Ankle Arthroscopy & Current Trends in Management

of Ankle InstabilitySafet Hatic II, DO, FAOAO

Orthopedic Associates of SW Ohio 11 November 2016

rthopedicssociatesO

of SW Ohio1-800-824-9861www.oaswo.com

Disclosures

• Consultant and speaker for Smith & Nephew

• Consultant for Arthrex

Overview• Introduction

• Epidemiology and anatomy of ankle instability (evaluation)

• Ankle arthroscopy

• portal anatomy and placement

• setup

• Basic techniques

• diagnostic arthroscopy

• anterior decompression; synovectomy; removal of loose body

• Advanced Techniques

• management of OLTs

• arthroscopic-assisted ORIF of the ankle

• Current concepts in lateral ankle ligament reconstruction

Objectives• Review pertinent anatomy and

biomechanics of ankle sprains

• Diagnostic pearls

• Review treatment of acute/chronic ankle instability

• Review surgical treatment options for chronic ankle instability

• Case Study: allograft lateral ankle ligament reconstruction

Ankle Sprains• Estimated 25,000 people experience an

ankle sprain DAILY

• Broad spectrum of patients

• Athletes

• Non-athletes

• All ages

• Typically an inversion mechanism

Anatomy: Lateral Ankle Ligaments

Biomechanics

• ATFL and CFL

• work synchronously

• ?? isolated CFL tears

Biomechanics• Peroneal tendons

• Dynamic stabilizers of the ankle

• Strength

• Critical for functional stability

• Occasionally used in some reconstructive procedures

• Loss of strength and dynamic function

•Difficult to establish strict criteria for ligamentous reconstruction on stress measurements alone

–High degree of variability in laxity

•Use with clinical indicators of instability

Radiographic Evaluation

AP View

Normal: <5mm >10mm <2mm diff.

•Lateral

•Mortise View

NORMAL: <4mm >1mm 8-15 deg

•Stress x-rays

–Talar tilt view

–Anterior drawer view

•CT, MRI

•Arthrogram

Radiography

Physical Exam

• Swelling

• Ecchymosis

• Tenderness to palpation anterolateral ankle

• Evaluate for concomitant pathology/injuries

•Anterior Drawer Test & Talar Tilt Test

•Talar Tilt Angle

–Measured on stress AP radiograph view with ankle IR 30° (Mortise)

•Acute and Chronic sprains

•Numerous methods

• I-III or mild to severe

•Often confusing and not relevant to treatment algorithm

Grading and Classification

•Grade I

–ATFL and CF stretches

•Grade II

–ATFL tears and CFL stretches

•Grade III

–Rupture of ATFL and CFL

• Important distinction

–Single vs Double Ligament injuries

•Must determine status of CFL in chronic ankle instability

•May influence type of reconstruction

Grading and Classification

Portal Anatomy• surface anatomy & intra-articular anatomy

• superficial NV structures and tendons

• clearly mark anatomy

• joint line

• DP artery

• greater saphenous vein

• anterior tibial tendon

• peroneus tertius tendon

• superficial peroneal nerve

Stetson and Ferkel JAAOS Jan/Feb 1996

Portal Placement• Distend ankle joint w/ 10 to 15 ml LR

• 18 or 20 g needle just medial to anterior tibialis tendon

• ID exact location of anteromedial portal

• Incise SKIN ONLY; blunt dissection w/ mosquito and blunt obturator

Portal Placement• Anterior Ankle Arthroscopy

• Anteromedial

• Anterolateral

• Posterolateral

• Feiwell & Frey (Foot & Ankle, 1993)

Anteromedial Portal

• Medial to anterior tib tendon

• 1st portal

• easy to establish

• 9 mm lateral to greater saphenous v.

• 7.5 mm lateral to greater saphenous n.

Stetson and Ferkel JAAOS Jan/Feb 1996

Anterolateral Portal

• established under direct visualization

• lateral to peroneus tertius

• 6.2 mm from intermediate br. of superficial peroneal n.

• location variable depending upon pathology

Stetson and Ferkel JAAOS Jan/Feb 1996

Posterolateral Portal

• Lateral to Achilles

• 1-1.5 cm proximal to distal tip of fibula

• Sural n. and lesser saphenous v. are at risk

• 6 mm posterior to sural n.

Alternative Portals

• Anterocentral

• Posterocentral

• Posteromedial

Portal Placement

• Posterior ankle arthroscopy

• Posterolateral

• Posteromedial

Stetson and Ferkel JAAOS Jan/Feb 1996Hsu et al. JAAOS Jan 2014

inferior extensor retinaculum, and cal-caneofibular ligament. For arthro-scopic purposes, posterior facet anat-omy forms the basis for portalplacement. Unless the interosseous lig-ament is torn, the anterior and medialfacets are largely inaccessible due to thethickness of the ligament filling the tar-sal canal.

