Arthroscopy and Endoscopy of the Foot and Ankle: Principle and Practice [1st ed.] 978-981-13-0428-6, 978-981-13-0429-3

This book provides detailed information in foot and ankle arthroscopy and endoscopy. It explores and introduces these su

444 73 63MB

English Pages VIII, 688 [682] Year 2019

Report DMCA / Copyright

DOWNLOAD FILE

Polecaj historie

Arthroscopy and Endoscopy of the Foot and Ankle: Principle and Practice [1st ed.]
 978-981-13-0428-6, 978-981-13-0429-3

Table of contents :
Front Matter ....Pages i-viii
Front Matter ....Pages 1-1
Setup, Equipment and Surgical Instruments (Samuel K. K. Ling, Tun Hing Lui)....Pages 3-12
Surgical Arthroscopic Anatomy (Miki Dalmau-Pastor, Jordi Vega, Francesc Malagelada, Maria Cristina Manzanares)....Pages 13-27
Evidence-Based Medicine of Arthroscopy and Endoscopy of the Foot and Ankle (Rocco Papalia, Guglielmo Torre, Nicola Maffulli)....Pages 29-33
Front Matter ....Pages 35-35
Ankle Arthroscopy: Osteoarticular Procedures (Nicholas Yeo, Alastair Younger, Andie Veljkovic, Feras Waly, Andrea Veljkovic, Yinghui Hua et al.)....Pages 37-115
Ankle Arthroscopy: Soft Tissue Procedures (Chi Pan Yuen, Tun Hing Lui, Jorge Batista, Masato Takao, Kentaro Matsui, Haruki Odagiri et al.)....Pages 117-171
Posterior Subtalar Arthroscopy (Peter A. J. de Leeuw, Jan Ophuis, Gino M. M. J. Kerkhoffs, Kevin Koo, Peter Rosenfeld, Thomas Bauer et al.)....Pages 173-222
Anterior Subtalar Arthroscopy (Diane Hei Yan Tai, Tun Hing Lui, Sally H. S. Cheng)....Pages 223-240
Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy (Diane Hei Yan Tai, Tun Hing Lui, Thomas S. Roukis, Amanda Slocum, Thomas Bauer, Hoi Yan Lam)....Pages 241-275
Naviculocuneiform Arthroscopy: Surgical Approaches and Application (Tun Hing Lui)....Pages 277-285
Tarsometatarsal (Lisfranc) Arthroscopy (Hoi Yan Lam, Tun Hing Lui, Chun Man Ma)....Pages 287-306
First Metatarsophalangeal Arthroscopy (Phinit Phisitkul, Vinay Hosuru Siddappa, Davide Edoardo Bonasia, Annunziato (Ned) Amendola, Kenneth J. Hunt, Philip J. York et al.)....Pages 307-358
Metatarsophalangeal Arthroscopy of Lesser Toes (Caio Nery, Daniel Baumfeld, Wai Chung Chan, Tun Hing Lui, Sally H. S. Cheng)....Pages 359-394
Interphalangeal Arthroscopy: Surgical Approaches and Application (Ka Yuk Fan, Tun Hing Lui)....Pages 395-406
Front Matter ....Pages 407-407
Achilles Tendoscopy and Endoscopic Procedures for Pathologies of the Achilles Tendon (Alastair Younger, Thomas S. Roukis, Ho Lam Chai, Tun Hing Lui, Mahmut Nedim Doral, Gazi Huri et al.)....Pages 409-460
Posterior Tibial Tendoscopy (Samuel Ka Kin Ling, Tun Hing Lui, Shin Yeung Chiu)....Pages 461-477
Peroneal Tendoscopy (Yuk Nam Yeung, Tun Hing Lui, Ka Hei Leung, Wai Chung Chan, Jordi Vega, Miki Dalmau et al.)....Pages 479-512
Flexor Hallucis Longus Tendoscopy (Chun Man Ma, Tun Hing Lui, Tsz Lung Choi, Jorge Batista, Raymond Peter Lee, Cheuk-Hang Sin)....Pages 513-540
Flexor Digitorum Longus Tendoscopy: An Overview of Surgical Approaches and Application (Raymond Peter Lee, Tun Hing Lui)....Pages 541-547
Extensor Tendoscopy (Adam Yiu Chung Lau, Tun Hing Lui, Raymond Peter Lee, Cheuk-Hang Sin)....Pages 549-569
Front Matter ....Pages 571-571
Bone Endoscopy (Dennis King Hang Yee, Tun Hing Lui, Tze Wang Chan)....Pages 573-586
Soft Tissue Endoscopy (Sally H. S. Cheng, Tun Hing Lui, Angela W. H. Ho, Dror Robinson, Mustafa Yassin, Damian C. Y. Mak et al.)....Pages 587-688

Citation preview

Tun Hing Lui Editor

Arthroscopy and Endoscopy of the Foot and Ankle Principle and Practice

123

Arthroscopy and Endoscopy of the Foot and Ankle

Tun Hing Lui Editor

Arthroscopy and Endoscopy of the Foot and Ankle Principle and Practice

Editor Tun Hing Lui Department of Orthopaedics and Traumatology North District Hospital Hong Kong China

ISBN 978-981-13-0428-6    ISBN 978-981-13-0429-3 (eBook) https://doi.org/10.1007/978-981-13-0429-3 Library of Congress Control Number: 2018965472 © Springer Nature Singapore Pte Ltd. 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Preface

I have had the privilege to experience firsthand the advances of foot and ankle surgery during my 27  years of practice, and have witnessed technological advances in instrument design which have enabled my friends and colleagues from all over the world develop many innovative procedures to tackle foot and ankle conditions. I started preparing this book 2 years ago with the aim of summarizing the current research together, and have found that as time went on, it was difficult for me to not continually expand the book’s chapter index because so many new frontiers have continually been explored. From the scoping of larger defined spaces such as the ankle to the scoping of the small interphalangeal joints and then the scope of defined but extra-articular spaces such as tendon sheaths, progressing to the scope of non-confined spaces such as the inter-metatarsal space, brilliant colleagues from all over the world have relentlessly pushed the boundaries of imagination in where our scope can reach. I am optimistic about our future developments and believe that there will continually be advances in foot and ankle surgery for many years to come; I anticipate that 10 years later I might need to start rewriting this book from scratch. I must acknowledge my good friend Dr. Roukis for initializing and giving life to this project. I also like to thank the Institute of Biomedicine and Biotechnology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Science and Shenzhen University for their help during preparation of this book. My boss and mentor Dr. Ngai who allowed me the freedom to focus on foot and ankle surgery back when it was still a relatively undeveloped subspecialty; you will always have my respect and gratitude. Last but not least, I must take this opportunity to acknowledge my beloved wife Eva who has supported and tolerated my many late-night writing sessions, and my sons Ken and Joe, you boys are the joy of my life. Hong Kong

Tun Hing Lui

v

Contents

Part I General Principle 1 Setup, Equipment and Surgical Instruments�����������������������������������������������������������   3 Samuel K. K. Ling and Tun Hing Lui 2 Surgical Arthroscopic Anatomy���������������������������������������������������������������������������������  13 Miki Dalmau-Pastor, Jordi Vega, Francesc Malagelada, and Maria Cristina Manzanares 3 Evidence-Based Medicine of Arthroscopy and Endoscopy of the Foot and Ankle�������������������������������������������������������������������������������������������������  29 Rocco Papalia, Guglielmo Torre, and Nicola Maffulli Part II Foot and Ankle Arthroscopy 4 Ankle Arthroscopy: Osteoarticular Procedures�������������������������������������������������������  37 Nicholas Yeo, Alastair Younger, Andie Veljkovic, Feras Waly, Andrea Veljkovic, Yinghui Hua, Shiyi Chen, Chi Pan Yuen, Tun Hing Lui, Thomas S. Roukis, Shek Ng, Thomas Bauer, Peter A. J. de Leeuw, Jan Ophuis, and Gino M. M. J. Kerkhoffs 5 Ankle Arthroscopy: Soft Tissue Procedures������������������������������������������������������������� 117 Chi Pan Yuen, Tun Hing Lui, Jorge Batista, Masato Takao, Kentaro Matsui, Haruki Odagiri, Stephane Guillo, and Reiji Higashiyama 6 Posterior Subtalar Arthroscopy��������������������������������������������������������������������������������� 173 Peter A. J. de Leeuw, Jan Ophuis, Gino M. M. J. Kerkhoffs, Kevin Koo, Peter Rosenfeld, Thomas Bauer, Tun Hing Lui, Thomas S. Roukis, Phinit Phisitkul, Davide Edoardo Bonasia, Annunziato (Ned) Amendola, and Davide Deledda 7 Anterior Subtalar Arthroscopy��������������������������������������������������������������������������������� 223 Diane Hei Yan Tai, Tun Hing Lui, and Sally H. S. Cheng 8 Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy��������������������������������������������������������������� 241 Diane Hei Yan Tai, Tun Hing Lui, Thomas S. Roukis, Amanda Slocum, Thomas Bauer, and Hoi Yan Lam 9 Naviculocuneiform Arthroscopy: Surgical Approaches and Application ������������� 277 Tun Hing Lui 10 Tarsometatarsal (Lisfranc) Arthroscopy ����������������������������������������������������������������� 287 Hoi Yan Lam, Tun Hing Lui, and Chun Man Ma

vii

viii

11 First Metatarsophalangeal Arthroscopy������������������������������������������������������������������� 307 Phinit Phisitkul, Vinay Hosuru Siddappa, Davide Edoardo Bonasia, Annunziato (Ned) Amendola, Kenneth J. Hunt, Philip J. York, Tun Hing Lui, Thomas S. Roukis, Jordi Vega, Miki Dalmau, and Hoi Yan Lam 12 Metatarsophalangeal Arthroscopy of Lesser Toes��������������������������������������������������� 359 Caio Nery, Daniel Baumfeld, Wai Chung Chan, Tun Hing Lui, and Sally H. S. Cheng 13 Interphalangeal Arthroscopy: Surgical Approaches and Application������������������� 395 Ka Yuk Fan and Tun Hing Lui Part III Foot and Ankle Tendoscopy 14 Achilles Tendoscopy and Endoscopic Procedures for Pathologies of the Achilles Tendon ��������������������������������������������������������������������� 409 Alastair Younger, Thomas S. Roukis, Ho Lam Chai, Tun Hing Lui, Mahmut Nedim Doral, Gazi Huri, Naila Babayeva, Egemen Turhan, Gürhan Dönmez, Charles Churk Hang Li, E. Rabat, J. Torrent, M. Bernaus, and Wai Chung Chan 15 Posterior Tibial Tendoscopy��������������������������������������������������������������������������������������� 461 Samuel Ka Kin Ling, Tun Hing Lui, and Shin Yeung Chiu 16 Peroneal Tendoscopy��������������������������������������������������������������������������������������������������� 479 Yuk Nam Yeung, Tun Hing Lui, Ka Hei Leung, Wai Chung Chan, Jordi Vega, Miki Dalmau, and Diane Hei Yan Tai 17 Flexor Hallucis Longus Tendoscopy������������������������������������������������������������������������� 513 Chun Man Ma, Tun Hing Lui, Tsz Lung Choi, Jorge Batista, Raymond Peter Lee, and Cheuk-Hang Sin 18 Flexor Digitorum Longus Tendoscopy: An Overview of Surgical Approaches and Application������������������������������������������������������������������� 541 Raymond Peter Lee and Tun Hing Lui 19 Extensor Tendoscopy ������������������������������������������������������������������������������������������������� 549 Adam Yiu Chung Lau, Tun Hing Lui, Raymond Peter Lee, and Cheuk-Hang Sin Part IV Foot and Ankle Endoscopy 20 Bone Endoscopy ��������������������������������������������������������������������������������������������������������� 573 Dennis King Hang Yee, Tun Hing Lui, and Tze Wang Chan 21 Soft Tissue Endoscopy ����������������������������������������������������������������������������������������������� 587 Sally H. S. Cheng, Tun Hing Lui, Angela W. H. Ho, Dror Robinson, Mustafa Yassin, Damian C. Y. Mak, E. Rabat, J. Torrent, M. Bernaus, Youichi Yasui, Wataru Miyamoto, J. Chance Miller, Masato Takao, T. W. Chan, Heinz Lohrer, Jason C. Y. Mok, and Cheuk-Hang Sin

Contents

Part I General Principle

1

Setup, Equipment and Surgical Instruments Samuel K. K. Ling and Tun Hing Lui

Contents 1.1       Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3 1.2       A Brief History of the Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4 1.3       General Operating Theatre Setup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5 1.3.1   Illumination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5 1.3.2   Ventilation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5 1.3.3   Temperature and Humidity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5 1.3.4   Surgical Table. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5 1.3.5   Fluoroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6 1.4       Modern Arthroscopy Setup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6 1.4.1   Arthroscope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6 1.4.2   Camera Head. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7 1.4.3   Arthroscopic Light Source. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8 1.4.4   Video Module/Recording Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8 1.4.5   Printers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8 1.4.6   TV/Monitor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8 1.4.7   Fluid Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9 1.4.8   Motorised Module. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9 1.4.9   Radiofrequency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10 1.4.10  Probes, Forceps, Awls and Curettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10 1.4.11  Other Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11 1.5       Ending Remarks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12

S. K. K. Ling (*) Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Hong Kong, China T. H. Lui Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Hong Kong, China Institute of Biomedicine and Biotechnology, Shenzhen Institutes of Advanced Technology—Chinese Academy of Science, Shenzhen, China Department of Orthopaedics, Southern Medical University, Guangzhou, China

1.1

Introduction

Operating theatres can be regarded as the centre of any orthopaedic service, with many surgeons ‘living’ in them. The name operating theatre/surgical theatre arises from historical contexts, with surgery previously performed in an open hall on an elevated table surrounded by a tiered amphitheatre for spectators/students to observe and learn. These dated theatres have now been superseded by operating rooms with a thoroughly controlled artificial environment, allowing meticulous regulation of luminosity, airflow, temperature and humidity. Concurrently, the actual surgical operations have also progressed from a being gruesome and gory procedure to its current trademark of being sterile and sleek [1].

© Springer Nature Singapore Pte Ltd. 2019 T. H. Lui (ed.), Arthroscopy and Endoscopy of the Foot and Ankle, https://doi.org/10.1007/978-981-13-0429-3_1

3

4

1.2

S. K. K. Ling and T. H. Lui

A Brief History of the Scope

The arthroscope in orthopaedic surgery stems from the groundwork laid down by the general surgeon’s endoscope. One of the first documented uses dates back two centuries ago in the 1800s when Philipp Bozzini used a lichtleiter (light conductor) to perform the first cystoscopy. The lichtleiter comprised of a container which held a candle with its flames mirrored into a speculum piece. Aside from a candle’s flickering flame, other illumination methods included the use of gasoline and turpentine combustion, which were an occupational hazard with often disastrous outcomes. Development of these early devices was hindered by the availability to provide a constant, bright and safe illumination until the late 1880s when the ground-breaking invention of the lightbulb shook the world. This pivotal technological breakthrough in human history also ushered endoscopy into a new era of growth. It solved the previous problem of an unstable and unsafe illumination source and eventually allowed Leiter and Nitze to successfully develop an incandescent bulb endoscope. Lightbulb illumination greatly amplified the usability of the endoscope, and surgeons began employing this instrument in various cavities such as the bladder, abdomen and thorax. The concomitant development of specific instruments such as the retrograde knife, forceps, shavers, etc. greatly expanded the functionality of the scope and enabled it to evolve away from being a purely diagnostic tool to becoming a therapeutic instrument. Scope development then slightly plateaued until another boom came in the 1970s with the development of fibre optic technology by the likes of Charles Kao in addition to the dawn of the television era. Visibility was drastically improved by the fibre optic light cables, and the television monitor allowed surgeons/assistants/nurses to simultaneously view the image on a large screen rather than rely on the relatively clumsy direct visualisation through an eyepiece [2–4] (Fig. 1.1). In the orthopaedic speciality, Takagi, who is sometimes dubbed the father of arthroscopy, pioneered new ground when he introduced the scope into the knee joint during the early 1900s. His prodigy Watanabe and many forefathers from all parts of the globe continued to innovate and inaugurate during the last century, and via the dedication of these experts, the clinical function of the arthroscope progressively expanded into other regions of the body such as the shoulder, hip and spine. The recent few decades have continued to produce research which has expanded the function of the scope, especially in the realm of small joint arthroscopy such as those in the foot [1, 5–10].

Fig. 1.1  Arthroscopy setup

1  Setup, Equipment and Surgical Instruments

1.3

General Operating Theatre Setup

1.3.1 Illumination Compared to open surgeries, theatre illumination is of secondary importance in surgeries involving a scope. However, as a general rule, high-quality artificial lighting with a minimum of 40 K lux is recommended. Theatre illumination is most important when establishing the portals or during other adjunct procedures, but after the scope has been inserted, many surgeons prefer a dimmed theatre which reduces glare  and enables better focus on the arthroscopic monitor [8, 11–14].

1.3.2 Ventilation As with illumination, ventilation requirements are less stringent in scope-assisted surgeries since incisions are generally smaller with less openly exposed tissue. Plenum-ventilated theatres, which work on the basis of a positive pressure system where air flows outwards from the high-pressure aseptic zone to the relatively lower pressure clean zone of the theatre via air vents, are generally adequate. A recommendation of less than 35 colony-forming units/m3 is a standard requirement in plenum-ventilated theatres, while ultraclean theatres (such as those used in arthroplasty surgery) should be equipped with a laminar flow system with less than 10 colony-­forming units/m3 [8, 12–17].

1.3.3 Temperature and Humidity Although staff sometimes prefer cooler temperatures, a goal of 24–26° Celsius surrounding the patient is advised to prevent hypothermia; this is achieved via creating a warm microclimate using reflective blankets or warm airflow mattresses. Some evidence suggests that airflow mattresses may

5

be less preferred compared to reflective blankets due to the theoretical creation of turbulence hindering the direction of airflow at the aseptic zone; however, as with the previous criteria, there is no evidence that this plays a significant role in arthroscopic/endoscopic surgery. Aside from temperature, optimal theatre humidity should be regulated at around 40–60% [8, 12–16].

1.3.4 Surgical Table The surgical table is at the centre of the aseptic zone and should be versatile enough to adapt for different surgical positioning; most modern tables are adjustable for height and tilt with multiple readily interchangeable modular. The load capacity generally exceeds 400  kg to cater for larger patients and are sometimes motorised to allow easier movement. While the base is usually stainless steel, carbon fibre is frequently employed for the upper parts as it is strong, light and radiolucent. External covering materials are made from durable materials with smooth surfaces that allow easier cleaning and facilitate the maintenance of a sterile environment. For foot and ankle surgeries, patient positioning is relatively straightforward, and most surgical tables are sufficient. Bolsters, holders and triangle positioners are commonly deployed, but usage varies greatly between surgeons; some units also apply distraction devices which help enhance the ease of visualisation. With the use of smaller (1.9 and 2.7  mm) arthroscopes, the need for invasive distractors is rare. Non-invasive distraction methods are more commonly used and can be classified into controlled or uncontrolled one; controlled methods include using prefabricated sterile straps/Kerlix clove-hitch knots, but the drawback is the risk of ligament and nerve damage. Uncontrolled methods such as gravity/manual distraction have much lower reports of complications; however, the extent of distraction is rarely maintained for prolonged periods [8, 12, 13].

6

S. K. K. Ling and T. H. Lui

1.3.5 Fluoroscopy

1.4

Fluoroscopy is frequently required in orthopaedic operations; thus the theatre room must be safely shielded to minimise the occupational irradiation hazard to all staff, especially the ones in the clean areas who are often not wearing personal protective gear such as lead aprons. The theatre itself must have adequate space to accommodate the fluoroscopy machines, and the surgical tables must be radiolucent (Fig. 1.2). Many advanced fluoroscopic setups allow outputs to multiple monitors which are dispersed at tactical sites to allow ready visualisation by all staff at different angles of the theatre [12, 13, 18–20].

If you fail to plan, you are planning to fail; this adage is especially true in arthroscopic/endoscopic surgery. Since practicality of the surgical extent is often limited by the choice of portals and whether the specific instruments are available, preoperative planning must include the deliberate preparation of the specific arthroscope required as well as the corresponding instruments [1, 13, 21–23].

Fig. 1.2 Fluoroscopy

Modern Arthroscopy Setup

1.4.1 Arthroscope The arthroscope is the most important tool and is required to transmit high-definition images with a uniform brightness. Modern arthroscopes are generally manufactured with stainless steel and constructed using scratch-resistant lens, laser-­ welded joints, soldered windows and reinforced tubing. The first decision the surgeon must make is choosing the size of arthroscope. For larger joints/cavities in larger build patients, the 4.0 mm arthroscope is often the scope of choice; however, for smaller build patients, the 2.7 mm arthroscope is a valuable option. The visualisation field is greater for the 4.0 mm arthroscope, which facilitates identification of pathologic tissues from normal anatomic structures and therefore orientation. Moreover, the 4.0  mm arthroscope is more robust and can sustain more forceful manipulation without being damaged. Finally, the fluid inflow rate is higher for 4.0 mm arthroscope which can help to maintain a functional working space during endoscopy. In surgery involving smaller joints such as the first metatarsal-phalangeal joint, smaller arthroscopes such as the 1.9 mm scope are required. Aside from the size, the viewing angle of the scope is also important; these traditionally come in 0°, 30° and 70°. The 0° viewing angle scope means that the optical axis is directly in line with the barrel axis; although orientation is easy, its applicability is limited as rotation of the scope barrel does not change the total visual field. The 30° viewing angle scope is a more commonly employed tool because the total visual field is tripled via simple rotation of the scope, making it a versatile instrument for a thorough inspection of cavities such as the ankle joint. Modern scopes use a wide-angle system allowing visualisation of 90°; with the 30° oblique viewing wide-angle scope, a delicate balance is struck as it still allows the surgeon to see along the optical axis, enabling direct visualisation of the direction/plane during advancement of the scope. This is in contrast to the 70° scope where the angle is too oblique (even with the 90° wide angle) and a blind spot is present anterior to the scope. The surgeon cannot visualise the direction of scope advancement, making manipulation of the scope riskier as fragile structures can be iatrogenically traumatised. However, the 70° viewing angle allows for visualisation of some structures that cannot be

1  Setup, Equipment and Surgical Instruments

reached by the 30° scope, and thus it is still a convenient tool in the well-stocked arthroscopic armoury. The combination of using different viewing portals, external manipulation of the joint involved as well varied viewing angle scopes allows for an adequate assessment of most structures [1, 3, 13, 24– 27]. Aside from the size and viewing angle, the barrel length of the scope must also be carefully chosen according to the site of arthroscopy/endoscopy. Many centres will be equipped with the 180 mm standard barrel length arthroscopes which are universally used in knee arthroscopies. However, for arthroscopy of smaller, shallower joints such as those in the feet, a short barrel scope (e.g. 100 mm) allows the surgeon to stabilise themselves by resting a finger tripod on the patient’s skin instead of performing the procedure in a freehand manner. This allows the surgeon to maintain more precise control and decreases the risk of inadvertent motion such as backing out of the scope. Most scope setups have a trocar/cannula which matches in diameter size and barrel length (e.g. 2.7 mm scope with 3.0 mm cannula). The blunt trocar/cannula helps dissection during establishment of the portal and subsequently becomes a protective sheath for the arthroscope and a fluid conduit. The difference of the diameter of the cannula and the scope can determine the rate of inflow and affect the distension of the working space (details will be discussed in the session of fluid maintenance). The importance of this cannula as a protective sleeve for the scope is especially pronounced while using smaller-diameter arthroscopes (e.g. 1.9 mm) which are less resistant to bending (Fig. 1.3) [28].

7

1.4.2 Camera Head The arthroscope normally has two major attachments: the light source and the camera module. Modern camera m ­ odules are all in high definition (newer ones may be in 4 K definition) and often coupled with programmable buttons controlling functions such as capturing a photo, starting/stopping the recording, zooming, printing, etc. (Fig. 1.4). The mount onto the scope must be secured but also easily exchangeable, and the camera head must be amenable to sterilisation procedures [8, 13].

Fig. 1.4  Camera head

Fig. 1.3 Arthroscope

8

S. K. K. Ling and T. H. Lui

1.4.3 Arthroscopic Light Source

1.4.6 TV/Monitor

The arthroscopic light source should provide a brilliant, consistent, crisp illumination transmitted via fibre optic cables. Most systems use LED since they are highly energy efficient and provide a cool daylight equivalent luminosity at 7000 K. Some light cables have reinforced tubing to protect the fibre optics in the aim of improving durability [8, 13, 14].

Standard setups have one primary monitor, with a corresponding resolution of at least equal to the camera’s output (Fig. 1.5). Many modernised theatres have multiple screens strategically embedded at different angles, allowing the assistants/nurses easier visualisation of the ongoing arthroscopic procedure. In addition, many teaching hospitals are often able to link and broadcast live images from the scope to distant locations for facilitation of educational activities.

1.4.4 Video Module/Recording Module The camera is attached to a video module with recording functions as a standard feature. Due to the huge file sizes from the increasing higher video definition, adequate storage space is essential. Despite current systems providing terabytes of on-board storage, many hospitals still need a ­centralised data storage centre to safeguard the data. Medicallegal implications regarding storage of sensitive personal data vary in each country and should be adhered to. Aside from simple recording functions, some companies also provide modules which enhance the raw images with pre-calibrated parameters specific to the structures targeted; these processed images aim to improve overall clarity and allow clearer focus on the important structures [8, 13, 14].

1.4.5 Printers Fig. 1.5 Monitors

Despite the increased usage of videos, photographs still occupy a significant role in medical documentation. Modern units usually enable printing via standard digital printers, though many medical centres prefer to use thermal printers which generally ensure a more consistent recolour reproduction.

1  Setup, Equipment and Surgical Instruments

9

1.4.7 Fluid Management

1.4.8 Motorised Module

Aside from the above-mentioned basics, additional equipment such as insufflators are often required in arthroscopic surgeries. Insufflators help maintain a constant accurate fluid flow to sustain a preset pressure inside the arthroscopic/ endoscopic cavity; these modules are generally equipped with functions such as lavage and drainage. The types of fluid used vary from different units, but the general principle is to use a rapidly absorbed medium which is physiologically/osmotically compatible with articular cartilage; the more common choices are ringer lactate and isotonic saline. Since foot and ankle endoscopy/arthroscopy involves smaller spaces, and thus smaller bore arthroscopes, the usage of fluid insufflators may be less important since gravity and fluid pressure are usually adequate. While using the 2.7  mm arthroscope with the 3.0 mm cannula, the recommendation is to use a 3 l fluid bag which is elevated as high as possible; this will produce a flow rate of approximately 75  ml/min. Consequently, a faster flow rate can be obtained if the same 2.7 mm scope is used in concert with a larger 3.7 mm diameter cannula. A larger 4.0 mm scope with a 4.5 mm cannula can produce a flow rate of 110  ml/min; but one must be weary of over-distension and extravasation which is often distressing to the patient and carries the risk of producing compartment syndrome [3, 7, 8, 13, 14].

Aside from consoles which enable adequate visualisation, many specific arthroscopic instruments are required. The most common is the motorised module with a hand-piece that couples with a burr or a shaver tip. Typical hand-pieces can control the direction of rotation through buttons on the hand-piece (or via a footswitch) allowing the instrument to rotate clockwise and anticlockwise or to oscillate (Fig. 1.6). In addition, they are often connected to a suction unit with a lever to allow gradient control over the suction power. The arthroscopic instruments comes in various sizes chosen in correspondence to the size of the arthroscope used. The majority are disposable one-use instruments which need to be powerful but precise, as well as allowing an easy interchanging mechanism for a wide selection of blades that caters for different situations. Similarly, the burrs also come in a range of speciality blades, with the size, angle and edge design tailored towards different procedures. These are also mostly disposable one-use instruments that need to provide efficient debridement for bone removal since blunt burrs can generate a significant amount of thermal energy leading to inadvertent burns [8, 13].

Fig. 1.6 Hand-piece

10

S. K. K. Ling and T. H. Lui

1.4.9 Radiofrequency

1.4.10 Probes, Forceps, Awls and Curettes

Another commonly employed tool is the radiofrequency module which creates ionised particles to vaporise tissue. Advanced designs increase patient safety by allowing the console to monitor the intra-articular/intra-cavity fluid temperature in real time, providing the surgeon with direct feedback during ablation procedures (Fig. 1.7).

The simple probe functions as an extension of the surgeons’ finger to provide tactile sensation during arthroscopy. Most probes have a curved and blunt end; and they are designed to allow assessment of surfaces such as chondral lesions, as well as acting as retractors to clear the view during arthroscopic assessment. Forceps, awls and curettes come in a variety of different sizes, tip designs and angulations to provide the surgeon with a comprehensive arsenal of instruments to tackle various areas through the limited working space of an arthroscopic/endoscopic portal (Fig. 1.8) [8, 13, 14, 21, 22].

Fig. 1.7  Radiofrequency module

Fig. 1.8  Probes and curettes

1  Setup, Equipment and Surgical Instruments

11

1.4.11 Other Instruments

1.5

Many implants have been specifically designed to be used during arthroscopic procedures including customised screws, suture anchors, mini-plates, etc. (Fig.  1.9). Specialised suture passers also aid the notoriously difficult procedure of passing and tying knots via small arthroscopic portals. There are already too many variations to document one by one, and newer products are being launched on a continual basis.

On the whole, surgical theatres have evolved into an ordered and meticulously calibrated artificial environment that upholds stringent standards, starting macroscopically in hospital zoning plans down to the specific positioning of equipment inside the operating room. Concurrently, arthroscopy/endoscopy has come a long way from a relatively novel gimmicky apparatus to its current status as a bread-and-butter tool in any modern orthopaedic unit. Various inventions have vaulted the arthroscopic/endoscopic hardware into periods of drastic development and growth; and alongside these technological advances in hardware, innovative surgeons have been able to expand the software of arthroscopic/endoscopic knowledge through hard work and dedication. Currently, we are able to reach nearly all areas of the body using the scope and have been able to tackle diseases via minimally invasive surgical techniques which were only dreamt of a few decades ago. Many new advances are still incessantly published in various ­journals, and the newer generation of orthopaedic surgeons have increasingly embraced arthroscopic/endoscopic skills. The anticipated trend in the near future is a blurring of lines between the traditional segregation from those who identify themselves as ‘open surgeons’ and those who are ‘arthroscopists’.

Fig. 1.9  Miscellaneous instruments

Ending Remarks

12

References 1. Cakic JN. Arthroscopy. Bone and Joint 360. 2013;2(4):2–5. 2. Burman MS.  Arthroscopy or the direct visualization of joints: an experimental cadaver study. 1931. Clin Orthop Relat Res. 2001;390:5–9. 3. Dalton McGlamry E, Banks AS. McGlamry’s comprehensive textbook of foot and ankle surgery. Philadelphia: Lippincott Williams & Wilkins; 2001. 2326 p. 4. Jackson RW.  A history of arthroscopy. Arthroscopy. 2010;26(1):91–103. 5. Watanabe M.  Memories of the early days of arthroscopy. Arthroscopy. 1986;2(4):209–14. 6. Jackson RW.  Memories of the early days of arthroscopy: 1965– 1975. The formative years. Arthroscopy. 1987;3(1):1–3. 7. Casteleyn PP, Handelberg F.  Distraction for ankle arthroscopy. Arthroscopy. 1995;11(5):633–4. 8. Guhl JF, Boynton MD, Parisien JS.  Foot and ankle arthroscopy. Berlin: Springer Science & Business Media; 2004. 300 p. 9. DeMaio M.  Giants of orthopaedic surgery: Masaki Watanabe MD. Clin Orthop Relat Res. 2013;471(8):2443–8. 10. Takagi K. The classic. Arthroscope. Kenji Takagi. J. Jap. Orthop. Assoc., 1939. Clin Orthop Relat Res. 1982;167:6–8. 11. Kieser CW, Jackson RW. How cold light was introduced to arthroscopy. Arthroscopy. 2006;22(4):345–50. 12. Ramachandran M. Basic orthopaedic sciences: the Stanmore guide. Boca Raton, FL: CRC Press; 2006. 321 p. 13. Strobel MJ.  Manual of arthroscopic surgery. Berlin: Springer Science & Business Media; 2013. 1081 p. 14. Prejbeanu R. Atlas of knee arthroscopy. New York: Springer; 2014. 197 p. 15. Dharan S, Pittet D. Environmental controls in operating theatres. J Hosp Infect. 2002;51(2):79–84.

S. K. K. Ling and T. H. Lui 16. Spagnolo AM, Ottria G, Amicizia D, Perdelli F, Cristina ML. Operating theatre quality and prevention of surgical site infections. J Prev Med Hyg. 2013;54(3):131–7. 17. Thomas S, Palmer R, Phillipo E, Chipungu G.  Reducing bacterial contamination in an Orthopedic theatre ventilated by natural ventilation, in a developing country. J Infect Dev Ctries. 2016;10(5):518–22. 18. Chan KB, Lui TH.  Role of ankle arthroscopy in management of acute ankle fracture. Arthroscopy. 2016;32(11):2373–80. 19. Chen X-Z, Chen Y, Liu C-G, Yang H, Xu X-D, Lin P. Arthroscopy-­ assisted surgery for acute ankle fractures: a systematic review. Arthroscopy. 2015;31(11):2224–31. 20. Lui TH, Ling SKK. Calcaneal fractures have universally poor outcomes regardless of management. Evid Based Med. 2015;20(1):13. 21. Lui TH. Arthroscopy and endoscopy of the foot and ankle: indications for new techniques. Arthroscopy. 2007;23(8):889–902. 22. van Dijk CN, van Bergen CJA. Advancements in ankle arthroscopy. J Am Acad Orthop Surg. 2008;16(11):635–46. 23. Hsu AR, Gross CE, Lee S, Carreira DS.  Extended indica tions for foot and ankle arthroscopy. J Am Acad Orthop Surg. 2014;22(1):10–9. 24. Lui TH, Yuen CP. Small joint arthroscopy in foot and ankle. Foot Ankle Clin. 2015;20(1):123–38. 25. Lui TH, Ling SKK, Yuen SCP.  Endoscopic-assisted cor rection of hallux valgus deformity. Sports Med Arthrosc. 2016;24(1):e8–13. 26. van Dijk CN.  Ankle arthroscopy: techniques developed by the Amsterdam foot and ankle school. Amsterdam: Springer Science & Business; 2014. 413 p. 27. Lui TH.  Medial subtalar arthroscopy. Foot Ankle Int. 2012 Nov;33(11):1018–23. 28. Porter DA, Schon L.  Baxter’s the foot and ankle in sport. Amsterdam: Elsevier Health Sciences; 2008. 652 p.

