same dedicated small instrumentation- same dedicated small instrumentation- posterior approach by triangulation through two posteromedial- posterior approach by triangulation through two posteromedial and posterolateral portals and posterolateral portals - no traction - no traction - no previous distension- no previous distension



ANKLE JOINT ANATOMYANKLE JOINT ANATOMYPosterior side Posterior side - validation of the proposed procedure by anatomic study - validation of the proposed procedure by anatomic study - easiest way to reach the posterior gutter and to treat spotted - easiest way to reach the posterior gutter and to treat spotted joint pathologyjoint pathology


Ljoi F Ljoi F et al. Arthroscopy, 2003et al. Arthroscopy, 2003Posterior approach to the ankle: Posterior approach to the ankle: an anatomic studyan anatomic study

Sitler DF, Amendola A, Bailey CS, Than LM, Spouge A.Sitler DF, Amendola A, Bailey CS, Than LM, Spouge A. JBJS, 2002 JBJS, 2002Posterior ankle arthroscopy: an anatomic studyPosterior ankle arthroscopy: an anatomic study

ANKLE JOINT ANATOMYANKLE JOINT ANATOMYPosterior side Posterior side - new procedure by prone position recently proposed by Sim JA- new procedure by prone position recently proposed by Sim JA- new posteromedial portal placed just posterior to the posterior- new posteromedial portal placed just posterior to the posterior colliculus of the medial malleolus lifting anteriorly the posteriorcolliculus of the medial malleolus lifting anteriorly the posterior tibial tendontibial tendon- less easy way to reach the posterior gutter compared to the - less easy way to reach the posterior gutter compared to the former, but big idea former, but big idea


Sim JA, Lee BK, Kwak JHSim JA, Lee BK, Kwak JH Arthroscopy, 2006 Arthroscopy, 2006New posteromedial portal for ankle arthroscopyNew posteromedial portal for ankle arthroscopy

courtesy Sim JA

ANKLE JOINT PATHOLOGYANKLE JOINT PATHOLOGYPosterior side Posterior side - new proposed portals coaxial to the posterior malleolar line- new proposed portals coaxial to the posterior malleolar line- authors consider this procedure easy and safe to reach the- authors consider this procedure easy and safe to reach the posterior tibiotalar recess posterior tibiotalar recess - portals are equidistant to neurovascular structures compared to- portals are equidistant to neurovascular structures compared to conventional portals conventional portals - unclear the patient assessment- unclear the patient assessment


Acevedo J, Bush MT, Ganey TM, Hutton WC, Acevedo J, Bush MT, Ganey TM, Hutton WC, Ogden JA. Ogden JA. Arthroscopy,Arthroscopy, 2000 2000Coaxial portals for posterior ankle arthroscopy: anCoaxial portals for posterior ankle arthroscopy: anAnatomic study with clinical correlation on 29 ptsAnatomic study with clinical correlation on 29 pts

...our clinical results suggest this ...our clinical results suggest this technique for posteromedial and technique for posteromedial and posterolateral portal is safe, posterolateral portal is safe, effective and reproducible.effective and reproducible.

POSTERIOR ANKLE ARTROSCOPYPOSTERIOR ANKLE ARTROSCOPY- many portals describedmany portals described- few completed anatomic studies on safety and respect of - few completed anatomic studies on safety and respect of neurovascular bundleneurovascular bundle- prone positioning of the patient - prone positioning of the patient - procedures need triangulation or previous protection of TP - procedures need triangulation or previous protection of TP tendon sheathtendon sheath- usual anesthesia - usual anesthesia - instrumentation for small joints depending surgeon’s request- instrumentation for small joints depending surgeon’s request


the sharper the respect of originalthe sharper the respect of originalprocedure the safest the surgery, procedure the safest the surgery, avoiding lesions of risk structures avoiding lesions of risk structures

