Arthroscopic Posterior Subtalar Arthrodesis: Surgical Technique Jesús Vilá y Rico, M.D., Ph.D., Cristina Ojeda Thies, M.D., Ph.D., and Guillermo Parra Sanchez, M.D.
Abstract: Surgical fusion of the subtalar joint is a procedure indicated to alleviate pain of subtalar origin, such as in posttraumatic osteoarthritis, adult-acquired flatfoot deformity, and other disorders. Open subtalar arthrodesis has been performed with predictable results, but concerns exist regarding injury to proprioception and local vascularity due to wide surgical dissection. Minimally invasive techniques try to improve results by avoiding these issues but have a reputation for being technically demanding. We describe the surgical technique for arthroscopic subtalar arthrodesis, which has proved to be a safe and reliable technique in our experience, with consistent improvements in American Orthopaedic Foot & Ankle Society scores.
S
ubtalar arthrodesis entails surgical fusion of the posterior aspect of the subtalar joint to alleviate pain in patients with conditions such as post-traumatic arthritis after calcaneal fractures or adult-acquired flatfoot deformity due to posterior tibial tendon dysfunction, as well as other disorders. Permanent loss of motion in the subtalar joint hardly affects the function of the foot and ankle because the neighboring joints easily compensate for regional loss of motion. Arthroscopic subtalar arthrodesis was initially described by Tasto in 1992,1 using the classic anterolateral, posterolateral, and associated portals, with the patient in the lateral decubitus position. Arthroscopic arthrodesis is associated with less soft-tissue damage, respecting the vascularization and proprioception of the calcaneus and talus, which could promote fusion.2 Endoscopic posterior portals offer excellent access to the back of the ankle. They have been shown to be safe and reproducible, with few complications, and allow a
From Hospital Universitario Doce de Octubre (J.V.y.R., C.O.T.); Department of Surgery, Universidad Complutense (J.V.y.R.); and Hospital de Torrejón (G.P.S.), Madrid, Spain. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received May 4, 2015; accepted October 27, 2015. Address correspondence to Jesús Vilá y Rico, M.D., Ph.D., Calle del Alcalde Sainz de Baranda 29, 2 , Madrid 28009, Spain. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/15417/$36.00 http://dx.doi.org/10.1016/j.eats.2015.10.009
great view and control of the joint surfaces to be resected.3 We describe our technique for arthroscopic posterior subtalar arthrodesis (Tables 1 and 2).
Surgical Technique Hindfoot Endoscopic Technique Unlike the technique originally proposed by Tasto,1 using anterolateral and posterolateral portals and placing the patient in the lateral decubitus position, we perform arthroscopic subtalar arthrodesis using posterior endoscopic portals following a similar technique as originally described by van Dijk et al.4 The procedure is performed with the patient under spinal anesthesia, and a thigh tourniquet is applied. The patient is placed in a prone position, and a small support is placed under the lower shin, allowing for free movement of the ankle. No soft-tissue distraction device is used, and no previous distension is performed. We routinely use a 4mm 30 arthroscope and arthroscopy system from the same manufacturer (Stryker, Kalamazoo, MI) for posterior ankle arthroscopy. No traction is applied. With the ankle in a neutral position, the main landmarks are drawn (the lateral malleolus, the medial and lateral borders of the Achilles tendon, and the sole of the foot). A straight line is drawn from the tip of the lateral malleolus to the Achilles tendon, parallel to the sole of the foot. Both the posterolateral and posteromedial portals are made just above this line and near the Achilles tendon. The posterolateral portal is made first. After a vertical skin incision is made, the subcutaneous layer is split using a mosquito clamp. The
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Table 1. Key Points The patient is placed in the prone position. The main ankle landmarks are drawn with the ankle in a neutral position. The posterolateral portal is created first. The posteromedial portal is created second by “walking” the instruments along the trocar of the posterolateral portal. The crural fascia is debrided to create a working area. The FHL is an important landmark and marks the medial margin of the “safe” area. The joint is debrided from posterolateral to posteromedial and from anterolateral to anteromedial. The joint is stabilized using two retrograde cannulated screws inserted under direct visualization through the arthroscope. For postoperative treatment, a posterior ankle splint is used for 3 wk; a walker-type ankle-foot orthosis is then used for 8-12 wk, with progressive weight bearing. FHL, flexor hallucis longus.