Posterior AnkleArthroscopy

Typically, posterior ankle impinge-ment results from trauma or repeti-tive overuse and commonly occurs inballet dancers and soccer players.5 Itencompasses a broad array of pa-thology including os trigonum, os-teophytes, loose bodies, synovitis,and posttraumatic malunions. Pa-tients most commonly present withgeneralized hindfoot discomfort andpain during maximal or forced ankleplantar flexion. With the patient sit-ting and the knee flexed 90°, repeti-tive plantar flexion with or withoutrotational stress can reproduce pain,

crepitus, or grinding and is helpfulfor identifying sources of impinge-ment. In addition to a careful physi-cal examination, imaging studies, in-cluding weight-bearing radiographs,may reveal bony sources of impinge-ment. MRI and magnetic resonancearthrography also may be of diag-nostic value to better delineate hind-foot pathology from normal sur-rounding structures.

Surgical TechniqueA posterior approach with the pa-tient positioned prone is most com-monly used for posterior ankle andsubtalar arthroscopy. Portals areplaced adjacent to the Achilles ten-don posteromedially and posterolat-erally6 (Figure 1). A small bump isplaced under the distal lower leg toallow ankle motion. The posteriorapproach minimizes potential dam-age to the arteries of the tarsal canaland sinus tarsi.7

Portal placement is guided by astraight line drawn from the tip ofthe lateral malleolus to the Achilles

tendon, running parallel to the soleof the foot. The posterolateral portalis made just superior to this line, im-mediately adjacent to the border ofthe Achilles tendon. The posterome-dial portal is established in the samemanner, immediately adjacent to themedial border of the Achilles tendon.Care must be taken to avoid injuryto the calcaneal branch of the lateralplantar nerve. The nick and spreadtechnique is used to establish the lat-eral portal, and subcutaneous dissec-tion is performed with a small hemo-stat aimed inferiorly toward the firstweb space. After the hemostatreaches bone, a blunt trochar withan arthroscopic sleeve is inserted.The posteromedial portal is madeand a small hemostat is used to dis-sect soft tissue; the hemostat is ad-vanced anteriorly along the arthro-scope toward the posterior subtalarjoint until it reaches bone.3 For sub-talar arthrodesis, an accessory thirdportal may be created at the level ofthe sinus tarsi to introduce a large-diameter blunt trocar for distraction.In the posterior approach, the work-

ing space is created by removing theadipose tissue overlying the posterioraspect of the ankle and subtalar jointsalong with a small portion of the pos-terior talocalcaneal ligament and pos-terior joint capsule (Figure 2). The ar-throscope can be positioned at the edgeof the ankle and subtalar joints to viewthe articular surfaces. The flexor hal-lucis longus (FHL) tendon is a criticallandmark and should be identified toavoid injury to the neurovascular bun-dle located medially. Inflammation ofthe FHL tendon should be investigatedroutinely.8 To remove an os trigo-num, trigonal process, or osteo-phytes, it is often necessary to par-tially detach the posterior talofibularligament, FHL retinaculum, and pos-terior talocalcaneal ligament. Theuse of an electrocautery device, burr,or osteotome may help to remove thebony fragment.

A, Clinical photograph of the posterolateral portal (PLP) and posteromedialportal (PMP) in relation to the Achilles tendon. These portals are used in aposterior subtalar arthroscopic approach. B, Illustration demonstrating theunderlying anatomy near the posterior portals.

Figure 1

Andrew R. Hsu, MD, et al

January 2014, Vol 22, No 1 11

Setup• General, regional, or local anesthesia

• Patient position

• surgeon preference

• consider concomitant procedures

• +/- tourniquet

• Consider distraction technique

• Andrews: supine knee holder; gravity for distraction

• Yates and Grana: supine knee holder; loop of gauze around ankle and surgeon’s foot

• Parisien: 45 deg semilateral decubitus

• Guhl: supine w/ beanbag & mechanical distractor

Patient Position: Supine Manual Distraction

Ankle Distraction• Invasive vs non-invasive techniques

• Consider laxity of joint and location of pathology

Patient Position: Ankle Distraction (Lateral)

Anterior Pathology• May be best visualized w/ dorsiflexion of the

ankle w/o distraction

• Distraction tightens anterior capsule

anterior capsule, leading to a reduc-tion of the anterior working area18

(Figure 3). Second, loose bodies andosteophytes are usually located inthe anterior compartment of the an-kle joint. Dorsiflexion creates an an-terior working area, which makes re-moval easy. Introduction of salinesolution opens the anterior workingarea. In the case of a loose body anddistraction, the loose body may fallinto the posterior aspect of the joint,which makes removal more diffi-cult. Third, in the dorsiflexed posi-tion, the talus is concealed in thejoint, thereby protecting the carti-lage from potential iatrogenic dam-age.18

