Ankle Arthroscopy With Microfracture for Osteochondral Defects of the Talus Suman Medda, M.D., Ian M. Al’Khafaji, M.D., and Aaron T. Scott, M.D.
Abstract: Therapeutic arthroscopy with microfracture leads to fibrocartilaginous repair and is an effective treatment of osteochondral lesions of the talus. A full diagnostic arthroscopy is performed, and then attention is turned to the osteochondral defect. We describe in detail patient positioning, ankle distraction, portal placement, steps of the diagnostic arthroscopy, and the technique of microfracture. We then discuss the special considerations to be taken regarding the use of a distractor, protection of neurovascular structures, and the indications for microfracture.
A
nkle arthroscopy has been commonly described with the patient in the supine position through the use of anteromedial and anterolateral portals. It can be performed under general, spinal, epidural, and even local anesthesia. It can be used as a diagnostic modality when a patient’s pathology is unclear. It has been established as a viable modality of treatment for anterior impingement and osteochondral defects.1-3 Complications of the procedure include neurological injury, vascular injury, aneurysm, and infection; however, it is a relatively low-risk procedure. Contraindications include localized soft-tissue infection and severe degenerative joint disease.4 Osteochondral lesions have been attributed to local avascular necrosis, trauma, degenerative joint disease, joint misalignment, and genetic predisposition.5 They can be diagnosed on plain films or with advanced imaging. The optimal treatment of these lesions has not yet been established and may be related to their size and location and to the patient. Arthroscopic microfracture of osteochondral defects leads to fibrocartilaginous repair and has shown good efficacy in leading to significant functional improvement.6 Further study
From the Wake Forest Baptist Medical Center, Winston Salem, North Carolina, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received June 15, 2016; accepted September 9, 2016. Address correspondence to Suman Medda, M.D., Wake Forest Baptist Medical Center, 1 Medical Center Boulevard, Winston Salem, NC 27103, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16551/$36.00 http://dx.doi.org/10.1016/j.eats.2016.09.013
must be done to better define indications for this procedure.7
Surgical Technique Patient Setup The patient is placed supine on the operating room table. At our institution we provide sedation supplemented with regional blocks, but spinal/epidural blocks and general anesthesia are also acceptable. A tourniquet should be placed around the upper thigh, and the thigh is placed in a thigh holder (Fig 1A). The lower extremity is prepared and draped in a standard sterile fashion. The extremity is elevated, and the tourniquet is inflated. A noninvasive ankle distractor (Smith and Nephew GUHL noninvasive ankle distractor) is attached to the side of the operating table and set to 30 foot-pounds of inline traction using a limb positioner (Smith and Nephew Spider 2; Fig 1B, Video 1). Anteromedial Portal Placement The medial malleolus and tibialis anterior tendon are carefully palpated for the anteromedial portal (Fig 2A). The lateral malleolus and extensor digitorum longus should also be palpated to identify landmarks for the anterolateral portal, which is later placed under direct visualization (Fig 2B). To create the anteromedial portal, a 20-gauge needle is advanced just medial to the tibialis anterior tendon into the joint and 20 mL of sterile saline is injected to distend the joint space. A stab incision is made over the injection site through the skin. The incision is bluntly deepened down into the joint with a tonsil with care taken to avoid the saphenous vein and nerve. A blunt trocar (Stryker Endoscopy 2.7-mm Trocar) is introduced (Fig 2C) followed by the
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Fig 1. (A) With the patient supine, a tourniquet (white arrow) was placed around the left upper thigh, and the left leg was placed in a thigh holder (red arrow). (B) With the patient supine, a noninvasive ankle distractor (white arrow) was applied to the left foot and set to 30 foot-pounds of inline traction.
Fig 2. (A) With the patient supine, the medial malleolus and tibialis anterior tendon were palpated on the left lower extremity to serve as landmarks for the anteromedial portal (white circle). (B) With the patient supine, the lateral malleolus and extensor digitorum longus were palpated on the left lower extremity to identify landmarks for the anterolateral portal (white circle), which would be later placed under direct visualization. (C) With the patient supine, the blunt trocar (white arrow) was advanced into the anteromedial portal of the left ankle. (EDL, extensor digitorum longus; EHL, extensor hallucis longus; Saph., saphenous vein; SPN, superficial peroneal nerve; TA, tibialis anterior.)
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tracked laterally to assess the anterior talar dome and talar neck. Then the arthroscope is moved superiorly to assess the anterior tibia. During this time articular pathology, such as osteochondral lesions and soft-tissue injuries, can be diagnosed visually.