mosquito clamp is directed anteriorly, pointing toward the first interdigital space. Once the tip of the clamp touches bone, it is exchanged for the arthroscope shaft, with the blunt obturator and trocar pointing in the same direction, to protect the neurovascular bundle. The trocar is placed extra-articularly at the level of the ankle joint. Then, the posteromedial portal is made. The posteromedial portal is made at the same level as the posterolateral portal but on the medial side of the Achilles tendon. After the skin incision, a mosquito clamp is introduced and directed toward the shaft of the arthroscope at a 90 angle. After touching the shaft of the arthroscope with the clamp, the surgeon uses the shaft as a guide to “walk” anteriorly toward the ankle joint, touching the arthroscope shaft all the way down, until the clamp reaches the bone and can be seen with the arthroscope. The tip of the shaver is directed in a similar manner toward the lateral aspect of the posterior subtalar joint. It is important to create the posterior endoscopic portals in this reproducible manner because injury to the posterior tibial neurovascular bundle is thus avoided (Fig 1). A hole must be opened in the crural fascia to create a working area in the posterior aspect of the ankle joint. A tight and thickened crural fascia can hinder the free movement of instruments, and in these cases, it can be helpful to enlarge the hole in the fascia using a punch or shaver. The subtalar joint capsule and surrounding fatty tissue can be removed. After removal of the very thin joint capsule of the subtalar joint, the posterior compartment Table 2. Pearls Sometimes, a third portal in the sinus tarsi is useful to view the most anterior aspect of the joint. The first screw should be placed in the anterior aspect of the posterior subtalar joint. We do not use any bone graft. Adequate coaptation of the joint should be confirmed as the screws are inserted while the arthroscope is withdrawn.
Fig 1. Endoscopic view of posterior region of ankle compared with anatomic view. (1) Posterolateral process. (2) Posterior subtalar joint. (3) Flexor hallucis longus muscle. (4) Posterior talofibular ligament and intermalleolar ligament. (5) Flexor hallucis longus retinaculum. Image courtesy of the late Pau Golanò, professor in the Human Anatomy & Embryology Unit at the University of Barcelona.
of the subtalar joint can be inspected. Within the ankle joint, we can identify the posterior tibiofibular ligament and the posterior talofibular ligament. The flexor hallucis longus (FHL) tendon is an important landmark, with the safe area lying lateral to this tendon because the neurovascular structures and the flexor digitorum communis tendon lie medial to this tendon (Fig 1). To avoid iatrogenic damage to the posterior tibial bundle, motorized instruments must be used with caution around the medial area. Standard motorized instruments (3.5-mm shaver and burr; Stryker) are used for soft-tissue debridement and removal of the ossicle or posterolateral process. A small chisel (straight or curved) and a periosteal elevator can be useful for removing cartilage. Instruments are introduced through the posteromedial portal. Arthrodesis Technique The joint is debrided from posterolateral to posteromedial and from anterolateral to anteromedial, until subchondral bone is visible on both aspects of the complete subtalar joint surface (Fig 2). The structures of the sinus tarsi mark the anterior limit of the posterior subtalar joint. A third portal can be made at the sinus tarsi to improve visualization of the anterior aspect of the posterior subtalar joint. After preparation of the joint surfaces, the arthrodesis is stabilized with two 7.3-mm cannulated screws
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Fig 2. Posterior subtalar arthroscopy of right hindfoot in a patient with grade II adultacquired flatfoot deformity. The patient is in the prone position, and visualization is performed through the posterolateral portal. The sequence shows preparation of the articular surfaces of the (A, B) talus and (C, D) calcaneus and screw placement. (A, B) Debridement of the chondral surface with a small chisel and 3.5-mm shaver. (C) Introduction of the K-wire guide. (D) The fusion is stabilized with two 7.3-mm cannulated screws. (E) Compression of the joint surfaces can be directly viewed as the arthroscope is withdrawn.
(Synthes, Paoli, PA) at the most anterior aspect of the joint, from the calcaneus to the talus. It is important to achieve perfect coaptation of the joint surfaces to ensure joint fusion; we recommend visualizing joint compression as the arthroscope is withdrawn while inserting the screws (Video 1). We do not use bone graft to augment fixation.
Postoperative Management Postoperative management usually comprises 3 weeks of immobilization in a posterior ankle splint, followed by progressive partial weight bearing protected by crutches and a walker-type ankle-foot orthosis, until complete and unprotected weight bearing is allowed after 8 to 12 weeks.
