SLR - October 2017 - Brittany R. Staples; Neil A. Ermitano
Ankle Arthroscopy: An Update
Reference: Vega J, Dalmau-Pastor M, Malagelada F, Fargues-Polo B, Pena F. Ankle Arthroscopy: An Update. JBJS. 2017 Aug 16;99(16):1395–1407.
Scientific Literature Review
Reviewed By: Brittany R. Staples, DPM; Neil A. Ermitano, DPM
Residency Program: SSM Health DePaul Hospital, St. Louis, MO
Podiatric Relevance: Ankle arthroscopy is an essential method in treating a myriad of ankle pathologies. These authors discuss updated arthroscopic techniques and considerations that may prove beneficial to the podiatric surgeon.
Methods: Two primary techniques have arisen with regards to arthroscopy consisting of either “continuous and fixed noninvasive distraction” or “dorsiflexion of the ankle with distraction.” The latter has risen in popularity due to a significant reduction in complication rates. Portal placement remains a mainstay of arthroscopic ankle procedures given the intricate anatomy of the ankle, which has not significantly changed since the practice came into favor. However, caution is still recommended with regard to the anterolateral port, which has been associated with higher complication rates due to superficial peroneal nerve injury. In addition, the use of an anterocentral port is no longer recommended. Indications for arthroscopy are essential to consider prior to candidate selection, which include patients presenting with osseous impingement, soft-tissue impingement secondary to inversion ankle sprains, ankle instability, traumatic injuries and osteochondral lesions (OCLs).
Results: In treating OCLs, the ability to arthroscopically assess and treat a given lesion is accomplished using a classification based on location zones. The centromedial zone, which is the most common, and the centrolateral zone, which is the second most common. The goal of treatment is to create an optimal biologic environment. To facilitate the biological reparative process, three key methods of OCL treatment have been recognized: osteochondral fixation, subchondral microfracture and tissue transplantation through an arthroscopic approach. In regards to traumatic injuries, ankle arthroscopy has proven useful in visualizing the extent of osseous and soft-tissue injury and thus assisting in fracture reduction. Lastly, recent literature advocating for arthroscopic ankle joint arthrodesis has become increasingly preferred compared to the traditional open arthrodesis, largely due to superior postoperative pain control, reduced cost, increased fusion rate and reduced mortality.
Conclusion: As the authors noted, a newer discussion in ankle arthroscopy includes the concept of rotational instability and microinstability, which has been identified as a large contributor to symptomatic ankle pain, as a result of a compromised deltoid ligament and anterior talo-fibular ligaments. Recognizing the various arthroscopic indications and ankle pathologies aids the podiatric surgeon in developing an appropriate treatment regimen through an arthroscopic approach as newer arthroscopic technologies become available.