Fig 3. With the patient supine and the arthroscope in the anteromedial portal, the joint space between the tibia (superior) and talus (inferior) was appreciated with inflamed synovium (white arrow).
arthroscope (Stryker Endoscopy 2.7-mm 30 A/C, 1288 HD camera; Video 1). The injected normal saline is evacuated from the joint once the cannula is introduced. Diagnostic Arthroscopy: Part 1 A thorough evaluation of the joint is performed. The joint space between the tibia and talus is appreciated, and often times inflamed synovium anteriorly and posteriorly can be noticed (Fig 3). The arthroscope is moved medially and then distally to assess the medial gutter and deltoid ligament. The arthroscope is then
Anterolateral Portal Placement An anterolateral portal is then made through direct visualization. A 20-gauge needle is inserted just lateral to the peroneus tertius tendon at the level of the joint line and is directly visualized by the arthroscope (Fig 4A). A stab incision is then made over the needle insertion site through the skin. The incision is bluntly deepened to the joint with a small tonsil (Fig 4B). Care is taken to avoid the intermediate and medial dorsal cutaneous branches of the superficial peroneal nerve. A blunt trocar is then used to enter the joint under visualization (Video 1). Osteochondral Defect Preparation A probe (Smith and Nephew Elite calibrated probe) can now be introduced into the anterolateral portal. Attention is directed to the osteochondral defect. In our case the lesion is found in the lateral talar dome, which can best be initially accessed with our initial visualization and working portals. Medial lesions may need to be visualized in the anterolateral portal while working through the anteromedial portal. The probe is used to elevate the unstable cartilage around the base and within the perimeter of the osteochondral defect (Fig 5). An arthroscopic shaver (Smith and Nephew Dyonics Powermini 2.0-mm full radius shaver) is used to debride some of the loose flaps of cartilage (Fig 6). The probe can be used to measure the size of the lesion. A small sharp curette (Smith and Nephew Ferkel 15
Fig 4. (A) With the patient supine and the arthroscope in the anteromedial portal, a 20-gauge needle (white arrow) was inserted just lateral to the peroneus tertius tendon of the left ankle at the level of the joint line and was directly visualized by the arthroscope. (B) With the patient supine and the arthroscope in the anteromedial portal, a 20-gauge needle was inserted at the location of the anterolateral portal of the left ankle. A skin incision was then made, and a tonsil (white arrow) was used to bluntly dissect down to the joint before a trocar was introduced.
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Fig 5. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, a probe (white arrow) was introduced into the anterolateral portal of the left ankle and used to elevate the unstable cartilage (red arrow) around the base and within the perimeter of the osteochondral defect of the talus (pictured inferiorly).
Fig 7. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, a small sharp curette (white arrow) was introduced into the anterolateral portal of the left ankle and used to remove the remaining unstable cartilage (red arrow).
open curette 2.5 mm) is used to remove the remaining unstable cartilage (Fig 7). Care is taken to ensure that the stable border cartilage is oriented perpendicularly to subchondral bone so that it can contain the microfracture hematoma that will later be created. Large loose bodies are removed from the joint using a grasper (Smith and Nephew grasper 2.7-mm straight; Fig 8). An anterior lesion curette (Smith and Nephew Ferkel 15
anterior lesion curette, 2.5 mm) is used to further debride the anterior defect (Fig 9). The instrument is mainly used to scrape away the anterior cartilage, which is difficult to access. A second arthroscopic cannula (Stryker Endoscopy 2.8-mm cannula) is connected to suction and used to capture the remaining loose fragments from the joint (Fig 10). The base of the
Fig 6. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, an arthroscopic shaver (white arrow) was introduced into the anterolateral portal of the left ankle to debride some of the loose flaps of cartilage (red arrow).
Fig 8. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, a grasper (white arrow) was introduced into the anterolateral portal of the left ankle to remove large loose bodies (red arrow) from the left ankle joint.
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Fig 9. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, an anterior lesion curette (white arrow) was introduced into the anterolateral portal of the left ankle and was used to further debride the anterior defect (red arrow).
osteochondral defect is further debrided using the arthroscopic shaver (Video 1). Synovectomy At this point, the arthroscopic shaver and arthroscope are reversed. The arthroscope is brought in through the anterolateral portal, and the arthroscopic shaver is
Fig 10. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, an arthroscopic cannula (white arrow) was introduced into the anterolateral portal of the left ankle and connected to suction and used to capture the remaining loose fragments (red arrow) from the left ankle joint.
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Fig 11. With the patient supine and the arthroscope in the anterolateral portal of the left ankle, the talofibular articulation was assessed with the talus on the left (white arrow) and the fibula on the right (red arrow).
introduced through the anteromedial portal. The chondral defect is again visualized. Attention is then turned to the synovectomy portion of the procedure. The arthroscopic shaver is used to debride the hypertrophic and inflamed posterior synovial tissue until it had been adequately debrided. Diagnostic Arthroscopy: Part 2 The arthroscope is then tracked laterally and inferiorly to assess the talofibular articulation (Fig 11) and lateral
Fig 12. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, a microfracture pick (white arrow) was introduced through the anterolateral portal of the left ankle and used to create several small fractures in the subchondral bone (red arrow).