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Discussion Recent innovations in surgical technique tend toward less invasive approaches, allowing for a quicker recovery and hypothetically better results because of reduced soft-tissue injury. Regarding the union and complication rates, the outcomes of arthroscopic subtalar arthrodesis are excellent. There are few comparative studies of open and arthroscopic arthrodesis, but arthroscopic techniques tend to achieve quicker union, with a lower complication rate.5 The published literature reports an overall union rate ranging from 91% to 100% after subtalar arthroscopic arthrodesis. Although it is difficult to accurately determine the time of union, our results in 65 consecutive cases are comparable to those published, with a union rate of 95.4% after an average of 11.2 weeks (range, 9 to 16 weeks) and with an acceptable complication rate (12.3%); most complications appearing in our series were minor and related to hardware issues. A meticulous technique when inserting the screws minimizes the rate of complications and the need for implant removal. Thorough knowledge of the foot and ankle anatomy and a standardized technique are critical to reduce the risk of iatrogenic injury during the described procedure. Although the skin incisions for the endoscopic posterior portals are safe because the nearby vascular and nervous structures are not superficial or adjacent to the Achilles tendon, the creation of a working area during posterior endoscopy carries a potentially high risk of injury to the posterior neurovascular structures: the sural nerve in the lateral region and the tibial neurovascular bundle medially.6,7 The tibial neurovascular bundle (tibial nerve and posterior tibial artery and veins) is the structure closest to the midline on the medial side of the hindfoot and is the structure most vulnerable to injury during posterior endoscopy. Iatrogenic injury to the medial calcaneal branch of the tibial nerve leads to a decrease in sensitivity in the calcaneal area of the foot. In 146 consecutive endoscopic procedures reported by Zengerink and van Dijk,8 they observed 2 complications (1.4%) corresponding to a decrease in sensitivity in the plantar calcaneal area of the foot. A close relation between the calcaneal branch of the tibial nerve and the FHL tendon has been reported.9 In other words, the FHL tendon acquires special relevance because the tibial
neurovascular bundle is located medial to it, and the FHL tendon is considered the main endoscopic landmark because its lateral border determines the working area.4 Arthroscopic subtalar arthrodesis has proved to offer at least similar results to open techniques, and it may achieve higher rates of fusion and lower complication rates than open techniques when compared directly. It is a safe and reliable procedure, provided that the surgical technique is carefully followed. It provides a high union rate without needing bone graft, with an acceptable rate of complications. When performing this technique, the surgeon must take care not to injure the neurovascular structures, mainly the posterior tibial neurovascular bundle medially and the sural nerve laterally. The FHL tendon is an important landmark at the medial margin of the safe working area.
References 1. Tasto JP. Arthroscopic subtalar arthrodesis. Techniques in Foot & Ankle Surgery 2003;2:122-128. 2. Roster B, Kreulen C, Giza E. Subtalar joint arthrodesis: Open and arthroscopic indications and surgical techniques. Foot Ankle Clin 2015;20:319-334. 3. Hendrickx RPM, de Leeuw PAJ, Golano P, van Dijk CN, Kerkhoffs GMMJ. Safety and efficiency of posterior arthroscopic ankle arthrodesis. Knee Surg Sports Traumatol Arthrosc 2015;23:2420-2426. 4. Van Dijk CN, Scholten PE, Krips R. A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthroscopy 2000;16:871-876. 5. Tuijthof GJM, Beimers L, Kerkhoffs GMMJ, Dankelman J, van Dijk CN. Overview of subtalar arthrodesis techniques: Options, pitfalls and solutions. Foot Ankle Surg 2010;16: 107-116. 6. Amendola A, Lee K-B, Saltzman CL, Suh J-S. Technique and early experience with posterior arthroscopic subtalar arthrodesis. Foot Ankle Int 2007;28:298-302. 7. Vilá J, Vega J, Mellado M, Ramazzini R, Golanó P. Hindfoot endoscopy for the treatment of posterior ankle impingement syndrome: A safe and reproducible technique. Foot Ankle Surg 2014;20:174-179. 8. Zengerink M, van Dijk CN. Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2012;20:1420-1431. 9. Golanò P, Mariani PP, Rodríguez-Niedenfuhr M, Mariani PF, Ruano-Gil D. Arthroscopic anatomy of the posterior ankle ligaments. Arthroscopy 2002;18:353-358.