POSTERIOR ANKLE ARTROSCOPYPOSTERIOR ANKLE ARTROSCOPYmany portals describedmany portals described- postero-medial- postero-medial- postero-lateral - postero-lateral - postero-lateral accessory - postero-lateral accessory - transachilleous- transachilleous anatomic risk areasanatomic risk areas- posterior tibial artery- posterior tibial artery- posterior tibial nerve- posterior tibial nerve- FHL tendon- FHL tendon- small saphenous vein- small saphenous vein- saphenous nerve- saphenous nerveVan Dijk portals Van Dijk portals - postero medial - postero medial - postero lateral- postero lateral


courtesy Ferkel RD

Van Dijk arthroscopic procedureVan Dijk arthroscopic procedure- only posterior recess treatment- only posterior recess treatment- prone patient assessment- prone patient assessment- possibility of traction pulling by a belt around the surgeon’s- possibility of traction pulling by a belt around the surgeon’s waistwaist- selected anesthesia- selected anesthesia


Van Dijk arthroscopic procedureVan Dijk arthroscopic procedureoriginal procedureoriginal procedure- towel under the leg to lift the foot out the border of table- towel under the leg to lift the foot out the border of table- portals and anatomic risk areas to be marked- portals and anatomic risk areas to be marked- no inflation needed- no inflation needed- triangulation of instruments on transverse plane- triangulation of instruments on transverse plane- wide accuracy in exploring posterior joint recess and extra - wide accuracy in exploring posterior joint recess and extra capsular space capsular space


Posterior pathologyPosterior pathologyAnatomic districts affected by spotted problems Anatomic districts affected by spotted problems 1. posterior ankle joint recess1. posterior ankle joint recess2. posterior ankle extrarticular space2. posterior ankle extrarticular space3. posterior subtalar joint recess3. posterior subtalar joint recess4. posterior rearfoot area4. posterior rearfoot area5. Achilles' tendon front region5. Achilles' tendon front region


Posterior arthroscopic treatmentPosterior arthroscopic treatmentANKLE JOINT SPACEANKLE JOINT SPACE1. ankle joint posterior gutters (between talus 1. ankle joint posterior gutters (between talus tibial and peroneal malleolus) tibial and peroneal malleolus) 2. posterior subtalar joint 2. posterior subtalar joint KIND OF PATHOLOGYKIND OF PATHOLOGY1. posterior chondral defects1. posterior chondral defects2. loose bodies2. loose bodies3. lesions of the posterior ligaments complex3. lesions of the posterior ligaments complex


Posterior arthroscopic treatmentPosterior arthroscopic treatmentANKLE JOINT SPACEANKLE JOINT SPACE1. ankle joint posterior gutters (between talus 1. ankle joint posterior gutters (between talus tibial and peroneal malleolus)tibial and peroneal malleolus) 2. posterior subtalar joint2. posterior subtalar joint KIND OF PATHOLOGYKIND OF PATHOLOGY1. posterior chondral defects1. posterior chondral defects2. loose bodies2. loose bodies3. lesions of the posterior ligaments complex3. lesions of the posterior ligaments complex


Posterior arthroscopic treatmentPosterior arthroscopic treatmentANKLE JOINT SPACEANKLE JOINT SPACE1. ankle joint posterior gutters (between talus 1. ankle joint posterior gutters (between talus tibial and peroneal malleolus) tibial and peroneal malleolus) 2. posterior subtalar joint 2. posterior subtalar joint KIND OF PATHOLOGYKIND OF PATHOLOGY1. posterior chondral defects1. posterior chondral defects2. loose bodies2. loose bodies3. lesions of the posterior ligaments complex3. lesions of the posterior ligaments complex


Posterior arthroscopic treatmentPosterior arthroscopic treatmentANKLE EXTRARTICULAR SPACEANKLE EXTRARTICULAR SPACE1. posterior extrarticular and extracapsular 1. posterior extrarticular and extracapsular anatomic space anatomic space - FHL tendon- FHL tendon - symptomatic os trigonum- symptomatic os trigonum - posterior adhesions with stiffness- posterior adhesions with stiffness