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and placed in a long CAM boot. The patient continues non-weight-bearing restrictions for 4 additional weeks but starts active range of motion out of the boot. At 6 weeks, the patient starts gradual increase in weight bearing and is transitioned out of the boot. At this time, formal physical therapy is started.
Discussion
Fig 13. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, the water pressure within the left ankle joint was released and good bleeding was observed from the microfracture sites (white arrow).
gutter (Video 1). This aspect of the diagnostic arthroscopy is not performed earlier as these 2 areas are better assessed with the scope in the anterolateral portal. Microfracture Attention is again turned to the osteochondral defect. The arthroscope is once again introduced through the anteromedial portal. As stated before, the arthroscope may need to be placed in the anterolateral portal for medial lesions. A microfracture pick (Smith and Nephew, 65 ) is introduced through the anterolateral portal and used to create several small pick holes in the subchondral bone (Fig 12). Care is taken to ensure that the pick is perpendicular to subchondral bone and that the microfracture sites are spaced widely enough to prevent unintended further fracture. The awl is hand driven into subchondral bone; however, careful malleting is sometimes required depending on bone quality. After placing the final pick hole, the water pressure within the joint is released, and good bleeding should be observed from the microfracture sites (Fig 13, Video 1). Irrigation, Closure, and Casting A thorough lavage of the joint is performed, and the arthroscopic instrumentation is removed. The skin is closed with superficial 3-0 nylon horizontal mattress sutures. Dry sterile dressings are applied, and the patient is placed in a well-padded short leg fiberglass cast. Postoperative Care The patient is made noneweight bearing. At the first clinic visit at 2 weeks, the patient is taken out of the cast
The technique of dorsiflexing the joint to introduce and exchange instruments is commonly used. However, a thorough arthroscopic diagnostic exam is difficult without the use of joint distraction. Some studies have suggested that distraction may lead to many of the common complications of ankle arthroscopy.8 Distraction creates tension on the neurovascular structures and decreases the distance between the anterior joint space and the overlying neurovascular structures.9 Invasive distraction has been linked with pin track infections and stress fractures,10 thus noninvasive distraction methods are more commonly used. Although the use of a distractor has yielded a higher neurological complication rate, many of these complications resolve over time. There may be efficacy in intermittent distraction. In one consecutive series review of 1,305 ankle arthroscopies, no complications could be attributed to ankle distraction when intermittent soft-tissue distraction was used.11 Additionally, anterior ankle pathology is better accessed without distraction. Using intermittent distraction would allow ideal access to both anterior and posterior pathology (Table 1). The superficial anatomy serves as a guide for portal placement. When the foot is pulled into adduction, the superficial branches of the peroneal nerve can be seen. The superficial peroneal nerve divides into its intermediate and medial dorsal cutaneous branches approximately 6 to 7 cm proximal to the tip of the fibula. The intermediate branch runs superficial to the Table 1. The Advantages and Disadvantages of Various Forms of Distraction Used in Ankle Arthroscopy Advantages Continuous distraction
Disadvantages
Ideal visualization of Reported increased rates of posterior ankle neurological injury pathology Increased joint space for Increased tension on instrumentation neurovascular structures Decreased space between neurovascular structures and portals No distraction/ Ideal visualization of Decreased visualization of dorsiflexion anterior ankle posterior pathology pathology Intermittent Decreased total time Increased need for surgeon distraction under distraction intervention during case Ideal visualization of anterior and posterior pathology
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ANKLE ARTHROSCOPY Table 2. Ankle Arthroscopy Portal Locations, Important Structures to Avoid, and Pearls Portal
Location
Anteromedial Anterolateral
Important Structures to Avoid
Just medial to tibialis anterior tendon Just lateral to peroneus tertius
Anterocentral
Just medial to extensor hallucis longus
Posterolateral
Just lateral to achilles tendon 1.2 cm above tip of lateral malleolus Just medial to Achilles tendon at same level of posterolateral portal
Posteromedial
Create this portal first
Branches of superficial peroneal nerve (both sides of portal) Anterior neurovascular bundle including deep peroneal nerve and anterior tibial artery (medial to portal) Sural nerve and small saphenous vein (lateral to portal)
Create under direct visualization
Posterior tibial neurovascular bundle including tibial nerve and posterior tibial artery (medial to portal)
Use extreme caution when creating this portal due to its proximity to critical structures
