foot and ankle arthroscopy practical aspects and indications rj stillwell, ms4...

FOOT AND ANKLE ARTHROSCOPY

Practical Aspects and Indications

RJ Stillwell, MS4r.j.stillwell@gmail.com

ARTHROSCOPY ADVANTAGES

Minimal soft tissue dissection

Small capsular incisions

Decreased postoperative pain

Decreased stiffness

Early return to function

PRACTICAL ASPECTS OF ARTHROSCOPY

Arthroscopes

• 4.0-mm / 2.7-mm• 30 deg / 70 deg

PRACTICAL ASPECTS OF ARTHROSCOPY

Hand Instruments

• Picks / Osteotomes

PRACTICAL ASPECTS OF ARTHROSCOPY

Hand Instruments

• Probes

PRACTICAL ASPECTS OF ARTHROSCOPY

Hand Instruments

• Curettes – cupped / ring

PRACTICAL ASPECTS OF ARTHROSCOPY

Power Instruments

• Cutters / Shavers / Burrs / Abraders• Thermoablation – RF wands / YAG laser• Aspiration when attached to suction

PRACTICAL ASPECTS OF ARTHROSCOPY

Power Instruments

• Shavers – side-cutting / open-ended / full-radius• Smooth / single incisor / double incisor

PRACTICAL ASPECTS OF ARTHROSCOPY

Patient positioning

• Supine / stirrup / distraction• Lateral decubitus for STJ

Anesthesia

Hemostasis

• Tourniquet / epi

ANTERO-MEDIAL PORTAL

ANTERO-LATERAL PORTAL

ANATOMYTopographic

• Foot Ankle Int. 2000 Oct;21(10):860-3. Fourth toe flexion sign: a new clinical sign for identification of the superficial peroneal nerve. Stephens MM, Kelly PM.

ANATOMYTopographic

• The course of the superficial peroneal nerve in relation to the ankle position: anatomical study with ankle arthroscopic implications. Peter A. J. de Leeuw,1 Pau Golanó,2 Inger N. Sierevelt,3 and C. Niek van Dijk3

DIAGNOSTIC ARTHROSCOPY?

• Imaging inconclusive?• Diagnostic injections?• Conservative treatment exhausted?

ANKLE WASHOUT?Cochrane Database Syst Rev. 2010 May 12;(5):CD007320.Joint lavage for osteoarthritis of the knee.

CONCLUSIONS:Joint lavage does not result in a relevant benefit for patients with knee osteoarthritis in terms of pain relief or improvement of function.

N Engl J Med. 2002 Jul 11;347(2):81-8.A controlled trial of arthroscopic surgery for osteoarthritis of the knee.

CONCLUSIONS:Sham-controlled - outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.

Arthroscopy. 2009 Dec;25(12):1478-90.

Evidence-based indications for ankle arthroscopy.

Glazebrook MA, Ganapathy V, Bridge MA, Stone JW, Allard JP.

Scranton PE Jr, McDermott JE. Anterior tibiotalar spurs: Acomparison of open versus arthroscopic debridement. FootAnkle. 1992;13:125-129.

• Shorter recovery time with arthroscopy

• The bigger the spur, the longer the recovery

Kim SH, Ha KI. Arthroscopic treatment for impingement of the anterolateral soft tissues of the ankle. J Bone Joint Surg Br 2000;82:1019-1021..

Anterolateral impingement of the ankle should be considered in apatient with chronic anterolateral pain after an injury, regardless of the stability of the ankle.

It has been noted that early resection of impinging synovium inhibits the progression of the cascade to chronic synovitis and scar-tissue formation.

Meislin RJ, Rose DJ, Parisien JS, et al. Arthroscopic treatment of synovialimpingement of the ankle. Am J Sports Med 1993;21:186–9.

Bassett FH, Gates HS, Billys JB, et al. Talar impingement by the anteroinferiortibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain.J Bone Joint Surg Am 1990;72:55–9.

OSTEOCHONDRAL LESIONS

OSTEOCHONDRAL LESIONS

OSTEOCHONDRAL LESIONS

Perpendicular edges provide a circumferential barrier to hold the fibrocartilage plug in place during the healing process.

Promote bleeding of the trabecular bone beneath the subchondral bone plate to facilitate fibrocartilage formation.

OSTEOCHONDRAL LESIONS

OSTEOCHONDRAL LESIONS

Ferkel RD, Zanotti RM, Komenda GA, et al. Arthroscopic treatment of chronic osteochondral lesions of the talus: long-term results. Am J Sports Med 2008; 36(90):1750–62.

OSTEOCHONDRAL LESIONS

For arthroscopic debridement of OCD lesions associated with any technique of subchondral bone penetration (curettage, drilling, or microfracture) in lesions under 15 mm in diameter, there is no evidence that one technique is superior to another.

OSTEOCHONDRAL LESIONS

Parisien JS. Arthroscopic treatment of osteochondral lesions of the talus. Am J Sports Med 1986;14:211-217.

Compared 10 patients who were non–weight bearing for 6 weeks with 8 patients who were allowed to bear weight as tolerated after an arthroscopic debridement and curettage or drilling.

There was no difference in outcomes, with good results in nearly 90% of patients in both groups.

ANKLE ARTHRODESIS

Myerson and Quill published the first comparative study between open and arthroscopic ankle arthrodesis.

They noted a similar fusion rate (94% v 100%), but significant shorter time to fusion in the arthroscopic group (8.7 weeks) compared with the open group (14.5 weeks).

Myerson MS, Quill G. Ankle arthrodesis. A comparison of an arthroscopic and an open method of treatment. Clin Orthop Relat Res 1991:84-95.

ANKLE ARTHRODESISGougoulias NE, Agathangelidis FG, Parsons SW. Arthroscopic ankle arthrodesis. Foot Ankle Int 2007;28:695-706.

• Gougoulias compared patients with arthroscopic ankle fusions that had minor deformity before surgery with patients who had varus or valgus deformity of more than 15° (maximum, 45°).

• There was 1 nonunion in each group, and the mean time to union was similar (13.1 and 11.6 weeks, respectively).

• Outcomes were similar, with good results in 79% and 80%, respectively.

The authors suggested that contrary to the generally accepted opinion that deformity over 15° is a contraindication to arthroscopic ankle fusion, a good correction and fusion rate could be achieved with arthroscopic ankle arthrodesis in those patients.

ANKLE ARTHRODESIS

ANKLE ARTHRODESIS

• Loose bodies• Arthrofibrosis• Fractures• Septic arthritis• OA?

LESS EVIDENCE

SUBTALAR ARTHROSCOPY

Sinus Tarsi Syndrome

• Interosseous ligament / cervical ligament• Arthrofibrosis / synovitis• Soft tissue impingement• Os trigonum• Arthrodesis

FIRST MTPJ ARTHROSCOPY

• Osteochondral lesions• Synovitis• Loose bodies• Arthrofibrosis• Osteophytes limiting dorsiflexion• Sesamoid pathology• Excision of gouty tophi

TENDOSCOPY• Peroneus Longus / Brevis

• FHL

• Tibialis Posterior

• Achilles Tendon