Posterior arthroscopic treatmentPosterior arthroscopic treatmentANKLE EXTRARTICULAR SPACEANKLE EXTRARTICULAR SPACE1. posterior extrarticular and extracapsular 1. posterior extrarticular and extracapsular anatomic space anatomic space - FHL tendon- FHL tendon - os trigonum- os trigonum - posterior adhesions with stiffness- posterior adhesions with stiffness


Posterior arthroscopic treatmentPosterior arthroscopic treatmentANKLE EXTRARTICULAR SPACEANKLE EXTRARTICULAR SPACE2. rear extrarticular and iuxta tendon 2. rear extrarticular and iuxta tendon anatomic space: Haglund’s diseaseanatomic space: Haglund’s disease


Both compartments ankle pathologyBoth compartments ankle pathologyAnterior association with posterior recess or with rearfoot side:Anterior association with posterior recess or with rearfoot side:What to do? Many questions on the table:What to do? Many questions on the table:- which kind of solution must be adopted?- which kind of solution must be adopted?- which kind of patient assessment has to be privileged?- which kind of patient assessment has to be privileged?- has the surgeon change during surgery the pt. assessment? - has the surgeon change during surgery the pt. assessment? - at least, has the surgeon to propose the patient a two-time- at least, has the surgeon to propose the patient a two-time treatment?treatment?


Both compartments ankle pathologyBoth compartments ankle pathologySolutions from the surgeon’s experienceSolutions from the surgeon’s experience1. double coaxial portals: use 1. double coaxial portals: use limited to joint pathology onlylimited to joint pathology only

2. prone posterior ankle approach firstly,2. prone posterior ankle approach firstly, anterior approach secondly with the kneeanterior approach secondly with the knee in flexion and up-side down visualizationin flexion and up-side down visualization


Acevedo J, Bush MT, Ganey TM, Hutton WC, Acevedo J, Bush MT, Ganey TM, Hutton WC, Ogden JA. Ogden JA. Arthroscopy,Arthroscopy, 2000 2000Coaxial portals for posterior ankle arthroscopy: anCoaxial portals for posterior ankle arthroscopy: anAnatomic study with clinical correlation on 29 ptsAnatomic study with clinical correlation on 29 pts


Both compartments ankle pathologyBoth compartments ankle pathologySolutions from the surgeon’s experienceSolutions from the surgeon’s experience3. double posteromedial portals in supine assessment, after 3. double posteromedial portals in supine assessment, after anterior treatmentanterior treatment - mild external rotation of the leg- mild external rotation of the leg - portals anterior and postero-medial to be marked- portals anterior and postero-medial to be marked - longitudinal triangulation of the instruments- longitudinal triangulation of the instruments - possibility to treat anterior and posterior problems into the - possibility to treat anterior and posterior problems into the joint and in the outer spacejoint and in the outer space


Both compartments ankle pathologyBoth compartments ankle pathologyAnkle joint simultaneous anterior and posterior (articular and Ankle joint simultaneous anterior and posterior (articular and extra articular) pathologyextra articular) pathologyarthroscopic treatment of the anterior articular problems by - arthroscopic treatment of the anterior articular problems by standard anterior portalsstandard anterior portals- scope access to the posterior joint recess or to the rearfoot - scope access to the posterior joint recess or to the rearfoot area through two posteromedial portals area through two posteromedial portals - placement secondary to anatomic studies to validate the- placement secondary to anatomic studies to validate the procedureprocedure