2

Surgical Arthroscopic Anatomy Miki Dalmau-Pastor, Jordi Vega, Francesc Malagelada, and Maria Cristina Manzanares

Contents 2.1     Tibiotalar Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14 2.1.1  Articular Surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  16 2.1.2  Capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  17 2.1.3  Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  18 2.2     Subtalar Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  21 2.2.1  Subtalar Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  23 2.3     First Metatarsophalangeal Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  25 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  27

M. Dalmau-Pastor (*) Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona, Barcelona, Spain Manresa Health Science School, University of Vic – Central University of Catalonia, Vic, Barcelona, Spain

Foot and ankle arthroscopy continues to evolve, and a thorough knowledge of relevant anatomy is important to avoid complications. For this purpose, we have focused this chapter in the anatomy of the main arthroscopic areas in the foot and ankle: the joint, subtalar joint and first metatarsophalangeal joint.

GRECMIP (Groupe de Recherche et d’Etude en Chirurgie Mini-Invasive du Pied et de la Cheville), Merignac, France J. Vega Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona, Barcelona, Spain Foot and Ankle Unit, Hospital Quirón Barcelona, Barcelona, Spain F. Malagelada Foot and Ankle Unit, Orthopaedic and Trauma Surgery, Heatherwood and Wexham Park Hospitals, Frimley Health NHS Trust, Ascot, Berkshire, UK M. C. Manzanares Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona, Barcelona, Spain

© Springer Nature Singapore Pte Ltd. 2019 T. H. Lui (ed.), Arthroscopy and Endoscopy of the Foot and Ankle, https://doi.org/10.1007/978-981-13-0429-3_2

13

14

2.1

M. Dalmau-Pastor et al.

Tibiotalar Joint

The ankle joint is a load-bearing joint that unites the leg and foot. It is formed by the inferior articular surfaces of the tibial and fibular distal epiphyses and the medial, lateral and dorsal articular surfaces of the talus. The talus is firmly gripped between the tibia and the two malleoli, medial and lateral, which form a mortise to receive the talus. The ankle is a ginglymus or hinge-type synovial joint with a single axis of movement (bimalleolar axis). The bimalleolar axis allows dorsiflexion (flexion) and plantar flexion (extension) of the ankle and foot in the sagittal plane. Creation of arthroscopic portals will not be discussed in detail in this chapter as ankle arthroscopic portals are performed following a well-established protocol that ensures portals to be made within “safety areas”. Numerous tendinous and neurovascular structures cross the ankle joint in a proximodistal direction, and arthroscopic ankle portals have to be performed in such a way that injury to these structures is prevented. This fact creates some “danger areas” where creation of portals has to be avoided and “safety areas” where creation of portals can be considered safe. The location of the anterior ankle arthroscopic portals has been well described, and the classic portals—anteromedial and anterolateral—allow the realization of all the modern arthroscopic techniques (Fig. 2.1). Surgeon has to be aware that the exact proximodistal location of the portal will ultimately depend of the technique to be used: distraction or dorsiflexion. If distraction has to be used, the portal needs to be created just at the joint line to allow a proper arthroscopic

procedure. However, if dorsiflexion is being used, portals should be located according the pathology to be treated. –– Anteromedial portal: created just medial to tibialis anterior tendon, within a safety area for the saphenous nerve and greater saphenous vein. –– Anterolateral portal: this portal can be created lateral or medial to the superficial peroneal nerve, which is usually previously marked and identified with an ankle inversion and the fourth toe sign [1, 2]. As the nerve moves laterally from ankle inversion to neutral position, the safety area to create the anterolateral portal is medial to the superficial peroneal nerve and lateral to peroneus tertius tendon. When addressing posterior ankle pathology, hindfoot endoscopic portals [3] with the patient in prone position are recommended. The classic hindfoot endoscopic portals—posterolateral and posteromedial—are located at the junction of the planes created at the level of the tip of the lateral malleolus and the medial and lateral borders of the calcaneal tendon (Fig. 2.2). However, endoscopic portal location can be modified according the pathology to be treated. Distal portals to the standard posterolateral and posteromedial can be created to treat insertional calcaneal tendinopathy. The creation of these portals does not have a risk for injuries when performed close to the calcaneal tendon. However, the creation of a working area during hindfoot endoscopy has a high potential risk of injury to the posterior neurovascular structures. A systematic technique when creating this space and working lateral to the flexor hallucis longus tendon are both recommended in order to avoid complications.

7

6 5

AM

4

3

2 AL

Fig. 2.1  Transversal section at the level of the tibiotalar joint showing the position of the anterior portals. AM anteromedial portal, AL anterolateral portal. (1) Dorsal intermediate cutaneous nerve (branch of superficial peroneal nerve, highlighted in yellow). (2) Peroneus tertius tendon. (3) Extensor digitorum longus tendon. (4) Dorsomedial cutaneous nerve (branch of superficial peroneal nerve, highlighted in yellow). (5) Anterior neurovascular bundle (anterior tibial artery and accompanying veins, deep peroneal nerve). (6) Extensor hallucis longus tendon. (7) Tibialis anterior tendon

1

2  Surgical Arthroscopic Anatomy

15

10 9 1 2 8

3 7 4

PM

Fig. 2.2  Transversal section at the level of the distal fibula showing the position of the posterior endoscopic portals. Removing of posterior fat tissue to create a working area and opening the posterior joint capsule are necessary to access the ankle joint. PM posteromedial endoscopic portal, PL posterolateral endoscopic portal. (1) Peroneus brevis tendon. (2) Peroneus longus tendon. (3) Fibulotalocalcaneal ligament (fascia of

6

5

PL

the deep posterior compartment or Rouvière and Canela ligament). (4) Sural nerve (highlighted in yellow). (5) Calcaneal tendon. (6) Plantaris tendon. (7) Flexor hallucis longus tendon (with low-lying muscle belly). (8) Posteromedial neurovascular bundle (posterior tibial artery and accompanying veins, tibial nerve highlighted in yellow). (9) Flexor digitorum longus tendon. (10) Tibialis posterior tendon

16

2.1.1 Articular Surfaces The anatomic characteristics of the tibiotalar joint put in risk the cartilage of the different surfaces when instruments are introduced. The talus contributes with three articular surfaces to the ankle joint: medial, lateral and dorsal. The medial articular surface is a comma-shaped surface with its head located anterior; it articulates with the articular surface of the tibial malleolus. The lateral articular surface is triangular with its vertex located plantar. It articulates with the articular surface of the lateral malleolus. The dorsal articular surface or talar dome is the main articular surface of the talus in the ankle joint. It is wider anteriorly than posteriorly. Convex in the sagittal plane and slightly concave in the frontal plane, it articulates with the distal articular surface of the tibia. This orientation of the talar dome

M. Dalmau-Pastor et al.

makes most of the osteochondral lesions to be located in zones 4 or 6 from the schema proposed by Raikin et al. [4]. These are the zones where more contact exists and logically where more lesions appear (Fig. 2.3). Iatrogenic damage to the talar cartilage is possible during ankle arthroscopy due the narrow space to manoeuvre the instruments; in fact, this can be a more frequent problem than usually reported [5]. The distal articular surface of the tibia is complementary to the talar dome, concave in the sagittal plane and wider anteriorly than posteriorly. The articular surface of the tibial malleolus and that of the fibular malleolus fixes the talus medially and laterally ensuring stability of the ankle joint. This cartilaginous surface is at risk if arthroscopic portals are not performed in its right location: when portals are more distal than appropriate, the direction of the instruments can produce involuntary damage to the tibial distal cartilage.

Fig. 2.3  Anterior view (left) and dorsal view of the talus (right) demonstrating area with increased contact (grey area) and nine-zone grid scheme. According to the literature, zones 4 and 6 are where more lesions appear

2  Surgical Arthroscopic Anatomy

17

2.1.2 Capsule The capsule of the ankle joint, while similar to the capsule of any other joint, has one important difference. The insertion of the anterior capsule on tibia and talus occurs at a distance from the cartilage, 4.3 mm (0.5–9.0 mm) and 2.4 mm (1.8–3.3 mm) in the tibia and talus, respectively [3]. This fact is one of the key factors for ankle arthroscopy, as this anterior capsular

Fig. 2.4  Lateral view of an osteoarticular dissection of the ankle joint. Anterior ankle joint capsule has been preserved. The ankle is in dorsiflexion in order to demonstrate anterior working area for ankle arthroscopy. (1) Tibialis anterior tendon. (2) Dorsal talonavicular ligament. (3) Anterior ankle joint capsule. (4) Anterior tibiofibular ligament. (5) Calcaneofibular ligament. (6) Calcaneal tendon

recess allows the arthroscopist to create a working area. Nevertheless, the size of this area depends on the position of the foot, being larger in dorsiflexion of the ankle and diminishing when working with distraction of the ankle (Fig. 2.4). The capsule of the ankle joint is in close contact with the subcutaneous tissue; if rupture of the capsule during arthroscopic procedure is produced, an oedema of the subcutaneous tissue will appear.

4 3

2 1 6 5

18

2.1.3 Ligaments Ligaments stabilizing the ankle joint are usually divided in those that join the distal epiphyses of the tibia and fibula and those that join the leg and the foot.

2.1.3.1 Ligaments That Join the Distal Epiphyses of the Tibia and Fibula Anterior Tibiofibular Ligament This is the weakest of the syndesmotic ligaments and the first to be injured when the fibula is externally rotated. It is originated in the anterior tubercle of the tibia, and its fibres are laterally and distally directed to the anterior margin of the

Fig. 2.5  Anterior view of an osteoarticular dissection of the ankle joint and correlation with the arthroscopic view during ankle arthroscopy. (1) Anterior tibiofibular ligament. (2) Anterior talofibular ligament

M. Dalmau-Pastor et al.

lateral malleolus. The fibres of the ligament become larger as more distally are. The anterior tibiofibular ligament is a multifascicular ligament, being its most distal (and longest) fibres separated of the rest of the ligament by a fibroadipose tissue (Fig. 2.5). This is probably due to its relation with a branch of the peroneal artery [6]. The distal fascicle of the anterior tibiofibular ligament is in contact with the anterolateral part of the talar dome, contact that should not be considered pathological [7], and has been widely studied because of its relationship with anterolateral soft-tissue impingement [8–11]. The distal fascicle of the anterior tibiofibular ligament is a constant structure, present in 100% of our dissections, and it is often wrongly named as Bassett’s ligament.

2  Surgical Arthroscopic Anatomy

Posterior Tibiofibular Ligament According to Sarrafian, this ligament is formed by superficial and deep components [12]. The superficial component originates at the posterior edge of the lateral malleolus and is directed medial and proximal until its insertion into the posterior tubercle of the tibia. The deep component, also known as transverse ligament [12], originates in the proximal area of the malleolar fossa and directs medially to insert into the posterior edge of the tibia, just posterior to the cartilaginous surface of the inferior articular surface. This ligament forms a true labrum, augmenting the distal tibial articular surface, and articulates with the posterior part of the talar dome. The deep component is the only part of the posterior tibiofibular ligament visible through anterior ankle arthroscopy [13]. Interosseous Tibiofibular Ligament It is a dense mass of short fibres that is the distal continuation of the interosseous membrane. Intermalleolar Ligament The intermalleolar ligament is a constant structure located in the posterior part of the ankle. It is located between the posterior tibiofibular ligament and the posterior talofibular ligament [13]. The intermalleolar ligament is a thickening of the posterior ankle joint capsule that originates from the medial facet of the lateral malleolus and directs medially to the tibia and talus. It seems to have a role in posterior ankle impingement: the ligament becomes tense during dorsiflexion and relaxes during plantar flexion. A trauma due to the forced dorsiflexion can produce an injury to the intermalleolar ligament; plantar flexion relaxes the ligament; thus repeated plantar flexion can cause trapping between the tibia and talus and lead to chronic inflammation and impingement.

19

2.1.3.2 Ligaments Joining the Leg to the Foot Skeleton Lateral Collateral Ligament Anterior Talofibular Ligament

It is the most frequently injured ligament of the ankle. Although one- or three-band morphologies have been described [14, 15], this ligament is typically composed of two separated bands. It has a quadrilateral morphology and a close relationship with the capsule. From the anterior margin of the lateral malleolus, it directs anteromedially in order to insert on the lateral talar body, in the area just anterior to the lateral articular surface for the lateral malleolus (Fig. 2.5). The inferior band is tensed through all range of motion, while the superior band is only tense during plantar flexion, thus being the most frequently injured. The presence of a fibrocartilage at its talar insertion transfers the major part of the tension at the fibular enthesis of the ligament; this is the reason why most of the injuries are located at the fibular part of the ligament [16]. Calcaneofibular Ligament

It is a cord-like ligament originated at the anterior edge of the fibular malleolus. It has connections with the inferior fascicle of the anterior talofibular ligament, as the insertion of both ligaments is very close. In neutral position of the ankle, the ligament directs posteriorly, medially and distally in order to insert in a small tubercle just posterior to the peroneal tubercle of the calcaneus. It is the only component of the LCL that controls two joints (ankle and subtalar) and is tensed throughout the entire arc of motion of the ankle joint. However, the ligament is relaxed in valgus position and tensed in varus of the rearfoot.

20

M. Dalmau-Pastor et al.

Posterior Talofibular Ligament

It inserts on the malleolar fossa and directs medial with an almost horizontal orientation to insert on the posterior surface of the talus and in the lateral talar process (or os trigonum if present). Part of this ligament fuses with the

Fig. 2.6  Posterior view of an osteoarticular dissection of the ankle where the os trigonum has been detached from the talar body; fibres of the posterior talofibular ligament are still inserted in the os trigonum but separated from the rest of the ligament after sharp dissection. Although fibres of the posterior talofibular ligament insert both on the talar body and os trigonum, different fascicles are not observed in the specimen. In the MRI, fibres of the posterior talofibular ligament are observed inserting in the talar body and os trigonum. (1) Calcaneal tendon. (2) Os trigonum. (3) Posterior talofibular ligament (os trigonum fibres). (4) Posterior talofibular ligament (talar body fibres). (5) Intermalleolar ligament. (6) Posterior tibiofibular ligament

intermalleolar ligament, a ligament that must be considered as a constant structure [13]. Although it has been described in the literature that two fascicles exist within the posterior talofibular ligament when an os trigonum is present [17], we had not observed this in our dissections (Fig. 2.6).

6 5 4 3

4

2

1

3 2

2  Surgical Arthroscopic Anatomy

Medial Collateral Ligament

The medial collateral ligament or deltoid ligament is originated in the tibial malleolus, and from that point, it expands to insert in the navicular, talus and calcaneus. Most descriptions agree in that it is composed by two layers, one superficial and one deep [18]. Up to six components have been described. Three of them are constant structures: the tibiospring ligament, tibionavicular ligament and deep posterior tibiotalar ligament. The other three components (superficial posterior tibiotalar ligament, tibiocalcaneal ligament and deep anterior tibiotalar ligament) are not constant. It has to be noted that this division in bands is quite artificial, as the bands are continuous to one another. Tendons of tibialis posterior and flexor digitorum longus cover part of the ligament. This ligament is injured during eversion sprains of the ankle.

21

2.2

Subtalar Joint

The subtalar joint is formed by the plantar part of the talus and the dorsal part of the calcaneus (Fig. 2.7). It is usually divided into an anterior subtalar joint and a posterior subtalar joint, separated by the sinus tarsi and canal tarsi. The sinus tarsi is a cone-shaped structure with a lateral exit (Fig. 2.8) that progressively narrows medially to become the canal tarsi, which has a medial exit (Fig. 2.9). These two structures are located at the level of the neck of the talus, being this point that separates the anterior from the posterior subtalar joints. Inside the sinus tarsi numerous blood vessels, sensory nerve endings and adipose tissue are found, in addition to some of the ligamentous structures of the subtalar joint (cervical ligament, interosseous talocalcaneal ligament and the three roots of the inferior extensor retinaculum) [19]. The posterior subtalar joint is formed by the concave posterior articular surface of the plantar part of the talus and the convex posterior articular surface of the dorsal part of the calcaneus. This part of subtalar joint is accessible through the classical lateral subtalar portals or standard hindfoot endoscopic portals.

Lateral

4 5

Medial

3

2 1

Lateral

Fig. 2.7  Dorsal view of calcaneus and plantar view of talus demonstrating the articular surfaces of the subtalar joint. (1) Sinus tarsi. (2) Canal tarsi. (3) Posterior subtalar articular surfaces. (4) Sustentaculum tali. (5) Anterior and middle subtalar articular surfaces

22

M. Dalmau-Pastor et al.

Fig. 2.8  Lateral view of talus and calcaneus forming the subtalar joint. (1) Talar dome. (2) Talar lateral articular surface. (3) Subtalar joint. (4) Sinus tarsi. (5) Talar head

1

2

4

3

1 2

3

4

5 6

Fig. 2.9  Medial view of talus and calcaneus forming the subtalar joint. (1) Talar dome. (2) Talar medial articular surface. (3) Tarsi canal. (4) Posterior subtalar joint. (5) Talar head. (6) Anterior subtalar joint. (7) Sustentaculum tali

7

5

2  Surgical Arthroscopic Anatomy

Sural nerve and branches of the superficial peroneal nerve, anterolateral malleolar artery, lesser saphenous vein and peroneal tendons are at risk when creating classic subtalar joint portals (anterolateral ventral, anterolateral dorsal, posterolateral ventral and posterolateral dorsal) [20]. Due to this, hindfoot endoscopic portals are the portals of choice to scope the posterior subtalar joint, and classic subtalar portals are commonly used as accessory portals. The anterior subtalar joint is formed by the anterior articular surface of the plantar part of the talus, quadrilateral or slightly oval and flat, and the anterior articular surface of the dorsal part of the calcaneus, similar in shape. In about 30% of the cases [12], the anterior subtalar joint is subdivided, and then three subtalar joints can be observed: anterior, middle and posterior subtalar joints. Arthroscopic examination of the anterior subtalar joint is also possible [21] through the anterior classical subtalar joint portals (anterolateral subtalar and dorsolateral midtarsal portals) or through accessory medial portals (medial midtarsal and the medial tarsal canal portals) [21–24]. It has to be noted that due to its biomechanical properties, the anterior and middle subtalar joints are, together with the talonavicular joint, forming the talocalcaneonavicular joint. This includes the convex articular surface of the head of the talus and the concave posterior articular surface of the navicular. The spring ligament complex also helps to complete the articular surface for the joint, also known as coxa pedis.

23

2.2.1 Subtalar Ligaments Some of the ligaments that stabilize the subtalar joint, as the calcaneofibular and deltoid ligaments, also stabilize  the ankle and therefore have been discussed previously.

2.2.1.1 Interosseous Talocalcaneal Ligament The interosseous talocalcaneal ligament is a flat, thick, band-­ like ligament occupying about half of the medial part of the tarsal canal and is probably the most important subtalar joint stabilizer. It extends from the talus towards the calcaneus following an oblique direction from dorsal-medial to ­ plantar-lateral. 2.2.1.2 Cervical Ligament The cervical ligament originates from the superolateral calcaneal surface just in front of sinus tarsi and is directed medially to insert on an inferolateral tubercle located on the talus neck. It has an orientation of approximately 45 degrees on the horizontal plane and is formed by multiple bands. These extend in different directions that indicate its adaptation to the different functional needs of the talus during movements [19].

24

M. Dalmau-Pastor et al.

2.2.1.3 Spring Ligament Complex The spring ligament complex is composed by the superomedial and plantar calcaneonavicular ligaments and by the calcaneonavicular component of the bifurcate ligament. The plantar calcaneonavicular band is a strong and large triangular ligament, important for maintenance of the ­longitudinal arch. It has a thin cartilage layer, where the talar

head will articulate. It fills the space between calcaneus and navicular (Fig. 2.10). The superomedial calcaneonavicular ligament shares its origin with the tibiocalcaneal part of the superficial deltoid ligament and joins laterally with fibres of the tibionavicular component of the deltoid ligament [6].

1 5 2

6 7

3 4

Fig. 2.10  Sagittal section of the rearfoot. (1) Flexor hallucis longus muscle belly. (2) Calcaneal tendon. (3) Talar posterolateral tubercle. (4) Subtalar joint. (5) Talocalcaneal interosseous ligament. (6) Talonavicular joint. (7) Spring ligament complex

2  Surgical Arthroscopic Anatomy

2.2.1.4 Bifurcate Ligament The bifurcate ligament has a “Y” or “V” shape spanning from calcaneus to navicular and cuboid. It is formed by two different components, calcaneonavicular and calcaneocuboid. The calcaneonavicular component, which forms part of the spring ligament complex, helps to increase the articular surface of the talocalcaneonavicular joint. The calcaneocuboid ligament originates from the anterior part of the sinus tarsi and inserts into the dorsal aspect of the cuboid [6].

25

The first MTP joint differs from the one of the lesser toes in its bigger size and in its sesamoid mechanism [27], embedded in the first MTP joint plantar plate. The existence of this plantar plate and its associated sesamoids is necessary to improve the stability of the first MTP joint, in which the osteoarticular configuration is inherently unstable. This is because the proximal phalanx has a shallow cavity in which the metatarsal head articulates. Most of the stability of this joint is provided by the capsular-ligamentous sesamoid complex [28]. This capsular-ligamentous complex is formed by a confluence of structures that includes the collateral ligaments 2.2.1.5 Inferior Extensor Retinaculum and plantar plate, the abductor hallucis, adductor hallucis The inferior extensor retinaculum (IER) is an aponeurotic and flexor hallucis brevis muscles [28, 29]. structure that is continuous to the crural fascia. This structure Thus, the joint capsule is reinforced on the plantar surface prevents bowstringing or subluxation of the tibialis anterior, by the plantar plate, a fibrocartilaginous structure that conextensor hallucis longus, extensor digitorum longus and per- tains the two sesamoid bones. The sesamoid bones, one oneus tertius tendons [12]. It has a Y or X shape and plays an medial and one lateral, are separated by a rounded ridge important role in subtalar stabilization [25]. (crista) situated in the plantar articular surface of the metaThe stem part of the Y-shaped retinaculum has three roots tarsal head and by a fibrous groove that complements the that arise from the canal and sinus tarsi: a lateral, an interme- crista. The two sesamoids protrude slightly through the dordiate and a medial one [19]. The retinaculum runs medially sal surface of the plantar plate, each concave longitudinally and divides into the oblique superomedial band, which in its dorsal part to fit the plantar articulating surface of the inserts on the anterior aspect of the tibial malleolus, and the metatarsal head. In addition, the sesamoids help to protect oblique inferomedial band, which splits to insert on the the flexor hallucis longus and to maintain its course along the abductor hallucis muscle and on the navicular and medial plantar aspect of the toe. Arthroscopic assessment and treatcuneiform. In approximately 25% of the cases, an additional ment of sesamoid lesions is one of the main indications for oblique superolateral band is found [12]. This band, which first MTP join arthroscopy. varies considerably in size and gives an X-shaped morpholLigaments stabilizing the first MTP joint are the medial ogy to the IER, crosses the ATFL and inserts on the lateral collateral and lateral collateral ligaments. These are fan-­ surface of the lateral malleolus. It seems that in the Brostrom-­ shaped structures divided in a metatarsophalangeal and a Gould procedure, this is the band used to augment the ATFL metatarsosesamoid ligament. They have a common origin repair [25]. situated at the medial and lateral epicondyle of the metatarsal head and are connected by intermediate fibres [27, 29]. The collateral ligaments fan out distally and plantarward to 2.3 First Metatarsophalangeal Joint anchor into the base of the proximal phalanx. The metatarsosesamoid ligaments, posterior to the collateral ones, insert The metatarsophalangeal (MTP) joint of the first toe is a con- into the margins of the plantar plate and their respective sesadyloid joint between the concave proximal surface of the moid. Their function is to hold the sesamoids in their respecproximal phalanx and the rounded head of the first metatar- tive grooves. In addition, an intersesamoid ligament exists to sal. Total range of motion of this joint is 110°, ranging from connect the sesamoids. 35° plantar flexion to 75° dorsiflexion [26].

26

M. Dalmau-Pastor et al.

Different arthroscopic approaches to the first MTP joint have been described. Standard portals are the dorsomedial, dorsolateral and medial portals (Fig. 2.11). Extensor hallucis longus tendon and first MTP joint line should be marked before surgery. The dorsomedial and dorsolateral portals are located at both sides of the extensor hallucis longus tendon, and the medial portal is located midway between the

1 2

3 4

5

6

Fig. 2.11  Dorsal view of a superficial dissection of the nerves of the first toe. (1) Deep peroneal nerve. (2) Superficial peroneal nerve forming the dorsomedial nerve of the first toe. (3) Dorsolateral nerve of the first toe. (4) Dorsomedial nerve of the second toe. (5) Dorsomedial portal for first toe arthroscopy. (6) Dorsolateral portal for first toe arthroscopy

dorsal and plantar aspects of the joint. With the use of these portals, the whole joint can be inspected and treated [30]. Both the dorsomedial digital nerve (DMDN) and the dorsolateral digital nerve (DLDN) are at risk of iatrogenic injury when performing dorsal portals. Skin incision and blunt dissection down to the joint are recommended to avoid nerve injury.

2  Surgical Arthroscopic Anatomy

References

27

14. Milner CE, Soames RW. Anatomical variations of the anterior talofibular ligament of the human ankle joint [correspondence]. J Anat. 1997;191:457–8. 1. Stephens MM, Kelly PM. Fourth toe in flexion sign: a new clini 15. Milner CE, Soames RW. Anatomy of the collateral ligaments of the cal sign for identification of the superficial nerve. Foot Ankle Int. human ankle joint. Foot Ankle Int. 1998;19:757–60. 2000;21(10):860–3. 16. Kumai T, Takakura Y, Rufai A, Milz S, Benjamin M. The functional 2. de Leeuw PA, Golanó P, Sierevelt IN, van Dijk CN.  The course anatomy of the human anterior talofibular ligament in relation to of the superficial peroneal nerve in relation to the ankle position: ankle sprains. J Anat. 2002;200(5):457–65. anatomical study with ankle arthroscopic implications. Knee Surg 17. Gursoy M, Dag F, Mete BD, Bulut T, Uluc ME.  The anatomic Sports Traumatol Arthrosc. 2010;18(5):612–7. variations of the posterior talofibular ligament associated with os 3. van Dijk CN, Scholten PE, Krips R.  A 2-portal endoscopic trigonum and pathologies of related structures. Surg Radiol Anat. approach for diagnosis and treatment of posterior ankle pathology. 2015;37(8):955–62. Arthroscopy. 2000;16:871–86. 18. Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, 4. Elias I, Zoga AC, Morrison WB, Besser MP, Schweitzer ME, Götzens V, vanDijk CN. Anatomy of the ankle ligaments: a pictorial Raikin SM.  Osteochondral lesions of the talus: localization and essay. Knee Surg Sports Traumatol Arthrosc. 2010;18(5):557–69. morphologic data from 424 patients using a novel anatomical grid 19. Li SY, Hou ZD, Zhang P, et  al. Ligament structures in the tarsal scheme. Foot Ankle Int. 2007;28(2):154–61. sinus and canal. Foot Ankle Int. 2013;34(12):1729–36. 5. Vega J, Golanó P, Peña F.  Iatrogenic articular cartilage injuries 20. Jerosch J. Subtalar arthroscopy: indications and surgical technique. during ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc. Knee Surg Sports Traumatol Arthrosc. 1998;6:122–8. 2016;24(4):1304–10. 21. Lui TH.  Clinical tips: anterior subtalar (talocalcaneonavicular) 6. Golanó P, Vega J, Pérez-Carro L, Götzens V.  Ankle anatomy for arthroscopy. Foot Ankle Int. 2008;29:94–9. the arthroscopist. Part II: role of the ankle ligaments in soft tissue 22. Mekhail AO, Heck BE, Ebraheim NA, Jackson WT. Arthroscopy impingement. Foot Ankle Clin. 2006;11(2):275–96. of the subtalar joint: establishing a medial portal. Foot Ankle Int. 7. Bassett FH III, Gates HS III, Billys JB, Morris HB Nikolaou 1995;16:427–32. PK. Talar impingement by the anteroinferior tibiofibular ligament: 23. Lui TH, Chan KB, Chan LK.  Portal safety and efficacy of antea cause of chronic pain in the ankle after inversion sprain. J Bone rior subtalar arthroscopy: a cadaveric study. Knee Surg Sports Joint Surg Am. 1990;72:55–9. Traumatol Arthrosc. 2010;18:233–7. 8. Akseki D, Pinar H, Bozkurt M, Yaldiz K, Araç S. The distal fascicle 24. Lui TH.  Medial subtalar arthroscopy. Foot Ankle Int. of the anterior inferior tibiofibular ligament as a cause of antero-­ 2012;33:1018–23. lateral ankle impingement. Results of arthroscopic resection. Acta 25. Dalmau-Pastor M, Yasui Y, Calder JD, Karlsson J, Kerkhoffs GM, Orthop Scand. 1999;70:478–82. Kennedy JG. Anatomy of the inferior extensor retinaculum and its 9. Akseki D, Pinar H, Yaldiz K, Akseki NG, Arman C. The anterior role in lateral ankle ligament reconstruction: a pictorial essay. Knee inferior tibiofibular ligament and talar impingement: A cadaveric Surg Sports Traumatol Arthrosc. 2016;24(4):957–62. study. Knee Surg Sports Traumatol Arthrosc. 2002;10:321–6. 26. Shereff MJ, Bejjani FJ, Kummer FJ. Kinematics of the first meta 10. Bartonícek J. Anatomy of the tibiofibular syndesmosis and its clinitarsophalangeal joint. J Bone Joint Surg Am. 1986;68(3):392–8. cal relevance. Surg Radiol Anat. 2003;25:379–86. 27. Haines RW, McDougall A. The anatomy of hallux valgus. J Bone 11. Nikolopoulus CE, Tsirikos AI, Sourmelis S, Papachristou Joint Surg Br. 1954;36(2):272–93. G.  The accessory anteroinferior tibiofibular ligament as a cause 28. McCormick JJ, Anderson RB. The great toe: failed turf toe, chronic of talar impingement. A cadaveric study. Am J Sports Med. turf toe, and complicated sesamoid injuries. Foot Ankle Clin. 2004;32:389–95. 2009;14(2):135–50. 12. Sarrafian SK.  Anatomy of the foot and ankle. Descriptive, topo 29. Alvarez R, Haddad RJ, Gould N, Trevino S.  The simple bunion: graphic, functional. 2nd ed. Philadelphia: J.B. Lippincott Co; 1993. anatomy at the metatarsophalangeal joint of the great toe. Foot 13. Golanó P, Mariani PP, Rodríguez-Niedenfuhr M, Mariani PF, Ankle. 1984;4(5):229–40. Ruano-Gil D.  Arthroscopic anatomy of the posterior ankle liga 30. Davies MS, Saxby TS.  Arthroscopy of the first metatarsophalanments. Arthroscopy. 2002;18:353–8. geal joint. J Bone Joint Surg Br. 1999;81-B:203–6.

3

Evidence-Based Medicine of Arthroscopy and Endoscopy of the Foot and Ankle Rocco Papalia, Guglielmo Torre, and Nicola Maffulli

Contents 3.1     Introduction to Microinvasive Surgery of the Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  29 3.2     Anterior Ankle Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  30 3.2.1  Description and Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  30 3.2.2  Clinical Outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  30 3.2.3  Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  31 3.3     Posterior Ankle Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  31 3.3.1  Description and Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  31 3.3.2  Clinical Outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  31 3.3.3  Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  32 3.4     Achilles Tendoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  32 3.4.1  Clinical Outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  32 3.4.2  Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  32 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  33

3.1

R. Papalia · G. Torre Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy N. Maffulli (*) Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, UK Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy e-mail: [email protected]

Introduction to Microinvasive Surgery of the Ankle

Arthroscopy of the ankle was firstly introduced for experimental evaluation of the joint by Burman in 1931 [1], who carried out a cadaver study to show effectiveness of rudimental arthroscopic techniques. However, widespread clinical use was observed only in the 1970s, as technical difficulties in exploring such a narrow joint space were overcame only with technological progress. In 1972, Watanabe, after having developed knee arthroscopy, described a series of 24 patients who had undergone anterior ankle arthroscopy [2]. At present, microinvasive surgery is a mainstream development in orthopaedic surgery: thus, arthroscopy of the ankle is routinely worldwide. The implementation of arthroscopic technology led to the development of different techniques, to explore and treat pathologies of the several compartments the ankle joint is composed of. The anterior approach is useful especially for the management of tibio-­ talar joint space pathology, including anterior impingement

© Springer Nature Singapore Pte Ltd. 2019 T. H. Lui (ed.), Arthroscopy and Endoscopy of the Foot and Ankle, https://doi.org/10.1007/978-981-13-0429-3_3

29

30

R. Papalia et al.

syndrome, chondral defects, ankle instability, loose bodies, and arthrofibrosis [3]. However, to access the posterior tibio-­ talar joint space, the placement of two supplementary posterior portals was proposed, to further improve ankle arthroscopy, as the convexity of the talar dome and other anatomical peculiarity make it impossible to reach this space from the anterior portals. Van Dijk et al. [4] in 2000 described a posterior endoscopic approach to the hindfoot, and this resulted successful to address pathologies of periarticular space, including congenital bony problems such as an os trigonum and other causes of posterior impingement. Furthermore, subtalar joint space can be accessed through this way, and debridement of an arthritic subtalar joint can be carried out, as well as a talo-calcaneal arthrodesis with screws. A variety of other pathologies treated by hindfoot endoscopy have been described in the literature, including bone cysts excision, talar fractures fixation, pigmented villonodular synovitis and frozen ankle [5]. To further improve the microinvasive approaches to the ankle, a video-assisted tendon sheath endoscopy (named “tendoscopy”) was developed for the diagnosis and treatment of pathologies of the tendons around the ankle. In 1995, Wertheimer et  al. [6] described a technique for tibialis posterior tendon synovitis, and in 1997 Van Dijk et al. [7] developed tendoscopy of the peroneal, tibialis anterior and Achilles tendons. Ankle pathology, especially when trauma is involved, can damage several structures inside and outside the joint. Therefore, the synergistic microinvasive approach to the ankle has had major impacts to surgeons and patients. However, since these techniques are relatively recent, high-quality scientific evidence is not available yet. In this chapter, the three techniques (anterior arthroscopy, posterior endoscopy and tendoscopy) are evaluated separately, focusing on indication to surgery, surgical techniques and clinical results.