Abstract: Surgical fusion of the subtalar joint is a procedure indicated to alleviate pain of subtalar origin, such as in posttraumatic osteoarthritis, adult-acquired flatfoot deformity, and other disorders. Open subtalar arthrodesis has been performed with predictable results, but concerns exist regarding injury to proprioception and local vascularity due to wide surgical dissection. Minimally invasive techniques try to improve results by avoiding these issues but have a reputation for being technically demanding. We describe the surgical technique for arthroscopic subtalar arthrodesis, which has proved to be a safe and reliable technique in our experience, with consistent improvements in American Orthopaedic Foot & Ankle Society scores.
S
ubtalar arthrodesis entails surgical fusion of the posterior aspect of the subtalar joint to alleviate pain in patients with conditions such as post-traumatic arthritis after calcaneal fractures or adult-acquired flatfoot deformity due to posterior tibial tendon dysfunction, as well as other disorders. Permanent loss of motion in the subtalar joint hardly affects the function of the foot and ankle because the neighboring joints easily compensate for regional loss of motion. Arthroscopic subtalar arthrodesis was initially described by Tasto in 1992,1 using the classic anterolateral, posterolateral, and associated portals, with the patient in the lateral decubitus position. Arthroscopic arthrodesis is associated with less soft-tissue damage, respecting the vascularization and proprioception of the calcaneus and talus, which could promote fusion.2 Endoscopic posterior portals offer excellent access to the back of the ankle. They have been shown to be safe and reproducible, with few complications, and allow a
From Hospital Universitario Doce de Octubre (J.V.y.R., C.O.T.); Department of Surgery, Universidad Complutense (J.V.y.R.); and Hospital de Torrejón (G.P.S.), Madrid, Spain. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received May 4, 2015; accepted October 27, 2015. Address correspondence to Jesús Vilá y Rico, M.D., Ph.D., Calle del Alcalde Sainz de Baranda 29, 2 , Madrid 28009, Spain. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/15417/$36.00 http://dx.doi.org/10.1016/j.eats.2015.10.009
great view and control of the joint surfaces to be resected.3 We describe our technique for arthroscopic posterior subtalar arthrodesis (Tables 1 and 2).
Surgical Technique Hindfoot Endoscopic Technique Unlike the technique originally proposed by Tasto,1 using anterolateral and posterolateral portals and placing the patient in the lateral decubitus position, we perform arthroscopic subtalar arthrodesis using posterior endoscopic portals following a similar technique as originally described by van Dijk et al.4 The procedure is performed with the patient under spinal anesthesia, and a thigh tourniquet is applied. The patient is placed in a prone position, and a small support is placed under the lower shin, allowing for free movement of the ankle. No soft-tissue distraction device is used, and no previous distension is performed. We routinely use a 4mm 30 arthroscope and arthroscopy system from the same manufacturer (Stryker, Kalamazoo, MI) for posterior ankle arthroscopy. No traction is applied. With the ankle in a neutral position, the main landmarks are drawn (the lateral malleolus, the medial and lateral borders of the Achilles tendon, and the sole of the foot). A straight line is drawn from the tip of the lateral malleolus to the Achilles tendon, parallel to the sole of the foot. Both the posterolateral and posteromedial portals are made just above this line and near the Achilles tendon. The posterolateral portal is made first. After a vertical skin incision is made, the subcutaneous layer is split using a mosquito clamp. The
Arthroscopy Techniques, Vol 5, No 1 (February), 2016: pp e85-e88
e85
e86
J. VILÁ Y RICO ET AL.
Table 1. Key Points The patient is placed in the prone position. The main ankle landmarks are drawn with the ankle in a neutral position. The posterolateral portal is created first. The posteromedial portal is created second by “walking” the instruments along the trocar of the posterolateral portal. The crural fascia is debrided to create a working area. The FHL is an important landmark and marks the medial margin of the “safe” area. The joint is debrided from posterolateral to posteromedial and from anterolateral to anteromedial. The joint is stabilized using two retrograde cannulated screws inserted under direct visualization through the arthroscope. For postoperative treatment, a posterior ankle splint is used for 3 wk; a walker-type ankle-foot orthosis is then used for 8-12 wk, with progressive weight bearing. FHL, flexor hallucis longus.