inferior extensor retinaculum and anterior to the common extensors of the fourth and fifth toes and then travels down the foot between the third and fourth metatarsals. The medial branch crosses the anterior aspect of the ankle superficial to the common extensors and runs parallel to the extensor hallucis longus tendon before dividing distally into 3 dorsal digital branches.4,8 Distending the ankle joint with 15 to 20 mL of sterile saline prior to portal placement displaces neurovascular structures from the joint space. The anteromedial portal is created at the level of the ankle joint just medial to the tibialis anterior tendon and lateral to the saphenous vein. The anterolateral portal is made just lateral to the peroneus tertius tendon under direct visualization to avoid neurovascular structures and tendons. It is important to make the portal incision through skin only and then bluntly dissect down to the joint space to avoid neurovascular structures. Other portals have been described and may be required. The anterocentral portal is created between the extensor hallucis longus and the anterior neurovascular bundle. The posterolateral portal is created just lateral to the Achilles tendon and 1.2 cm proximal to the distal tip of the lateral malleolus. The posteromedial portal is created at the Table 3. Treatment Modality Stratification Based on Size of Osteochondral Defects of the Talus Technique Arthroscopic debridement, microfracture, and curettage Osteochondral autogenous graft or autologous chondrocyte transplantation (ACT)
ACT or allograft Athrodesis or prosthetic replacement
Pearls
Saphenous vein (medial to portal)
Indications Lesions 50 years12
Use extreme caution when creating this portal due to its proximity to critical structures
same location just medial to the Achilles tendon. Extreme caution is to be taken when creating the anterocentral and posteromedial portal due to its proximity to the anterior neurovascular (deep peroneal nerve, anterior tibial artery) and posteromedial neurovascular (tibial nerve, posterior tibial artery) bundles, respectively (Table 2). Diagnostic ankle arthroscopy is performed when nonoperative approaches to diagnosis have failed and the patient continues to have significant ankle symptoms unresponsive to conservative treatment. Although many defects can be visualized on both plain film and magnetic resonance imaging, there is a high incidence of missed or delayed diagnosis of osteochondral lesions of the talus with unexplained chronic ankle pain.13 While the use of therapeutic arthroscopy is well supported for anterior impingement and osteochondral defects, there is not yet sufficient evidence for its use in the treatment of septic arthritis, ankle instability, and removal of loose bodies. There is evidence against its use in the treatment of arthritis. There is insufficient literature for its use in the management of fracture and synovitis.3 The optimal treatment for cartilage lesions has not yet been established. Conservative treatment can include casting with or without weight bearing. Potential operative interventions include chondroplasty, microfracture, and osteochondral autologous transplantation. Studies have shown equivocal patient satisfaction scores between these interventions,14,15 while other studies have shown that the size of the osteochondral defect may affect the outcome of intervention.16 It has been suggested that lesions less than 150 mm2 generally respond to arthroscopic marrow stimulation, while defects larger than this require osteochondral transplantation. In one study of 120 ankles undergoing microfracture, 10.5% of lesions 150 mm2.6 Some investigators have stratified treatment modalities based on defect size (Table 3).12 Others have suggested that defect size and patient age do not correlate with functional outcomes.17 Further
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research is required into the optimal treatment, which may differ based on history of trauma, body mass index, and other comorbidities.
References 1. van Dijk CN, Scholte D. Arthroscopy of the ankle joint. Arthroscopy 1997;13:90-96. 2. Amendola A, Petrik J, Webster-Bogaert S. Ankle arthroscopy: outcome in 79 consecutive patients. Arthroscopy 1996;12:565-573. 3. Glazebrook MA, Ganapathy V, Bridge MA, Stone JW, Allard JP. Evidence-based indications for ankle arthroscopy. Arthroscopy 2009;25:1478-1490. 4. Ferkel RD, Scranton PE. Current concepts review: arthroscopy of the ankle and foot. J Bone Joint Surg Am 1993;75:1233-1242. 5. O’Loughlin PF, Kennedy JG. Current concepts in the diagnosis and treatment of osteochondral lesions. Am J Sports Med 2010;38:392-404. 6. Lee KB, Bai LB, Chung JY, Seon JK. Arthroscopic microfracture for osteochondral lesions of the talus. Knee Surg Sports Traumatol Arthrosc 2010;18:247-253. 7. Donnenwerth MP, Roukis TS. Outcome of arthroscopic debridement and microfracture as the primary treatment for osteochondral lesions of the dome. Arthroscopy 2012;28:1902-1907. 8. Young BH, Flanigan RM, DiGiovanni BF. Complications of ankle arthroscopy utilizing a contemporary noninvasive distraction technique. J Bone Joint Surg Am 2011;93: 963-968.
9. de Leeuw PA, Golano P, Clavero JA, van Dijk CN. Anterior ankle arthroscopy, distraction or dorsiflexion? Knee Surg Sports Traumatol Arthrosc 2010;18:594-600. 10. Ferkel RD, Heath DD, Guhl JF. Neurological complications of ankle arthroscopy. Arthroscopy 1996;12:200-208. 11. Zengerink M, van Dijk CN. Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2012;20: 1420-1431. 12. Giannini S, Francesca V. Operative treatment of osteochondral lesions of the talar dome: current concepts review. Foot Ankle Int 2004;25:168-175. 13. Ferkel RD, Scaglione NA, Del Pizzo W, et al. Arthroscopic treatment of osteochondral lesions of the talus: technique and results. Orthop Trans 1990;14:172-173. 14. Gobbi A, Francisco RA, Lubowitz JH, Allegra F, Canata G. Osteochondral lesions of the talus: randomized controlled trial comparing chondroplasty, microfracture, and osteochondral autograft transplantation. Arthroscopy 2006;22: 1085-1092. 15. Knutsen G, Drogset JO, Engebretsen L, et al. A randomized trial comparing autologous chondrocyte implantation within microfracture. J Bone Joint Surg Am 2007;89:21052112. 16. Chuckpaiwong B, Berkson EM, Theodore GH. Microfracture for osteochondral lesions of the ankle: outcome analysis and outcome predictors of 105 cases. Arthroscopy 2008;24:106-112. 17. Polat G, Erdil ME, Kizilkurt T, Kilicoglu O, Asik M. Longterm results of microfracture in the treatment of talus osteochondral lesions. Knee Surg Sports Traumatol Arthrosc 2016;24:1299-1303.