3.2

Anterior Ankle Arthroscopy

3.2.1 Description and Indications The anterior approach to the ankle is widely used to address anterior tibio-talar impingement, since this pathology is common in active subjects, who experience pain and limitation of joint motion. Anterior impingement develops from bone or soft tissue issues [3]. Bony impingement is the main indication to ankle arthroscopy and is mainly caused by osteophytes formation of tibio-talar joint surfaces. The location of the osteophytes (anteromedial or anterolateral aspect of the talus) influences the outcome of arthroscopy [8]. However, indications to ankle anterior arthroscopy do not limit to bony impingement and include also joint instability and intra-articular loose bodies. Joint instability is common and strictly connected to anterolateral soft tissue impingement. Inflamed

and torn ligaments can be entrapped into the anterolateral aspect of ankle joint, between the lateral malleolus and the talus, after inversion injuries [3]. Repetitive ankle sprains not only lead to ankle instability with capsule and ligament laxity but also induce repetitive inflammation and development of fibrotic tissue in the context of ligaments. Therefore, when ligaments do not require reconstruction or repair through an open approach, arthroscopic debridement is recommended, in order to free ligamentous tissue, excise redundant fibrous tissue and restore joint motion. Furthermore, synovitis of the ankle is a cause of impingement, as synovial hypertrophy causes joint stiffness and pain. Arthroscopic debridement and synovectomy are indicated, providing the ankle with decompression and removal of inflamed tissue. Apart from impingement syndrome and its causes, it is relevant to cite two more indications to anterior ankle arthroscopy: osteochondral lesions of the talar dome and small fragment fractures. These conditions can be either traumatic or secondary to degenerative pathology of the bone and cartilage, and surgery is mandatory, especially when displaced fragments are present, limiting joint function and causing severe pain. Osteochondral lesions of the talus (OLTs) involve the cartilage and subchondral bone and are mainly caused by trauma, ischaemia and severe osteoarthritis. In these patients, together with extensive arthroscopic debridement, microfracturing of uncovered bone is recommended, to provide the site with marrow bleeding and consequent formation of reparative tissue [9].

3.2.2 Clinical Outcomes Two retrospective series published in 2002 and 2011 reported concordant results after arthroscopy for anterolateral impingement, in terms of Mieslin’s criteria for subjective satisfaction, where 67 of 105 patients in the first series considered the outcomes excellent and 25 good; in the second series, of 41 patients, 34 reported good or excellent outcomes. However, in the first series, a few complications occurred, including four deep infections and one case of synovial fistula. A prospective study by Kim and Ha [10] reported outcomes of arthroscopic debridement in 52 patients; of these, Mieslin’s criteria were considered excellent in 77% and good in 17%. Other five series presented outcomes of anterolateral impingement, reporting good to excellent results for the majority of the patients, ranging from 63% to 98%. The American Orthopaedic Foot and Ankle Society (AOFAS) score was evaluated in a recent series by Parma et al. [11] in 80 patients with anterolateral impingement. Improvement was from a mean of 51 to 78 points. The same study reported five superficial infections and two cases of numbness of the dorsal aspect of the foot. Concerning anteromedial impingement, fewer studies have been published. Van Dijk et  al. compared the results of

3  Evidence-Based Medicine of Arthroscopy and Endoscopy of the Foot and Ankle

patients with anteromedial impingement and those with anterolateral impingement. Debridement for anteromedial impingement produced significantly superior in terms of patient satisfaction and Visual Analogue Scale (VAS). Murawski and Kennedy reported outcomes of 41 young, active patients (mean age, 31 years) treated for anteromedial impingement: 93% of subjects reported full satisfaction after arthroscopic procedure, and the mean AOFAS score improved from 62 to 91 points. Similarly, the mean Short Form-36 (SF-36) improved from 62 to 92. The average return to sport was 7 months. Complication rate was 7%, including neurapraxia of superficial peroneal nerve, arthrofibrosis and one case of complex regional pain syndrome.

3.2.3 Surgical Technique The surgery is performed with the patient supine. Popliteal block of spinal or general anaesthesia can be used [3]; tough local blocks are considered efficient and safe. A leg holder at the thigh can be used, to fully relax the muscles of the calf; the use of a tourniquet at the root of the thigh is also advocated by some authors. Non-invasive distraction devices are applied at hindfoot, to produce a widening of the joint space when the arthroscope is inserted. Two standard arthroscopic anteromedial and anterolateral portals are produced, using the nick and spread technique. The anteromedial portal is produced at the level of joint line and just medial to the tibialis anterior tendon. The anterolateral portal is usually made under direct arthroscopic visualization and placed at the same level, lateral to the common extensor tendon or the peroneus tertius tendon [12]. Arthroscopic exploration of the joint is carried out, through a standard 4 mm arthroscope or a dedicated 2.7  mm arthroscope with a 30° angled lens. Additional portals, for a wider visualization of the joint space, can be placed just anteriorly to the tip of medial and lateral malleoli. For debridement of soft tissue, a 3.5  mm oscillating shaver is used, and all excessive tissue is removed under direct visualization. Bone spurs are also addressed through a 4–5.5  mm bone cutter. A single nylon suture is used per portal, and a sterile compressive dressing is applied.

3.3

Posterior Ankle Endoscopy

3.3.1 Description and Indications This approach was developed in late 1990s, to address pathologies of the hindfoot, which were not accessible for treatment through standard anterior arthroscopy [13]. The term ‘endoscopy’ underlines that no access to a joint space is performed, but a composite articular and periarticular space is explored. Several authors suggested already the use of

31

posterior accessory portals during anterior arthroscopy, with the aim to reach several structures of the ankle, which are not accessible from anterior portals, given the geometry of the joint. However, a systematic approach to posterior hindfoot endoscopy was firstly developed and published by Van Dijk et al. in 2000 [4]. From this advancement in surgical approach to the ankle, several indications were added to the existing ones, which were limited to the anterior approach. Among these novel indications are posterior ankle impingement; subtalar joint pathologies, including osteoarthritis; retrocalcaneal bursitis; and other synovitis. Similarly to anterior impingement, “posterior impingement syndrome” embraces several different pathologies, which cause a reduction in plantar flexion range of movement of the ankle. Bony alterations, yielding to impingement, include the os trigonum, hypertrophy of Stieda’s tubercle of the talus and fracture fragments. Other causes of posterior ankle pain and impingement are flexor hallucis longus (FHL) tendinopathy or tenosynovitis and intermalleolar ligament tears [5]. Osteochondral defects of the posterior region of the talus can also be addressed through drilling of the area, during posterior endoscopy, using bone marrow stimulation techniques. The accessibility to subtalar joint is considered the main advantage of this technique, since osteoarthritis of this site is common and debilitating. Some patients with combined tibio-talar and subtalar osteoarthritis have been reported in the literature, and the use of posterior approach to the ankle demonstrated good results. Arthroscopic management of subtalar osteoarthritis is not limited to debridement of degenerated chondral tissue and resection of bone spurs but allows also posterior arthroscopic subtalar arthrodesis (PASTA) in advanced disease. Extended indications to retrocalcaneal space pathologies include Haglund deformity of the calcaneus, also known as retrocalcaneal bursitis. The great spur which forms at the insertion of Achilles tendon can be debrided endoscopically.

3.3.2 Clinical Outcomes PAI induced by the presence of an os trigonum is by far the main pathology which requires posterior endoscopy. Six studies reported a significant improvement in the AOFAS score of 99 ankles, with a decrease in VAS for pain (62 patients, >6 points decrease). Major complications included deep infections, persistent pain and dysaesthesia, with a rate of 20° of talar tilt. The stress radiographs are made with the foot held in approximately 10° of plantar flexion. The leg is held in slight internal rotation (20°) for an anteroposterior radiograph for measurement of talar tilt. The author applies 150  N force with a Telos device® (Telos SE, Telos Japan Co. Ltd., Tokyo, Japan) or manual maximum stress. Magnetic resonance imaging (MRI) is helpful for identifying PTFL tears, and three-dimensional computed tomography (3D-CT) is helpful for determining the size of the avulsion fragment of the lateral malleolus and whether the PTFL attachment site is included within the avulsion fragment.

5.6.3 Contraindications • Infection. • Lateral malleolus avulsion fracture with a sizable fragment allowing fracture fixation. If the avulsion fragment is big enough, a reduction and internal fixation procedure is the first treatment choice to be considered. However, if the patient has a long history and MRI demonstrates elongation and denature of the ankle lateral ligaments, the author still prefers the ligament reconstruction. • Moderate-to-severe ankle osteoarthritis. The author considers that patients with minor osteoarthritis (Tanaka’s classification stage, ≤2 [86]) after severe ankle sprains, without excessive varus alignment, are also candidates for “scopic PAC,” although this view may be controversial.

5.6.4 Author’s Preferred Technique The majority of the figures in this chapter are from cadaveric studies, but several images (Figs. 5.49d, e, 5.50b, and 5.54) are from a clinical case treated by the author, as explained in the figure captions.

5.6.4.1 Preoperative Planning The approximate lengths of the PTFL, ATFL, and CFL should be calculated using the preoperative MRI scan because a systematic review has suggested that there is wide variation in the lengths of ATFLs (12.0–24.8 mm) and CFLs (18.5–35.8 mm) [87]. PTFL and ATFL are calculated with the transvers view. CFL are calculated with the sagittal view by looking at several consecutive slides. Although 3D MRI can be useful, it is not yet generalized.

160

C. P. Yuen et al.

5.6.4.2 Patient Positioning The patient is placed in the lateral decubitus position and securely maintained in that position using several side holders. When anterior ankle arthroscopy is being performed, the surgical bed is inclined so as to have the patient in as close to a supine position as possible. Conversely, when hindfoot endoscopy is being performed, the surgical bed is inclined so as to have the patient in as close to a prone position as possible.

a

b

5.6.4.3 Portal Design Anteromedial (AM), accessory anterolateral (AAL), and subtalar (ST) portals are used to create the anterior talar, fibular, and calcaneal bone tunnels (Fig. 5.47). If needed for other intra-articular pathologies, an anterolateral (AL) portal may also be created. Posteromedial (PM) and posterolateral (PL) portals of hindfoot endoscopy [14] are used to create the posterior talar bone tunnel. Details of the portals are described in the following session.

Fibular end

c

d

10-15mm ATFL 20mm

PTFL 20mm

10-15mm ATFL graft end

CFL 30mm

10-15mm

ATFL

PTFL

CFL

PTFL graft end

10-15mm CFL graft end

Fig. 5.47 (a) (1) Anteromedial portal (AM portal), (2) accessory anterolateral portal (AAL portal), (3) subtalar portal (ST portal), (4) posterolateral portal (PL portal). (b) A free tendon was folded into a trifurcate shape, including a single double-folded ATFL, single-bundle PTFL, and single-bundle CFL. (c) The ATFL, CFL, and PTFL are 20, 30, and 20  mm long, respectively. The diameters of the fibular end,

PTFL graft end, ATFL graft end, and the CFL graft end are 6, 4.5, 4.5, and 4.5 mm, respectively. (d) The tendon graft construct consisting of the single-bundle ATFL, PTFL and CFL. Surgeon needs to suture the two tendons at the fibular end. The length of the free tendon needs >170 mm

5  Ankle Arthroscopy: Soft Tissue Procedures

5.6.4.4 Step-by-Step Description of the Technique Graft Preparation First, an autogenous gracilis tendon or semitendinosus tendon is harvested; an allogenic tendon may also be used. The length of the free tendon should be >170 mm, with a length >220  mm being preferable. Therefore, the author recommends an autogenous semitendinosus tendon rather than a gracilis tendon because the former is usually longer than the latter. If possible, an allogenic Achilles tendon is more preferable because it is so long and strong that surgeons can determine the length of the graft without concern that a harvested tendon might be too short. The tendon is folded into a trifurcate shape, including a 20-mm-long double-folded ATFL, 20-mm-long single-bundle PTFL, and a 30-mm-long single-bundle CFL (Fig.  5.47c). The length of the reconstructed ligament should be determined using the preoperative MRI scan as a reference. The ends of the tendon graft need to include 10–15-mm-long loops that permit a thread to be passed through each looped end during the delivery of the graft into the bone tunnel. Moreover, the length of the graft looped end should be shorter than the depth of the bone tunnel so that the length of the graft can be adjusted by pulling the graft deeper into the tunnel by pulling the induction thread when the induced ligament is slack. The diameter of each looped end of the graft is measured with a cylindrical sizer. To avoid intraoperative fractures when drilling bone tunnels, the diameters of the fibular end, PTFL graft end, and ATFL graft end are recommended to be ≤7, ≤5, and ≤6 mm, respectively; the surgeon can refer to the preoperative X-ray and CT for guidance. Since the location of the CFL attachment is ≥12  mm from the posterior

161

talocalcaneal joint [87, 88], surgeons need not be concerned about the CFL graft end diameter, which is usually thinner than the fibular ends. The author recommends a double-folded ATFL for two reasons. First, because the ATFL is the first ligament to be injured during a lateral ankle sprain, the author believes that the reconstructed ATFL should be as strong as possible to decrease the risk of postoperative instability recurrence. Second, the ligament graft may be created by folding one continuous tendon (Fig.  5.47c). If the tendon is not long enough to allow the creation of a double-folded ATFL, the ATFL can also be reconstructed as a single bundle, but the surgeon will need to suture two separate tendons together to create a trifurcate-shaped graft, at the fibular graft end, and the construct may be weakened. It is impossible to create a trifurcate-shaped graft consisting of three single bundles by folding one continuous tendon (Fig. 5.47d).

5.6.4.5 Anterior Ankle Arthroscopy The AM portal is created just medial to the anterior tibialis tendon, at the joint level. A 4 or 2.7 mm, 30° arthroscope is inserted through the AM portal to assess any associated intra-articular lesion. If there is no intra-articular lesion requiring approach through the AL portal, the author does not create an AL portal. This helps to decrease the risk of superficial peroneal nerve injury. When a portal is created, a 5–7 mm skin incision is carefully made using a No. 11 surgical blade. Mosquito forceps are used to gently spread the subcutaneous tissue, and the ankle capsule is penetrated with the tip of the mosquito forceps. Although a smaller shaver and radiofrequency probe are available, the author uses probes of the same size as those used during knee arthroscopy.

162

C. P. Yuen et al.

Anterior Talar Bone Tunnel Creation The ankle should be kept dorsiflexed to allow the surgeon to have a clear view of the talar insertion point of the ATFL.  Before the AAL portal is created, a needle is inserted into the portal site to confirm good talar ATFL footprint accessibility on the anterolateral side of the talus. The AAL portal is made approximately 20 mm anterior to the tip of the distal fibula. The shaver and radiofrequency probe are ­introduced into the joint, through the AAL portal, to debride the inflamed and hypertrophied synovium and the ATFL remnant from its talar insertion. A

a

b

micro-fracture awl is used to mark the center of the footprint, and a 2.4 mm guidewire is inserted through the AAL portal to drill the talus, from the ATFL footprint, toward the distal end of the medial malleolus. The author does not recommend penetrating the talus with the 2.4 mm guidewire; its insertion should stop before reaching the far cortex of the talus. The guidewire is then over-drilled, using a drill having the same diameter as the graft loop end, to create a 20-mm-deep tunnel. The drill diameter is usually 4.5–6.0 mm (Fig. 5.48).

c

Fig. 5.48 (a) AM portal view: the ATFL (black star) attached below the resident’s tip (filled circle). (b) A 20-mm-deep bone tunnel of the talar neck was over-drilled. (c) The talar tunnel was safely created; a tunnel wall fracture did not occur

5  Ankle Arthroscopy: Soft Tissue Procedures

163

Fibular Bone Tunnel Creation Looking from the AM portal, the slightly raised area near the articular tip can be mistaken for the inferior tip of the distal fibula. Recently, this area began to be called the “resident’s tip” among the ankle arthroscopic surgeons. Surgeons should ensure that the ATFL footprint is positioned just below the resident’s tip. If the ATFL footprint cannot be easily visualized using a 30° arthroscope, a 70° arthroscope is a viable alternative. The ATFL remnant is debrided using the shaver and radiofrequency probe via the AAL portal. A needle is inserted just distal to the fibular obscure tip [14] pointing medially toward the ankle joint. This confirms ATFL and CFL fibular footprint accessibility of the ST portal before its creation. The arthroscope is then switched to the AAL portal, and the CFL footprint is debrided using the shaver and radiofrequency probe via the ST portal. The appropriate position

a

b

d

e

Fig. 5.49 (a) A needle is used to prick the ATFL footprint before ST portal creation. The fibular tunnel position (open circle) must be below the resident’s tip (filled circle), which is near the articular tip (filled inverted triangle). The ATFL was already debrided. (b) Looking from the AAL portal, the CFL (white star) is visible at the fibular attachment after resection of the ATFL and the anterolateral ankle capsule. (c) The

for the fibular tunnel is between the ATFL and CFL footprint. A 2.4 mm guidewire is introduced via the ST portal and is inserted into the bisection of the lateral malleolus. The guidewire position is confirmed with frontal and lateral fluoroscopic views. This guidewire should not be inserted from the AAL portal, as the orientation of the guidewire insertion increases the risk of an intraoperative fibular fracture. After the guidewire insertion, it is over-drilled to create a 20-mm-­ deep bone tunnel (Fig. 5.49). The surgeon needs to pay close attention to the temperature of the intra-articular fluid to avoid burning the skin when using the radiofrequency probe at the distal fibula, which is very close to the skin. The author prefers the Quantum 2 system® (Smith & Nephew Plc, London, UK) because it can be operated at a lower temperature than other radiofrequency probes.

c

20-mm-deep fibular tunnel is over-drilled. (d) A guidewire is inserted into the bisection of the lateral malleolus, confirmed by fluoroscopy (frontal view). (e) A lateral view (fluoroscopy) is also used to confirm the guidewire’s position. A pin will be passed along the diagonal line (arrow) of the bone tunnel (open square) for graft delivery. (Figures d and e are from the clinical case.)

164

C. P. Yuen et al.

Calcaneal Bone Tunnel Creation Viewed from the AAL portal, the CFL remnant is debrided using the shaver and radiofrequency probe, through the ST portal. The surgeon must pay close attention to the peroneal tendons, which appear after debriding the CFL remnant, because they run just superficial to the CFL.  The shaver opening can be safely directed toward the calcaneus, with debridement continuing to the posterior talocalcaneal joint and the lateral wall of the calcaneus. The CFL footprint can usually be observed even if the CFL is torn and elongated (Fig.  5.50a). The distance between the CFL insertion

a

b

Fig. 5.50 (a) A posterior talocalcaneal joint (asterisk) is observed, and the CFL (white star) footprint is debrided. (b) The CFL footprint center (open circle) is on the perpendicular line (white line) from the midpoint (showed by black line) of the posterior subtalar joint [88]. The guide-

footprint center on calcaneus and midpoint of the lateral border of the posterior facet of the subtalar joint is 17.2 mm (14.4–21.0  mm) [88]. The CFL footprint center is on the perpendicular line from the midpoint of the posterior subtalar joint [88] (Fig. 5.50b). A 2.4 mm guidewire is inserted to the CFL footprint via the ST portal. A 25-mm-deep calcaneal tunnel is created in the same fashion as described above (Fig.  5.50c, d). The guidewire position can be confirmed using fluoroscopy (Fig.  5.50b), if the surgeon lacks confidence in having determined the appropriate tunnel position.

c

d

wire position is confirmed using fluoroscopy. The guidewire inserted via ST portal is almost on the perpendicular line (white line). (c) A 25-mm-deep calcaneal tunnel is over-drilled. (d) The tunnel was safely created. (Figure b is from the clinical case.)

5  Ankle Arthroscopy: Soft Tissue Procedures

Posterior Talar Bone Tunnel Creation/Hindfoot Endoscopy Hindfoot endoscopy is performed in accordance with the van Dijk method [87]. If pathological os trigonum and flexor ­hallucis longus tenosynovitis exist, they need to be removed and debrided, respectively. Additionally, the PTFL footprint, located on the posterolateral talar process [89], needs to be debrided. A 10–15-mm-deep posterior talar tunnel is then over-drilled from the PL portal (Fig. 5.51a, b). The direction

a

b

Fig. 5.51 (a) The PTFL (filled triangle) is attached to the posterior process. (b) The posterior talar tunnel is over-drilled from the PL portal. (c) The tunnel was safely created. A suture anchor is inserted to the bot-

165

of the tunnel is planned in accordance with the preoperative CT scan. Drawing a figure of the anterior and posterior talar tunnel on the transverse view of the CT scan is recommended before surgery. Intraoperative fluoroscopy is also useful for confirming the guidewire direction and absence of interference with the anterior talar tunnel. A suture anchor is inserted into the anterior end of the tunnel, with one of the suture limbs retrieved by a suture retriever to the ST portal (Fig. 5.51c, d), for later graft delivery.

c

d

tom of the tunnel. (d) One limb of the thread is introduced into the ST portal using a suture retriever

166

C. P. Yuen et al.

Introduction and Fixation of the Graft A 1.6 mm Passing pin® (Meira, Nagoya, Japan) is penetrated the far cortex of the tunnel and the opposite skin. By passing the threads through the eye of the passing pin and pulling out the passing pin, the induction threads are individually passed into the calcaneal, fibular, and anterior talar tunnels. To pull the graft into the fibular tunnel, a passing pin is inserted from the anterior edge of the bone tunnel inlet, along the diagonal line of the tunnel, to the proximal-posterior corner; fluoroscopy may be used to confirm the direction. Even if this technique is ineffective and penetration of the posterior skin is difficult, a suture anchor is an option for introducing the graft into the fibular tunnel, in a manner similar to that used for the posterior talar tunnel. The lateral limbs of the induction threads of all the three bone tunnels are retrieved to the ST portal by means of a mosquito forceps. Then, all of the graft ends, which are connected to the induction threads, are introduced into the tunnels through the ST portal by pulling the threads. The tendon graft is fixed in position using interference screws in the fibular, anterior talar, and calcaneal tunnels. The author prefers using 15-mm-long screws that are of same diameter as the tunnels. The fibular end is fixed first, followed by the ATFL graft end and the CFL end, while the ankle is in a neutral position; sufficient tension needs to be manually applied to all threads to create tension in the graft. If there are lack of

surgical assistants, mosquito forceps can be used to hold the threads against the skin in order to keep the graft tensioned. The PTFL end of the graft is connected with one limb of the thread of the suture anchor, which was introduced to the ST portal beforehand. The PTFL end of the graft is directed to the posterior talar tunnel by pulling the other limb of the thread via PL portal. The free end of the thread limb connected with the PTFL end is retrieved to the PL portal, using a suture retriever. Finally, the PTFL end is fixed to the posterior talar tunnel by suturing both ends of the suture anchor thread, while the ankle is in a neutral position (Fig. 5.52). A short interference screw may also be inserted into the posterior talar tunnel, in addition to the suture anchor, to aid in fixation. When a bio-composite screw is used, caution should be paid during fixation as the screw may be broken when the screw insertion direction is incorrect. Moreover, the small-­ sized guidewire of the interference screw may bend or break during screw fixation because of its overly flexible nature. The author recommends that the guidewire should not be inserted deeper than the bottom of the tunnel or that the screw is carefully fixed without a guidewire. After graft fixation, full range of ankle dorsiflexion and plantar flexion is confirmed, and the lateral ankle stability is checked using fluoroscopy. The arthroscopic portals are then closed using 3-0 or 4-0 nonabsorbable sutures.

PTFL

a

b

c

ATFL CFL

Fig. 5.52 (a) The reconstructed ATFL is viewed from the AM portal. (b) The reconstructed CFL and PTFL are viewed from the PL portal. (c) The PTFL is fixed, with a suture anchor, into the posterior talar tunnel

5  Ankle Arthroscopy: Soft Tissue Procedures

5.6.4.6 Complications and Management • Complications may arise that are similar to those associated with arthroscopic ATFL and CFL reconstructions and with hindfoot endoscopy. • Fracture of the posterior talar process during interference screw fixation might be the specific complication associated with the “scopic PAC” procedure. That is the reason why the author recommends the suture anchor fixation in the posterior talar tunnel. • If the screw fixation is not secure, the screw may be easily dislodged when removing the screw driver. In such cases, a larger screw may be needed, and the bone tunnel may need to be grafted with cancellous bone graft in order to improve the bone purchase of screw fixation. Bone grafting can be performed arthroscopically with a fan-shaped device (e.g., an ear scope or a 3-mm-diameter drill sleeve) as a guide into the tunnel. Another fixation option is fixing the graft with an endobutton on the opposite cortical bone surface after screw removal. • If the graft length is too short or too long to allow fixation with appropriate tension, it may be adjusted by re-­suturing the looped end to change the graft length. • If the distal fibular tunnel fractures during drilling, the surgeon can change the direction of bone drilling toward the fibular long axis. This creates a deeper bone tunnel, and the graft can be fixed with an interference screw or a suture button to fix the graft. If there is only a crack fracture, it is treated non-operatively with cast immobiliza-

167

tion, and the postoperative rehabilitation program is modified to accommodate the period of cast immobilization. If the fracture is displaced or a displaced fragment exists, the fracture is treated by open reduction and internal fixation with plates, screws, or Kirschner wires. • If the peroneal tendon is accidentally sectioned during CFL remnant debridement, suture of the tendon is performed using the open technique.

5.6.4.7 Postoperative Care • The treated ankle should be immobilized, using a splint, after surgery. The author does not recommend cast immobilization, as it may lead to ankle stiffness. • The patient is allowed to walk, with full weight bearing, on the second postoperative day because the screw fixation is usually adequately strong to permit normal daily activities. However, the author recommends the use of an ankle brace for at least 3 months to minimize the risk of reinjury during the early postoperative period. • Active ankle range-of-motion exercises, involving dorsiflexion and plantar flexion, should begin on the day following the surgery. During these exercises, the patient’s heel should not rest on the bed or floor so as to avoid anterior drawer stress. Finally, varus-valgus and internal-­ external rotation movements are permitted 4 weeks after surgery. • Running is permitted 3 months after the surgery, if sufficient muscle strength has been recovered.

168

C. P. Yuen et al.

5.6.4.8 Outcomes A cadaveric study has been conducted to study the feasibility of this technique. The fibular tunnel was created below the resident’s tip. ATFL and CFL were anatomically reconstructed. Although the fibular tunnel was positioned in front of the malleolar fossa, which is the anatomical fibular insertion site of the PTFL [89], the PTFL was almost anatomically reconstructed and was tensioned using the ankle manual test of the DERST (Fig.  5.53). Full range of ankle motion was preserved. The author treated a 26-year-old woman who experienced daily right ankle sprains, even after undergoing a Broström repair. Her anterior drawer translation decreased from 12 mm to 6 mm, and the talar tilt angle decreased from 29° to 13.6° after “scopic PAC.” The Japanese Society for the Surgery of the foot scale score also improved from 60 to 81. The patient still experiences occasional ankle sprains due to the

functional insufficiency of the peroneal muscle, but the number of sprains has drastically decreased, and her subjective pain and ankle stability have improved (Fig. 5.54). Because an open PTFL/ATFL/CFL reconstruction technique does not exist, a comparison between arthroscopic and open surgeries cannot be made. However, the author believes that open PTFL/ATFL/CFL reconstruction surgery would require a large incision. Thus, this arthroscopic technique (scopic PAC) provides a large advantage for approaching the deeper soft tissues without large incisions, subcutaneous nerve damage, or postoperative infections, even though the surgical time might be long because of the procedure’s technical demands.

PTFL

a

b

ATFL

c

CFL

Fig. 5.53 (a) A fibular tunnel is created below the resident’s tip (filled circle). (b) The PTFL are almost anatomically reconstructed. (c) The PTFL is tensioned using the ankle dorsiflexion and external rotational stress test (DERST)

5  Ankle Arthroscopy: Soft Tissue Procedures

169

a

b

c

d

e

f

g

h

1

2

4

3 3

Fig. 5.54  Pictures are from the clinical case of 26-year-old woman. (a) The preoperative anterior drawer translation is 12 mm. (b) The preoperative talar tilt angle is 29°. (c) The reconstructed PTFL (filled triangle) is observed from the PM portal. (d) The anatomically reconstructed ATFL (black star) and CFL (white star) are observed from the AAL portal. (e) The postoperative anterior drawer translation is 6  mm. (f)

The postoperative talar tilt angle is 13.6°. (g) 3D CT demonstrates the position of the distal fibular (white number 1), anterior talar (white number 2), and calcaneal tunnels (white number 3). (h) 3D CT demonstrates the position of the posterior talar tunnel (white number 4). A small bone fragment remains because it was not a free body and stayed within the PTFL remnant

5.6.5 Summary

located [89], this method provides the most anatomical PTFL reconstruction, in addition to also providing for anatomical ATFL and CFL reconstructions. The availability of this technique may encourage ankle surgeons to treat patients with extreme lateral ankle instability.

An arthroscopic PTFL, ATFL, and CFL reconstruction method (scopic PAC) has been successfully developed. Although the fibular tunnel is positioned in front of the malleolar fossa, where the anatomical PTFL attachment site is

170

References 1. Lui TH, Chan WK, Chan KB. The arthroscopic management of frozen ankle. Arthroscopy. 2006;22(3):283–6. 2. Cui Q, Milbrandt T, Millington S, Anderson M, Hurwitz S.  Treatment of posttraumatic adhesive capsulitis of the ankle: a case series. Foot Ankle Int. 2005;26(8):602–6. 3. Goldman AB, Katz MC, Freiberger RH.  Posttraumatic adhesive capsulitis of the ankle: arthrographic diagnosis. AJR Am J Roentgenol. 1976;127(4):585–8. 4. Griffiths HJ, Utz R, Burke J, Bonfiglio T. Adhesive capsulitis of the hip and ankle. AJR Am J Roentgenol. 1985;144(1):101–5. 5. Lundberg BJ.  The frozen shoulder. Clinical and radiographical observations. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabolism. Acta Orthop Scand Suppl. 1969;119:1–59. 6. Bucala R, Makita Z, Koschinsky T, Cerami A, Vlassara H.  Lipid advanced glycosylation: pathway for lipid oxidation in vivo. Proc Natl Acad Sci U S A. 1993;90(14):6434–8. 7. Brostroem L, Liljedahl SO, Lindvall N.  Sprained ankles. II. Arthrographic diagnosis of recent ligament ruptures. Acta Chir Scand. 1965;129:485–99. 8. Clayton ML, Miles JS, Abdulla M. Experimental investigations of ligamentous healing. Clin Orthop Relat Res. 1968;61:146–53. 9. Cerezal L, Abascal F, Garcia-Valtuille R, Canga A.  Ankle MR arthrography: how, why, when. Radiol Clin N Am. 2005;43(4):693– 707. viii 10. Cerezal L, Llopis E, Canga A, Rolon A.  MR arthrography of the ankle: indications and technique. Radiol Clin N Am. 2008;46(6):973–94. v 11. Shamsi B, Falk JN, Pettineo SJ, Ali S. Clinical review of adhesive capsulitis of the ankle: an introductory article and clinical review. Foot Ankle Online J. 2011;4:2. 12. Shaffer MA, Okereke E, Esterhai JL Jr, Elliott MA, Walker GA, Yim SH, et al. Effects of immobilization on plantar-flexion torque, fatigue resistance, and functional ability following an ankle fracture. Phys Ther. 2000;80(8):769–80. 13. Lui TH.  Arthroscopic capsular release of the ankle joint. Arthros Tech. 2016;5(6):e1281–e6. 14. van Dijk CN, Scholten PE, Krips R.  A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthroscopy. 2000;16(8):871–6. 15. Lui TH.  Lateral plantar nerve neuropraxia after FHL tendos copy: case report and anatomic evaluation. Foot Ankle Int. 2010;31(9):828–31. 16. Ekstrand J, Trapp H. The incidence of ankle sprains in soccer. Foot Ankle. 1990;11:41–4. 17. Garrick JG. The frequency of injury, mechanism of injury and epidemiology of ankle sprains. Am J Sports Med. 1977. 18. Guillo S, Archbold P, Perera A, Bauer T, Sonnery-Cottet B. Arthroscopic anatomic reconstruction of the lateral ligaments of the ankle with gracilis autograft. Arthrosc Tech. 2014;3(5):e593–8. 19. Bosien WR, Staples OS, Russell SW. Residual disability following acute ankle sprains. J Bone Joint Surg. 1955;37-A:1237–43. 20. Freeman MA. Instability of the foot after injuries to the lateral ligament of the ankle. J Bone Joint Surg. 1965;47-B:669–77. 21. Hertel J. Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. J Athl Train. 2002;37:364–75. 22. Tropp HP, Odenrick P, Gillquist J. Stabilometry recordings in functional and mechanical instability of the ankle joint. Int J Sports Med. 1985;6:180–2. 23. Wilkerson GB, Nitz AJ. Dynamic ankle stability: mechanical and neuromuscular interrelationships. J Sport Rehabil. 1994;3:43–57. 24. Neuschwander TB, Indresano AA, Hughes TH, Smith BW.  Footprint of the lateral ligament complex of the ankle. Foot Ankle Int. 2013;34:582–6.