Double posteromedial portalDouble posteromedial portal- placed in “risk” area because the neurovascular bundle- placed in “risk” area because the neurovascular bundle- externally to FHL tendon well palpable under the skin- externally to FHL tendon well palpable under the skin- access long the anterior margin of Achilles’ tendon - access long the anterior margin of Achilles’ tendon - presence of - presence of safe safe triangular area triangular area surrounded by calcanear surrounded by calcanear tuberosity (inferior) FHL (anterior) tuberosity (inferior) FHL (anterior) Achilles’ tendon (posterior)Achilles’ tendon (posterior)- area wide almost 25-30 mm- area wide almost 25-30 mm²²


courtesy Ferkel RD

Double posteromedial portalDouble posteromedial portalANATOMIC TRIANGULAR AREAANATOMIC TRIANGULAR AREAWell delimited by easy palpable anatomic structures as:Well delimited by easy palpable anatomic structures as:- upper calcanear tuberosity - upper calcanear tuberosity - posterior margin of FHL tendon which protects the tibial bundle- posterior margin of FHL tendon which protects the tibial bundle- anterior margin of Achilles’ tendon - anterior margin of Achilles’ tendon


Double posteromedial portalDouble posteromedial portalANATOMIC TRIANGULAR AREAANATOMIC TRIANGULAR AREAAround it lie some important anatomic path at risk :Around it lie some important anatomic path at risk :- calcanear branch of posterior tibial nerve (motor and sensitive)- calcanear branch of posterior tibial nerve (motor and sensitive)- posterior tibial neurovascular - posterior tibial neurovascular bundlebundle

To avoid any unwished collision theTo avoid any unwished collision thesurgeon must:surgeon must:- gently move ahead the cannula from - gently move ahead the cannula from one of the portals to the peroneal one of the portals to the peroneal compartment until touchingcompartment until touching- make a triangulation on longitudinal- make a triangulation on longitudinal plane pushing the shaver from the plane pushing the shaver from the second portal until seeing the tipsecond portal until seeing the tip


Surgical techniqueSurgical techniqueSupine assessment in mild leg external rotation Supine assessment in mild leg external rotation - leg-holder with tourniquet- leg-holder with tourniquet- both anterior and posterior portals to be marked- both anterior and posterior portals to be marked- possibility to keep the foot in traction- possibility to keep the foot in traction- treatment - treatment of the ankle pathology in anterior compartmentof the ankle pathology in anterior compartment- external rotation of the surgical table- external rotation of the surgical table


Surgical techniqueSurgical technique- skin incision- skin incision- from inferior portal the cannula is inserted along the superior - from inferior portal the cannula is inserted along the superior calcaneal margin to peroneal malleolus calcaneal margin to peroneal malleolus - - from superior portal the shaver proceeds to the same malleolusfrom superior portal the shaver proceeds to the same malleolus- on the posterior tibio -peroneal margin the instruments stop - on the posterior tibio -peroneal margin the instruments stop - triangulation of instruments on longitudinal plane - triangulation of instruments on longitudinal plane - direct sight of tip of shaver- direct sight of tip of shaver- possibility to lead out surgery reversing the instruments- possibility to lead out surgery reversing the instruments


Surgical treatmentSurgical treatmentposterior ankle joint reachable - posterior ankle joint reachable - posterior margin exploration of lateral malleolus and talar dome- posterior margin exploration of lateral malleolus and talar dome- inferior margin of tibial plateau visible - inferior margin of tibial plateau visible - posterior loose bodies removal- posterior loose bodies removal- symptomatic os trigonum treatment- symptomatic os trigonum treatment- debridement of FHL tendon - debridement of FHL tendon impingementimpingement- subtalar pathology assessment- subtalar pathology assessment


patient assessment n

ot changed

patient assessment n

ot changed

both compartments one step treatment

both compartments one step treatment

anterior and postero-medial portalsanterior and postero-medial portals

safe reproducible procedure

safe reproducible procedure

Conclusions Conclusions

low surg

ical m

orbidity

low surg

ical m

orbidity


THANK YOU FOR THANK YOU FOR YOUR ATTENTIONYOUR ATTENTION


ADVANCED ANKLE AND SUBTALAR ARTHROSCOPY USE OF MEDIAL PORTALS IN ANKLE ARTHROSCOPY Francesco Allegra...

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