Abstract: Therapeutic arthroscopy with microfracture leads to fibrocartilaginous repair and is an effective treatment of osteochondral lesions of the talus. A full diagnostic arthroscopy is performed, and then attention is turned to the osteochondral defect. We describe in detail patient positioning, ankle distraction, portal placement, steps of the diagnostic arthroscopy, and the technique of microfracture. We then discuss the special considerations to be taken regarding the use of a distractor, protection of neurovascular structures, and the indications for microfracture.
A
nkle arthroscopy has been commonly described with the patient in the supine position through the use of anteromedial and anterolateral portals. It can be performed under general, spinal, epidural, and even local anesthesia. It can be used as a diagnostic modality when a patient’s pathology is unclear. It has been established as a viable modality of treatment for anterior impingement and osteochondral defects.1-3 Complications of the procedure include neurological injury, vascular injury, aneurysm, and infection; however, it is a relatively low-risk procedure. Contraindications include localized soft-tissue infection and severe degenerative joint disease.4 Osteochondral lesions have been attributed to local avascular necrosis, trauma, degenerative joint disease, joint misalignment, and genetic predisposition.5 They can be diagnosed on plain films or with advanced imaging. The optimal treatment of these lesions has not yet been established and may be related to their size and location and to the patient. Arthroscopic microfracture of osteochondral defects leads to fibrocartilaginous repair and has shown good efficacy in leading to significant functional improvement.6 Further study
From the Wake Forest Baptist Medical Center, Winston Salem, North Carolina, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received June 15, 2016; accepted September 9, 2016. Address correspondence to Suman Medda, M.D., Wake Forest Baptist Medical Center, 1 Medical Center Boulevard, Winston Salem, NC 27103, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16551/$36.00 http://dx.doi.org/10.1016/j.eats.2016.09.013
must be done to better define indications for this procedure.7
Surgical Technique Patient Setup The patient is placed supine on the operating room table. At our institution we provide sedation supplemented with regional blocks, but spinal/epidural blocks and general anesthesia are also acceptable. A tourniquet should be placed around the upper thigh, and the thigh is placed in a thigh holder (Fig 1A). The lower extremity is prepared and draped in a standard sterile fashion. The extremity is elevated, and the tourniquet is inflated. A noninvasive ankle distractor (Smith and Nephew GUHL noninvasive ankle distractor) is attached to the side of the operating table and set to 30 foot-pounds of inline traction using a limb positioner (Smith and Nephew Spider 2; Fig 1B, Video 1). Anteromedial Portal Placement The medial malleolus and tibialis anterior tendon are carefully palpated for the anteromedial portal (Fig 2A). The lateral malleolus and extensor digitorum longus should also be palpated to identify landmarks for the anterolateral portal, which is later placed under direct visualization (Fig 2B). To create the anteromedial portal, a 20-gauge needle is advanced just medial to the tibialis anterior tendon into the joint and 20 mL of sterile saline is injected to distend the joint space. A stab incision is made over the injection site through the skin. The incision is bluntly deepened down into the joint with a tonsil with care taken to avoid the saphenous vein and nerve. A blunt trocar (Stryker Endoscopy 2.7-mm Trocar) is introduced (Fig 2C) followed by the
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Fig 1. (A) With the patient supine, a tourniquet (white arrow) was placed around the left upper thigh, and the left leg was placed in a thigh holder (red arrow). (B) With the patient supine, a noninvasive ankle distractor (white arrow) was applied to the left foot and set to 30 foot-pounds of inline traction.
Fig 2. (A) With the patient supine, the medial malleolus and tibialis anterior tendon were palpated on the left lower extremity to serve as landmarks for the anteromedial portal (white circle). (B) With the patient supine, the lateral malleolus and extensor digitorum longus were palpated on the left lower extremity to identify landmarks for the anterolateral portal (white circle), which would be later placed under direct visualization. (C) With the patient supine, the blunt trocar (white arrow) was advanced into the anteromedial portal of the left ankle. (EDL, extensor digitorum longus; EHL, extensor hallucis longus; Saph., saphenous vein; SPN, superficial peroneal nerve; TA, tibialis anterior.)