mosquito clamp is directed anteriorly, pointing toward the first interdigital space. Once the tip of the clamp touches bone, it is exchanged for the arthroscope shaft, with the blunt obturator and trocar pointing in the same direction, to protect the neurovascular bundle. The trocar is placed extra-articularly at the level of the ankle joint. Then, the posteromedial portal is made. The posteromedial portal is made at the same level as the posterolateral portal but on the medial side of the Achilles tendon. After the skin incision, a mosquito clamp is introduced and directed toward the shaft of the arthroscope at a 90 angle. After touching the shaft of the arthroscope with the clamp, the surgeon uses the shaft as a guide to “walk” anteriorly toward the ankle joint, touching the arthroscope shaft all the way down, until the clamp reaches the bone and can be seen with the arthroscope. The tip of the shaver is directed in a similar manner toward the lateral aspect of the posterior subtalar joint. It is important to create the posterior endoscopic portals in this reproducible manner because injury to the posterior tibial neurovascular bundle is thus avoided (Fig 1). A hole must be opened in the crural fascia to create a working area in the posterior aspect of the ankle joint. A tight and thickened crural fascia can hinder the free movement of instruments, and in these cases, it can be helpful to enlarge the hole in the fascia using a punch or shaver. The subtalar joint capsule and surrounding fatty tissue can be removed. After removal of the very thin joint capsule of the subtalar joint, the posterior compartment Table 2. Pearls Sometimes, a third portal in the sinus tarsi is useful to view the most anterior aspect of the joint. The first screw should be placed in the anterior aspect of the posterior subtalar joint. We do not use any bone graft. Adequate coaptation of the joint should be confirmed as the screws are inserted while the arthroscope is withdrawn.
Fig 1. Endoscopic view of posterior region of ankle compared with anatomic view. (1) Posterolateral process. (2) Posterior subtalar joint. (3) Flexor hallucis longus muscle. (4) Posterior talofibular ligament and intermalleolar ligament. (5) Flexor hallucis longus retinaculum. Image courtesy of the late Pau Golanò, professor in the Human Anatomy & Embryology Unit at the University of Barcelona.
of the subtalar joint can be inspected. Within the ankle joint, we can identify the posterior tibiofibular ligament and the posterior talofibular ligament. The flexor hallucis longus (FHL) tendon is an important landmark, with the safe area lying lateral to this tendon because the neurovascular structures and the flexor digitorum communis tendon lie medial to this tendon (Fig 1). To avoid iatrogenic damage to the posterior tibial bundle, motorized instruments must be used with caution around the medial area. Standard motorized instruments (3.5-mm shaver and burr; Stryker) are used for soft-tissue debridement and removal of the ossicle or posterolateral process. A small chisel (straight or curved) and a periosteal elevator can be useful for removing cartilage. Instruments are introduced through the posteromedial portal. Arthrodesis Technique The joint is debrided from posterolateral to posteromedial and from anterolateral to anteromedial, until subchondral bone is visible on both aspects of the complete subtalar joint surface (Fig 2). The structures of the sinus tarsi mark the anterior limit of the posterior subtalar joint. A third portal can be made at the sinus tarsi to improve visualization of the anterior aspect of the posterior subtalar joint. After preparation of the joint surfaces, the arthrodesis is stabilized with two 7.3-mm cannulated screws
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Fig 2. Posterior subtalar arthroscopy of right hindfoot in a patient with grade II adultacquired flatfoot deformity. The patient is in the prone position, and visualization is performed through the posterolateral portal. The sequence shows preparation of the articular surfaces of the (A, B) talus and (C, D) calcaneus and screw placement. (A, B) Debridement of the chondral surface with a small chisel and 3.5-mm shaver. (C) Introduction of the K-wire guide. (D) The fusion is stabilized with two 7.3-mm cannulated screws. (E) Compression of the joint surfaces can be directly viewed as the arthroscope is withdrawn.
(Synthes, Paoli, PA) at the most anterior aspect of the joint, from the calcaneus to the talus. It is important to achieve perfect coaptation of the joint surfaces to ensure joint fusion; we recommend visualizing joint compression as the arthroscope is withdrawn while inserting the screws (Video 1). We do not use bone graft to augment fixation.
Postoperative Management Postoperative management usually comprises 3 weeks of immobilization in a posterior ankle splint, followed by progressive partial weight bearing protected by crutches and a walker-type ankle-foot orthosis, until complete and unprotected weight bearing is allowed after 8 to 12 weeks.