Mechanical distraction and use ofa small-diameter arthroscope may bebeneficial in some situations. Theseinclude treatment of ossicles, a soft-tissue impediment, a loose bodycaught in the joint space betweenthe fibula and tibia (the intrinsicsyndesmotic area), an OCD locatedin the posterior tibial plafond, andposterior ankle problems. An impor-tant alternative for the treatment ofposterior ankle problems is a two-portal posterior arthroscopy.11

Should distraction be indicated, aresterilizable noninvasive distrac-

tion device enables the surgeon tochange quickly from the dorsiflexedposition to the distracted positionand vice versa19 (Figure 4).

Surgical TechniqueThe anterior dorsiflexion proce-

dure4 is performed as outpatient sur-gery under general or epidural anes-thesia. The patient is placed in thesupine position with slight elevationof the ipsilateral buttock. A tourni-quet is placed around the upperthigh. The heel of the affected footrests on the very end of the operatingtable, thus making it possible for thesurgeon to fully dorsiflex the anklejoint by leaning against the sole ofthe patient’s foot (Figure 2). The twoprimary anterior portals used for an-terior ankle arthroscopy are the an-teromedial and anterolateral, locatedat the level of the joint line. Whentheir use is indicated, accessory an-terior portals are located just in frontof the tip of the medial or lateralmalleolus. Some surgeons combinethe anterior portals with a postero-lateral portal.20

The anteromedial portal is madefirst. After a skin incision has beencreated just medial to the tibialisanterior tendon, the subcutaneous

layer is bluntly divided with a hemo-stat. The 4-mm, 30°-angle arthro-scope, which we use routinely, is in-troduced in the fully dorsiflexedposition. Saline solution is then in-troduced into the joint. Under ar-throscopic control, the anterolateralportal is made by inserting a spinalneedle lateral to the peroneus tertiustendon while respecting the superfi-cial peroneal nerve (Figure 5).

Depending on the procedure per-formed, the instruments can be ex-changed between portals. Afterremoval of the instruments, the ar-throscopic incisions and accessoryportals are closed with Ethilon su-tures (Ethicon, Piscataway, NJ) to pre-vent sinus formation.

ComplicationsSeveral complications have been

described, including injury to neu-rovascular structures, instrumentbreakage, articular surface damage,neuroma formation, infection, andreflex sympathetic dystrophy.20-23

The superficial peroneal nerve is athighest risk, and injury to this nerveis associated with the anterolateralportal.20

Reports of complications in anklearthroscopy vary widely. With the useof either invasive or manual constantdistraction, complication rates of 9%to 17% have been reported.20-23

Figure 3

Schematic lateral view of the ankle joint. A, In dorsiflexion, the anterior working areais enlarged. B, Distraction of the ankle joint (arrows) results in tightening of theanterior capsule, reducing the anterior working area.

Figure 4

A resterilizable distraction device,which permits the surgeon to move theankle quickly from the dorsiflexedposition to the distracted position andvice versa.

C. Niek van Dijk, MD, PhD, and Christiaan J. A. van Bergen, MD

Volume 16, Number 11, November 2008 637

van Dijk and van Bergen JAAOS Nov 2008

Ankle Distraction• Invasive

• tibial, talar, or calcaneal pins + mechanical distractor device

• pins drilled lateral to medial

• steinmann pins 4-5 inches long and 3/16-in in diameter

• tibial 6.5-7.5 cm above joint line

• calcaneal pin 2.5 cm anterior and superior to posterior inferior calcaneal margin

Ankle Distraction• Invasive

• never penetrate medial cortex w/ pins

• distraction not to exceed 7-8 mm for more than 1.5 hours

• relative risk to SPN w/ proximal distractor pin

• avoid in osteoporotic bone and high performance athletes

Ankle Distraction• Non-invasive

• numerous techniques described

• periodically evaluate skin integrity

• limit force to <35-50 lbs for <1.5 hours

Guhl Ankle Distractor (S&N)

Equipment• Standard 4.0 mm 30-degree scope

• Alternative: 2.7 mm short 30-degree scope

• 70 degree scope available

• Shavers, graspers, curettes

• +/- thigh tourniquet

• Leg holders, etc.

• Pumps although gravity feed usually effective

21-Point Examination

• Intra-articular anatomy

• Systematic approach

• ‘same way every time’

Post-operative Mgmt

• careful attention to wound closure

• splint

• NWB until portals are healed

• may adjust according to pathology and additional procedures

Indications

• Diagnostic

• A look see…when all else fails.