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tracked laterally to assess the anterior talar dome and talar neck. Then the arthroscope is moved superiorly to assess the anterior tibia. During this time articular pathology, such as osteochondral lesions and soft-tissue injuries, can be diagnosed visually.
Fig 3. With the patient supine and the arthroscope in the anteromedial portal, the joint space between the tibia (superior) and talus (inferior) was appreciated with inflamed synovium (white arrow).
arthroscope (Stryker Endoscopy 2.7-mm 30 A/C, 1288 HD camera; Video 1). The injected normal saline is evacuated from the joint once the cannula is introduced. Diagnostic Arthroscopy: Part 1 A thorough evaluation of the joint is performed. The joint space between the tibia and talus is appreciated, and often times inflamed synovium anteriorly and posteriorly can be noticed (Fig 3). The arthroscope is moved medially and then distally to assess the medial gutter and deltoid ligament. The arthroscope is then
Anterolateral Portal Placement An anterolateral portal is then made through direct visualization. A 20-gauge needle is inserted just lateral to the peroneus tertius tendon at the level of the joint line and is directly visualized by the arthroscope (Fig 4A). A stab incision is then made over the needle insertion site through the skin. The incision is bluntly deepened to the joint with a small tonsil (Fig 4B). Care is taken to avoid the intermediate and medial dorsal cutaneous branches of the superficial peroneal nerve. A blunt trocar is then used to enter the joint under visualization (Video 1). Osteochondral Defect Preparation A probe (Smith and Nephew Elite calibrated probe) can now be introduced into the anterolateral portal. Attention is directed to the osteochondral defect. In our case the lesion is found in the lateral talar dome, which can best be initially accessed with our initial visualization and working portals. Medial lesions may need to be visualized in the anterolateral portal while working through the anteromedial portal. The probe is used to elevate the unstable cartilage around the base and within the perimeter of the osteochondral defect (Fig 5). An arthroscopic shaver (Smith and Nephew Dyonics Powermini 2.0-mm full radius shaver) is used to debride some of the loose flaps of cartilage (Fig 6). The probe can be used to measure the size of the lesion. A small sharp curette (Smith and Nephew Ferkel 15
Fig 4. (A) With the patient supine and the arthroscope in the anteromedial portal, a 20-gauge needle (white arrow) was inserted just lateral to the peroneus tertius tendon of the left ankle at the level of the joint line and was directly visualized by the arthroscope. (B) With the patient supine and the arthroscope in the anteromedial portal, a 20-gauge needle was inserted at the location of the anterolateral portal of the left ankle. A skin incision was then made, and a tonsil (white arrow) was used to bluntly dissect down to the joint before a trocar was introduced.
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Fig 5. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, a probe (white arrow) was introduced into the anterolateral portal of the left ankle and used to elevate the unstable cartilage (red arrow) around the base and within the perimeter of the osteochondral defect of the talus (pictured inferiorly).
Fig 7. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, a small sharp curette (white arrow) was introduced into the anterolateral portal of the left ankle and used to remove the remaining unstable cartilage (red arrow).
open curette 2.5 mm) is used to remove the remaining unstable cartilage (Fig 7). Care is taken to ensure that the stable border cartilage is oriented perpendicularly to subchondral bone so that it can contain the microfracture hematoma that will later be created. Large loose bodies are removed from the joint using a grasper (Smith and Nephew grasper 2.7-mm straight; Fig 8). An anterior lesion curette (Smith and Nephew Ferkel 15
anterior lesion curette, 2.5 mm) is used to further debride the anterior defect (Fig 9). The instrument is mainly used to scrape away the anterior cartilage, which is difficult to access. A second arthroscopic cannula (Stryker Endoscopy 2.8-mm cannula) is connected to suction and used to capture the remaining loose fragments from the joint (Fig 10). The base of the
Fig 6. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, an arthroscopic shaver (white arrow) was introduced into the anterolateral portal of the left ankle to debride some of the loose flaps of cartilage (red arrow).
Fig 8. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, a grasper (white arrow) was introduced into the anterolateral portal of the left ankle to remove large loose bodies (red arrow) from the left ankle joint.
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Fig 9. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, an anterior lesion curette (white arrow) was introduced into the anterolateral portal of the left ankle and was used to further debride the anterior defect (red arrow).
osteochondral defect is further debrided using the arthroscopic shaver (Video 1). Synovectomy At this point, the arthroscopic shaver and arthroscope are reversed. The arthroscope is brought in through the anterolateral portal, and the arthroscopic shaver is
Fig 10. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, an arthroscopic cannula (white arrow) was introduced into the anterolateral portal of the left ankle and connected to suction and used to capture the remaining loose fragments (red arrow) from the left ankle joint.