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J. VILÁ Y RICO ET AL.
Discussion Recent innovations in surgical technique tend toward less invasive approaches, allowing for a quicker recovery and hypothetically better results because of reduced soft-tissue injury. Regarding the union and complication rates, the outcomes of arthroscopic subtalar arthrodesis are excellent. There are few comparative studies of open and arthroscopic arthrodesis, but arthroscopic techniques tend to achieve quicker union, with a lower complication rate.5 The published literature reports an overall union rate ranging from 91% to 100% after subtalar arthroscopic arthrodesis. Although it is difficult to accurately determine the time of union, our results in 65 consecutive cases are comparable to those published, with a union rate of 95.4% after an average of 11.2 weeks (range, 9 to 16 weeks) and with an acceptable complication rate (12.3%); most complications appearing in our series were minor and related to hardware issues. A meticulous technique when inserting the screws minimizes the rate of complications and the need for implant removal. Thorough knowledge of the foot and ankle anatomy and a standardized technique are critical to reduce the risk of iatrogenic injury during the described procedure. Although the skin incisions for the endoscopic posterior portals are safe because the nearby vascular and nervous structures are not superficial or adjacent to the Achilles tendon, the creation of a working area during posterior endoscopy carries a potentially high risk of injury to the posterior neurovascular structures: the sural nerve in the lateral region and the tibial neurovascular bundle medially.6,7 The tibial neurovascular bundle (tibial nerve and posterior tibial artery and veins) is the structure closest to the midline on the medial side of the hindfoot and is the structure most vulnerable to injury during posterior endoscopy. Iatrogenic injury to the medial calcaneal branch of the tibial nerve leads to a decrease in sensitivity in the calcaneal area of the foot. In 146 consecutive endoscopic procedures reported by Zengerink and van Dijk,8 they observed 2 complications (1.4%) corresponding to a decrease in sensitivity in the plantar calcaneal area of the foot. A close relation between the calcaneal branch of the tibial nerve and the FHL tendon has been reported.9 In other words, the FHL tendon acquires special relevance because the tibial
neurovascular bundle is located medial to it, and the FHL tendon is considered the main endoscopic landmark because its lateral border determines the working area.4 Arthroscopic subtalar arthrodesis has proved to offer at least similar results to open techniques, and it may achieve higher rates of fusion and lower complication rates than open techniques when compared directly. It is a safe and reliable procedure, provided that the surgical technique is carefully followed. It provides a high union rate without needing bone graft, with an acceptable rate of complications. When performing this technique, the surgeon must take care not to injure the neurovascular structures, mainly the posterior tibial neurovascular bundle medially and the sural nerve laterally. The FHL tendon is an important landmark at the medial margin of the safe working area.
References 1. Tasto JP. Arthroscopic subtalar arthrodesis. Techniques in Foot & Ankle Surgery 2003;2:122-128. 2. Roster B, Kreulen C, Giza E. Subtalar joint arthrodesis: Open and arthroscopic indications and surgical techniques. Foot Ankle Clin 2015;20:319-334. 3. Hendrickx RPM, de Leeuw PAJ, Golano P, van Dijk CN, Kerkhoffs GMMJ. Safety and efficiency of posterior arthroscopic ankle arthrodesis. Knee Surg Sports Traumatol Arthrosc 2015;23:2420-2426. 4. Van Dijk CN, Scholten PE, Krips R. A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthroscopy 2000;16:871-876. 5. Tuijthof GJM, Beimers L, Kerkhoffs GMMJ, Dankelman J, van Dijk CN. Overview of subtalar arthrodesis techniques: Options, pitfalls and solutions. Foot Ankle Surg 2010;16: 107-116. 6. Amendola A, Lee K-B, Saltzman CL, Suh J-S. Technique and early experience with posterior arthroscopic subtalar arthrodesis. Foot Ankle Int 2007;28:298-302. 7. Vilá J, Vega J, Mellado M, Ramazzini R, Golanó P. Hindfoot endoscopy for the treatment of posterior ankle impingement syndrome: A safe and reproducible technique. Foot Ankle Surg 2014;20:174-179. 8. Zengerink M, van Dijk CN. Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 2012;20:1420-1431. 9. Golanò P, Mariani PP, Rodríguez-Niedenfuhr M, Mariani PF, Ruano-Gil D. Arthroscopic anatomy of the posterior ankle ligaments. Arthroscopy 2002;18:353-358.