C. P. Yuen et al. 25. Vega J, Golanó P, Pellegrino A, Rabat E, Peña F.  All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique. Foot Ankle Int. 2013;34:1701–9. 26. Cottom JM, Rigby RB. The “all-inside” arthroscopic Broström procedure: a prospective study of 40 consecutive patients. J Foot Ankle Surg. 2013;52:568–74. 27. Giza E, Shin EC, Wong SE. Arthroscopic suture anchor repair of the lateral ligament ankle complex: A cadaveric study. Am J Sports Med. 2013;41:2567–72. 28. Ferkel RD, Chams RN.  Chronic lateral instability: arthroscopic findings and long-term results. Foot Ankle Int. 2007;28(1):24–31. 29. Vega J, Rabat E. Innovations in chronic ankle instability. Rev Cir Pie. 2013;27(2):71–9. 30. van Dijk CN, Scholte D. Arthroscopy of the ankle joint. Arthroscopy. 1997;13(1):90–6. 31. Golanó P, Vega J, Pérez-Carro L, Götzens V. Ankle anatomy for the arthroscopist. Part I: the portals. Clin N Am. 2006;11:275–96. 32. Golanó P, Vega J, de Leeuw PAJ, Malagelada F, Manzanares MC, Götzens V, van Dijk CN. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg SportsTraumatol Arthrosc. 2010;18(5):557–69. 33. Golanó P, Dalmau-Pastor M, Vega J, Batista JP.  In: D’Hooghe PPRN, Kerkhoffs GMMJ, editors. The ankle in football, sports and traumatology: anatomy of the ankle. 1st ed. France: Springer; 2014. p. 1–24. 34. Corte-Real NM, Moreira RM. Arthroscopic repair of lateral ankle instability. Foot Ankle Int. 2009;30:213–7. 35. De Leeuw PAJ, Golanó P, Sierevelt IN, et  al. The course of the superficial peroneal nerve in relation to the ankle position: anatomical study with ankle arthroscopic implications. Knee Surg Sports Traumatol Arthrosc. 2010;18:612–7. 36. Bahr R, Pena F, Shine J, et  al. Biomechanics of ankle ligament reconstruction. An in  vitro comparison of the Brostr¨om repair, Watson-Jones reconstruction, and a new anatomic reconstruction technique. Am J Sports Med. 1997;25:424–32. 37. Schmidt R, Cordier E, Bertsch C, et al. Reconstruction of the lateral ligaments: do the anatomical procedures restore physiologic ankle kinematics? Foot Ankle Int. 2004;25:31–6. 38. Hamilton WG, Thompson FM, Snow SW. The modified Brostrom procedure for lateral ankle instability. Foot Ankle. 1993;14:1–7. 39. Brostrom L.  Sprained ankles VI.  Surgical treatment of “chronic” ligament ruptures. Acta Chir. Scand. 1966;132:551–65. 40. Javors JR, Violet JT. Correction of chronic lateral ligament instability of the ankle by use of the Broström technique. Clin Orthop. 1985;198:201–7. 41. Karlsson J, Bergsten T, Lansinger O, Peterson L.  Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg. 1988;70-A:581–8. 42. Karlsson J, Erikson BI, Bergsten T, et al. Comparison of two anatomic reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med. 1997;25:48–53. 43. Liu SH, Baker CL. Comparison of lateral ankle ligamentous reconstruction procedures. Am J Sports Med. 1994;22:313–7. 44. Watson-Jones R.  Fractures and other bone and joint injuries. Baltimore: Williams & Wilkins; 1940. p. 580–3. 45. Chrisman OD, Snook GA. Reconstruction of lateral ligament tears of the ankle: an experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Joint Surg. 1969;51-A:904–12. 46. van Dijk CN, Bossuyt PM, Marti RK. Medial ankle pain after lateral ligament rupture. J Bone Joint Surg. 1996;78-B:562–7. 47. Sefton GK, George J, Fitton JM, et al. Reconstruction of the anterior talofibular ligament for the treatment of the unstable ankle. J. Bone Joint Surg. 1979;61-B:352–4. 48. Ferkel RD, Heath DD, Guhl JF.  Neurological complications of ankle arthroscopy. Arthroscopy. 1996;12(2):200–8.

5  Ankle Arthroscopy: Soft Tissue Procedures 49. Zengerink M, van Dijk CN.  Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2012;20(8):1420–31. 50. Urgüden M, Cevikol C, Dabak TK, Karaali K, Aydin AT, Apaydin A.  Effect of joint motion on safety of portals in posterior ankle arthroscopy. Arthroscopy. 2009;25(12):1442–6. 51. Martin DF, Baker CL, Curl WW, Andrews JR, Robie DB, Haas AF. Operative ankle arthroscopy. Long-term followup. Am J Sports Med. 1989;17(1):16–23. discussion 23. 52. Nickisch F, Barg A, Saltzman CL, Beals TC, Bonasia DE, Phisitkul P, Femino JE, Amendola A.  Postoperative complications of posterior ankle and hindfoot arthroscopy. J Bone Joint Surg Am. 2012;94(5):439–46. https://doi.org/10.2106/JBJS.K.00069. 53. Acevedo JI, Mangone PG.  Arthroscopic lateral ankle ligament reconstruction. Tech Foot Ankle Surg. 2011;10:111–6. 54. Sanmarco GJ, Idusuyi OB. Reconstruction of the lateral ankle ligaments using a splits peroneus brevis tendon graft. Foot Ankle Int. 1999;20:97–103. 55. Schmidt R, Benesch S, Bertsch C, et  al. Biomechanical consequences of anatomical reconstruction of the lateral ligaments to the anklejoint complex: an in-vitro investigation. Deutsche Zeitschrift für Sportmedizin. 2003;54:136–41. 56. Messer TM, Cummins CA, Ahn J, Kelikian AS.  Outcome of the modified Broström procedure for chronic lateral ankle instability using suture anchors. Foot Ankle Int. 2000;21:996–1003. 57. Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle. 1980;1:84–9. 58. Lohrer H, Alt W, Gollhofer A. Neuromuscular properties and functional aspects of taped ankles. Am J Sports Med. 1999;27:69–75. 59. Freeman MA, Dean MR, Hanham IW.  The etiology and prevention of functional instability of the foot. J Bone Joint Surg Br. 1965;47:678–85. 60. Breitenseher MJ, Trattnig S, Kukla C, et  al. MRI versus lateral stress radiography in acute lateral ankle ligament injuries. J Comput Assist Tomogr. 1997;21:280–5. 61. Nauck T, Lohrer H, Gollhofer A. Evaluation of arthrometer for ankle instability: A cadáver study. Foot Ankle Int. 2010;31(7):612–8. 62. Ray RG, Christensen JC, Gusman DN. Critical evaluation of anterior drawer measurement methods in the ankle. Clin Orthop Relat Res. 1997;334:215–24. 63. Harper MC. Stress radiographs in the diagnosis of lateral instability of the ankle and hindfoot. Foot Ankle. 1992;13:435–8. 64. Frost SC, Amendola A.  Is stress radiography necessary in the diagnosis of acute or chronic ankle instability? Clin J Sort Med. 1999;9:40–5. 65. Broström L. Sprained ankles. V. Treatment and prognosis in recent ligament ruptures. Acta Chir Scand. 1966;132(5):537–50. 66. Golanó P, Vega J, Pérez-Carro L, Götzens V.  Ankle anatomy for the arthroscopist. Part II: Rol of the ankle ligaments in soft tissue inpimgement. Foot Ankle Clin. 2006;11(2):275–96. 67. Sarrafian SK.  Anatomy of the foot and ankle. Descriptive, topographic, functional. 2nd ed. Philadelphia: J.B. Lippincott Company; 1993. p. 159–217. 68. Burks RT, Morgan J. Anatomy of the lateral ankle ligaments. Am J Sport Med. 1994;22(1):72–7. 69. Neuschwander TB, Indresano AA, Hughes TH, Smith BW.  Footprint of the lateralligament complex of the ankle. Foot Ankle Int. 2013;34(4):582–6. 70. Kim ES, Lee KT, Park JS, et al. Arthroscopic anterior talofibular ligament repair for chronic ankle instability with a suture anchor technique. Orthopedics. 2011;34(4):1–5. 71. Barber FA, Click J, Britt BT. Complications of ankle arthroscopy. Foot Ankle. 1990;10:263–6.

171 72. Ferkel RD, Small HN, Gittins JE. Complications in foot and ankle arthroscopy. Clin Orthop Relat Res. 2001;391:89–104. 73. Matsui K, Burgesson B, Takao M, Stone J, Guillo S, Glazebrook M, ESSKA AFAS Ankle Instability Group. Minimally invasive surgical treatment of chronic ankle instability: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016;24:1040–8. 74. Matsui K, Takao M, Miyamoto W, Matsushita T.  Early recovery after arthroscopic repair compared to open repair of the anterior talofibular ligament for lateral instability of the ankle. Arch Orthop Trauma Surg. 2016;136:93–100. 75. Matsui K, Takao M, Miyamoto W, Innami K, Matsushita T. Arthroscopic Broström repair with Gould augmentation via an accessory anterolateral port for lateral instability of the ankle. Arch Orthop Trauma Surg. 2014;134:1461–7. 76. Takao M, Matsui K, Stone JW, Glazebrook MA, Kennedy JG, Guillo S, Calder JD, Karlsson J, Ankle Instability Group. Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle. Knee Surg Sports Traumatol Arthrosc. 2016;24:1003–6. 77. Broström L.  Sprained ankles, VI: surgical treatment of “chronic” ligament ruptures. Acta Chir Scand. 1966;132:551–65. 78. Girard P, Anderson RB, Davis WH, Isear JA, Kiebzak GM. Clinical evaluation of the modified Brostrom-Evans procedure to restore ankle stability. Foot Ankle Int. 1999;20:246–52. 79. Karlsson J, Bergsten T, Lansinger O, Peterson L.  Reconstruction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg Am. 1988;70:581–8. 80. Karlsson J, Lansinger O. Chronic lateral instability of the ankle in athletes. Sports Med. 1993;16:355–65. 81. Takao M, Oae K, Uchio Y, Ochi M, Yamamoto H.  Anatomical reconstruction of the lateral ligaments of the ankle with a gracilis autograft: a new technique using an interference fit anchoring system. Am J Sports Med. 2005;33:814–23. 82. Glazebrook M, Stone J, Matsui K, Guillo S, Takao M. Percutaneous ankle reconstruction of lateral ligaments (Perc-Anti RoLL). Foot Ankle Int. 2015;37:659–64. 83. Takao M, Glazebrook M, Stone J, Guillo S.  Ankle Arthroscopic Reconstruction of Lateral Ligaments (Ankle Anti-ROLL). Arthrosc Tech. 2015;4:e595–600. 84. Lui TH. Arthroscopic-assisted lateral ligamentous reconstruction in combined ankle and subtalar instability. Arthroscopy. 2007;23:554. e1-5. 85. Ozeki S, Kitaoka H, Uchiyama E, Luo ZP, Kaufman K, An KN. Ankle ligament tensile forces at the end points of passive circumferential rotating motion of the ankle and subtalar joint complex. Foot Ankle Int. 2006;27:965–9. 86. Tanaka Y, Takakura Y, Hayashi K, Taniguchi A, Kumai T, Sugimoto K. Low tibial osteotomy for varus-tyoe osteoarthritis of the ankle. J Bone Joint Surg Br. 2006;88:909–13. 87. Matsui K, Takao M, Tochigi Y, Ozeki S, Glazebrook M. Anatomy of anterior talofibular ligament and calcaneofibular ligament for minimally invasive surgery: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016;25(6):1892–902. (Epub ahead of print). 88. Matsui K, Oliva XM, Takao M, Pereira BS, Gomes TM, Lozano JM, ESSKA AFAS Ankle Instability Group, Glazebrook M.  Bony landmarks available for minimally invasive lateral ankle stabilization surgery: a cadaveric anatomical study. Knee Surg Sports Traumatol Arthrosc. 2016;25(6):1916–24. (Epub ahead of print). 89. Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, van Dijk CN. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010;18:557–69.

6

Posterior Subtalar Arthroscopy Peter A. J. de Leeuw, Jan Ophuis, Gino M. M. J. Kerkhoffs, Kevin Koo, Peter Rosenfeld, Thomas Bauer, Tun Hing Lui, Thomas S. Roukis, Phinit Phisitkul, Davide Edoardo Bonasia, Annunziato (Ned) Amendola, and Davide Deledda

The corresponding author of section 6.1 is Gino M. M. J. Kerkhoffs, Email: [email protected] The corresponding author of section 6.2 is Peter Rosenfeld, Email: [email protected] The corresponding author of section 6.3 is Thomas Bauer, Email: [email protected] The corresponding author of section 6.4 is Thomas S. Roukis, Email: [email protected] The corresponding author of section 6.5 is Phinit Phisitkul, Email: phinit-­[email protected] The corresponding author of section 6.6 is Davide Edoardo Bonasia, Email: [email protected] P. A. J. de Leeuw Academic Medical Center, Department of Orthopaedic Surgery, Amsterdam, The Netherlands Flevoziekenhuis, Department of Orthopaedic Surgery, Almere, The Netherlands Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherlands J. Ophuis Academic Medical Center, Department of Orthopaedic Surgery, Amsterdam, The Netherlands G. M. M. J. Kerkhoffs (*) Academic Medical Center, Department of Orthopaedic Surgery, Amsterdam, The Netherlands Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherlands Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands e-mail: [email protected] K. Koo Singapore General Hospital, Singapore, Singapore

P. Rosenfeld St. Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK e-mail: [email protected] T. Bauer Department of Orthopaedic Surgery, Ambroise Paré University Hospital, West Paris University, Boulogne Billancourt, France e-mail: [email protected] T. H. Lui Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China T. S. Roukis Orthopaedic Center, Gundersen Health System, La Crosse, WI, USA e-mail: [email protected] P. Phisitkul University of Iowa Hospitals and Clinics, Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA e-mail: [email protected] D. E. Bonasia · D. Deledda University of Torino, AO Mauriziano “Umberto I” Hospital, Department of Orthopaedics and Traumatology, Torino, Italy A. Amendola Duke University, Department of Orthopaedic Surgery, Durham, NC, USA

© Springer Nature Singapore Pte Ltd. 2019 T. H. Lui (ed.), Arthroscopy and Endoscopy of the Foot and Ankle, https://doi.org/10.1007/978-981-13-0429-3_6

173

174

P. A. J. de Leeuw et al.

Contents 6.1    Surgical Approach and Portals of Posterior Subtalar Arthroscopy. . . . . . . . . . . . . . . . . . . . . .  174 6.1.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  174 6.1.2  Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  175 6.1.3  Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  175 6.1.4  Author’s Preferred Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  175 6.1.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  181 6.2    Arthroscopic-Assisted Reduction and Fixation of Calcaneal Fractures . . . . . . . . . . . . . . . . . .  182 6.2.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  182 6.2.2  Indications for Arthroscopic Calcaneal Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  183 6.2.3  Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  183 6.2.4  Authors’ Preferred Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  183 6.2.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  190 6.3    Endoscopic Treatment of Calcaneo-­Fibular Impingement. . . . . . . . . . . . . . . . . . . . . . . . . . . . .  191 6.3.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  191 6.3.2  Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  192 6.3.3  Contra-Indications [58]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  192 6.3.4  Author Preferred Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  192 6.3.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  195 6.4    Arthroscopic Subtalar Release for Post-Traumatic Arthrofibrosis of the Posterior Subtalar Joint. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  196 6.4.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  196 6.4.2  Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  196 6.4.3  Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  196 6.4.4  Author’s Preferred Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  196 6.4.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  202 6.5    Arthroscopic Subtalar Arthrodesis: Lateral vs Posterior Approaches . . . . . . . . . . . . . . . . . . .  204 6.5.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  204 6.5.2  Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  204 6.5.3  Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  204 6.5.4  Author’s Preferred Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  204 6.5.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  211 6.6    Arthroscopic Resection of Talocalcaneal Coalition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  212 6.6.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  212 6.6.2  Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  213 6.6.3  Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  213 6.6.4  Author’s Preferred Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  213 6.6.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  219 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  220

6.1

 urgical Approach and Portals S of Posterior Subtalar Arthroscopy

Peter A. J. de Leeuw, Jan Ophuis, and Gino M. M. J. Kerkhoffs

6.1.1 Introduction Subtalar joint pathology is mainly characterized by ankle pain on weight bearing specifically on uneven ground and traditionally was treated by open surgery following a failed conservative treatment regime. However, with the introduction of minimally invasive foot and ankle surgery and with the enhancements of specified instruments nowadays, most pathologies around the subtalar joint can be treated arthroscopically.

Several portals have been described to assess the subtalar joint. Parisien et al. [1] described a combined anterior and posterior portal, Frey et al. [2] introduced the middle portal, Mekhail et  al. [3] described the medial portal, and Ferkel et al. [4] described the accessory anterolateral and posteromedial portals. To ascertain a reliable, reproducible, and safe minimally invasive approach, routine portals should be used which allow the surgeon to assess a wide variety of different pathologies. Different portals for different cases could more easily lead to iatrogenic damage to our patients. Therefore the authors prefer the use of the posterolateral and posteromedial portals, as described for hindfoot endoscopy by van Dijk et al. [5]. Based on these portals [5, 6], Beimers et al. [7] described an arthroscopic technique for subtalar joint arthrodesis. An

6  Posterior Subtalar Arthroscopy

175

additional sinus tarsi portal is used only in case of need for additional distraction to optimize joint debridement.

bar itself. Tarsal coalitions appear to be present in about 1% of the population [8–11].

6.1.2 Indications

6.1.3 Contraindications

Subtalar arthroscopy can potentially be useful as a diagnostic tool in patients with persistent swelling, pain, stiffness, or locking of the subtalar joint when conservative treatment has proven insufficient and additional diagnostics do not support the clinical diagnosis. Arthroscopy of the subtalar joint is used for treating a variety of pathologies and can be divided in osseous, soft tissue, or cartilage pathology. Osseous pathology includes the symptomatic os trigonum, loose bodies, or post-traumatic calcifications. Pathology of soft tissue primarily includes excessive scar tissue, impingement of syndesmotic soft tissue, and villonodular synovitis. Cartilage pathology mainly includes posterior located talar or calcaneal osteochondral defects, chondromatosis, and osteoarthritis. In case of end-stage (post-traumatic) disabling symptomatic osteoarthritis, an arthrodesis of the subtalar joint can be considered. Subtalar joint arthrodesis can also be performed in treatment of congenital pathologies such as subtalar coalitions. The coalitions around the subtalar joint predominantly cause pain due to the micromotions in the

The general principles whether to perform surgery or not are eligible for subtalar joint arthroscopy as well. Furthermore in case of an arthroscopic-assisted subtalar fusion, one could argue whether severe bone loss following osteoarthritis is a contraindication.

6.1.4 Author’s Preferred Technique The authors prefer the use of the posterolateral and posteromedial portals for hindfoot endoscopy. The portals can be used safely and reproducibly and additionally provide access to the talocrural joint in case of combined pathology to both the subtalar and talocrural joint. No invasive distractors are needed, and the surgery can be performed with the patient in the prone position, either under either general or spinal anesthesia without the need to change the position of the ankle throughout the procedure to optimize the surgical orientation. Last but not least, the surgeon’s posture is persistently good throughout the surgery.

176

6.1.4.1 Preoperative Planning If following that a profound and detailed history taking and physical examination subtalar joint pathology are suspected, weight bearing lateral and anterior to posterior radiographs should be requested. If these underline the clinical suspicion and the diagnosis is clear, no additional investigations are necessary. If in doubt or in case of cystic lesions with or without bone loss, a computed tomography including reconstructions can be considered. The first line of treatment is conservative with most frequently pain medication, physical therapy, and an insole or orthopedic shoes, and also an infiltration with either steroids or hyaluronic acid could be con-

Fig. 6.1 Thirty-year-old female patient with pain at the level of the subtalar joint based on a bony coalition

P. A. J. de Leeuw et al.

sidered. In case of persistent quality of life diminishing, complaints surgery should be considered. In this chapter a 30-year-old female patient is presented with a bony coalition of the subtalar joint (Fig. 6.1). She presented with pain on weight bearing specifically when walking on uneven ground. The symptoms started following a simple ankle sprain which was treated following the RICE rules [12]. At follow-up the ankle was graded as a grade 1 ankle sprain, and she started physiotherapy. Despite the conservative treatment regime, symptoms persisted, and she was scheduled for an arthroscopic subtalar joint fusion.

6  Posterior Subtalar Arthroscopy

6.1.4.2 Patient Positioning The arthroscopic subtalar fusion is performed in an outpatient setting and can be performed both under general, spinal, or local regional anesthesia. The correct side is marked to prevent wrong-side surgery, a tourniquet is applied at the upper leg, and the patient is subsequently positioned in the prone position. Prophylactic intravenous antibiotics are given. At the level of the tourniquet, a support is placed. A second support is placed under the lower leg, just proximal to the ankle joint, to allow for a full range of ankle motion throughout the procedure (Fig. 6.2).

Fig. 6.2  The patient is positioned in the prone position; the ankle is supported to allow for a free range of motion. The posterolateral portal is located at the level of the distal fibula just lateral to the Achilles tendon (arrow)

177

6.1.4.3 Portal Design The standard portals for hindfoot arthroscopy are used. With the ankle in the 90° position, a line parallel to the sole of the foot is drawn from the distal tip of the lateral malleolus toward the Achilles tendon. The line is then extended over the Achilles tendon to the medial side, still parallel to the foot sole with the ankle in the 90° position. In feet with normal morphology, the posterolateral and medial portal are located 1 cm anterior to the Achilles tendon and on or proximal to the previous drawn line (Fig. 6.2). As noted by van Sterkenburg et al., it can be useful to make the posterolateral and posteromedial portal more posteriorly in patients with cavus feet and more anteriorly from the Achilles tendon in patients with flatfeet, due to the calcaneal inclination [13]. Only in case of a very tight subtalar joint an additional third portal is used, which is located at the level of the sinus tarsi [7]. The optimal location is determined during surgery under direct visualization with the use of a needle. The sinus tarsi portal can be used in case additional distraction is needed to adequately debride the remaining cartilage. A large diameter blunt trocar can be introduced to distract the joint.

178

6.1.4.4 Step-by-Step Description of the Technique The posterolateral portal is made first as a vertical stab incision only affecting the skin, and a mosquito clamp is used to spread the subcutaneous layer. The foot is now in a slightly plantarflexed position. The clamp is directed anteriorly, toward the interdigital web space between the first and second toes. When the tip of the clamp touches the bone, it is exchanged for a 4.5 mm arthroscopic cannula with the blunt trocar pointing in the same direction. The trocar is situated extra-articularly at the level of the posterior talar process and is exchanged for the 4.0 mm 30° arthroscope, directed laterally. At this time the scope is still outside the joint in the fatty tissue overlying the capsule. Second the posteromedial portal is made with a vertical stab incision through the skin only, and a mosquito clamp is introduced through the posteromedial portal and is directed toward the arthroscope shaft at a 90° angle, until the clamp contacts the arthroscope. The ankle is still in a slight plantarflexed position, and the arthroscope has remained in position. The arthroscope shaft is used as a guide for the mosquito clamp to travel anteriorly. While in contact with the arthroscope shaft, the clamp glides over the shaft toward the ankle joint until the bone is reached. Once the arthroscope and clamp are both touching the bone, the mosquito clamp is left in position, and the arthroscope is pulled slightly backward and tilted until the tip of the clamp comes into view. The soft tissue layer covering the joints consists of fatty tissue and the deep crural fascia. On the lateral side, a specific part of the crural fascia can be recognized: the Rouvière ligament. The clamp is now directed to the lateral side in an anterior and slightly plantar direction. This movement creates an opening in the crural fascia just lateral to the posterior talar process. The fatty tissue and subtalar joint capsule are subsequently opened. The mosquito clamp is exchanged for a 5  mm full-radius shaver or bonecutter shaver. With a few turns of the shaver, the subtalar joint capsule and soft tissue are gently removed. The opening of the shaver blade is facing toward the bone. This part of the procedure is carried out in a blind fashion. The shaver is then retracted, and the scope is brought anteriorly through the opening in the crural fascia to visualize the posterolateral aspect of the subtalar joint. Once the joint is recognized, the opening in the crural fascia is enlarged to create more working area. The cranial part of the posterior talar process is freed from the Rouvière ligament and crural fascia to identify the flexor hallucis longus (FHL) tendon (Fig. 6.3a). The FHL tendon is an important safety landmark. The neurovascular bundle runs just medial to this tendon; therefore, the area lateral to the FHL tendon is regarded as being safe. After the identification of the FHL tendon, the specific pathology can be identified and addressed.

P. A. J. de Leeuw et al.

The bonecutter shaver can now be used to debride the remaining cartilage from the subtalar joint in case of osteoarthritis. In case of a fibrous or osseous coalition, these need to be addressed first to improve access to the subtalar joint for subsequently debridement of the cartilage. In case of the talocalcaneal coalition, the talus and calcaneus are connected by the talocalcaneal bar that is located at the medial side. A small size chisel (4.0 or 6.0 mm) is introduced through the posteromedial or posterolateral portal into the area of the bar. An attempt can be made to remove the bar by using the small size chisel in order to further open up the joint (Fig. 6.3b). Removal of the articular cartilage of the posterior subtalar joint is performed with the shaver and the ring curettes (Fig. 6.3c). The different portals are interchangeably used for optimal debridement. After removal of all the articular cartilage, the subchondral bone is entered to expose the highly vascular cancellous bone. Using the small size chisel, deep longitudinal grooves are made in the subchondral cancellous bone of the talus and calcaneus (Fig. 6.3d). It is important to significantly open the dense subchondral bone plate to create a bleeding subchondral bone bed on both sides of the joint (Fig. 6.3e). If additional access is needed, the sinus tarsi portal can be created. A skin incision is made at the level of the sinus tarsi. A spinal needle is introduced via the sinus tarsi portal and is directed toward the tip of the lateral malleolus. At the level of the subtalar joint, the spinal needle is pointing posteriorly. The arthroscope is used to check the position of the needle. Following removal of the spinal needle, the large diameter blunt trocar (4.0 mm) is inserted through the sinus tarsi portal and is maneuvered toward the posterior subtalar joint. The blunt trocar is now forced into the subtalar joint to open up the joint. Following complete debridement, a vertical skin incision is made at the tip of the heel for introduction of two lag screws. Using fluoroscopy, the 6.5 mm lag screws are positioned across the posterior subtalar joint (Fig. 6.4). The estimated length and direction of the two screws can be preoperatively planned on the lateral weight bearing radiograph of the ankle. Before insertion of the two screws, it is important to check the alignment of the hindfoot. Compression of the posterior subtalar joint surfaces can be checked arthroscopically when tightening the screws. The skin is closed with transcutaneous sutures.

6.1.4.5 Complications and Management As with any surgery, neurovascular complications could occur. The potential iatrogenic nerve injuries for each portal, as described for subtalar joint arthroscopy, in general can be diminished by using the nick and spread technique following the skin incision. Specifically injury to the sural nerve with the creation of the posterolateral portal could occur. Additionally, iatrogenic damage to the posterior neurovascular bundle potentially could occur if the landmark for hindfoot endoscopy, being the flexor hallucis longus tendon, is not

6  Posterior Subtalar Arthroscopy

179

a

b

c

1

2 2

2

4

3

3 3

d

e

2

3

PROXIMAL

MEDIAL

LATERAL

DISTAL

Fig. 6.3  Arthroscopic posterior right subtalar fusion. (a) After opening the deep crural fascia and before addressing the pathology, the flexor hallucis longus (1) should be identified. (2) Talus (3) calcaneus. (b) In case of a narrow subtalar joint, the chisel can be used to open up the joint. (c) During the joint debridement with the use of curettes and the bonecutter shaver, it is mandatory to remove the entire bony coalition

Fig. 6.4  Under fluoroscopic control the non-cannulated 6.5 mm cancellous screws are inserted

(4). (d) Completion of the debridement is followed by opening up the subchondral bone with the osteotome in a tramrail fashion. (e) At the end of the arthroscopic procedure, all the cartilage have been removed, and the subchondral layers from both the talus and calcaneus have been damaged with the osteotome

180

respected. In case of the subtalar arthrodesis, the positioning of the screws should be performed under fluoroscopic control to prevent screw malpositioning. Also, as specified in the surgical technique, before compressing the joint with the screws, check and maintain the alignment. To optimize union both biology and stability are needed; therefore, the subchondral bone should be adequately debrided and damaged up to

P. A. J. de Leeuw et al.

bleeding surfaces and compression over the joint obtained with the large diameter partially treated screws, respectively. Infection is another potential complication which is minimized by antibiotics at induction and well performed no longer than necessary surgery in a non-­ compromised host. Nondelayed and delayed unions can either be caused by infection, the host itself, or by suboptimal surgery.

6  Posterior Subtalar Arthroscopy

6.1.4.6 Postoperative Care Following subtalar joint arthroscopy, most patients can be discharged on the day of surgery. To prevent edema, a compression bandage is applied, and patients are advised to elevate the affected limb when not walking during the first week following surgery. On average, postoperative care consists of partial weight bearing for 2–3 days supported by elbow crutches. To prevent postoperative stiffness, active non-­weight -bearing range of motion exercises are advised starting directly after the completion of surgery. In case an osteochondral defect is treated arthroscopically, non-weight bearing in a lower leg cast for at least 2  weeks postoperatively is advised. At 2 weeks following surgery, the cast is replaced for a weight bearing cast or a controlled action motion (CAM) walker boot for an additional 4 weeks.

Fig. 6.5  In the presented case at 6 weeks following surgery, weight bearing radiographs were made showing signs of union

181

In case an arthroscopic subtalar arthrodesis is performed, a non-weight bearing lower leg cast is provided for 4 weeks, followed by a walker boot for another 2 weeks. At 6 weeks following surgery, anteroposterior and lateral weight bearing ankle radiographs are made (Fig. 6.5). With radiographic signs of union of the subtalar arthrodesis, the patient is allowed full weight bearing without further support. If in doubt an additional 2 weeks in a walker boot can be considered.

6.1.5 Summary The reproducible and relatively safe two-portal hindfoot arthroscopic approach provides optimal access to the subtalar joint and can be used to treat a wide variety of subtalar pathology including the subtalar fusion.

182

6.2

P. A. J. de Leeuw et al.

Arthroscopic-Assisted Reduction and Fixation of Calcaneal Fractures

Kevin Koo and Peter Rosenfeld

6.2.1 Introduction The optimal management of displaced intra-articular calcaneal fractures is controversial and remains a topic that has generated great interest and strong opinions [14–16]. While there are studies that have shown improved functional outcomes and patient satisfaction with surgical treatment compared with nonoperative treatment [17, 18], these are challenged by other reports, indicating that surgical treatment has no significant benefits [19, 20]. The traditional extended L-shaped lateral incision has been the workhorse approach for open reduction and internal fixation (ORIF) of calcaneal fractures. It was designed to avoid the blood supply to the lateral wall flap and still offer good visualization of the fracture (Fig. 6.6). However, this approach is associated with a high wound complication rate of up to 37% and infection rates of up to 20% [21–25]. This has led to a more recent trend toward less invasive surgical techniques and approaches for managing displaced calcaneal fractures [26–32]. Early results have shown lower complication rates with promising clinical and radiographic outcomes for certain fracture patterns and patient populations [26–33]. These techniques include limited sinus tarsi incision and fixation, percutaneous fixation with pins and/or screws, external fixation, and arthroscopic-assisted fixation. In this chapter, we present our method of performing arthroscopy as the primary technique in fracture reduction and fixation. The benefits of this technique include decreased soft tissue trauma, preservation of the local vascular supply, removal of loose fragments, and more accurate articular reduction. The surgical time is similar and often much less with experience. Potential disadvantages include unfamiliarity with the anatomy and technique, as well as a steep learning curve. There are also theoretical concerns of fluid extravasation. Woon et  al. [34], in their review of 22 patients with Sanders type II fractures who underwent arthroscopic-­ assisted reduction and fluoroscopy-guided percutaneous fixation, reported significant correction of the Bohler angle without articular subsidence, in addition to improved visual analog scale scores, the Medical Outcomes Study 36-Item Short Form scores, and the AOFAS Ankle-Hindfoot Scale scores through 2-year follow-up. Rammelt et  al. [29] performed percutaneous reduction and screw fixation in 61 patients with Sanders type II fractures and used arthroscopy to confirm anatomic reduction in 33 of the cases. With a minimum follow-up of 2 years, the

Fig. 6.6  This shows how the extended lateral approach (L-shaped incision indicated by the solid line) preserves the blood supply to the calcaneal skin flap. A more proximal incision (indicated by the dotted line) would compromise this blood supply

mean AOFAS score was 92.1, and the Bohler angle and calcaneal width were reduced to the values of the uninjured side. Most patients (90.0%) underwent surgery within 10 days after the initial injury. There were no cases of postoperative wound edge, hematoma, or infection. Sivakumar et  al. [35] reviewed a series of 13 displaced intra-articular calcaneal fractures treated with combined fluoroscopy and arthroscopy to aid percutaneous reduction and internal fixation. Mean postoperative improvement in the Bohler angle was 18.3°, with subsidence of 1.7° at final follow-­up and good functional outcome scores.

6  Posterior Subtalar Arthroscopy

6.2.2 I ndications for Arthroscopic Calcaneal Fixation 1. All calcaneal fractures that were types II and III by Sanders classification [36] can be surgically managed using this technique. Type IV fractures were treated by primary fusion, using the same technique, with arthroscopic reduction and debridement of articular surfaces and subtalar fusion using cannulated screws. Both joint depression and tongue-type fractures can be managed using this technique. 2. Comorbidities or compliance factors that would normally contraindicate open surgery were still included in the arthroscopic group, and this is one of the areas where arthroscopic calcaneal fixation has an advantage. These traditional contraindications were based around wound healing issues, such vascular compromise, skin problems, smoking, and diabetes. We did not use these as contraindications to arthroscopic surgery.

6.2.3 Contraindications 6.2.3.1 Absolute Contraindication 1. Sanders type I (undisplaced) fractures do not require open or arthroscopic surgery. 2. Open fractures. 3. Active infection.

183

4. Patients unfit for anesthesia due to multiple comorbidities or debilitating systemic illness(es). 5. Patients non-compliant to postoperative rehabilitation plan.

6.2.3.2 Relative Contraindication 1. Fractures more than 3  weeks old. This makes fracture reduction more difficult due to early callus formation, and consent should be taken for open surgery should the minimally invasive technique fail to get reasonable reduction.

6.2.4 Authors’ Preferred Technique 6.2.4.1 Preoperative Planning All cases have preoperative imaging with radiographs as well as CT scans with classification of the injury according to Sanders. The Sanders classification uses the coronal CT image that shows the posterior facet in its widest profile and allows stratification into four types: type I fractures are undisplaced, type II fractures are two-part fractures, type III fractures are three-part fractures with depression of the central fragment, and type IV fractures are comminuted with four or more fragments. Types II and III can be further subdivided based on two vertical lines that divide the posterior fragment into three equal sections (A, lateral; B, central; C, medial).

184

6.2.4.2 Patient Positioning A single dose of antibiotics is given as prophylaxis to all patients at the induction of anesthesia. The patient is positioned in the lateral decubitus position on the uninjured side with the operated extremity draped and a tourniquet applied to the proximal calf. The knee and leg are supported on a bolster to allow hindfoot access and manipula-

Fig. 6.7  Setup in the operating theater, demonstrating that the surgeon has an adequate work space, as well as unobstructed views to both the intraoperative fluoroscopic images and the arthroscopy monitor

P. A. J. de Leeuw et al.

tion. The image intensifier comes in ventral to the patient, allowing for easy imaging with lateral views: Broden’s and axial Harris views. The monitor for the arthroscopy camera is placed dorsal to the patient. The surgeon, at the foot of the operating table, has an adequate working space, with unobstructed views to both the intraoperative fluoroscopic images and the arthroscopy monitor (Fig. 6.7).