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Fig 11. With the patient supine and the arthroscope in the anterolateral portal of the left ankle, the talofibular articulation was assessed with the talus on the left (white arrow) and the fibula on the right (red arrow).
introduced through the anteromedial portal. The chondral defect is again visualized. Attention is then turned to the synovectomy portion of the procedure. The arthroscopic shaver is used to debride the hypertrophic and inflamed posterior synovial tissue until it had been adequately debrided. Diagnostic Arthroscopy: Part 2 The arthroscope is then tracked laterally and inferiorly to assess the talofibular articulation (Fig 11) and lateral
Fig 12. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, a microfracture pick (white arrow) was introduced through the anterolateral portal of the left ankle and used to create several small fractures in the subchondral bone (red arrow).
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and placed in a long CAM boot. The patient continues non-weight-bearing restrictions for 4 additional weeks but starts active range of motion out of the boot. At 6 weeks, the patient starts gradual increase in weight bearing and is transitioned out of the boot. At this time, formal physical therapy is started.
Discussion
Fig 13. With the patient supine and the arthroscope in the anteromedial portal of the left ankle, the water pressure within the left ankle joint was released and good bleeding was observed from the microfracture sites (white arrow).
gutter (Video 1). This aspect of the diagnostic arthroscopy is not performed earlier as these 2 areas are better assessed with the scope in the anterolateral portal. Microfracture Attention is again turned to the osteochondral defect. The arthroscope is once again introduced through the anteromedial portal. As stated before, the arthroscope may need to be placed in the anterolateral portal for medial lesions. A microfracture pick (Smith and Nephew, 65 ) is introduced through the anterolateral portal and used to create several small pick holes in the subchondral bone (Fig 12). Care is taken to ensure that the pick is perpendicular to subchondral bone and that the microfracture sites are spaced widely enough to prevent unintended further fracture. The awl is hand driven into subchondral bone; however, careful malleting is sometimes required depending on bone quality. After placing the final pick hole, the water pressure within the joint is released, and good bleeding should be observed from the microfracture sites (Fig 13, Video 1). Irrigation, Closure, and Casting A thorough lavage of the joint is performed, and the arthroscopic instrumentation is removed. The skin is closed with superficial 3-0 nylon horizontal mattress sutures. Dry sterile dressings are applied, and the patient is placed in a well-padded short leg fiberglass cast. Postoperative Care The patient is made noneweight bearing. At the first clinic visit at 2 weeks, the patient is taken out of the cast
The technique of dorsiflexing the joint to introduce and exchange instruments is commonly used. However, a thorough arthroscopic diagnostic exam is difficult without the use of joint distraction. Some studies have suggested that distraction may lead to many of the common complications of ankle arthroscopy.8 Distraction creates tension on the neurovascular structures and decreases the distance between the anterior joint space and the overlying neurovascular structures.9 Invasive distraction has been linked with pin track infections and stress fractures,10 thus noninvasive distraction methods are more commonly used. Although the use of a distractor has yielded a higher neurological complication rate, many of these complications resolve over time. There may be efficacy in intermittent distraction. In one consecutive series review of 1,305 ankle arthroscopies, no complications could be attributed to ankle distraction when intermittent soft-tissue distraction was used.11 Additionally, anterior ankle pathology is better accessed without distraction. Using intermittent distraction would allow ideal access to both anterior and posterior pathology (Table 1). The superficial anatomy serves as a guide for portal placement. When the foot is pulled into adduction, the superficial branches of the peroneal nerve can be seen. The superficial peroneal nerve divides into its intermediate and medial dorsal cutaneous branches approximately 6 to 7 cm proximal to the tip of the fibula. The intermediate branch runs superficial to the Table 1. The Advantages and Disadvantages of Various Forms of Distraction Used in Ankle Arthroscopy Advantages Continuous distraction
Disadvantages
Ideal visualization of Reported increased rates of posterior ankle neurological injury pathology Increased joint space for Increased tension on instrumentation neurovascular structures Decreased space between neurovascular structures and portals No distraction/ Ideal visualization of Decreased visualization of dorsiflexion anterior ankle posterior pathology pathology Intermittent Decreased total time Increased need for surgeon distraction under distraction intervention during case Ideal visualization of anterior and posterior pathology
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ANKLE ARTHROSCOPY Table 2. Ankle Arthroscopy Portal Locations, Important Structures to Avoid, and Pearls Portal
Location
Anteromedial Anterolateral
Important Structures to Avoid
Just medial to tibialis anterior tendon Just lateral to peroneus tertius
Anterocentral
Just medial to extensor hallucis longus
Posterolateral
Just lateral to achilles tendon 1.2 cm above tip of lateral malleolus Just medial to Achilles tendon at same level of posterolateral portal
Posteromedial
Create this portal first