• Therapeutic

• continue to evolve

Indications• Anterior & Posterior ankle impingement

• Loose bodies

• Osteochondral lesions

• Ankle instability

• Arthrofibrosis

• Infection (septic arthritis)

• Ankle arthritis (arthroscopic arthrodesis)

• Ankle fractures (ORIF tib/fib and syndesmosis reduction/fixation)

Soft Tissue Lesions

• 30-50% of ankle joint lesions

• not always clinically apparent

• consider congenital bands, post-traumatic changes, gout, synovitis, RA, PVNS, infection, ganglions, and athrofibrosis

• effective diagnostic and therapeutic tool

Anterior Soft Tissue Impingement

• anterolateral soft tissue impingement

• related to inversion sprains

• unexplained persistent anterolateral ankle pain

• exhaust conservative options

Anterior Soft-tissue Impingement

• Three Primary sites for anterolateral impingement

• Superior portion of anterior inferior tibiofibular ligament

• Distal to anterior inferior tibiofibular ligament

• Anterior talofibular ligament and lateral gutter

Anterior Soft-tissue Impingement

• DDx

• OCD or instability

• MRI and stress radiographs

• D & S of anterolateral aspect with removal of inflamed synovium

Arthroscopic Mgmt OLTs

• Benefits

• Excellent diagnostic modality

• Most of the ankle can be visualized with the use of accessory portals (76% Muir)

• No risk of malleolar non-union

Principles of Marrow Stimulation

• All unstable cartilage is removed

• Calcified cartilage layer removed

• Preserve subchondral plate

Principles of Marrow Stimulation

• Prepared lesion

• stable defect w/ vertical walls

• contained lesion to hold clot

Microfracture• Multiple holes or microfractures

• Arthroscopic Awls

• No thermal necrosis

• Tip perpendicular to bone surface

• 30, 45 or 90 degree awls

• Holes close together but not contiguous

• 3 – 4mm spacing between holes

• Make peripheral holes first

Microfracture• Assessment

• confirm adequate number of holes

• reduce irrigation fluid pump

• fat droplets and blood confirm depth

• adequate depth usually around 2-4 mm

Arthroscopic Assisted ORIF Ankle Fractures

• Indications are expanding for use of arthroscopy in ankle fractures

• Assist w/ assessment of syndesmotic and deltoid instability

• Avoid fluid extravasation (gravity only)

Complications

• overall rate of 9%

• 49% neurologic

• SPN (56%)

• Ferkel et al.

Ankle Arthroscopy

• Familiarity w/ surface anatomy is paramount

• Systematic approach

• Useful modality for variety of pathology

• both diagnostic and therapeutic

Current Trends in Management of

Chronic Ankle Instability

Non-operative Treatment• RICE/Immobilization

• Lateral heel wedge for flexible hindfoot varus

• Functional rehabilitation

• Strengthening/Achilles tendon stretching

• Proprioceptive training

• Ankle bracing and taping

Surgical Indication• Symptomatic instability despite bracing

and functional rehabilitation

• Associated pathology

• OLTs

• Peroneal tendon tear

• Hindfoot varus

• Fracture

• Direct anatomic repair

• Anatomic vs nonanatomic reconstruction

• Augmented vs nonaugmented reconstruction

Surgical Treatment Options

Surgical Treatment Options: Over 80 Techniques

• Anatomic repair

• Brostrom

• Gould (modified Brostrom)

• Karlsson

• Ahlgen and Larsson

• Sjolin

• Reconstruction

• Watson-Jones

• Elmslie

• Chrisman-Snook

• Evans

• Larsen

• Colville

Modified Brostrom• Direct anatomic repair w/ Gould

modification

Direct Anatomic Repair• Advantages

• Restoration of normal anatomy

• No morbidity from harvesting grafts

• Can convert to augmented or tendon graft procedure

• Disadvantages

• Inability to stabilize subtalar instability

• Weak and attenuated tissue

• Failure to reconstruct CF ligament

Anatomic Lateral Ankle Ligament Reconstruction

• Indications

• chronic lateral ankle ligament instability

• significant subtalar instability/attenuation of CFL

• athlete ?

Hatic--Anatomic Lateral Ankle Ligament Reconstruction• Graft selection

• allograft vs autograft

• donor site morbidity

• reliability of donor allografts

• semitendinosus or anterior tibialis

• 0.75 x 22 cm

Thank You

• shatic@oaswo.com

• twitter @DrHatic

rthopedicssociatesO

of SW Ohio1-800-824-9861www.oaswo.com