6  Posterior Subtalar Arthroscopy

6.2.4.3 Portal Design The subtalar joint can either be accessed arthroscopically laterally or posteriorly [37]. Our preferred approach for calcaneal fractures is the lateral approach. The anatomic landmarks for portal placement are the lateral malleolus, the sinus tarsi, and the posterior fibula. Three arthroscopic portals have been described, to give maximal view of the posterior facet of the calcaneum. The anterolateral portal is placed over the anterior calcaneal process approximately 1 cm distal and 2 cm anterior to the tip of the fibula. The middle portal is placed

Fig. 6.8  Landmarks for subtalar arthroscopic portals. ALP anterolateral portal, MP middle portal, PLP posterolateral portal, PT peroneal tendons

185

directly over the sinus tarsi, 1 cm anterior to the tip of the fibula. There are no structures at risk with these portals. The posterolateral portal is placed in line with the others, 1 cm behind the fibula and peroneal tendons. The sural nerve is at risk; therefore a nick-and-spread technique is used to minimize this risk (Fig. 6.8).

186

6.2.4.4 Step-by-Step Description of the Technique Portal Entry, Debridement, and Visualization The subtalar joint was visualized using a standard 30°, 4.0 mm knee arthroscope inserted into the anterolateral portal, with the shaver (3.5 mm handheld incisor shaver, Smith & Nephew, Andover, MA) in the middle portal. The initial view is obscured by the sinus tarsi contents as there is no capsule to enter. A working area needs to be created—the tip of the shaver is located, and careful shaving of the fatty tissues reveals the anterior border of the subtalar joint. Some resection of the cervical ligament or continuation of the inferior extensor retinaculum may be necessary. Continued shaving laterally will reveal the entire posterior facet and lateral wall (Fig. 6.9). The joint is examined, and the fracture hematoma is cleared away. A third posterolateral portal may be

P. A. J. de Leeuw et al.

needed to expose the lateral wall and lateral joint line better. The posterior facet is examined for displacement and incongruities (Fig. 6.10). Any loose osteochondral fragments are removed.

Fig. 6.10  Arthroscopic picture from the anterolateral portal showing the depressed lateral fragment of the posterior facet (marked “X”). “Y” is the anterior process of the calcaneum

Fig. 6.9  Arthroscopic picture showing a 3.5 mm shaver placed through the anterolateral portal. The camera was placed in the middle portal. A thorough debridement is essential for adequate visualization of the posterior facet

6  Posterior Subtalar Arthroscopy

Fracture Reduction This requires elevation of the posterior facet and manipulation of the joint fragments to achieve an accurate articular reduction. The posterior facet is elevated first, via the posterior heel and calcaneal tuberosity. First, the depressed superolateral fragment of the posterior facet is elevated using a cannulated screwdriver. This is inserted percutaneously through the secondary fracture line as it exits posteriorly (Figs. 6.11 and 6.12). Once this fragment is reduced on X-ray, it is temporarily held with a guide wire passed through the screwdriver. This can be used later to insert a

187

“raft” screw. Further fine-tuning of the reduction is achieved arthroscopically using direct manipulation of the fragments through either of the anterior portals with a periosteal elevator (Fig.  6.13). The fragments are elevated, derotated, and temporarily held with K-wires. The reduction is held temporarily with 1.6  mm wires (Fig.  6.14) and confirmed using a combination of arthroscopy (Fig. 6.15) and fluoroscopy (Fig. 6.16). Multiple fragments are reduced working from medial to lateral, using multiple K-wires in a “kebab” technique.

Fig. 6.11  Intraoperative photo showing a screwdriver inserted percutaneously into the calcaneal tuberosity

Fig. 6.13  Further fine-tuning of the reduction was achieved using direct manipulation of the fragments through either the anterolateral or middle portal with a periosteal elevator (asterisk)

Fig. 6.12  Intraoperative image showing how the screwdriver can lever the depressed superolateral fragment of the posterior facet toward the joint line

Fig. 6.14  Articular fragments held temporarily with a 1.6 mm K-wire

188

Fig. 6.15  Arthroscopic confirmation of fracture reduction via the anterolateral portal. “L” represents the lateral articular fragment. “M” represents the medial

P. A. J. de Leeuw et al.

Fig. 6.16  Fluoroscopic confirmation of fracture reduction

6  Posterior Subtalar Arthroscopy

Fracture Fixation We use cannulated, 6.5  mm screws (Synthes, Solothurn, Switzerland). Guide wires are passed across the fractures using direct vision for the entry point (we aim to be 5–10 mm below the joint line) and image-intensifier guidance to ensure the joint is not perforated. The wires are directed to the sustentaculum, and screws are then introduced percutaneously through the lateral skin, using the “nick-and-spread” technique to avoid the sural nerve. The screws are inserted under direct arthroscopic vision entering the lateral wall 5–10 mm below the articular surface (Fig. 6.17) and angled toward the sustentaculum. We now use the larger 6.5 mm screws as the smaller 4.5 cannulated screws provided inadequate purchase and fixation. Fixation of the anterior process of the calcaneus and calcaneocuboid joint may be necessary and can be performed via the anterior portals. We will fix the anterior process if it is significantly displaced. We do this using a lag screw. Finally the reduction is confirmed on fluoroscopy (Fig. 6.18). The incisions are closed with interrupted nonabsorbable monofilament sutures and nonocclusive dressings, and a backslab plaster is applied.

189

slab is changed to an Aircast boot (DonJoy Global, Vista, CA), and physiotherapy is commenced, with a focus on passive and active movement of the subtalar and ankle joints. Progressive weight bearing with crutches starts at 6  weeks with an Aircast boot as required.

6.2.4.5 Postoperative Care The patients are discharged the next day, once they were competent with non-weight bearing ambulation, with advise to maintain strict elevation for the first week. At 2 weeks, the wounds are inspected, and sutures are removed. The back-

6.2.4.6 Outcomes Thirty-three fractures in 30 patients who had presented to our tertiary foot and ankle trauma center in central London were treated with percutaneous arthroscopic calcaneal osteosynthesis for calcaneal fractures, and the data was prospectively collected [38]. The mean patient age at injury was 39 years. The mean follow-up period was 24 months. Of our patients, 58% were smokers at injury. Of the 33 fractures, 46% were classified as grade II and 54% as grade III.  The mean length of stay was 1.92  days. At the final follow-up visit, the mean Bohler angle had increased from 11.10° (range 2°–24°) to 23.41° (range 15°–35°). The modified American Orthopaedic Foot and Ankle Society scale score was 72.18 (range 18–100), the calcaneal fracture scoring system score was 79.34 (range 42–100), and the visual analog scale score was 29.50 (range 0–100). Direct visualization of the fracture site allowed accurate restoration of the articular surface and correction of heel varus. Furthermore, it was associated with a high self-reported functional outcome and a return to pre-injury employment levels. Also, the results did not appear to be influenced by tobacco consumption.

Fig. 6.17  Arthroscopic photo showing position of the screw 5–10 mm below the subtalar articular surface

Fig. 6.18 Final fluoroscopy confirming reduction and implant position

190

6.2.4.7 Complications and Management We had a single case of a superficial port site infection and two cases of prominent screws, which were removed. No cases of deep infection developed, and no conversion to subtalar fusion was required. This technique significantly reduced the incidence of postoperative wound complications.

P. A. J. de Leeuw et al.

6.2.5 Summary Arthroscopic-assisted reduction and fixation of calcaneal fractures is a minimally invasive method of treating Sanders type II and III fractures. After overcoming the initial learning curve, it can potentially equip the surgeon with a safe, low-­complication, and high-patient satisfaction technique that can be used for most patients, regardless of whether they are smokers or not.

6  Posterior Subtalar Arthroscopy

6.3

Endoscopic Treatment of Calcaneo-­ Fibular Impingement

Thomas Bauer and Tun Hing Lui

6.3.1 Introduction It is still inconclusive of what is the optimal treatment of intra-articular calcaneal fractures because both the operative and non-operative treatments have significant associated complications [39]. Besides post-traumatic subtalar osteoarthritis, malunited intra-articular calcaneal fractures can lead to complex hindfoot deformities. Widened heel, hindfoot deformity (hindfoot valgus deformity associated with pes planus deformity), calcaneo-fibular impingement, peroneal tendons dysfunction, and post-traumatic subtalar degeneration are well-known results of calcaneal malunion and cause significant disability for the patients [40]. The patients would complain of difficulty with shoe wear, pain on walking on uneven ground as a result of subtalar osteoarthritis. They also often complain of lateral heel pain due to calcaneo-fibular impingement, lateral subtalar osteoarthritis, and peroneal tendonitis or subluxation [41]. Calcaneo-fibular impingement syndrome is a common complication following malunited calcaneal fracture, presenting as lateral hindfoot pain around the lateral malleolar tip. It is caused by increased width of the calcaneus together with varus deformity of the posterior calcaneal tuberosity or hindfoot valgus [40–42]. The resultant decreased space between the lateral malleolar tip and the lateral calcaneal wall leads to calcaneo-fibular impingement syndrome [43]. The source of pain has both bony and soft tissue components. The soft tissue component includes entrapment of the peroneal tendons in the retromalleolar groove and under the lateral malleolar tip and fibrosis in the lateral subtalar recess with entrapment of branches of the sural nerve. It is sometimes difficult to differentiate the calcaneo-fibular impingement pain from the lateral heel pain caused lateral subtalar osteoarthritis and peroneal pathologies [40, 44, 45]. Calcaneo-fibular impingement is essentially a clinical diagnosis characterized by local tenderness under the lateral malleolar tip. The pain can be elicited or exacerbated by forced hindfoot valgus test, but positive negative test cannot exclude the impingement syndrome [43]. Because subtalar osteoarthritis, hindfoot deformity, and peroneal tendinopathy can be the other causes of heel pain, it is important to determine the exact causes of heel pain before correctly formulating the management plan [39, 40]. Radiographic measurements of Bohler’s angle, talar declination angle, talocalcaneal angle, and height of the calcaneus have been used to assess reduction of the intra-articular calcaneal fracture. However, these measurements do no cor-

191

relate with the final clinical outcome [46, 47]. Computed tomogram with coronal reconstruction is useful for preoperative planning as it helps to assess the type of calcaneal malunion and accurately identify the size and location of the lateral calcaneal exostosis. The relationship between the calcaneal exostosis and the lateral malleolus, the extent of arthritis of the posterior subtalar joint can also be studied [48]. These information can help the surgeon to determine the locations of the portals, the location and amount of bone resection to accommodate both the impingement and lateral subtalar arthritis. There are two surgical strategies to handle symptomatic calcaneal malunion. The first one is to correct all the deformities with calcaneal osteotomies or subtalar distraction bone-block arthrodesis [49–51]. The other one is to focus on those aspects that are most clinically impressive [44, 45, 47, 52–54]. Algorithms for the treatment of calcaneal malunion have been developed. These are based on the malunion type, extent of subtalar degeneration and hindfoot deformity [48, 55]. However, there is no concrete correlation between the types of malunion and the final functional outcome [40, 45, 47, 50, 51, 56]. In symptomatic calcaneal malunion, subtalar in-situ or bone-block distraction arthrodesis cannot completely relieve the lateral heel pain because calcaneo-fibular impingement and peroneal tendinopathy are important contributions to the pain. Lateral decompression with soft tissue debridement and lateral calcaneal ostectomy is essential surgical component in order to achieve optimal outcome [42, 44, 45, 47, 57]. Most of the major complications associated with lateral calcaneal decompression are related to complications associated with the lengthy incisions and extensive soft tissue dissection including wound necrosis and recurrence of the symptoms due to fibrosis, painful scar formation, or peroneal tendons adhesions [50]. Endoscopic lateral calcaneal decompression for Sander type I calcaneal malunions has been proposed by Lui in order to reduce these complications [52]. This endoscopic approach starts with posterior subtalar arthroscopy, the soft tissue envelop is stripped from the lateral calcaneal cortex in order to create a working area for subsequent lateral calcaneal ostectomy. This subperiosteal approach can minimize the risk of wound complications, sural nerve injury or peroneal tendons injury. Beside accurate bone and soft tissue decompression and peroneal tendons decompression, this endoscopic approach allows assessment and treatment of concomitant pathologies of the posterior subtalar joint. Arthroscopic subtalar arthrodesis can be performed through the same approach. The endoscopic lateral decompression can be performed with the patient in supine or prone position, depending on the presence of concomitant anterior or posterior ankle impingement. Respective anterior arthroscopic or posterior endoscopic ankle decompression can be performed together with the endoscopic lateral calcaneal decompression [53].

192

The technical details of the two-portal endoscopic technique for the treatment of the calcaneo-fibular impingement after calcaneal malunion are described below.

6.3.2 Indications Symptomatic calcaneo-fibular impingement after thalamic type calcaneal fractures.

P. A. J. de Leeuw et al.

6.3.4 Author Preferred Technique 6.3.4.1 Preoperative Planning Calcaneo-fibular impingement should be demonstrated clinically. Lateral and axial radiographs of the calcaneus can confirm the diagnosis. Computed tomogram is useful for preoperative planning by locating the lateral cortical bulge, position of the peroneal tendons, and extent of subtalar osteoarthritis (Fig. 6.19). Magnetic resonance imaging may be indicated if peroneal tendon problems are suspected [58].

6.3.3 Contra-Indications [58] • Other causes of lateral heel pain including peroneal tendon problems, calcaneocuboid arthrosis, symptomatic hardware, and/or sural nerve problems. • The calcaneo-fibular impingement is due to hindfoot valgus malalignment rather than lateral calcaneal bulge. • There is significant calcaneal deformity warranting open corrective osteotomy.

Fig. 6.19  Computed tomogram with 2D coronal reconstruction is useful for assessment of the calcaneo-fibular impingement and lateral subtalar joint degenerative changes

6  Posterior Subtalar Arthroscopy

6.3.4.2 Patient Positioning The patient is in lateral position. The operation is performed under general anesthesia with a popliteal block. A thigh tourniquet (300 mmHg) is applied for a bloodless surgical field. 6.3.4.3 Portal Design The procedure is performed with two subtalar portals (Fig. 6.20). The anterolateral portal locates 2 cm anterior and 1  cm distal to the lateral malleolar tip, which is just anterior to the sinus tarsi. Skin portal incision is made and followed by blunt dissection of the subcutaneous tissue with a mosquito clamp. A blunt-tipped trocar is introduced pointing posteriorly and inferiorly until the underlying bone is reached. The trocar is then advanced posteriorly along the bone surface. The soft tissue and peroneal tendons are progressively peeled off from the lateral ­

Fig. 6.20  Two-portals endoscopic lateral calcaneal decompression

193

c­ alcaneal wall to create a working space under the lateral malleolar tip. A 4.0 mm arthroscope is then introduced via the anterolateral portal. The other portal is the posterolateral subtalar portal. It is located with a spinal needle under arthroscopic visualization. The portal is 2 cm posterior and 1 cm distal to the lateral malleolar tip. The locations of the portals should be modified according to the exact location of the lateral calcaneal exostosis and to the position of the peroneal tendons. By palpating the lateral aspect of the hindfoot, anatomical landmarks are recognized from anterior to posterior: sinus tarsi, lateral malleolar tip, peroneal tendons, tendo Achilles. The anterior and posterior margins of the lateral calcaneal prominence are palpated and the portals are created 1 cm from the margins in order to create a working space around the prominence and assess its exact extent.

194

6.3.4.4 Step-By-Step Description of the Technique • Firstly, scar tissue and fibrosis on the subtalar joint and lateral calcaneal cortex of the calcaneus and around the lateral malleolus is resected. This is performed with a 4.5  mm shaver. The portals are interchangeable as the viewing and working portals. The anatomic landmarks including the sinus tarsi, the posterior subtalar joint, the lateral malleolar tip, and the peroneal tendons are examined in sequence from anterior to posterior. • The peroneal tendons are frequently laterally subluxed over the lateral malleolar tip because of the calcaneal malunion. They are carefully released from the retrofibular groove distally. With the scope in the posterolateral portal the peroneal tendons are then progressively released from the tip of the malleolus and the retromalleolar groove. There is always a thick fibrotic tissue around the tendons and it is always necessary to perform a partial resection of the distal part of the superior peroneal retinaculum to open the space. In almost 50% of the patients, a complete

Fig. 6.21  Endoscopic lateral calcaneal ostectomy with a burr. a: lateral calcaneal wall

P. A. J. de Leeuw et al.









resection of the retinaculum is necessary to obtain a complete release of the tendons. Lastly, the lateral calcaneal bone prominence around the lateral malleolus is resected with a motorized burr (Fig.  6.21). The resection is considered adequate if the subtalar joint space can be clearly visualized and the 5.0 mm burr can pass through the space between the calcaneus and the lateral malleolar tip easily. Finally, the peroneal tendons are examined again to make sure that there is no more bony or soft tissue impingement on the tendons. The peroneal tendons can be examined for any tear or degeneration with peroneal tendoscopy via the posterolateral portal. Concomitant procedures of the posterior subtalar joint including loose bodies removal, resection of degenerated lateral part of the joint (Fig.  6.22), or arthroscopic arthrodesis can be performed if indicated via the same portals. 20 mL of ropivacaïne 7.5% is injected after closure of the portal incisions.

Fig. 6.22  Endoscopic resection of the degenerated lateral part of the posterior subtalar joint. a: talar facet; b: calcaneal facet; and c: posterior subtalar joint

6  Posterior Subtalar Arthroscopy

6.3.4.5 Complications and Management [58] • Sural nerve injury • Peroneal tendon injury • Posterior subtalar joint injury • Residual impingement 6.3.4.6 Postoperative Care Postoperatively, free mobilization and immediate full weight bearing as tolerated is authorized if lateral decompression is the sole procedure. If subtalar arthrodesis is also performed, cast immobilization and non-weight bearing for 45 days is instructed. 6.3.4.7 Outcome Material and Methods Fifteen patients with symptomatic calcaneo-fibular impingement following thalamic type calcaneal fractures that was treated with endoscopic lateral calcaneal decompression were retrospectively reviewed. All the patients suffering from calcaneo-fibular impingement were included whatever the fracture was fixed or not and even if there were complications after surgery (infection, wound necrosis). Preoperative clinical assessment included determination of the location of pain (calcaneo-­fibular impingement syndrome, deep hindfoot pain), motion range of the ankle joint and hindfoot alignment on full weight bearing. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot functional score was also charted before the operation [59]. Preoperative computed tomogram with 2D coronal reconstructions was performed to assess the configuration of calcaneo-fibular bony impingement, details of the peroneal tendons (dislocated from the retromalleolar groove or not), osteoarthritis of the subtalar joint and to classify the calcaneal malunion according to the Stephen and Sanders classification [48]. The mean follow-up was 2 years (12–90 months). At latest follow-up, the clinical assessment was repeated and a satisfaction survey was conducted (very satisfied, satisfied,

195

poorly satisfied, and dissatisfied). Statistical analysis was performed on continuous variables using a Fisher’s Exact Test. Results Six patients were very satisfied with the surgical outcome, seven were satisfied, and two were not satisfied. Pain and local tenderness at the lateral malleolar tip was subsided in all the patients. The AOFAS score improved from an overall mean preoperative score of 47 (SD = 18) to a mean postoperative score of 68.5 (SD  =  13) (NS). The 2 patients who were not satisfied had persistent deep pain with a positive forced hindfoot valgus test. Follow-up CT scan showed an incomplete resection of the lateral subtalar osteoarthritis. Arthroscopic resection of the degenerated lateral part of the subtalar joint and release of the peroneal tendons were performed a year later. After 9  months, the patients had no calcaneo-­ fibular impingement symptom and only experienced very mild deep subtalar pain when walking. There were two minor complications recorded. One patient had transient sural nerve hypoesthesia and one patient had superficial wound infection which was successfully treated with oral antibiotic.

6.3.5 Summary The two-portal endoscopic lateral calcaneal decompression is very efficient surgical treatment to relieve symptoms of calcaneo-fibular impingement following calcaneal malunion. Through the same endoscopic approach, assessment and treatment of concomitant subtalar lesions is possible. This technique forms an important component of “symptom-­ focusing” surgical treatment of most of calcaneal malunions. Although there was no significant improvement in the overall hindfoot functional scores, most of the patients were satisfied with the final clinical outcome after endoscopic lateral calcaneal decompression [60].

196

6.4

P. A. J. de Leeuw et al.

 rthroscopic Subtalar Release A for Post-Traumatic Arthrofibrosis of the Posterior Subtalar Joint

intra-articular or painful retained internal metallic fixation requiring removal, and avascular osteonecrosis of the subtalar joint posterior facet are all contraindications to arthroscopic release of post-traumatic subtalar joint arthrofibrosis.

Thomas S. Roukis

6.4.1 Introduction The optimal treatment of displaced intra-articular fractures of the calcaneus remains elusive [61–65]. Myriad factors that might influence the clinical results of calcaneal fracture treatment have been reported, and anatomical reduction of the subtalar joint posterior facet articular surface does not guarantee an improved clinical outcome [61–65]. Arthrofibrosis is a known complication following traumatic injury to the subtalar joint [66–69]. In addition to osseous impingement from malaligned articular surfaces, fibrosis of the interosseous ligaments within the sinus tarsi [70] and nerve impingement can occur [71]. Similar to other human joints, arthroscopic release of symptomatic arthrofibrosis through debridement, arthrolysis, and osseous prominence resection of the sinus tarsi to liberate the posterior facet of the subtalar joint has been proposed [2, 52, 54, 60, 72–80].

6.4.2 Indications Arthrofibrosis of the subtalar joint is believed to result from an exaggerated local fibrotic healing response following traumatic injury or surgery. It is characterized by painful and globally restricted joint range of motion with a soft endpoint [81]. Tethering of the peroneal tendons to the lateral wall of the calcaneus, the so-called sub-fibular calcaneal impingement, is frequently associated with arthrofibrosis of the subtalar joint and should be addressed when identified [52, 54, 60, 74, 80]. Arthroscopic release of the subtalar joint is indicated when patients who have failed conservative care options including physiotherapy, insole, shoe modifications, and local corticosteroid injection continue with painful impingement and limitation of motion that result in functional impairment.

6.4.3 Contraindications Contraindications include those germane to any surgery including active infection, active chronic pain syndromes, peripheral vascular disease insufficient to allow healing, lymphedema obscuring soft tissue and osseous topographic landmarks, and restricted range of motion secondary to advanced post-traumatic degenerative joint disease. Specific to the subtalar joint, hostile or heavily scarred soft tissues,

6.4.4 Author’s Preferred Technique 6.4.4.1 Preoperative Planning Proper diagnosis is paramount prior to treating post-­ traumatic arthrofibrosis of the subtalar joint arthroscopically. A thorough clinical examination is always important and should include non-weight bearing and weight bearing analysis of the foot with particular attention paid to the midfoot and hindfoot. Palpation and range of motion of the subtalar joint are performed with special attention paid to the anterior process of the calcaneus and calcaneocuboid joint especially when this articulation was involved in the fracture pattern. Additionally, the sinus tarsi should be palpated and provocative testing performed by compressing this region while simultaneously inverting and everting the hindfoot. Apprehension with reproduction of the patient’s symptoms with this test implicates impingement but does not confirm whether this is purely soft tissue, osseous, or a combination of these. Finally, the posterior subtalar joint line is palpated noting the quality and quantity of subtalar joint mobility, as well as any subluxation or tethering of the peroneal tendons to the underlying calcaneus. Fullness, induration, pain with palpation, as well as clicking or catching/ locking with range of motion are assessed and compared to the contralateral foot. Careful comparison to the contralateral foot is obligatory. If the patient has undergone surgical intervention, the location and mobility of incision(s) should be determined. Specific to postoperative arthrofibrosis, a thorough review of the prior medical records including operative report should be conducted to determine if anything of importance but not identified on clinical examination could be pertinent. Weight bearing anterior-posterior, oblique, and lateral foot radiographs should be obtained. Calcaneal axial [82] and Bröden’s views from 0 to 40° in 10° increments [83] are helpful in assessing calcaneal morphology, as well as the posterior, middle, and anterior subtalar joint articulations, respectively. Collectively, these radiographic views allow rather complete evaluation of the subtalar joint complex for any contributing osseous pathology, as well as a determination of the overall osseous functional alignment and complement the clinical exam. Comparison with the contralateral uninvolved foot to determine the patient’s specific normal calcaneal morphology can be useful. Computerized tomography without contrast is routinely employed to assess for pathology not identified on clinical examination and/or plain film radiographs and plan treatment.

6  Posterior Subtalar Arthroscopy

Fluoroscopic-guided intra-articular radiopaque contrast with the addition of local anesthesia and short-acting corticosteroid is useful for several reasons. First, local anesthetic verified as deposited intra-articular can confirm that the pathology responsible for the patient’s pain is truly intra-­ articular. Second, the corticosteroid can reduce inflammation and foster improved ability to tolerate and progress through physiotherapy. Finally, the radiopaque contrast outline of the joint can demonstrate cartilaginous defects, synovial thickening, and overall working space in the joint.

6.4.4.2 Patient Positioning The patient is positioned on the operating room table in the supine position with a gel-positioning roll under their ipsilateral thigh to control physiologic external rotation of their lower extremity. If the operating room table cannot be rotated

197

enough to safely allow access to the lateral hindfoot, then either a surgical assistant to manually hold the leg internally rotated or a beanbag with the patient partially rolled into a lateral position should be employed. Regardless of position, their heel should partially hang off the end of the table to facilitate drainage of fluid into the arthroscopic drape collection bag, as well as ease mobility of the mini C-arm image intensification should this be required during the procedure. All pertinent equipment should be placed on a large Mayo stand adjacent to the surgeon for easy access. The author prefers the patient to be under general and regional local anesthesia with a thigh tourniquet employed for a bloodless field should this arise. To reduce infection risk, the forefoot is covered with a sterile incise adhesive barrier [84], and the arthroscopic drape collection bag is applied such that the least amount of skin is exposed.

198

6.4.4.3 Portal Design As with all foot and ankle arthroscopic approaches, iatrogenic damage to regional nerves, vessels, and tendon structures represents the greatest concern with subtalar joint arthroscopy. Fortunately, the safety of lateral subtalar joint arthroscopy portals to access the sinus tarsi, posterior facet, and lateral calcaneal wall has been studied in detail [2, 73, 84–86]. The main portals are the anterior, middle, and posterior portals [2, 73, 84–87] with additional accessory anterior [86], medial [3], and posterior hindfoot [7, 88] portals possible should adjacent osseous structures and/or articulations require access. Specific to arthroscopic subtalar release for post-traumatic fibrosis, only the anterior and middle portals are routinely employed (Fig. 6.23). The anterior portal is identified just below and approximately 2.5 cm distal to the tip of the fibula. This incision is between 17 mm [2] and 21 mm [84] from the nearest nerve, specifically the intermediate dorsal cutaneous branch of the superficial peroneal nerve or dorsolateral cutaneous nerve branch of the sural nerve. The middle portal is identified directly over the sinus tarsi approximately 1 cm anterior to the tip of the fibula. This incision is 21  mm [84] from the same nerves identified for the anterior portal.

P. A. J. de Leeuw et al.

Fig. 6.23  Intraoperative photograph demonstrating placement of a small joint full-radius shaver in the anterior portal and a 4 mm, 30° arthroscope in the middle portal during performance of an arthroscopic release of post-traumatic subtalar joint arthrofibrosis

6  Posterior Subtalar Arthroscopy

199

6.4.4.4 Step-by-Step Description of the Technique Arthroscopy of the subtalar joint is traditionally performed with a 2.7 mm 30° or similar-sized arthroscope; however, for practical reasons the author prefers to employ a 4 mm 30° arthroscope. First, the field of view is greater, which facilitates identification of intra-articular structures and therefore orientation. Second, the equipment is more robust and can sustain more forceful manipulation with less risk of being damaged. Third, the volume of fluid delivered/time is more than with smaller arthroscopic equipment, which is better able to distend the taught capsule and maintain a functional working space. Finally, most facilities have numerous sets of 4  mm 30° arthroscopes and equipment, whereas smaller arthroscopes and equipment are in short supply. The middle portal is established first. The axis of the sinus tarsi is identified by first marking out the lateral malleolus and then identifying and marking the calcanealcuboid joint which is performed by first dorsiflexing the foot at the ankle to 90° and carrying an imaginary line from the anterior crest of the tibia to the lateral aspect of the sole of the foot as previously described [89, 90]. The sinus tarsi is located midway between the distal-anterior tip of the lateral malleolus and the calcaneal-cuboid joint. An 18 gauge spinal needle is inserted into sinus tarsi and advanced medially with a slight posterior and plantar angulation until it is felt on the medial side of the foot near the sustentaculum tali inferior to the medial malleolus. Verification of the proper location within the sinus tarsi involves several maneuvers. First, the foot is first dorsiflexed and plantarflexed multiple times, and then the hindfoot is inverted and everted multiple times. If the Steinmann Pin is truly within the sinus tarsi and not the ankle joint which lies in a

close proximity, the pin will not move with dorsiflexion and plantarflexion since this represents ankle motion and instead it will move with inversion and eversion of the hindfoot since this represents subtalar motion. If there is any doubt, then the use of image intensification will verify proper placement within the sinus tarsi and not the ankle joint. A 35 cc syringe is then connected to the 18 gauge spinal needle. Although controversial [91, 92], the author prefers bupivacaine 0.25% with 1:200,000 epinephrine to insufflate the sinus tarsi. After verifying the location of the middle portal, a small amount of local anesthesia is deposited directly subcutaneous at this location. The e­ pinephrine creates blanching of the skin and facilitates maintenance of location identified for the middle portal incision, which is performed with a No. 11 scalpel blade. This is followed by insertion of a straight hemostat through the soft tissues and capsule in standard “nick-and-spread” technique. The hemostat is advanced from lateral to medial across the sinus tarsi while maintaining direct contact with the dorsal surface of the calcaneus to minimize iatrogenic cartilage injury. The hemostat is repeatedly mobilized in a proximal and distal manner similar to how a windshield wiper moves across the windshield to release fibrous adhesions directly off the underlying bone and facilitate creation of a working space within the sinus tarsi. A blunt-tipped trocar and cannula are inserted through the middle portal employing the same pathway as created with the hemostat. The cannula is maintained in the joint overlying the calcaneus, and the trocar is removed. The arthroscope is inserted into the cannula, and the joint contents are visualized. Patience is obligatory as identification of any known structure can be thoroughly frustrating since visualization is routinely suboptimal analogous to driving through a blizzard (Fig. 6.24).

b

Fig. 6.24  Intra-articular arthroscopic image through the middle portal demonstrating the sinus tarsi filled with fibrotic and synovitic tissues (a). The visualization is analogous to the limited visibility that occurs while driving through a blizzard (b)

200

Next, the anterior portal is identified just below and approximately 2.5 cm distal to the tip of the fibula, and the location is confirmed through visualization of an 18 gauge needle inserted into the sinus tarsi at this location. After verifying the location that affords repeated direct access through the anterior portal into the sinus tarsi, a small amount of local anesthesia is deposited directly subcutaneous at this location for the reasons mentioned previously. This is followed by insertion of a straight hemostat through the soft tissues and capsule in standard “nick-and-spread” technique until it comes into view (Fig. 6.25). The image is focused with the focal point being the hemostat itself. The hemostat is moved in dorsal-plantar and proximal-distal directions, and these motions are compared with what is shown on the video screen. The camera is rotated until the motions of the hemostat and those shown on the video screen are identical thereby achieving proper orientation. The light cord is rotated as needed to keep the instrumentation and areas of interest in view. Next, the hemostat is withdrawn, and an arthroscopic small joint full-radius shaver (Fig.  6.26) or radiofrequency wand (Fig. 6.27) is inserted into the joint and employed to resect acute and chronic synovitis, as well as fibrotic tissues. Soft tissue resection continues until the entire posterior facet of the subtalar joint and sinus tarsi can be visualized (Fig. 6.28). It is important to place the subtalar joint through its full range of motion to verify that no soft tissue or osseous (Fig. 6.29) impingement remains, as well as to document the final motion available. Osseous pathology that impedes the subtalar joint (Fig.  6.30) or tethers the peroneal tendons

P. A. J. de Leeuw et al.

Fig. 6.26  Visualization of a small joint full-radius shaver within the sinus tarsi. The 4 mm, 30° arthroscope is in the middle portal and the shaver through the anterior portal

Fig. 6.27  Visualization of a radiofrequency wand within the sinus tarsi and advanced along the anterior aspect of the talar body adjacent to the posterior facet of the subtalar joint. The 4 mm, 30° arthroscope is in the middle portal and the wand through the anterior portal

Fig. 6.25  Visualization of the small straight hemostat within the sinus tarsi. The 4 mm, 30° arthroscope is in the middle portal and the hemostat through the anterior portal

(Fig. 6.31) should be resected until unrestricted motion to the limits available is achieved. After removal of the arthroscopic equipment, the incisions are closed in two layers, specifically the subdermal tissues with absorbable suture and the skin edges with nonabsorbable sutures.

6  Posterior Subtalar Arthroscopy Fig. 6.28 Arthroscopic image montage following debridement of the subtalar joint posterior facet (left side of image) and sinus tarsi (right side of image). The talus is at the top and the calcaneus the bottom of the image

201 Superior Lateral

Medial Inferior

Fig. 6.29 Computed tomography 2D (top row) and 3D (bottom row) images demonstrating osseous impingement within the sinus tarsi secondary to malunion of a calcaneal fracture

6.4.4.5 Complications and Management The most common complication following arthroscopic subtalar release for post-traumatic arthrofibrosis is neurological injury that can have an unpredictable course but usually resolves without intervention. Failure to access and/or achieve complete debridement of the pathologic soft tissue or osseous pathology is possible but preventable by properly recognizing situations that are not amenable to an arthroscopic approach preoperatively, employing accessory portals liberally or converting to an open approach intraoperatively once recognized. Iatrogenic cartilage injury to the subtalar joint posterior facet is possible especially during the index soft tissue resection when visualization is the most compromised but is minimized through meticulous technique. Finally, incision healing problems leading to tethering of tendons to the skin or delayed wound healing can occur with improper portal location or excessive manipulation of the soft tissue envelope.