Branches of superficial peroneal nerve (both sides of portal) Anterior neurovascular bundle including deep peroneal nerve and anterior tibial artery (medial to portal) Sural nerve and small saphenous vein (lateral to portal)
Create under direct visualization
Posterior tibial neurovascular bundle including tibial nerve and posterior tibial artery (medial to portal)
Use extreme caution when creating this portal due to its proximity to critical structures
inferior extensor retinaculum and anterior to the common extensors of the fourth and fifth toes and then travels down the foot between the third and fourth metatarsals. The medial branch crosses the anterior aspect of the ankle superficial to the common extensors and runs parallel to the extensor hallucis longus tendon before dividing distally into 3 dorsal digital branches.4,8 Distending the ankle joint with 15 to 20 mL of sterile saline prior to portal placement displaces neurovascular structures from the joint space. The anteromedial portal is created at the level of the ankle joint just medial to the tibialis anterior tendon and lateral to the saphenous vein. The anterolateral portal is made just lateral to the peroneus tertius tendon under direct visualization to avoid neurovascular structures and tendons. It is important to make the portal incision through skin only and then bluntly dissect down to the joint space to avoid neurovascular structures. Other portals have been described and may be required. The anterocentral portal is created between the extensor hallucis longus and the anterior neurovascular bundle. The posterolateral portal is created just lateral to the Achilles tendon and 1.2 cm proximal to the distal tip of the lateral malleolus. The posteromedial portal is created at the Table 3. Treatment Modality Stratification Based on Size of Osteochondral Defects of the Talus Technique Arthroscopic debridement, microfracture, and curettage Osteochondral autogenous graft or autologous chondrocyte transplantation (ACT)
ACT or allograft Athrodesis or prosthetic replacement
Pearls
Saphenous vein (medial to portal)
Indications Lesions 50 years12
Use extreme caution when creating this portal due to its proximity to critical structures
same location just medial to the Achilles tendon. Extreme caution is to be taken when creating the anterocentral and posteromedial portal due to its proximity to the anterior neurovascular (deep peroneal nerve, anterior tibial artery) and posteromedial neurovascular (tibial nerve, posterior tibial artery) bundles, respectively (Table 2). Diagnostic ankle arthroscopy is performed when nonoperative approaches to diagnosis have failed and the patient continues to have significant ankle symptoms unresponsive to conservative treatment. Although many defects can be visualized on both plain film and magnetic resonance imaging, there is a high incidence of missed or delayed diagnosis of osteochondral lesions of the talus with unexplained chronic ankle pain.13 While the use of therapeutic arthroscopy is well supported for anterior impingement and osteochondral defects, there is not yet sufficient evidence for its use in the treatment of septic arthritis, ankle instability, and removal of loose bodies. There is evidence against its use in the treatment of arthritis. There is insufficient literature for its use in the management of fracture and synovitis.3 The optimal treatment for cartilage lesions has not yet been established. Conservative treatment can include casting with or without weight bearing. Potential operative interventions include chondroplasty, microfracture, and osteochondral autologous transplantation. Studies have shown equivocal patient satisfaction scores between these interventions,14,15 while other studies have shown that the size of the osteochondral defect may affect the outcome of intervention.16 It has been suggested that lesions less than 150 mm2 generally respond to arthroscopic marrow stimulation, while defects larger than this require osteochondral transplantation. In one study of 120 ankles undergoing microfracture, 10.5% of lesions 150 mm2.6 Some investigators have stratified treatment modalities based on defect size (Table 3).12 Others have suggested that defect size and patient age do not correlate with functional outcomes.17 Further
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research is required into the optimal treatment, which may differ based on history of trauma, body mass index, and other comorbidities.
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9. de Leeuw PA, Golano P, Clavero JA, van Dijk CN. Anterior ankle arthroscopy, distraction or dorsiflexion? Knee Surg Sports Traumatol Arthrosc 2010;18:594-600. 10. Ferkel RD, Heath DD, Guhl JF. Neurological complications of ankle arthroscopy. Arthroscopy 1996;12:200-208. 11. Zengerink M, van Dijk CN. Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2012;20: 1420-1431. 12. Giannini S, Francesca V. Operative treatment of osteochondral lesions of the talar dome: current concepts review. Foot Ankle Int 2004;25:168-175. 13. Ferkel RD, Scaglione NA, Del Pizzo W, et al. Arthroscopic treatment of osteochondral lesions of the talus: technique and results. Orthop Trans 1990;14:172-173. 14. Gobbi A, Francisco RA, Lubowitz JH, Allegra F, Canata G. Osteochondral lesions of the talus: randomized controlled trial comparing chondroplasty, microfracture, and osteochondral autograft transplantation. Arthroscopy 2006;22: 1085-1092. 15. Knutsen G, Drogset JO, Engebretsen L, et al. A randomized trial comparing autologous chondrocyte implantation within microfracture. J Bone Joint Surg Am 2007;89:21052112. 16. Chuckpaiwong B, Berkson EM, Theodore GH. Microfracture for osteochondral lesions of the ankle: outcome analysis and outcome predictors of 105 cases. Arthroscopy 2008;24:106-112. 17. Polat G, Erdil ME, Kizilkurt T, Kilicoglu O, Asik M. Longterm results of microfracture in the treatment of talus osteochondral lesions. Knee Surg Sports Traumatol Arthrosc 2016;24:1299-1303.