6.4.4.6 Postoperative Care A Sir Robert Jones compression dressing is applied to control edema and immobilize the foot until suture removal [93]. Encouraging immediate full-protected weight bearing in a postoperative shoe minimizes recurrent arthrofibrosis. Once the sutures are removed at 2 to 3 weeks postoperative, the patient is enrolled into a structured physiotherapy program to achieve functional restoration of the subtalar joint range of motion. 6.4.4.7 Outcome Pooling of the data available in multiple small case series [2, 52, 54, 60, 72–80] reveals that arthroscopic release of post-­ traumatic subtalar joint arthrofibrosis has favorable outcomes. Pain resolution and meaningful improvement in function, albeit with limited improvement in range of motion, occurs. This parallels the author’s experience.

202

P. A. J. de Leeuw et al.

6.4.5 Summary Arthroscopic release of symptomatic arthrofibrosis through debridement, arthrolysis, and osseous prominence resection of the sinus tarsi and subtalar joint posterior facet was first described more than 30 years ago. The available literature

demonstrates routinely favorable outcomes, but formal comparative effectiveness data is lacking and warrants further investigation. As with all arthroscopic procedures, strict adherence to proper portal development and the principles of joint arthroscopy are obligatory.

a

b

c

d

Fig. 6.30  Arthroscopic visualization of the same osseous prominence shown in Fig. 6.29 within the sinus tarsi enmeshed in fibrotic tissues and abutting the talus, which is to the right (a). Following soft tissue debridement with a small joint full-radius shaver (b), an acromionizer is employed to resect the osseous prominence off the calcaneus (c). The

osseous resection is complete when no further impingement between the talus and calcaneus is achieved (d). Throughout these images, the 4 mm, 30° arthroscope is in the middle portal and the instruments through the anterior portal, the talus is at the top, calcaneus at the bottom, distal to the left, and proximal to the right

6  Posterior Subtalar Arthroscopy

203

a

b

c

d

Fig. 6.31 Arthroscopic visualization of osseous impingement and peroneal tendon tethering to the lateral wall of the calcaneus, which is to the left (a). Following soft tissue debridement with a small joint full-­ radius shaver, a small-shielded rotary burr is employed to resect the osseous prominence (b). The soft tissue debridement and osseous

resection are complete (c) when no further impingement or tethering of the peroneal tendons is achieved (d). Throughout these images, the 4 mm, 30° arthroscope is in the middle portal and the instruments through the anterior portal

204

6.5

P. A. J. de Leeuw et al.

 rthroscopic Subtalar Arthrodesis: A Lateral vs Posterior Approaches

Phinit  Phisitkul, Davide  Edoardo  Bonasia, Annunziato (Ned) Amendola

6.5.4 Author’s Preferred Technique and

6.5.1 Introduction Subtalar arthritis is a disabling condition that can interfere with patient quality of life due to pain, swelling, stiffness, and inability to accommodate uneven terrains. Open arthrodesis of the subtalar joint is an accepted standard of treatment for this condition, but the surgery can be associated with postoperative pain, sural nerve dysesthesia, wound dehiscence, and unsightly scar [94]. With the expanding indication in subtalar arthroscopy, the arthrodesis can be accomplished in a minimally invasive fashion with the aim of expedited postoperative recovery, minimized pain, and low complications [95–102]. Subtalar joint can be readily approached from lateral or posterior aspects, and the arthrodesis can be performed through either approach depending on surgeon experience and clinical settings. Familiarity with both approaches will allow surgeons to maximize the advantage of arthroscopy for the care of patients with subtalar pathologies.

6.5.2 Indications Generally, the patients should be treated with nonsurgical measures including anti-inflammatory medication, orthoses, physical therapy, and possibly cortisone injections prior to consideration of subtalar arthrodesis. Conditions that may benefit from arthroscopic subtalar arthrodesis include subtalar arthritis, symptomatic talocalcaneal coalition in adults, advanced adult-acquired flatfoot deformity with an unstable or rigid subtalar joint, and neuromuscular diseases with hindfoot deformity [103].

6.5.3 Contraindications Absolute contraindications include overlying infection and vascular insufficiency. Relative contraindications include joint ankyloses, bone loss, previous nonunion or malunion, and severe joint deformity [103]. Joint ankyloses may not have enough working area for arthroscopic procedures. Previous malunion or nonunion generally requires more extensive dissection or bore resection. Severe deformities are not amendable for arthroscopic approach due to the requirement of extensive soft tissue release and bony decompression with possible osteotomies.

Generally, posterior arthroscopic subtalar arthrodesis (PASTA) is preferred for isolated subtalar arthritis. The procedure is technically easier as the working area is further away from skin minimizing arthroscopic dislodgement. In addition, the contour of the joint as a saddle-shaped structure is more in line with the access from posterior allowing full access to the joint, while the lateral approach may have some limitation reaching the posteromedial corner. In addition, in cases with joint subluxation or congenital deformities, the joint might be situated more proximally, and the access may be impeded by the tip of the fibula. The lateral approach has a clear advantage in patients who require adjunctive procedures to be performed in supine position such as an anterior ankle arthroscopy, midfoot osteotomies, etc. On the other hand, patients with posterior ankle impingement will benefit from a posterior approach as the same posterior portals can be used for posterior ankle arthroscopy [104].

6.5.4.1 Preoperative Planning Weight bearing radiographs of the ankle and hindfoot are paramount for the diagnosis of subtalar arthritis. Saltzman hindfoot view is particularly helpful in the assessment of hindfoot deformity [105]. CT scan is critical in the assessment of osseous deformity such as impinging bone spurs, cystic lesions, or osseous coalitions [106]. MRI is helpful in the evaluation of cartilage damage, subchondral bone edema, accessory facets, and associated conditions such as OCD lesions of the talus or peroneal tendon pathologies [107, 108]. Patients with an equivocal clinical presentation may benefit from a diagnostic injection with a local anesthetic with or without cortisone. The results of injections should take into account the normal communications between ankle and subtalar joint in 14% of cases [109]. Patients should have a screening for other conditions that may impede the successful bone union such as poorly controlled diabetes, vitamin D deficiency, and smoking. Ideally all the patients should have HbA1c of 7 or less, vitamin D of 30 or more, and abstinence from tobacco of at least 4 weeks [110–112]. 6.5.4.2 Instrumentation The same set of instrumentation is applicable for both lateral and posterior approaches. Standard 4 mm 30° arthroscope is used together with normal saline irrigation. The fluid pump pressure is usually set at 40 mmHg or less to minimize fluid extravasation. A bone-cutting shaver of 4–4.5 mm is required together with a 4–4.5 mm barrel burr. Noninvasive joint distraction is not required.

6  Posterior Subtalar Arthroscopy

6.5.4.3 Lateral Approach Patient Positioning While the subtalar joint is approached from the lateral aspect, supine positioning with a bump behind the buttock to allow internal rotation of the leg is preferred. The patient should be place toward the end of the bed. A thigh tourniquet is routinely used. The surgeon performs the procedure in sitting position.

205

Portal Design Anterolateral, middle, and accessory posterolateral portals are used (Fig. 6.32).

Fig. 6.32  Arthroscopic portals for lateral approach to the subtalar joint (A, anterolateral, 1 cm distal and 2 cm anterior to the fibula tip; B, middle, just distal to the fibula tip; C, accessory posterolateral, just posterior to the peroneal tendons and just proximal to the fibula tip)

206

P. A. J. de Leeuw et al.

Step-by-Step Description of the Technique • A 4 mm arthroscope is inserted into the anterior recess of the posterior subtalar joint through an anterolateral portal. A shaver is inserted from the middle portal. • The cartilage is debrided from both calcaneal and talar facets using a shaver. The debridement is advanced from anterolateral to posteromedial (Figs.  6.33 and 6.34). When joint distraction is required, an accessory posterolateral portal is created. An 18 gauge hypodermic needle is used to guide this portal placement toward the joint line. An arthroscopic trocar is inserted from the accessory posterolateral portal to wedge the joint opened. • Once the cartilage is completely removed from the anterior half of the joint, a barrel bur is then inserted from the middle portal to create vascular channels on both surfaces of the subchondral bone (Fig. 6.35). • The posterior aspect of the joint is then approached with the arthroscope inserted from the middle portal and shaver

from the accessory posterolateral portal. The arthroscopic trocar is wedged into the joint from the anterolateral portal. The cartilage is removed, and the subchondral bone is prepared in the same fashion as the anterior half of the joint. • Optionally, demineralized bone matrix is then injected into the joint under direct visualization to fill any bone voids. • The foot is held in neutral or with a slight valgus heel alignment. • Fixation is performed using two cannulated screws. One screw is placed from the anterior aspect of the talar neck into the calcaneal tuberosity and the other from the posterior aspect of the calcaneal tuberosity into the talar body (Fig. 6.36). An additional screw from the neck of the calcaneus to the talar neck may be considered to enhance fixation. Irritation from the screw heads can be minimized by an adequate countersinking or preferably by using headless screws.

Fig. 6.33  Right subtalar joint after partial debridement of cartilage from the anterior aspect

Fig. 6.34  Right subtalar joint after complete cartilage debridement

6  Posterior Subtalar Arthroscopy

Fig. 6.35  Subchondral bone is prepared using a barrel burr

207

Fig. 6.36  Postoperative radiograph showing a typical hardware configuration from lateral approach

208

P. A. J. de Leeuw et al.

6.5.4.4 Posterior Approach Patient Positioning The patient is placed in prone position after a thigh tourniquet is applied. Gel rolls are used to support the patient’s torso. The patient is positioned toward the end of the bed with the feet just beyond it. The surgeon stands and operates from the end of bed. Portal Design Posterolateral, posteromedial, and accessory posterolateral portals are used (Fig. 6.37).

Fig. 6.37  Arthroscopic portals for posterior approach to the subtalar joint (A, posteromedial, just medial to the Achilles tendon and just proximal to the fibula tip; B, posterolateral, just medial to the Achilles tendon and just proximal to the fibula tip; C, accessory posterolateral, just posterior to the peroneal tendons and just proximal to the fibula tip)

6  Posterior Subtalar Arthroscopy

Step-by-Step Description of the Technique • A 4 mm arthroscope is inserted into the posterior aspect of the subtalar joint through a posterolateral portal. A shaver is inserted from the posteromedial portal. It is critical that the shaver is inserted and directed laterally toward the shaft of the arthroscopic cannula and then advanced anteriorly along with it. • The flexor hallucis longus tendon is then identified in the deep plane just posterior to the ankle joint by debriding fibrofatty tissue with the shaver. The flexor hallucis longus tendon will be used as a landmark to avoid an injury to the neurovascular structures immediately medial to it. • The cartilage is debrided from both calcaneal and talar facets using a shaver (Fig.  6.38). The debridement is advanced from posterior to anterior. When joint distraction is required, an accessory posterolateral portal is created at the location about 1  cm proximal to the posterolateral portal and immediately posterior to the peroneal tendon sheath. An 18 gauge hypodermic needle is used to guide this portal placement toward the joint line. An arthroscopic trocar is inserted from this accessory portal to wedge the joint opened. • Once the cartilage is completely removed from the posterior half of the joint, a barrel bur is then inserted from the posterolateral portal to create vascular channels on both surfaces of the subchondral bone (Fig. 6.39). • The anterior aspect of the joint is then approached with the arthroscope inserted from the posterolateral portal and shaver from the accessory posterolateral portal. The trocar

Fig. 6.38  Posterior view of the left subtalar joint (arrow) in an adult patient with a painful talocalcaneal coalition visualized through the posterolateral portal (star = flexor hallucis longus tendon)

209

Fig. 6.39  The posterior aspect of the left subtalar joint after a complete debridement visualized through the posterolateral portal. The arrow indicates an arthroscopic trocar inserted from the accessory posterolateral portal

is then placed into the posteromedial portal and wedged into the posteromedial aspect of the subtalar joint. The cartilage is removed, and the subchondral bone is prepared in the same fashion as the posterior half of the joint. • Optionally, demineralized bone matrix is then injected into the joint under direct visualization to fill any bone voids (Fig. 6.40). • The foot is held in neutral or with a slight valgus heel alignment. • Fixation is performed using two cannulated screws from the posterior aspect of the calcaneal tuberosity into the talar body (Fig. 6.41). An additional screw from the neck of the calcaneus to the talar neck may be considered to enhance fixation. Irritation from the screw heads can be minimized by an adequate countersinking or preferably by using headless screws.

6.5.4.5 Complications and Management Anatomical cadaver studies identified the anatomical structures in close proximity to the posterior and lateral portals for hindfoot arthroscopy. With the insertion of cannulas in posterolateral and posteromedial portals, the average cannula-­to-structure distance is on average 3.2  mm for the sural nerve, 4.8 mm for the small saphenous vein, 6.4 mm for the tibial nerve, 9.6 mm for the posterior tibial artery, 17 mm for the medial calcaneal nerve, and 2.7 mm for the flexor hallucis longus tendon [113]. When using a two-portal lateral (anterior and middle) approach to arthroscopic subtalar

210

P. A. J. de Leeuw et al.

An 8.5% complication rate was described in 186 patients undergoing posterior hindfoot arthroscopy for different conditions. These complications included plantar numbness (2.1%), Achilles tendon tightness (2.1%), sural nerve dysesthesia (1.6%), infection (1.1%), complex regional pain syndrome (1.1%), and posteromedial portal cyst (0.5%) [114]. When looking only at patients undergoing arthroscopic subtalar arthrodesis, complications may occur in up to 30% of the cases, with no significant difference compared to open arthrodesis (45%, p > 0.05). Complications after arthroscopic arthrodesis include painful hardware (13.0%), nonunion (5.8%), sural nerve dysesthesia (5.8%), painful scar (2.9%), and complex regional pain syndrome/neuropathic pain (1.5%) [99]. The complication rate does not seem to differ when arthroscopic arthrodesis is performed for adult-­acquired flatfoot deformity or post-traumatic arthritis [101]. While painful hardware can be easily removed after union and the other complications can be managed conservatively, nonunion is challenging and often requires open revision with autologous bone grafting and, sometimes, biological stimulation. Fig. 6.40  Demineralized bone matrix is injected to fill bone voids

6.5.4.6 Postoperative Care The postoperative care is identical for both approaches. The patient is immobilized using a plaster splint for 2 weeks followed by a cast for 4 weeks. Partial weight bearing in a boot together with gentle ankle motion is allowed at 6 weeks. The patient can resume full weight bearing at 10  weeks. At 12 weeks, the patient can use normal shoes and can progress activities as tolerated.

Fig. 6.41  Postoperative radiograph showing a typical hardware configuration from posterior approach

arthrodesis, the portal-to-nerve distances are on average 12  mm (range 4–24  mm) for the sural nerve and 17  mm (range 4–35 mm) for the superficial peroneal nerve. No vessels are usually at risk with this approach, but the peroneal tendon sheath and peroneus brevis tendon can be breached in up to 10% of the cases [87].

6.5.4.7 Outcomes In 2003, Tasto reported his series of 25 patients, undergoing lateral arthroscopic subtalar arthrodesis in lateral decubitus position and with anterolateral and posterolateral portals. At an average follow-up of 22 months, all 25 patients had clinical and radiographic union, with average time to union of 8.9 weeks [100]. In 2007, Glanzmann and Sanhueza-Hernandez described the results of 41 arthroscopic subtalar fusions, in 37 consecutive patients. The authors used anterolateral and posterolateral portals in a supine position. The average modified AOFAS ankle-hindfoot score improved from 53 points preoperatively to 84 at final follow-up (55 months). Union was achieved in all cases. Radiographic progression of degeneration in the adjacent joints was observed in three patients [115]. Rungprai et al. described the outcomes after open versus posterior arthroscopic subtalar arthrodesis in 121 patients. Both groups demonstrated significant improvement in visual analog scale (VAS) for pain, Short Form (SF)-36, Foot Function Index (FFI), and Angus and Cowell rating scores. There were no significant differences within the groups with respect to union rate and time to union among the various

6  Posterior Subtalar Arthroscopy

sizes of screws and types of bone graft. However, time to union, return to work, activities of daily living, and sports activities were significantly shorter for the arthroscopic arthrodesis group [99]. Vilá-Rico et  al. retrospectively reviewed 65 patients undergoing posterior arthroscopic subtalar arthrodesis, with a mean follow-up of 57.5 months. The authors described a 95.4% union rate after an average of 12.1 weeks. The AOFAS score improved from an average of 51.5 points preoperatively to 81.9 points after surgery [102]. Similar results were described in a smaller case series (19 patients) of posterior arthroscopic subtalar arthrodeses [98].

211

6.5.5 Summary Arthroscopic subtalar arthrodesis is a highly successful operation that allows a thorough joint preparation with minimal soft tissue stripping. Posterior approach is technically easier, but lateral approach permits other adjunctive procedures without repositioning. Complete awareness of the neurovascular anatomy is crucial for the safety of the procedures. While the bone union is quite predictable, the patients need to be counseled regarding hardware-related symptoms.

212

6.6

P. A. J. de Leeuw et al.

Arthroscopic Resection of Talocalcaneal Coalition

Davide  Deledda, Annunziato  (Ned)  Phinit Phisitkul, and Davide Edoardo Bonasia

Amendola,

6.6.1 Introduction Tarsal coalitions are not uncommon pathologies of the hindfoot, usually characterized by congenital abnormal fusion of two tarsal bones. In 1890, Leboucq described a failure of segmentation of the mesenchymal anlage of hindfoot bones during the embryonal period due to an autosomal dominant inheritance [9, 116]. Although most coalitions remain asymptomatic, in some cases these can become painful both in pediatric and adult patients [117]. Based on the tissue forming the coalitions, these can be divided into synostosis (bone), synchondrosis (cartilage), and syndesmosis (fibrous tissue). Tarsal coalitions occur in 1–6% of the population and are bilateral in approximately 50–60% of the cases [118]. The most common tarsal coalitions are talocalcaneal (TCCs) and calcaneonavicular coalitions (CNCs), representing 53% and 37% of all tarsal coalitions, respectively [119]. The clinical presentation and symptoms are fundamental in the decision making. While asymptomatic TCC should be observed or treated conservatively, the treatment of painful coalitions is still controversial. Currently, the first-line approach is conservative, including activity modification, orthoses, nonsteroidal anti-inflammatory drugs, physical

therapy, and cast immobilization in case of severe pain [118]. Many open treatments have been described in case of conservative management failure, including open resection, subtalar fusion, and triple arthrodesis. For a correct surgical indication, the surgeon has to take into account multiple parameters, including age and activity level of the patient, size of the coalition, and degeneration of the subtalar and surrounding joints. Based on the size of the TCC and articular degeneration of the subtalar/tarsal joints, TCC excision is indicated with a coalition of 50% of the subtalar joint or subtalar degeneration; triple arthrodesis is indicated when tarsal joint arthritis is present [120]. The age of the patient is another important aspect to be considered. In young and active patients with intact subtalar joint surfaces, an effort should be made to preserve subtalar motion with coalition excision. In case of persistent pain despite adequate coalition resection, subsequent fusion can always be considered. In the past years, many techniques have been described using interposition material (i.e., fat, flexor longus of the hallux) in order to reduce recurrence of the coalition, but no technique has shown to be superior [118]. With the improvement of endoscopic/arthroscopic surgery of the foot and ankle, new techniques have been described for arthroscopic resection of CNC and TCC [120– 122]. The aim of these new techniques is to achieve adequate coalition resection with less perioperative morbidity and faster recovery. Although the arthroscopic posterior approach has proven to be safe, resection of tarsal coalition still remains a new experimental procedure.

6  Posterior Subtalar Arthroscopy

213

6.6.2 Indications

resection of TCC is contraindicated when the coalition affects middle and anterior facets, since these areas cannot The surgeon should check the intensity of symptoms and the be approached with posterior arthroscopy [120]. The pressubtalar joint surface degeneration. In mildly symptomatic ence or suspect of infection is an absolute contraindication cases, (not continuous or low-grade pain) activity modifica- [123]. Based on the imaging findings, degenerated subtalar tions, medial arch inlay supports, University of California cartilage and coalition involving more than 50% of the subBiomechanics Laboratory orthoses, nonsteroidal anti-­ talar joint are a contraindication for excision (arthroscopic or inflammatory drugs, and physical therapy should be sug- open). In these cases, subtalar fusion or triple arthrodesis gested. In cases of severe pain or persistent symptoms despite (depending on the condition of the surrounding joints) is adequate conservative management, a 4–6 weeks cast immo- indicated [118]. bilization is recommended [118, 120]. Another contraindication is previous extensive posterior The main indications for arthroscopic TCC coalition ankle surgery: fibrotic scar tissue does not allow a correct resection are (1) isolated posterior facet coalition arthroscopic access and could increase the risk of iatrogenic (Fig. 6.42), (2) involving less than 50% of the total joint neurovascular lesions. Previous surgery can be considered as surface, and (3) with preserved subtalar joint. In addition a relative contraindication. to conventional radiographic studies, MRI and CT scan are recommended in order to assess size, shape, location, and tissue of the coalition together with the quality of sub- 6.6.4 Author’s Preferred Technique talar cartilage [120].

6.6.3 Contraindications Posterior arthroscopic excision of talocalcaneal coalition has some contraindication. The main contraindication is absence of symptoms. Asymptomatic patients should be followed-up and treated only in case of pain. In addition arthroscopic

6.6.4.1 Preoperative Planning The preoperative planning should include weight bearing dorsal-plantar and lateral views (Fig. 6.42) together with a non-weight bearing 45° oblique view of both feet. The ­posterior hindfoot view may be useful to exclude tibiocalcaneal malalignment [105]. In order to better identify the talocalcaneal synostosis, a Harris-Beath view can be achieved. The patient is placed in a standing position,

a

Fig. 6.42 (a) Lateral view and (b) sagittal CT scan showing fibrous talocalcaneal coalition of the posterior subtalar joint

b

214

with parallel feet on the cassette and the knees flexed at about 40°. The X-ray beam is directed at the posterior aspect of the ankle joint, with an inclination angle of 35–45° [124]. CT scan is the gold standard imaging technique to assess the size and location of bony coalitions (Fig. 6.42), whereas

P. A. J. de Leeuw et al.

MRI is more useful to identify the soft tissue pattern of the nonosseous coalition, together with associated soft tissue pathologies [118].

6  Posterior Subtalar Arthroscopy

215

6.6.4.2 Patient Positioning and Anesthesia Anesthesia could be general with regional or spinal block . Intravenous antibiotic prophylaxis is administered with cefazolin (2  g for adults and 30  mg/kg for children). The patient is positioned prone with the feet hanging off the operative table. Soft padding should be placed under the head, chest, and knees. A tourniquet is positioned at the thigh, proximally (Fig. 6.43a).

of a successful subtalar instillation). A longitudinal skin incision is made, and a smooth instrument is inserted toward the subtalar joint. The arthroscope is then inserted into the lateral recess of the subtalar joint. While performing posterior arthroscopy, the most important landmark is the flexor hallucis longus tendon (FHL). The FHL tendon should always be kept in medially, to protect the neurovascular bundle during the procedure. Flexion/extension maneuvers of the great toe helps the surgeon in identifying the FHL tendon. Then, the posteromedial (PM) portal can be established: this should be performed at the same level as the PL portal but medial and tangential to the Achilles tendon (Fig.  6.43c). A needle is inserted to mark the PM portal (Figs. 6.43c and 6.44a); it is important to ensure the portal is lateral to the FHL (Fig. 6.44b). Also for the PM portal, a longitudinal skin incision is made, and then blunt dissection is used to enter the ankle/subtalar joint. The instruments can then be switched from one portal to the other (Fig. 6.43d).

6.6.4.3 Portal Design The first portal is the posterolateral (PL). In order to determinate the correct portal position, the surgeon should mark the edges of the Achilles tendon and the medial and the lateral malleoli with a surgical pen. While the ankle is in the neutral position, a line parallel to the foot sole is drawn from the tip of the lateral malleolus to the Achilles tendon (Fig. 6.43b). The PL portal is placed in the corner above this line, adjacent to the Achilles tendon (Fig.  6.43b). The subtalar joint is injected with saline (inversion of the foot is the indirect sign

a

b

Fig. 6.43 (a) The patient is positioned prone with the feet hanging off the operative table. Soft padding should be placed under the head, chest, and knees. (b) Posteromedial (PM) and posterolateral (PL) portal

c

d

placement (see text). (c) PM portal placement under direct visualization. (d) The instruments can then be switched from one portal to the other

216

P. A. J. de Leeuw et al.

a

b

c

d

Fig. 6.44  Left foot. (a) PM portal placement under direct visualization. (b) Identification of the flexor hallucis longus (FHL) that should be kept medial throughout the whole procedure. (c) Identification of the

tibia (T) and talus (Ta). (d) Identification of the posterior inferior tibiofibular ligament (PITFL)

6  Posterior Subtalar Arthroscopy

6.6.4.4 Step-by-Step Description of the Technique The first step is synovectomy of the ankle/subtalar joint. This is performed with a shaver in order to correct, visualize, and approach the coalition (Fig. 6.44b). The arthroscope is passed above the posterior talofibular ligament (PTFL) and below the posterior inferior tibiofibular ligament (PITFL), to perform a global arthroscopic evaluation of the ankle joint (Figs.  6.44c, d, and 6.45). The arthroscope is then moved distally at the level of the PTFL and the posterolateral process (PLP) of the talus. The subtalar joint is located just distal to the PTFL and PLP. The subtalar joint is located 5 mm below the PTFL talar insertion. In case of osseous coalitions, identifying the subtalar joint can be challenging, and these landmarks can be extremely useful (Fig. 6.46a). In case of nonosseous coalitions, some degree of subtalar motion can be preserved, helping the surgeon in identifying the joint level. This can be done by inserting a probe or a freer elevator in the subtalar joint. Then, coalition resection a

c

217

can be performed; during this phase and during most of the surgery, the arthroscope is in the PL portal. To excise the coalition, the surgeon alternates the burr and shaver. The excision proceeds from posterior to anterior, until healthy cartilage is visualized (Fig. 6.46b–d). The excision can be extended laterally and medially, to complete the resection. In order to approach the anteromedial area of the coalition, the posteromedial corner of the subtalar joint needs to be removed. This is done with the arthroscope in the PL portal and the PM portal as the working portal. This allows for a creation of a 5 mm trough between the FHL and the medial aspect of the subtalar joint. The burr can then be advanced anteromedially. The last step is the evaluation of the excision and the cartilage condition. The healthy cartilage should be visualized from posterior to anterior, and the subtalar joint should be mobile. Motion can be tested with a smooth instrument levering the joint (Fig. 6.46e, f). In case of a correct motion, the excision can be considered adequate. Using the shaver, residual bony or cartilage fragments are removed, and the surfaces are smoothened. b

d

Fig. 6.45  Left foot. (a) A probe is used to elevate the posterior inferior tibiofibular ligament (PITFL) and inspect the ankle joint, including the (b) medial, (c) central, and (d) lateral portions. MM medial malleolus, LM lateral malleolus

218

P. A. J. de Leeuw et al.

a

b

c

d

e

f

Fig. 6.46  Left foot. (a) Identification of the talocalcaneal coalition (TCC). (b) Keeping the flexor hallucis longus (FHL) medial, a burr is used to excise the coalition medially and (c) laterally. (d) Once the

whole coalition is removed and healthy subtalar joint cartilage is visualized, the motion of the subtalar joint is checked with a probe (e, f) in order to make sure that adequate resection has been made

6  Posterior Subtalar Arthroscopy

219

6.6.4.5 Complications and Management In the literature, no complications have been described concerning the arthroscopic TCCs resection, since only case reports and technical noted are available. Regarding posterior ankle/subtalar arthroscopy, an 8% rate of complications was reported, including plantar numbness, sural nerve temporary tingling, Achilles tendon or FHL damages, local site infections, neurovascular lesions, and portal delayed healing [114, 123]. On the other hand, complications specifically related to open coalition resection include persistent symptoms and recurrence of the coalition.

AOFAS score from 23 preoperatively to 82 after surgery [121]. Knorr et al. described that the AOFAS score improved from 58 preoperatively to 91 points at last follow-up [125]. Similarly, Bernardino et al. reported a 55-point preoperative AOFAS score and 100 points at last follow-up [126]. The endoscopic techniques seem to be safe with good results, for both CNCs and TCCs. Compared to the open surgery, the arthroscopic approach requires a longer surgical time and a longer learning curve but has the potential advantage of reducing invasiveness and complications.

6.6.4.6 Postoperative Care After the surgery the patient can be discharged the same day (outpatient surgery). Range of motion (active motion of the ankle and passive motion of the first ray, to maintain the correct sliding of the FHL) exercises are allowed immediately together with weight bearing as tolerated. A postoperative boot is generally used to protect the joint, and reduce local pain and swelling, for 4 weeks. After 4 weeks the boot can be gradually dismissed, and full daily activities are resumed. Sports can be allowed 12 weeks after surgery.

6.6.5 Summary

6.6.4.7 Outcomes While open resection for both CNC and TCC is a widely accepted procedure with correct indications, arthroscopic excision can still be considered experimental. For CNC endoscopic resection, only a few case series have been published. Some authors described the outcomes of one to three cases of endoscopic resection of CNCs at short-term follow­up. Bauer et  al. [121] described an improvement of the

Arthroscopic resection for talocalcaneal coalitions is still an experimental procedure. Only few case reports are available in the literature. However, the results seem to be a promising with the theoretical advantages of reduced invasiveness and less comorbidities compared with open techniques. On the other hand, arthroscopic resection for talocalcaneal coalitions requires a long learning curve and is technically demanding. Larger case series and medium- to long-term follow-up studies are needed to better assess the results of this procedure. Competing Interests None. Funding None. The authors have nothing to disclose regarding the present chapter.

220

P. A. J. de Leeuw et al.

23. Gougoulias N, Khanna A, McBride DJ, Maffulli N. Management of calcaneal fractures: systematic review of randomized trials. Br Med Bull. 2009;92:153–67. 1. Parisien JS. Arthroscopic surgery. New York: McGraw-Hill; 1988. 24. Swanson SA, Clare MP, Sanders RW.  Management of 2. Frey CC, Gasser S, Feder KS. Arthroscopy of the subtalar joint. intra-­ articular fractures of the calcaneus. Foot Ankle Clin. Foot Ankle Int. 1994;15(8):424–8. 2008;13(4):659–78. 3. Mekhail AO, Heck BE, Ebraheim NA, Jackson WT. Arthroscopy 25. Abidi NA, Dhawan S, Gruen GS, Vogt MT, Conti SF.  Wound-­ of the subtalar joint: establishing a medial portal. Foot Ankle Int. healing risk factors after open reduction and internal fixation of 1995;16(7):427–32. calcaneal fractures. Foot Ankle Int. 1998;19(12):856–61. 4. Ferkel RD. Subtalar arthroscopy. In: Foot and ankle arthroscopy. 26. DeWall M, Henderson CE, McKinley TO, Phelps T, Dolan 2nd ed. Philadelphia: Wolters Kluwer; 1996. p. 335–52. L, Marsh JL.  Percutaneous reduction and fixation of dis 5. van Dijk CN, Scholten PE, Krips R.  A 2-portal endoscopic placed intra-articular calcaneus fractures. J Orthop Trauma. approach for diagnosis and treatment of posterior ankle pathol2010;24(8):466–72. ogy. Arthroscopy. 2000;16(8):871–6. 27. Kikuchi C, Charlton TP, Thordarson DB.  Limited sinus tarsi 6. Van Dijk CN, De Leeuw PA, Scholten PE.  Hindfoot endosapproach for intra-articular calcaneus fractures. Foot Ankle Int. copy for posterior ankle impingement. J Bone Joint Surg Am. 2013;34(12):1689–94. 2009;91(Suppl 2):287–98. 28. Kline AJ, Anderson RB, Davis WH, Jones CP, Cohen BE. Minimally 7. Beimers L, de Leeuw PA, van Dijk CN. A 3-portal approach for invasive technique versus an extensile lateral approach for intraarthroscopic subtalar arthrodesis. Knee Surg Sports Traumatol articular calcaneal fractures. Foot Ankle Int. 2013;34(6):773–80. Arthrosc. 2009;17(7):830–4. 29. Rammelt S, Amlang M, Barthel S, Gavlik JM, Zwipp 8. Ehrlich MG, Elmer EB.  Tarsal coalition. In: Jahss MH, ediH. Percutaneous treatment of less severe intra-articular calcaneal tor. Disorders of the foot and ankle. 2nd ed. Philadelphia: WB fractures. Clin Orthop Relat Res. 2010;468(4):983–90. Saunders; 1991. p. 921–8. 30. Tomesen T, Biert J, Frölke JP.  Treatment of displaced intra-­ 9. Leonard MA. The inheritance of tarsal coalition and its relationarticular calcaneal fractures with closed reduction and percutaneship to spastic flat foot. J Bone Joint Surg Br. 1974;56(3):520–6. ous screw fixation. J Bone Joint Surg Am. 2011;93(10):920–8. 10. Snyder RB, Lipscomb AB, Johnston RK.  The relationship of 31. Wang Q, Chen W, Su Y, et  al. Minimally invasive treatment of tarsal coalitions to ankle sprains in athletes. Am J Sports Med. calcaneal fracture by percutaneous leverage, anatomical plate, 1981;9(5):313–7. and compression bolts: the clinical evaluation of cohort of 156 11. Stormont DM, Peterson HA. The relative incidence of tarsal coalipatients. J Trauma. 2010;69(6):1515–22. tion. Clin Orthop Relat Res. 1983;181:28–36. 32. Wu Z, Su Y, Chen W, et al. Functional outcome of displaced intra-­ 12. Kerkhoffs GM, van den Bekerom M, Elders LA, van Beek articular calcaneal fractures: a comparison between open reducPA, Hullegie WA, Bloemers GM, de Heus EM, Loogman MC, tion/internal fixation and a minimally invasive approach featured Rosenbrand KC, Kuipers T. Diagnosis, treatment and prevention an anatomical plate and compression bolts. J Trauma Acute Care of ankle sprains: an evidence-based clinical guideline. Br J Sports Surg. 2012;73(3):743–51. Med. 2012;46(12):854–60. 33. Hsu AR, Anderson RB, Cohne BE. Advances in surgical manage 13. van Sterkenburg MN, Groot M, Sierevelt IN, Spennacchio PA, ment of intra-articular calcaneus Fractures. J Am Acad Orthop Kerkhoffs GM, van Dijk CN.  Optimization of portal placement Surg. 2015;23(7):399–407. for endoscopic calcaneoplasty. Arthroscopy. 2011;27(8):1110–7. 34. Woon CY, Chong KW, Yeo W, Eng-Meng Yeo N, Wong 14. Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, MK. Subtalar arthroscopy and fluoroscopy in percutaneous fixaThorogood M, Lamb SE, UK Heel Fracture Trial Investigators. tion of intra-articular calcaneal fractures: the best of both worlds. Operative versus non-operative treatment for closed, displaced, J Trauma. 2011;71(4):917–25. intra-articular fractures of the calcaneus: randomized controlled 35. Sivakumar BS, Wong P, Dick CG, Steer RA, Tetsworth trial. BMJ. 2014;349:g4483. K. Arthroscopic reduction and percutaneous fixation of selected 15. Buckley R.  Operative care did not benefit closed, displaced, calcaneus fractures: surgical technique and early results. J Orthop intra-articular calcaneal fractures. J Bone Joint Surg Am. Trauma. 2014;28(10):569–76. 2015;97(4):341. 36. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment 16. Pierce CJ, Wong KL, Calder JD.  Calcaneal fractures: selection in 120 displaced intraarticular calcaneal fractures. Results using a bias is key. Bone Joint J. 2015;97-B(7):880–2. prognostic computed tomography scan classification. Clin Orthop 17. Randle JA, Kreder HJ, Stephen D, Williams J, Jaglal S, Hu Relat Res. 1993;290:87–95. R.  Should calcaneal fractures be treated surgically? A meta-­ 37. Munoz G, Eckholt S. Subtalar arthroscopy: indications, technique analysis. Clin Orthop Relat Res. 2000;377:217–27. and results. Foot Ankle Clin. 2015;20(1):93–108. 18. Thordarson DB, Krieger LE. Operative vs nonoperative treatment 38. Pastides PS, Milnes L, Rosenfeld PF. Percutaneous arthroscopic of intra-articular fractures of the calcaneus: a prospective randomcalcaneal osteosynthesis: a minimally invasive technique for ized trial. Foot Ankle Int. 1996;17(1):2–9. displaced intra-articular calcaneal fractures. J Foot Ankle Surg. 19. Agren PH, Wretenberg P, Sayed-Noor AS. Operative versus non-­ 2015;54(5):798–804. operative treatment of displaced intra-articular calcaneal frac- 39. Lim EV, Leung JP. Complications of intraarticular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J tures. Clin Orthop Relat Res. 2001;391:7–16. Bone Joint Surg Am. 2013;95(15):1351–7. 40. Reddy V, Fukuda T, Ptaszek AJ.  Calcaneus malunion and non 20. Ibrahim T, Rowsell M, Rennie W, Brown AR, Taylor GJ, Gregg union. Foot Ankle Clin N Am. 2007;12:125–35. PJ. Displaced intra-articular calcaneal fractures: 15-year follow- 41. Kitaoka HB, Schaap EJ, Chao EY, An KN.  Displaced intra-­ ­up of a randomized controlled trial of conservative versus operaarticular fractures of the calcaneus treated non-operatively: tive treatment. Injury. 2007;38(7):848–55. clinical results and analysis of motion and ground reaction and 21. Buckley RE, Tough S.  Displaced intra-articular calcaneal fractemporal forces. J Bone Joint Surg Am. 1994;76:1531–40. tures. J Am Acad Orthop Surg. 2004;12(3):172–8. 42. Carr JB. Mechanism and pathoanatomy of the intraarticular calca 22. Gardner MJ, Nork SE, Barei DP, Kramer PA, Sangeorzan BJ, neal fracture. Clin Orthop Relat Res. 1993;290:36–40. Benirschke SK. Secondary soft tissue compromise in tongue-type 43. Isbister JF. Calcaneo-fibular abutment following crush fractures of calcaneus fractures. J Orthop Trauma. 2008;22(7):439–45. the calcaneus. J Bone Joint Surg Br. 1974;56:274–8.

References

6  Posterior Subtalar Arthroscopy 44. Braly GW, Bishop JO, Tullos HS. Lateral decompression for malunited os calcis fractures. Foot Ankle. 1985;6:90–2. 45. Chandler JT, Bonar SK, Anderson RB, Davis WH. Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures. Foot Ankle Int. 1999;20:18–24. 46. Crosby LA, Fitzgibbons T. Intraarticular calcaneal fractures results of closed treatment. Clin Orthop Relat Res. 1993;290:47–54. 47. Savva N, Saxby TS. In situ arthrodesis with lateral-wall ostectomy for the sequelae of fracture of the os calcis. J Bone Joint Surg Br. 2007;89:919–24. 48. Stephens HM, Sanders R. Calcaneal malunions: results of a prognostic computed tomography classification system. Foot Ankle Int. 1996;17:395–401. 49. Carr JB, Hansen ST, Bernischke SK.  Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle. 1988;9:81–6. 50. Clare MP, Lee WE 3rd, Sanders RW.  Intermediate to long-term results of a treatment protocol for calcaneal fracture malunions. J Bone Joint Surg Am. 2005;87:963–73. 51. Romash MM.  Reconstructive osteotomy of the calcaneus with subtalar arthrodesis for malunited calcaneal fractures. Clin Orthop Relat Res. 1993;290:157–67. 52. Lui TH. Endoscopic lateral calcaneal ostectomy for calcaneofibular impingement. Arch Orthop Trauma Surg. 2007;127:265–7. 53. Lui TH. Posterior ankle impingement syndrome caused by malunion of joint depressed type calcaneal fracture. Knee Surg Sports Traumatol Arthrosc. 2008;16:687–9. 54. Lui TH, Chan KB.  Arthroscopic management of late complications of calcaneal fractures. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1293–9. 55. Stapleton JJ, Belczyk R, Zgonis T. Surgical treatment of calcaneal fracture malunions and posttraumatic deformities. Clin Podiatr Med Surg. 2009;26:79–90. 56. Huang PJ, Fu YC, Cheng YM, Lin SY. Subtalar arthrodesis for late sequelae of calcaneal fractures: fusion in situ versus fusion with sliding corrective osteotomy. Foot Ankle Int. 1999;20:166–70. 57. Robinson JF, Murphy GA.  Arthrodesis as salvage for calcaneal malunions. Foot Ankle Clin N Am. 2002;7:107–20. 58. Lui TH. Endoscopic management of calcaneofibular impingement and posterior ankle impingement syndrome secondary to malunion of joint depressed type calcaneal fracture. Arthrosc Tech. 2018;7(2):e71–6. 59. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M.  Clinical rating systems for the ankle-hindfoot, midfoot and lesser toes. Foot Ankle Int. 1994;15:349–53. 60. Bauer T, Deranlot J, Hardy P. Endoscopic treatment of calcaneo-­ fibular impingement. Knee Surg Sports Traumatol Arthrosc. 2011;19(1):131–6. 61. Jiang N, Lin QR, Diao XC, et al. Surgical versus nonsurgical treatment of displaced intra-articular calcaneal fracture: a meta-­analysis of current evidence base. Int Orthop. 2012;36(8):1615–22. 62. Alexandridis G, Gunning A, Leenen LP. Patient-reported health-­ related quality of life after a displaced intra-articular calcaneal fracture: a systematic review. World J Emerg Surg. 2015;10(1):62. https://doi.org/10.1186/s13017-015-0056-z. 63. De Boer AS, Van Lieshout EM, Den Hartog D, et al. Functional outcome and patient satisfaction after displaced intra-articular calcaneal fractures: a comparison among open, percutaneous and non-operative treatment. J Foot Ankle Surg. 2015;54(3):298–305. 64. Sharr PJ, Mangupli MM, Winson IG, et al. Current management options for displaced intra-articular calcaneal fractures: non-­ operative, ORIF, minimally invasive reduction and fixation or primary ORIF and subtalar arthrodesis. A contemporary review. Foot Ankle Surg. 2016;22(1):1–8. 65. Gusic N, Fedel I, Darabos N, et  al. Operative treatment of intraarticular calcaneal fractures: anatomical and functional outcome of three different operative techniques. Injury. 2015;46:S130–3.

221 66. Meyer JM, Lagier R. Post-traumatic sinus tarsi syndrome: an anatomical and radiological study. Acta Orthop. 1977;48(1):121–8. 67. Piccolo P, Sanfilippo A, Corsello C. La sindrome seno-tarsica in esiti a fratture di calcagno. Chirurgia del Piede. 1988;12:87–91. 68. Zwipp H, Bemmerl JG, Holch M, et  al. Sinus tarsi and canalis tarsi syndromes. A post-traumatic entity. Foot Ankle Surg. 1996;2(3):181–8. 69. Frey C, Feder KS, DiGiovanni C. Arthroscopic evaluation of the subtalar joint: does sinus tarsi syndrome exist? Foot Ankle Int. 1999;20(3):185–91. 70. Lektrakul N, Chung CB, Lai YM, et  al. Tarsal sinus: arthrographic, MR imaging, MR arthrographic and pathologic findings in cadavers and retrospective study data in patients with sinus tarsi syndrome. Radiology. 2001;219(3):802–10. 71. Rein S, Manthey S, Zwipp H, et al. Distribution of sensory nerve endings around the human sinus tarsi: a cadaver study. J Anat. 2014;224(4):499–508. 72. Goldberger MI, Conti SF. Clinical outcome after subtalar arthroscopy. Foot Ankle Int. 1998;19(7):462–5. 73. Williams MM, Ferkel RD. Subtalar arthroscopy: indications, technique and results. Arthroscopy. 1998;14(4):373–81. 74. Elgafy H, Ebraheim NA.  Subtalar arthroscopy for persistent subfibular pain after calcaneal fractures. Foot Ankle Int. 1999;20(7):422–7. 75. Oloff LM, Schulhofer SD, Bocko AP. Subtalar joint arthroscopy for sinus tarsi syndrome: a review of 29 cases. J Foot Ankle Surg. 2001;40(3):152–7. 76. Lui TH. Arthroscopic subtalar release of post-traumatic subtalar stiffness. Arthroscopy. 2006;22(12):1364–e1. 77. Lee KB, Bai LB, Song EK, et al. Subtalar arthroscopy for sinus tarsi syndrome: arthroscopic findings and clinical outcomes of 33 consecutive cases. Arthroscopy. 2008;24(10):1130–4. 78. Ahn JH, Lee SK, Kim KJ, et  al. Subtalar arthroscopic procedures for the treatment of subtalar pathologic conditions: 115 consecutive cases. Orthopedics. 2009;32(12):891. https://doi. org/10.3928/01477447-20091020-12. 79. Siddiqui MA, Chong KW, Yeo W, et al. Subtalar arthroscopy using a 2.4-mm zero-degree arthroscope indication, technical experience and results. Foot Ankle Spec. 2010;3(4):167–71. 80. Yoshimura I, Ichimura R, Kanazawa K, et al. Simultaneous use of lateral calcaneal ostectomy and subtalar arthroscopic debridement for residual pain after a calcaneal fracture. J Foot Ankle Surg. 2015;54(1):37–40. 81. Bösch U. Arthrofibrose. Orthopade. 2002;31(8):785–90. 82. Zhang T, Chen W, Su Y, et  al. Does axial view still play an important role in dealing with calcaneal fractures? BMC Surg. 2015;15(1):19. https://doi.org/10.1186/s12893-015-0004-6. 83. Kwon DG, Chung CY, Lee KM, et al. Revisit of Bröden’s view for intra-articular calcaneal fracture. Clin Orthop Surg. 2012;4(3):221–6. 84. Tryfonidis M, Whitfield CG, Charalambous CP, et al. The distance between the sural nerve and ideal portal placements in lateral subtalar arthroscopy: a cadaveric study. Foot Ankle Int. 2008;29(8):842–4. 85. Parisien JS, Vangsness T.  Arthroscopy of the subtalar joint: an experimental approach. Arthroscopy. 1985;1(1):53–7. 86. Lui TH, Chan KB, Chan LK. Portal safety and efficacy of anterior subtalar arthroscopy: a cadaveric study. Knee Surg Sports Traumatol Arthrosc. 2010;18(2):233–7. 87. Lintz F, Guillard C, Colin F, et  al. Safety and efficiency of a 2-­portal lateral approach to arthroscopic subtalar arthrodesis: a cadaveric study. Arthroscopy. 2013;29(7):1217–23. 88. Phisitkul P, Tochigi Y, Saltzman CL, et al. Arthroscopic visualization of the posterior subtalar joint in the prone position: a cadaver study. Arthroscopy. 2006;22(5):511–5. 89. Roukis TS.  Determining the insertion site for retrograde intramedullary nail fixation of tibiotalocalcaneal arthrodesis: a radiographic and intraoperative anatomical analysis. J Foot Ankle Surg. 2006;45(4):227–34.

222 90. Roukis TS, Granger D, Zgonis T. A simple technique for performing percutaneous fixation of fifth metatarsal base fractures. J Am Podiatr Med Assoc. 2007;97(3):244–5. 91. Webb ST, Ghosh S. Intra-articular bupivacaine: potentially chondrotoxic? Br J Anaesth. 2009;102(4):439–41. 92. Chu CR, Coyle CH, Chu CT, et al. In vivo effects of single intra-­ articular injection of 0.5% bupivacaine on articular cartilage. J Bone Joint Surg Am. 2010;92(3):599–608. 93. Schade VL, Roukis TS. Use of a surgical preparation and sterile dressing change during office visit treatment of chronic foot and ankle wounds decreases the incidence of infection and treatment costs. Foot Ankle Spec. 2008;1(3):147–54. 94. Tuijthof GJ, et  al. Overview of subtalar arthrodesis techniques: options, pitfalls and solutions. Foot Ankle Surg. 2010;16(3):107–16. 95. Albert A, et  al. Posterior arthroscopic subtalar arthrodesis: ten cases at one-year follow-up. Orthop Traumatol Surg Res. 2011;97(4):401–5. 96. Amendola A, et  al. Technique and early experience with posterior arthroscopic subtalar arthrodesis. Foot Ankle Int. 2007;28(3):298–302. 97. Lee KB, et  al. Arthroscopic subtalar arthrodesis using a posterior 2-portal approach in the prone position. Arthroscopy. 2010;26(2):230–8. 98. Martin Oliva X, et al. Posterior arthroscopic subtalar arthrodesis: clinical and radiologic review of 19 cases. J Foot Ankle Surg. 2017;56(3):543–6. 99. Rungprai C, et al. Outcomes and complications after open versus posterior arthroscopic subtalar arthrodesis in 121 patients. J Bone Joint Surg Am. 2016;98(8):636–46. 100. Tasto JP. Arthroscopy of the subtalar joint and arthroscopic subtalar arthrodesis. Instr Course Lect. 2006;55:555–64. 101. Vila y Rico J, et al. Results of arthroscopic subtalar arthrodesis for adult-acquired flatfoot deformity vs posttraumatic arthritis. Foot Ankle Int. 2016;37(2):198–204. 102. Vila-Rico J, et al. Subtalar arthroscopic arthrodesis: technique and outcomes. Foot Ankle Surg. 2017;23(1):9–15. 103. Roster B, Kreulen C, Giza E. Subtalar joint arthrodesis open and arthroscopic indications and surgical techniques. Foot Ankle Clin. 2015;20(2):319–34. 104. Smyth NA, et al. Posterior hindfoot arthroscopy: a review. Am J Sports Med. 2014;42(1):225–34. 105. Saltzman CL, el-Khoury GY. The hindfoot alignment view. Foot Ankle Int. 1995;16(9):572–6. 106. Wilde PH, et  al. Resection for symptomatic talocalcaneal coalition. J Bone Joint Surg Br. 1994;76(5):797–801. 107. Niki H, et  al. Accessory talar facet impingement in pathologic conditions of the peritalar region in adults. Foot Ankle Int. 2014;35(10):1006–14.

P. A. J. de Leeuw et al. 108. Park HJ, et al. Accuracy of MR findings in characterizing peroneal tendons disorders in comparison with surgery. Acta Radiol. 2012;53(7):795–801. 109. Carmont MR, et al. Variability of joint communications in the foot and ankle demonstrated by contrast-enhanced diagnostic injections. Foot Ankle Int. 2009;30(5):439–42. 110. Hikata T, et al. High preoperative hemoglobin A1c is a risk factor for surgical site infection after posterior thoracic and lumbar spinal instrumentation surgery. J Orthop Sci. 2014;19(2):223–8. 111. Michelson JD, Charlson MD. Vitamin D status in an elective orthopedic surgical population. Foot Ankle Int. 2016;37(2):186–91. 112. Truntzer J, et al. Smoking cessation and bone healing: optimal cessation timing. Eur J Orthop Surg Traumatol. 2015;25(2):211–5. 113. Sitler DF, et al. Posterior ankle arthroscopy: an anatomic study. J Bone Joint Surg Am. 2002;84-A(5):763–9. 114. Nickisch F, et al. Postoperative complications of posterior ankle and hindfoot arthroscopy. J Bone Joint Surg Am. 2012;94(5):439–46. 115. Glanzmann MC, Sanhueza-Hernandez R.  Arthroscopic subtalar arthrodesis for symptomatic osteoarthritis of the hindfoot: a prospective study of 41 cases. Foot Ankle Int. 2007;28(1):2–7. 116. Leboucq H. De la Soudure Congenitale de Certains Os du Tarse. Bull Acad R Med Belg. 1890;4:103–12. 117. Varner KE, Michelson JD. Tarsal coalition in adults. Foot Ankle. 2000;21:669–72. 118. Lemley F, Berlet G, Hill K, et al. Current concepts review: tarsal coalition. Foot Ankle Int. 2006;27:1163–9. 119. Wray JB, Herndon CN.  Hereditary transmission of congenital coalition of the calcaneus to the navicular. J Bone Joint Surg Am. 1963;45:365–72. 120. Bonasia DE, Phisitkul P, Saltzman CL, et al. Arthroscopic resection of talocalcaneal coalitions. Arthroscopy. 2011;27:430–5. 121. Bauer T, Golano P, Hardy P.  Endoscopic resection of a calcaneonavicular coalition. Knee Surg Sports Traumatol Arthrosc. 2010;18:669–72. 122. Lui TH. Arthroscopic resection of the calcaneonavicular coalition or the “too long” anterior process of the calcaneus. Arthroscopy. 2006;22:903.e1–4. 123. Nickisch F, Barg A, Saltzman CL, Beals TC, Bonasia DE, Phisitkul P, Femino JE, Amendola A. Posterior ankle and hindfoot arthroscopy. JBJS Essent Surg Tech. 2012;2(3):e15. 124. Harris RI, Beath T. Etiology of peroneal spastic flat foot. J Bone Joint Surg Br. 1948;30:624–34. 125. Knörr J, Accadbled F, Abid A, et al. Arthroscopic treatment of calcaneonavicular coalition in children. Orthop Traumatol Surg Res. 2011;97:565–8. 126. Bernardino CM, Golanó P, Garcia MA, et al. Experimental model in cadavera of arthroscopic resection of calcaneonavicular coalition and its first in-vivo application: preliminary communication. J Pediatr Orthop B. 2009;18:347–53.

7

Anterior Subtalar Arthroscopy Diane Hei Yan Tai, Tun Hing Lui, and Sally H. S. Cheng

Contents 7.1    An Overview of Approaches to the Anterior Subtalar Joint. . . . . . . . . . . . . . . . . . . . . . . . . . .  223 7.1.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  223 7.1.2  Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  224 7.1.3  Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  224 7.1.4  Author-Preferred Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  224 7.1.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  230 7.2    A Global View of Arthroscopic Management of Sinus Tarsi Syndrome. . . . . . . . . . . . . . . . . .  231 7.2.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  231 7.2.2  Indications of Arthroscopic Debridement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  232 7.2.3  Contraindications of Arthroscopic Debridement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  232 7.2.4  Author-Preferred Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  233 7.2.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  239 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  239

The corresponding author of Section 7.1 is Tun Hing Lui, e-mail: [email protected] The corresponding author of Section 7.2 is Tun Hing Lui, e-mail: [email protected]

7.1

 n Overview of Approaches A to the Anterior Subtalar Joint

Diane Hei Yan Tai and Tun Hing Lui

D. H. Y. Tai Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Hong Kong SAR, China T. H. Lui (*) Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China Department of Orthopaedics, Southern Medical University, Guangzhou, China Institute of Biomedicine and Biotechnology, Shenzhen Institutes of Advanced Technology—Chinese Academy of Science, Shenzhen, China Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Hong Kong, China S. H. S. Cheng Prince of Wales Hospital, Sha Tin, Hong Kong e-mail: [email protected]

7.1.1 Introduction 7.1.1.1 Anatomy The subtalar joint is made up of anterior and posterior articulations separated by the sinus tarsi and tarsal canal. The anterior subtalar joint, which is also known as the talocalcaneonavicular joint, which the talar head articulates with the socket composing of the calcaneonavicular (spring) ligament, the posterior facet of the navicular and the anterior and middle facets of the calcaneus. The posterior subtalar joint involves the concave posterior facet of the talus, which articulates with the convex posterior facet of calcaneus.

© Springer Nature Singapore Pte Ltd. 2019 T. H. Lui (ed.), Arthroscopy and Endoscopy of the Foot and Ankle, https://doi.org/10.1007/978-981-13-0429-3_7

223

224

These alternating convex and concave surfaces and strong ligaments give rise to a relatively stable subtalar joint as evidenced by relatively low rate of subtalar joint dislocation [1].

7.1.1.2 Biomechanics Isman [2] demonstrated that the subtalar joint axis in the anteroposterior plane is about 23° medially deviated from the midline of the foot; and in the lateral plane, it is about 41° from the horizontal axis. However, variations in this oblique axis occur [3, 4]. There are three potential mechanisms of motion within the subtalar joint: rotation about the axis, translation along the axis, and the combination of both. Inman [5] described that the subtalar joint is a screw-like rotatory movement between the talus and the calcaneus. It is believed that the motion is also accompanied by certain degree of translation. McMaster [6] reported that the range of motion at the subtalar joint was 30°: 25° of inversion and 5° of eversion. Lanz [7] described the range from 30° of inversion to 30° of eversion. It is also reported that the degree of inversion is found to be greater than that of eversion [8]. The biomechanics of the subtalar joint is best explained as the triple joint complex, as illustrated by Jastifer [9], which includes the subtalar joint, the talonavicular joint, and the calcaneocuboid joint. 7.1.1.3 Pathology The pathology of the anterior subtalar joint includes primary osteoarthritis, post-traumatic osteoarthritis (e.g., calcaneum fracture, talus fracture, and subtalar dislocation), inflammatory arthritis, talocalcaneal coalition, arthrofibrosis, and osteochondral lesions. Clinically, these pathologies can lead to pain which indicates procedures including synovectomy, microfracture of the osteochondral lesion, capsular release, arthrodesis, and resection of coalition. The anterior subtalar joint can be reached by open medial approach or arthroscopically. 7.1.1.4 Surgical Approaches Classically, the anterior subtalar joint can be exposed through an open medial approach [10]. Weinraub [11], De Wachter [12], and Jeng [13] described the modification of this approach as a single medial approach to triple arthrodesis, particularly in patients with flatfeet deformities where lateral incision could lead to wound healing problems [14]. These medial approaches allow exposure of medial part of the anterior subtalar joint. The exposure can be improved by transecting the interosseous ligament. It is feasible in case of triple arthrodesis but not for other indications. Furthermore, the soft tissue dissection is extensive. Arthroscopy of the posterior subtalar joint was first described by Parisien in 1986 [15]. At present, posterior subtalar arthroscopy is a well-established technique to treat posterior subtalar joint pathology [16]. However, the number of reports on the arthroscopic approach to anterior

D. H. Y. Tai et al.

s­ubtalar joint remains small. El Rassi [17] employed the arthroscopic approach to resect symptomatic talocalcaneal coalition and for synovectomy of this joint. Recently, Lui has reported arthroscopic approaches to access different parts of the talocalcaneonavicular joint [18–24]. The posterior border of the joint can be reached through the tarsal canal arthroscopy [21, 22]. The medial part of the joint can be approached through the medial subtalar arthroscopy [21, 22]. The lateral part of the joint can be accessed through the anterior subtalar arthroscopy [18, 19]. These together with the talonavicular arthroscopy [20] allow surgeons to approach different portions of the talocalcaneonavicular joint arthroscopically.

7.1.2 Indications • Synovectomy for post-traumatic or inflammatory arthritis of the joint [25] • Resection of symptomatic talocalcaneal coalition • Release of arthrofibrosis of the joint [23, 24] • Isolated arthrodesis of the joint or as part of the triple arthrodesis [20] • Repair of the spring ligament [26, 27] • Debridement and microfracture of the osteochondral lesions of the talar head

7.1.3 Contraindications • Active extra-articular infection surrounding the joint • Lack of expertise

7.1.4 Author-Preferred Technique 7.1.4.1 Preoperative Planning Careful preoperative clinical examination especially the location of tender spot is mandatory to locate the site of pathology and appropriate choice of arthroscopic approach to the joint. Preoperative radiographs, computed tomogram, and magnetic resonance imaging are useful investigation to study the pathology. 7.1.4.2 Patient Positioning If only anterior subtalar arthroscopy is performed, the patient is put in lateral or prone position depending on the concomitant procedures needed. Otherwise, the patient is in supine position with the legs spread. This position can allow all the arthroscopic approaches to the anterior subtalar joint. A thigh tourniquet is applied to provide a bloodless operative field. Fluid inflow is by gravity and no arthro-pump is used. No continuous traction is applied. A 2.7 mm 30° arthroscope is used for this procedure.

225

7  Anterior Subtalar Arthroscopy

7.1.4.3 Portal Design Arthroscopic approach Anterior subtalar arthroscopy Tarsal canal arthroscopy

Medial subtalar arthroscopy

Talonavicular arthroscopy

Access 1. Lateral-plantar part of the talar head 2. Lateral part of the anterior and middle calcaneal facet 3. Lateral part of the spring ligament 1. Sinus tarsi 2. Tarsal canal 3. Posterior part of the anterior subtalar joint 4. Anterior part of the posterior subtalar joint 5. Superficial root of the inferior extensor retinaculum 1. Sustentaculum tali 2. Medial and plantar part of the talar head 3. Medial part of the spring ligament 4. Plantar-medial part of the talonavicular joint

Portals Dorsolateral midtarsal portal Anterolateral subtalar portal Anterolateral portal Medial tarsal canal portal

Medial tarsal canal portal Medial midtarsal portal

Portal location Junction between the talonavicular and calcaneocuboid joint Just above the angle of Gissane Just above the angle of Gissane and along axis of the tarsal canal At the medial end of the tarsal canal and usually between the tibialis posterior and flexor digitorum longus tendons Between the tibialis posterior and flexor digitorum longus tendons At the medial corner of the talonavicular joint just above the insertion of the tibialis posterior tendon

Please refer to Sect. 8.1

It should be noted that the approaches of adjacent areas share the same portal. The anterolateral subtalar portal is shared by the anterior subtalar and tarsal canal arthroscopies. The medial tarsal canal portal is shared by the tarsal canal and medial subtalar arthroscopies. The medial midtarsal portal is shared by the talonavicular arthroscopy and medial subtalar arthroscopy. The dorsolateral midtarsal portal is shared by the anterior subtalar and talonavicular arthroscopy (Fig. 7.1).

Fig. 7.1  The dorsolateral midtarsal portal (a) is shared by the anterior subtalar and talonavicular arthroscopy

226

7.1.4.4 Step-by-Step Description of the Technique It is usually unnecessary to have all arthroscopic approaches performed at the same time except in the case of diffuse synovitis of the joint. The arthroscopic approaches chosen depend on the pathology and the site of symptoms.

D. H. Y. Tai et al.



• Anterior Subtalar Arthroscopy • The anterolateral subtalar portal is the viewing portal, and the dorsolateral midtarsal portal is the working portal (Fig. 7.2). • Three to 4 mm incisions are made at the portal sites. The subcutaneous tissue is bluntly dissected with a hemostat.





• •



• Fig. 7.2  Anterior subtalar arthroscopy is performed via the dorsolateral midtarsal (a) and anterolateral subtalar (b) portals. The anterolateral subtalar portal is the viewing portal and the dorsolateral midtarsal portal is the working portal

Fig. 7.3  Arthroscopic views of lateral side of the anterior subtalar joint. (A) talocalcaneal articulation between the talar head and the anterior/middle calcaneal facet. (B) Talonavicular articulation between the talar head and navicular bone. (a) Talar head, (b) anterior/ middle calcaneal facet, (c) spring ligament, and (d) navicular bone

The portal tracts are created by advancing the hemostat toward the anterior subtalar joint. The arthroscope via the anterolateral subtalar portal is advanced along the anterior edge of the posterior subtalar joint, just anterior to the posterior band of the interosseous ligament. The arthroscopic instrument via the dorsolateral midtarsal portal is advanced along the plantar lateral side of the talar head to the lateral edge of anterior subtalar joint. The important ligamentous structures of the sinus tarsi are sandwiched between the arthroscope and arthroscopic instrument. The lateral capsule of the anterior subtalar joint is resected with an arthroscopic shaver. It should be cautious not to damage the articular cartilage of the talar head. The capsular resection can be proceeded distally to expose the lateral part of the spring ligament (Fig. 7.3). Sometimes the plantar lateral part of the talonavicular joint can be exposed. However, it is usually limited by the hindering of the arthroscope by the ligaments of the sinus tarsi. Hindfoot inversion can open up the lateral joint line of the anterior subtalar joint. However, it is usually insufficient space for insertion of the arthroscopic instrument across the joint to the medial gutter without cartilage damage. The arthroscopic procedures that can be done include synovectomy of the lateral part of the joint, resection of tarsal coalition at this region, release of the fibrotic lateral capsule, arthrodesis of the joint, and repair of the lateral part of the spring ligament.

7  Anterior Subtalar Arthroscopy

Tarsal Canal Arthroscopy • Through posterior subtalar arthroscopy, the lateral portion of the tarsal canal is cleared up with an arthroscopic shaver via the anterolateral subtalar portal under visualization through the middle subtalar portal. • After the lateral opening of the tarsal canal is identified, a 2.7 mm Wissinger rod with blunt conical end is inserted into the canal via the anterolateral subtalar portal and pointed toward the medial malleolar tip. The foot should be pronated so that the medial end of the tarsal canal opens up and allows the passage of the rod and subsequently arthroscopic instrument. The rod should exit at the anterior corner of the medial end of the tarsal canal just behind the sustentaculum tali. • The rod should not exit at the posterior corner of the medial end of the tarsal canal as the portal tract will project posterior to the flexor digitorum longus tendon and may damage the flexor hallucis tendon and the medial plantar nerve.

a

Fig. 7.4 (A) A 2.7 mm Wissinger rod with blunt conical end is inserted into the tarsal canal via the anterolateral subtalar portal and exits through the medial end of the tarsal canal just behind the sustentaculum

227

• The position of the rod is checked with fluoroscopy. The medial tarsal canal portal is then made at the tip of the rod (Fig. 7.4). • The anterolateral subtalar portal and medial tarsal canal portal are coaxial portals and interchangeable as the viewing and working portals (Fig. 7.5). • The primary indication of this approach is synovectomy of the tarsal canal, the posterior gutter of anterior subtalar joint, and the anterior gutter of the posterior subtalar joint. It can also provide arthroscopic assessment of the medial fracture lines of calcaneal fracture during arthroscopically assisted reduction and fixation of calcaneal fracture. Moreover, the lateral wall of the sinus tarsi including the superficial root of inferior extensor retinaculum can be clearly seen via the medial tarsal canal portal. This allows complete debridement of the sinus tarsi and arthroscopic-­ assisted repair or reconstruction of the superficial root of the inferior extensor retinaculum.

b

tali. The medial tarsal canal portal is then made at the tip of the rod. (B) Model shows the position of medial opening of the tarsal canal

228

a

D. H. Y. Tai et al.

b

c

Fig. 7.5  Tarsal canal arthroscopy. (A) Anterolateral subtalar portal is the working portal. (B) Medial tarsal canal portal is the viewing portal. (C) The anterolateral subtalar and medial tarsal canal portals are coaxial portals

7  Anterior Subtalar Arthroscopy

Medial Subtalar Arthroscopy • The medial midtarsal and medial tarsal canal portals are interchangeable as the viewing and working portals (Fig. 7.6). • The medial part of the anterior subtalar joint, including the sustentaculum tali, medial part of the talar head, and the spring ligament can be examined via this arthroscopic approach (Fig. 7.7). • Ideally, the medial tarsal canal portal is located between the posterior tibial tendon and the flexor digitorum longus tendon [22]. It can be established by inside-out technique as described above or made just posterior to the tibialis posterior tendon and dorsal to the sustentaculum tali. • It should be recognized that the medial gutter of the anterior subtalar joint is a deep space and deep to the tendon sheaths of the posterior tibial and flexor digitorum longus tendons. Instrumentation via the medial tarsal canal portal should be first pointed laterally till it hits the bony structure and then slides distally just above the sustentaculum tali. This should be performed gently in order to avoid iatrogenic cartilage damage of the talar head.

229

• The medial midtarsal portal is slightly dorsal to the medial gutter of anterior subtalar joint. Instrumentation via this portal, besides should go deeply, should point slightly plantarward. The insertion should be gentle and just above the sustentaculum tali in order to avoid iatrogenic cartilage damage of the talar head and the medial plantar nerve. • Sometimes, it is easier to introduce the instrument via the medial midtarsal portal to the medial side of the talonavicular joint first. The instrument is then swabbed plantarly along the medial side of the talar head to the medial gutter of the anterior subtalar joint. This should be done gently to avoid iatrogenic cartilage damage of the talar head. • Synovectomy of the medial gutter of the anterior subtalar joint, debridement and microfracture of osteochondral lesion of the medial talar head, and resection of tarsal coalition of this region can be performed via this approach. • Arthroscopic release of the medial part of the anterior subtalar joint can be performed. It is important to release the medial capsule plantarly as dorsal release can damage the blood supply to the medial talar body [23].

Fig. 7.6  Medial subtalar arthroscopy is performed via the medial midtarsal (a) and medial tarsal canal (b) portals

Fig. 7.7  Arthroscopic view of medial subtalar arthroscopy. (a) Medial part of the talar head and (b) sustentaculum tali

230

Approach to the Spring Ligament • Approach to superomedial spring ligament: medial subtalar arthroscopy, talonavicular arthroscopy, and posterior tibial tendoscopy. • Approach to the inferoplantar longitudinal ligament: anterior subtalar arthroscopy and talonavicular arthroscopy. • Details of arthroscopic or endoscopic repair of the spring ligament [26, 27] are beyond the scope of this chapter.

D. H. Y. Tai et al.

3. Injury to the flexor digitorum longus tendon during establishment of the medial tarsal canal portal through the inside-out technique [22] 4. Injury to the ligamentous structures of the sinus tarsi

7.1.4.6 Postoperative Care Postoperative care should depend on the procedure performed. Immediate mobilization is instructed in case of arthroscopic release of the joint. In contrast, the foot should be immobilized in a cast for 6–8 weeks if arthroscopic arthrodesis is performed.

Talonavicular Arthroscopy Please refer to Sect. 8.1 for details of talonavicular arthroscopy.

7.1.5 Summary

7.1.4.5 Complications 1. Iatrogenic cartilage damage of the talar head 2. Iatrogenic nerve injury including sural nerve, the dorsal intermediate cutaneous branch of the superficial peroneal nerve, tibial nerve, and medial plantar nerve

Different arthroscopic approaches are used for different parts of the talocalcaneonavicular joint. Careful preoperative assessment and planning allow surgeon to formulate the most appropriate combination of arthroscopic approaches for the patient.

7  Anterior Subtalar Arthroscopy

7.2

 Global View of Arthroscopic A Management of Sinus Tarsi Syndrome

Sally H. S. Cheng and Tun Hing Lui

231

in an increase in the total range of movements above 2.6° in any of the three planes, and that could explain the observation that patients with STS rarely present an objective hindfoot instability despite giving way to a major complaint [34].

7.2.1.2 Pathoanatomy and Pathogenesis The sinus tarsi is located in the hindfoot as a cone-shaped 7.2.1 Introduction anatomical space courses with progressive narrowing from Sinus tarsi syndrome (STS) refers to a condition related to anterolateral to posteromedial direction, with the walls the inflammatory changes and ligamentous tears occurring formed by part of the talocalcaneonavicular joint and the in the hindfoot, characterized by lateral foot pain, which posterior subtalar joint, and is continuous with the tarsal may be associated with subjective feeling of instability in canal medially. The space consists of fatty tissues and artethe hindfoot. Patients with STS usually present with pain at rial anastomoses between anterior lateral malleolar and the lateral side of the hindfoot in the 3rd to 4th decades of proximal lateral tarsal arteries, but some have anastomoses life, although the exact incidence and the prevalence of the with distal lateral tarsal artery and peroneal artery as well condition are not well reported. The pain is aggravated dur- [35]. There are five ligaments in the sinus tarsi, namely, the ing walking on uneven surfaces with sense of hindfoot “giv- medial, the intermediate and the lateral roots of the inferior ing way” upon weight bearing, and the pain resolved when extensor retinaculum, the cervical ligament, and the talocalthe affected foot is at rest [28]. There is focal tenderness at caneal interosseous ligament and numerous free nerve endthe lateral opening of the sinus tarsi, and there will be no ings and mechanoreceptors [36]. Because of the abundant gross physical signs of mechanical instability. Moreover, neural elements present in the synovium, the sinus tarsi may STS can associate with other tendon and ligamentous inju- be not just a physical space but also as a station to detect the nociceptive and proprioceptive information of the foot and ries of the ankle. The “canalis tarsi syndrome” has been described as a ankle, and the STS may result from any of the pathologies more severe variant of the condition; it had been reported in causing disorders of nociception and proprioception. STS can be due to ligamentous injuries that result in synowhich the patient complains of pain on the medial aspect of vitis and scar tissue formation in the sinus tarsi. Hemorrhage the hindfoot together with the typical pain of the STS. Despite it being a common foot and ankle problem, it or inflammation of the synovial recesses of the sinus tarsi can remains a poorly understood condition in the foot and ankle also cause scarring without tears of the associated ligaments. world as there is no agreement on pathognomonic history, The presence of sensory nerve endings in the fat pad inside clinical tests, or confirmative imaging studies for establish- the sinus tarsi could be a source of pain in STS because of the abundance of free nerve endings [37]. The findings were ing the diagnosis or etiology [29]. In the past, some people thought that the STS seems to be echoed by another study, which showed traumatic neuroma an inaccurate term that should be replaced with a specific of the deep peroneal nerve branches that innervate the sinus diagnosis [30], but with more understanding of the patho-­ tarsi or any space occupying lesion including ganglion or anatomy and the pathogenesis of the condition, nowadays pigmented villonodular synovitis causing irrigation of the people believe that STS is a distinct clinical-pathologic nerve endings could be the source of recalcitrant lateral ankle pain [38, 39]. entity with characteristic imaging manifestations. Because of the dense venous plexus in the sinus tarsi draining from talus and the capsule of the posterior talocal7.2.1.1 Etiology Some authors related the clinical condition of STS with caneal joint, there was a suggestion that the post-traumatic instability of the subtalar joint [31], which was commonly fibrotic changes in the wall of the veins and the surrounding seen after injury in dancers and athletes and can be associ- tissue disturb the venous outflow with subsequent increase in ated with talipes equinovarus or flatfoot deformity or high intrasinusal pressure which could be one of the possible factors in the pathogenesis of the STS [35]. body mass index [32]. Majority of the patients with STS is associated with history of single or a series of ankle sprains with an inversion 7.2.1.3 Differential Diagnosis sprain being the most common predisposing injury [33]. Other important causes of the lateral ankle pain include ankle Those ankle sprains or strains may result in significant inju- syndesmosis or lateral ligament injury, peroneal tendon ries to the talocalcaneal interosseous ligament (TCIL) and abnormalities and nerve entrapments, ankle or hindfoot fraccervical ligaments (CL) with subsequent instability of the tures or nonunion, other osseous abnormalities, osteochonsubtalar joint. A study on three-plane kinesiology of hindfoot dral lesions, impingement syndromes, neuropathic processes instability showed that neither CL nor the TCIL tear resulted such as peripheral mononeuropathies, radiculopathy, reflex

232

sympathetic dystrophy, and other chronic inflammatory processes such as chronic juvenile arthritis, gout, and pigmented villonodular synovitis. These causes should be kept in mind in patients with intractable symptoms or unusual patterns of pain.

7.2.1.4 Investigation and Imaging Although STS is a clinical condition in which the diagnosis could usually be confirmed with a detailed history and physical examination, there is increasing demand for specific and sensitive diagnostic tools for the chronic disease in orthopedic medicine. The diagnostic test for the STS is to inject the local anesthetic into the sinus tarsi, and there will be cessation of pain soon after the injection. Standing X-rays may show associated flatfoot or cavus foot deformity. X-ray and CT may show osteoarthritis of the subtalar joint as a cause of lateral heel pain. Before the era of the sophisticated investigations we have nowadays, arthrograms of the posterior subtalar joint in patients with STS may demonstrate a saclike anterior capsular protrusion and obliteration of synovial recesses of the posterior subtalar joint secondary to synovial hyperplasia and by cicatricial remodeling of ligament tissue [40, 41]. Electromyographic study may show abnormalities of peronei function during walking [14]. Magnetic resonance imaging is an indispensable tool to evaluate the scar formation, fibrosis, subtalar joint chronic synovitis, or associated ligamentous injuries [33, 42–44] The T1-hyperintense fat signal in the sinus tarsi space is diminished as the fat is replaced by either scar (low T2-weighted signal) or edematous tissue in chronic synovitis or nonspecific inflammatory changes (high T2-weight signal), and the ligaments may be disrupted (Q). MRI is sensitive to demonstrate the occult ganglion cyst or multiple abnormal fluid collections consistent with synovial cysts in the sinus tarsi region. Initial and reconstructed MR arthrograms along and perpendicular to the sinus tarsal ligaments axes could enhance the sensitivity of the MRI evaluation of individual tarsal sinus structures and ligament status [45]. There is a study comparing MRI and ankle arthroscopy sensitivity and specificity; it showed that MRI is useful for detecting the CL tears, sinus tarsi fat alterations, and the synovial thickening but may not be sensitive enough to detect ITCL tears [46]. A recent study has shown that F-18 fluoride positron-emission tomography/computed tomography is a useful tool and has a substantial therapeutic impact on management in patients

D. H. Y. Tai et al.

with chronic foot pain without certain diagnosis after clinical examination [47].

7.2.1.5 Treatment and Prognosis Conservative treatment is successful in some minor cases. Treatment includes anti-inflammatory drugs, cryotherapy, and corticosteroid injection into the sinus tarsi which is usually considered first. Physiotherapy such as ankle balance and proprioceptive training and muscle strengthening exercises to correct the foot biomechanics can be considered. Thorough biomechanical evaluation of the lower limbs and feet and use of custom-molded ankle orthoses to protect, immobilize, or realign the associated deformed foot can be helpful [48, 49]. Serial casting may be useful in patients with STS presented with recalcitrant peroneal spastic flatfoot [50]. Surgical treatment should be reserved for those who do not respond to conservative treatment, and this is proven to be effective in relieving sinus tarsi pain in long-term follow-­up [28, 51, 52]. Subtalar arthroscopy has been shown to be a relatively safe and effective tool to identify the pathologies in the subtalar joint causing STS, including the talocalcaneal interosseous ligament tear, cervical ligament tear, subtalar joint synovitis, arthrofibrosis, ganglion cyst, or other soft tissue impingements. Subtalar joint synovectomy was the most common procedure performed, and other arthroscopic decompression or debridement of those pathologies may lead to symptomatic and functional improvement [33, 53, 54]. Some patients with associated frank hindfoot instability may require ligamentous reconstruction.

7.2.2 Indications of Arthroscopic Debridement Arthroscopic intervention is indicated if the pain does not respond to conservative treatment.

7.2.3 Contraindications of Arthroscopic Debridement • Other causes of chronic lateral heel pain other than the joint pain. • Advanced stage of subtalar osteoarthrosis. • Significant hindfoot valgus deformity warrants deformity correction rather than arthroscopic treatment alone.

7  Anterior Subtalar Arthroscopy

7.2.4 Author-Preferred Technique 7.2.4.1 Preoperative Planning The other causes of chronic lateral heel pain should be excluded by clinical assessment and investigations. The axis of subtalar joint passes through centers of the talar head and the posterior calcaneal facet. It is approximately 42° upward from the horizontal in sagittal plane and 16–23° medial to midline of the foot in transverse plane. The capsule-ligamentous structures lateral to the axis can be injured during inversion injury. Compressive injury medial to the axis also rarely occurs (Fig. 7.8). The “zone of injury” centers on the sinus tarsi and can extend posteriorly to the lateral recess of the posterior subtalar joint, laterally to the lateral calcaneal wall, anteriorly to the lateral half of the anterior talocalcaneonavicular joint, and medially to the tarsal canal and medial subtalar recess (Fig. 7.9). Besides the sinus tarsi, tenderness should be tested over the lateral subtalar gutter, the lateral calcaneal wall especially just plantar to the angle of Gissane and the anterior talocalcaneonavicular joint. Rarely, there is tenderness around the medial subtalar joint line when compressive injury such as osteochondral lesion presents medial to the subtalar axis. This governs the extent of arthroscopic surgery needed. Posterior subtalar arthroscopy can approach the sinus tarsi, lateral calcaneal wall, and lateral subtalar gutter. If there is pain on deep palpation at the junction between the talonavicular joint and calcaneocuboid joint pointing medially and posteriorly, anterior subtalar arthroscopy and even talonavicular arthroscopy should also be performed [18–20]. If there is tenderness over the medial joint line of the anterior talocalcaneonavicular joint, medial subtalar arthroscopy [21, 22] is also indicated.

Fig. 7.8  During hindfoot inversion injury, the capsule-ligamentous structures lateral to the axis of the subtalar joints can be distracted and injured. The osteo-articular structures medial to the axis may have compressive injury

233

7.2.4.2 Patient Positioning The patient can be positioned supine, lateral, or prone if medial subtalar arthroscopy is not planned. The exact position depends on any concomitant procedure that will be performed also. If only posterior  +/-  anterior subtalar arthroscopy is planned, the lateral position of the patient is preferred. If medial subtalar +/- talonavicular arthroscopy is also indicated, the patient is in supine position with the legs spread. A 2.7 mm 30° arthroscope is used for this procedure. A thigh tourniquet is applied to provide a bloodless operative field. Fluid inflow is by gravity and no arthropump is used. 7.2.4.3 Portal Design Posterior subtalar arthroscopy is performed via the anterolateral and middle subtalar portals. The anterolateral subtalar portal is just dorsal to the angle of Gissane, and the middle subtalar portal is just anterior and distal to the tip of the lateral malleolus. Anterior subtalar arthroscopy can be performed via the anterolateral subtalar portal and dorsolateral midtarsal portal. The dorsolateral midtarsal portal is at the junction between the talonavicular and calcaneocuboid joints. The tarsal canal can be approached via the anterolateral subtalar portal and the medial tarsal canal portal. The medial tarsal canal portal is at the medial opening of the tarsal canal and usually just posterior to the tibialis posterior tendon. The medial subtalar arthroscopy allows access to the medial side of the anterior talocalcaneonavicular joint. This is performed via the medial tarsal canal portal and the medial midtarsal portal, which is at the medial side of the ­talonavicular joint just dorsal to the navicular insertion of the tibialis posterior tendon [20].

Fig. 7.9  The “zone of injury” centers on the sinus tarsi (a) and can extend posteriorly to the lateral recess of the posterior subtalar joint (b), laterally to the lateral calcaneal wall (c), anteriorly to the lateral half of the anterior talocalcaneonavicular joint (d), and medially to the tarsal canal and medial subtalar recess (e)

234

D. H. Y. Tai et al.

7.2.4.4 Step-by-Step Description of the Technique Posterior Subtalar Arthroscopy • 3–4 mm incisions are made at the anterolateral and middle subtalar portal sites. • The subcutaneous tissue is bluntly dissected with a hemostat aiming at the sinus tarsi. • The anterolateral and middle portals are interchangeable as the viewing and working portals (Fig. 7.10). The cervical ligament, the interosseous talocalcaneal ligament, and the intermediary root of inferior extensor retinaculum can be examined for any tear, scarring, or synovitis. The medial root of the inferior extensor retinaculum is usually obscured if the intermediary root is intact. The lateral root of the inferior extensor retinaculum cannot be seen with the scope via the anterolateral portal as the scope pass through the root. The lateral root of the inferior extensor retinaculum is barely seen with a 70° arthroscope via the middle portal. It is better examined via the posterolateral subtalar portal (lateral to the Achilles tendon) or the medial tarsal canal portal. The scope should be rotated in order to examine the roof of the sinus tarsi. • The fatty tissue of the sinus tarsi is resected with an arthroscopic shaver via the middle subtalar portal. Any ligament tear is debrided. The scar tissue over the ligaments is carefully curetted and removed. Any inflamed synovium is also resected (Fig. 7.11). • The floor of the sinus tarsi is carefully curetted to remove the fibrotic periosteum between the ligament insertions (Fig. 7.12). It is important to preserve the intact ligaments and their insertions.

Fig. 7.11  The anterolateral subtalar portal is the viewing portal, and the middle subtalar portal is the working portal. The fibrous tissue and inflamed synovium (a) are debrided with an arthroscopic shaver (b)

Fig. 7.12  The fibrous tissue at the floor of sinus tarsi (a) has been resected with preservation of the ligament insertions (b) Fig. 7.10  Posterior subtalar arthroscopy is performed via the anterolateral (a) and middle (b) subtalar portals

7  Anterior Subtalar Arthroscopy

235

• The anterolateral subtalar portal is the viewing portal. The arthroscope is inserted into the lateral recess of the posterior subtalar joint. The shaver at the middle subtalar portal serves as a retractor to retract the lateral capsuloligamentous layer laterally to improve the arthroscopic view. Any inflamed synovium or scar tissue, if present, is resected (Fig. 7.13). After removal of the pathological tissue, the integrity of the lateral capsuloligamentous layer is examined. • The arthroscope is then turned medially to examine the posterior subtalar joint proper. Subtalar inversion or hindfoot supination stress is applied to open up the lateral joint space. The condition of the subtalar cartilage is noted. Moreover, the amount of lateral joint line opening up and the amount of anterior and lateral shift of the posterior

a

Fig. 7.13  The anterolateral subtalar portal is the viewing portal, and the middle subtalar portal is the working portal. (A) Inflamed synovium is seen at the lateral recess of the right posterior subtalar joint. (B) The

calcaneal facet are also noted. Sometimes, the posterior calcaneal facet may shift medially rather than laterally (Fig.  7.14). This may imply insufficiency of the lateral ligamentous restraints and subtalar instability, especially if there is excessive anterior shift of the calcaneal facet and opening up of the lateral joint line. • The arthroscope is switched to the middle portal. The capsular reflection plantar to the angle of Gissane is examined for any synovitis. Synovectomy if indicated is performed by an arthroscopic shaver via the anterolateral portal. The portals can be interchangeable as the viewing and working portals to confirm complete debridement of the lateral calcaneal wall (Fig. 7.15).

b

inflamed tissue has been debrided. (a) Calcaneus, (b) posterior talar facet, and (c) inflamed synovium

236

Fig. 7.14  The anterolateral subtalar portal is the viewing portal. The calcaneus shifts medially upon inversion of the hindfoot. (a) Calcaneus and (b) posterior talar facet

D. H. Y. Tai et al.

Fig. 7.15  The fibrous tissue of the lateral calcaneal wall is resected with an arthroscopic shaver. (a) Lateral calcaneal wall, (b) lateral capsular reflection, and (c) fibrous tissue

7  Anterior Subtalar Arthroscopy

Anterior Subtalar Arthroscopy • It is indicated if there is tenderness at the lateral side of the anterior talocalcaneonavicular joint. • This is performed via the anterolateral subtalar portal (already created) and the dorsolateral midtarsal portal. A 3 mm incision is made at the dorsolateral midtarsal portal. The subcutaneous tissue is bluntly dissected with a hemostat pointing medially and posteriorly, along the plantar lateral side of the talar head. • The anterolateral subtalar portal and the dorsolateral midtarsal portal are interchangeable as the viewing and working portals (Fig.  7.16). The lateral capsule of the talocalcaneonavicular joint is resected. This should be performed carefully not to damage the cartilage of the talar head. • Synovectomy is performed if synovitis is present at the lateral side of the joint. • The joint space is opened up with subtalar inversion stress, and the cartilage is examined for any osteochondral lesion. The anterior calcaneal facet is traced distally, and the spring ligament can be seen. Sometimes, scar tissue or inflamed synovium can be present at the surface of the spring ligament. This should also be removed (Fig. 7.17). • The medial recess of the anterior subtalar joint may be seen but cannot be accessed through the anterior subtalar arthroscopy. If there is synovitis or osteochondral lesion at the medial side of the joint, medial subtalar arthroscopy is indicated.

237

Fig. 7.16  Anterior subtalar arthroscopy is performed via the anterolateral subtalar and dorsolateral midtarsal portals. (a) Dorsolateral midtarsal portal and (b) anterolateral subtalar portal

238

D. H. Y. Tai et al.

a

b

c

d

Fig. 7.17 (A) The anterolateral subtalar portal is the viewing portal. Inflamed synovium is seen at the lateral side of the right anterior subtalar joint. (B) The inflamed tissue is resected. (C) The dorsolateral midtarsal portal is the viewing portal, and the anterolateral subtalar portal is

the working portal. The fibrous tissue is seen covering the spring ligament. (D) After resection of the fibrous tissue, the spring ligament can be seen. (a) Talar head, (b) anterior calcaneal facet, (c) navicular bone, (d) inflamed synovium, (e) fibrous tissue, and (f) spring ligament

7  Anterior Subtalar Arthroscopy

Medial Subtalar Arthroscopy • This is performed via the medial midtarsal and medial tarsal canal portals. They are interchangeable as the viewing and working portals. • A 3–4 mm incision is made at the point just dorsal to the sustentaculum tali and just posterior to the tibialis posterior tendon. This creates the medial tarsal canal portal. The subcutaneous tissue is bluntly dissected down to the posterior tibial tendon sheath. The tendon sheath is incised open. The trocar-cannula is then inserted deep to the tendon sheath into the medial subtalar recess. • A 3–4 mm incision is made at the medial midtarsal portal. The underlying tissue is bluntly dissected by a hemostat pointing laterally, posteriorly, and slightly plantarly. The capsule is perforated by the tip of the hemostat, and the medial subtalar recess is entered. • The inflamed synovium of the medial recess is resected. After clearance of the pathological tissue, the articular cartilage of the plantar medial part of the talar head is examined for any osteochondral lesion. If osteochondral lesion is present, debridement and microfracture of the lesion are performed (Fig. 7.18). • Tarsal canal arthroscopy is rarely performed unless diffuse synovitis of both anterior and posterior subtalar joints is documented in preoperative MRI.

Fig. 7.18  Medial subtalar arthroscopy of a left foot is performed with the medial midtarsal portal as the viewing portal. An osteochondral lesion is noted at the medial aspect of the talar head. (a) Talar head, (b) sustentaculum tali, and (c) osteochondral lesion

239

7.2.4.5 Complications and Management Please refer to individual Sects. 6.1 and 7.1 for complications of posterior, anterior, and medial subtalar arthroscopies. 7.2.4.6 Postoperative Care Bulky dressing is applied for 2 weeks. Weight-bearing walking and ankle and hindfoot mobilization have begun after the bulky dressing is removed.

7.2.5 Summary Chronic lateral heel pain after inversion injury can be due to numerous causes. The concept of “zone of injury” allows the surgeon to formulate the appropriate arthroscopic treatment for individual patient.

References 1. Perugia D, Basile A, Massoni C, Gumina S, Rossi F, Ferretti A.  Conservative treatment of subtalar dislocations. Int Orthop. 2002;26:56–60. 2. Isman RE, Inman VT.  Anthropometric studies of the human foot and ankle. Bull Prosthet Res. 1969;10:97–129. 3. Van Langelaan EJ.  A Kinematical analysis of the tarsal joints. An X-ray photogrammetric study. Acta Orthop Scand Suppl. 1983;204:1–269. 4. Van den Bogert AJ, Smith GD, Nigg BM.  In vivo determination of the anatomical axes of the ankle joint complex: an optimization approach. J Biomech. 1994;27:1477–88. 5. Inman V.  The joints of the ankle. Baltimore: The Williams & Wilkins Company; 1976. 6. McMaster M. Disability of the hindfoot after fracture of the tibial shaft. J Bone Joint Surg Br. 1976;58:90–3. 7. Lanz T, Wachsmuth W. Praktische Anatomie. Springer; 1972. 8. American medical association: guides to the evaluation of permanent impairment. 3rd ed. Chicago: AMA; 1988. p. 60. 9. Jastifer JR, Gustafson PA.  The subtalar joint: Biomechanics and functional representations in the literature. The Foot. 2014;24(4):203–9. 10. Yu GV.  Subtalar joint arthrodesis  – Refinements in technique. Podiatry Institute Update 1990. Chapter 4. 11. Weinraub GM, Schuberth JM, Lee M, Rush S, Ford L, Neufeld J, Yu J.  Isolated medial incisional approach to subtalar and talonavicular arthrodesis. Foot Ankle. 2010;49:326–30. 12. De Wachter J, Knpp M, Hintermann B. Double-hindfoot arthrodesis through a single medial approach. Tech Foot Ankle Surg. 2007;6:1–6. 13. Jeng CL, Tankson CJ, Myerson MS. The single medial approach to triple arthrodesis: a cadaver study. Foot Ankle Int. 2006;27:1122–5. 14. Pell RF, Myerson MS, Schon LC. Clinical outcome after primary triple arthrodesis. J Bone Joint Surg [Am]. 2000;82(A):47–57. 15. Parisien JS. Arthrscopy of the posterior subtalar joint: a preliminary report. Foot Ankle. 1986;6:219–24. 16. Beimers L, Frey C, van Dijk CN. Arthroscopy of the posterior subtalar joint. Foot Ankle Clin. 2006;11:369–90.

240 17. El Rassi G, Riddle E, Kumar J. Arthrofibrosis involving the middle facet of the talocalcaneal joint in children and adolescents. J Bone Joint Surg Am. 2005;87:2227–31. 18. Lui TH.  Clinical tips: anterior subtalar (talocalcaneonavicular). Arthrosc Foot Ankle Int. 2008;29:94–6. 19. Lui TH, Chan KB, Chan LK.  Portal safety and efficacy of anterior subtalar arthroscopy: a cadaveric study. Knee Surg Sports Traumatol Arthrosc. 2010;18:233–7. 20. Lui TH.  New technique of arthroscopic triple arthrodesis. Arthroscopy. 2006;22:464.e1–5. 21. Lui TH.  Medial subtalar arthroscopy. Foot Ankle Int. 2012;33:1018–23. 22. Lui TH, Chan LK, Chan KB. Medial subtalar arthroscopy: a cadaveric study of the tarsal canal portal. Knee Surg Sports Traumatol Arthrosc. 2013;21:1279–82. 23. Lui TH. Arthroscopic capsular release of the talocalcaneonavicular joint. Arthrosc Tech. 2016;5:e1305–9. 24. Lui TH. Arthroscopic release of lateral half of the talocalcaneonavicular joint. Arthrosc Tech. 2016;5:e1471–4. 25. Lui TH.  Synovitis of the tarsal canal: an uncommon cause of lateral heel pain after triple arthrodesis. J Foot Ankle Surg. 2017;56:255–7. 26. Lui TH. Endoscopic repair of the superficial deltoid ligament and Spring ligament. Arthrosc Tech. 2016;5:e621–5. 27. Lui TH.  Arthroscopic repair of superomedial spring ligament via talonavicular arthroscopy. Arthrosc Tech. 2017;6:e31–5. 28. Klausner VB, McKeigue ME. The sinus tarsi syndrome: a cause of chronic ankle pain. Phys Sportsmed. 2000;28(5):75–80. 29. Pisani G, Pisani PC, Parino E. Sinus tarsi syndrome and subtalar joint instability. Clin Podiatr Med Surg. 2005;22(1):63–77. vii. 30. Frey C, Feder KS, DiGiovanni C.  Arthroscopic evaluation of the subtalar joint: does sinus tarsi syndrome exist? Foot Ankle Int. 1999;20(3):185–91. 31. Kjaersgaard-Andersen P, Andersen K, Søballe K, Pilgaard S. Sinus tarsi syndrome: presentation of seven cases and review of the literature. J Foot Surg. 1989;28(1):3–6. 32. Giorgini RJ, Bernard RL.  Sinus tarsi syndrome in a patient with talipes equinovarus. J Am Podiatr Med Assoc. 1990;80(4):218–22. 33. Oloff LM, Schulhofer SD, Bocko AP.  Subtalar joint arthroscopy for sinus tarsi syndrome: a review of 29 cases. J Foot Ankle Surg. 2001;40(3):152–7. 34. Kjaersgaard-Andersen P, Wethelund JO, Helmig P, Søballe K. The stabilizing effect of the ligamentous structures in the sinus and canalis tarsi on movements in the hindfoot. An experimental study. Am J Sports Med. 1988;16(5):512–6. 35. Schwarzenbach B, Dora C, Lang A, Kissling RO.  Blood ves sels of the sinus tarsi and the sinus tarsi syndrome. Clin Anat. 1997;10(3):173–82. 36. Akiyama K, Takakura Y, Tomita Y, Sugimoto K, Tanaka Y, Tamai S. Neurohistology of the sinus tarsi and sinus tarsi syndrome. J Orthop Sci. 1999;4(4):299–303.

D. H. Y. Tai et al. 37. Rein S, Manthey S, Zwipp H, Witt A. Distribution of sensory nerve endings around the human sinus tarsi: a cadaver study. J Anat. 2014;224(4):499–508. 38. Dellon AL, Barrett SL.  Sinus tarsi denervation: clinical results. J Am Podiatr Med Assoc. 2005;95(2):108–13. 39. Light M, Pupp G.  Ganglions in the sinus tarsi. J Foot Surg. 1991;30(4):350–5. 40. Meyer JM, Lagier R.  Post-traumatic sinus tarsi syndrome. An anatomical and radiological study. Acta Orthop Scand. 1977;48(1):121–8. 41. Taillard W, Meyer JM, Garcia J, Blanc Y. The sinus tarsi syndrome. Int Orthop. 1981;5(2):117–30. 42. Dozier TJ, Figueroa RT, Kalmar J. Sinus tarsi syndrome. J La State Med Soc. 2001;153(9):458–61. 43. Steinbach LS. Painful syndromes around the ankle and foot: magnetic resonance imaging evaluation. Top Magn Reson Imaging. 1998;9(5):311–26. 44. Klein MA, Spreitzer AM. MR imaging of the tarsal sinus and canal: normal anatomy, pathologic findings, and features of the sinus tarsi syndrome. Radiology. 1993;186(1):233–40. 45. Lektrakul N, Chung CB, Lai YM, Theodorou DJ, Yu J, Haghighi P, et  al. Tarsal sinus: arthrographic, MR imaging, MR arthrographic, and pathologic findings in cadavers and retrospective study data in patients with sinus tarsi syndrome. Radiology. 2001;219(3):802–10. 46. Lee KB, Bai LB, Park JG, Song EK, Lee JJ. Efficacy of MRI versus arthroscopy for evaluation of sinus tarsi syndrome. Foot Ankle Int. 2008;29(11):1111–6. 47. Fischer DR, Maquieira GJ, Espinosa N, Zanetti M, Hesselmann R, Johayem A, et al. Therapeutic impact of [(18)F]fluoride positron-­ emission tomography/computed tomography on patients with unclear foot pain. Skeletal Radiol. 2010;39(10):987–97. 48. Shear MS, Baitch SP, Shear DB. Sinus tarsi syndrome: the importance of biomechanically-based evaluation and treatment. Arch Phys Med Rehabil. 1993;74(7):777–81. 49. Giorgini RJ. Bernard RL. Sinus tarsi syndrome in a patient with talipes equinovarus. (R)J Am Podiatr Med Assoc. 1990;80(4):218–22. 50. Kinoshita M, Okuda R, Yasuda T, Abe M. Serial casting for recalcitrant peroneal spastic flatfoot with sinus tarsi syndrome. Orthop Sci. 2005;10(5):550–4. 51. Kuwada GT. Long-term retrospective analysis of the treatment of sinus tarsi syndrome. J Foot Ankle Surg. 1994;33(1):28–9. 52. Lowy A, Schilero J, Kanat IO. Sinus tarsi syndrome: a postoperative analysis. J Foot Surg. 1985;24(2):108–12. 53. Lee KB, Bai LB, Song EK, Jung ST, Kong IK. Subtalar arthroscopy for sinus Tarsi syndrome: arthroscopic findings and clinical outcomes of 33 consecutive cases. Arthroscopy. 2008;24(10):1130–4. https://doi.org/10.1016/j.arthro.2008.05.007. Epub 2008 Jun 16. 54. Ahn JH, Lee SK, Kim KJ, Kim YI, Choy WS. Subtalar arthroscopic procedures for the treatment of subtalar pathologic conditions: 115 consecutive cases. Orthopedics. 2009;32(12):891.

8

Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy Diane Hei Yan Tai, Tun Hing Lui, Thomas S. Roukis, Amanda Slocum, Thomas Bauer, and Hoi Yan Lam

Contents 8.1    Surgical Approaches and Portals of Midtarsal Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . .  242 8.1.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  242 8.1.2  Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  243 8.1.3  Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  243 8.1.4  Author-Preferred Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  243 8.1.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  246 8.2    Arthroscopic Management of Talonavicular Osteochondral Defects . . . . . . . . . . . . . . . . . . . .  247 8.2.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  247 8.2.2  Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  247 8.2.3  Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  247 8.2.4  Author-Preferred Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  248 8.2.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  253 8.3    Arthroscopic Decompression of Calcaneocuboid Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  255 8.3.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  255 8.3.2  Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  255 8.3.3  Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  255 8.3.4  Author-Preferred Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  256 8.3.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  259

The corresponding author of section 8.1 is Tun Hing Lui, Email: [email protected] The corresponding author of section 8.2 is Thomas S. Roukis, Email: [email protected] The corresponding author of section 8.3 is Tun Hing Lui, Email: [email protected] The corresponding author of section 8.4 is Thomas Bauer, Email: [email protected] The corresponding author of section 8.5 is Tun Hing Lui, Email: [email protected] D. H. Y. Tai Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Hong Kong SAR, China

T. S. Roukis Orthopaedic Center, Gundersen Health System, La Crosse, WI, USA e-mail: [email protected]

T. H. Lui (*) Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China

A. Slocum Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China

Department of Orthopaedics, Southern Medical University, Guangzhou, China

T. Bauer Department of Orthopedic Surgery and Traumatology, Ambroise Paré University Hospital, West Paris University, Boulogne Billancourt, France e-mail: [email protected]

Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Science, Shenzhen, China Department of Orthopaedics and Traumatology, Chinese University of Hong Kong, Hong Kong, China

H. Y. Lam Department of Orthopaedics and Traumatology, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China

© Springer Nature Singapore Pte Ltd. 2019 T. H. Lui (ed.), Arthroscopy and Endoscopy of the Foot and Ankle, https://doi.org/10.1007/978-981-13-0429-3_8

241

242

D. H. Y. Tai et al. 8.4    Endoscopic Treatment of Calcaneonavicular Coalition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  260 8.4.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  260 8.4.2  Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  260 8.4.3  Contra-Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  260 8.4.4  Author Preferred Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  261 8.4.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  264 8.5    Arthroscopic Triple Arthrodesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  265 8.5.1  Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  265 8.5.2  Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  265 8.5.3  Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  266 8.5.4  Author-Preferred Technique/Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  266 8.5.5  Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  272 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  273

8.1

 urgical Approaches and Portals S of Midtarsal Arthroscopy

Diane Hei Yan Tai and Tun Hing Lui

8.1.1 Introduction 8.1.1.1 Anatomy The talonavicular joint is defined as a ball-and-socket joint. It allows multiaxial movements as it is a component of the talocalcaneonavicular joint, also called the anterior subtalar joint, and a component of the transverse midtarsal joints. It is supported by the dorsal talonavicular, deltoid, and plantar calcaneonavicular (spring) ligaments. There are important neurovascular structures and tendons around the talonavicular joint including the long saphenous vein and nerve dorsomedially; the dorsalis pedis artery and deep peroneal nerve dorsolaterally; the tibialis anterior, extensor hallucis longus, and extensor digitorum longus tendons dorsally; and the tibialis posterior tendon plantarmedially. The calcaneocuboid joint is defined as a saddle-shaped joint and is a component of the transverse midtarsal joint. It allows complex triplanar movements with the subtalar and talonavicular joints. It is supported by the plantar ligaments and the peroneal longus tendon and dorsally supported by the bifurcate and calcaneocuboid ligaments. The intermediate dorsal cutaneous nerve passes superiorly and the sural nerve passes plantarlaterally. The extensor digitorum brevis muscle sits directly on the superior aspect of the joint. The peroneal tendons pass by inferolaterally. 8.1.1.2 Biomechanics Mann [1] reported that the transverse tarsal joint is a functional unit which consists of the talonavicular and calcaneocuboid joints. The primary movement of these joints is in the plane of abduction and adduction. The location of the navicular bone in the medial longitudinal arch of the foot makes it

important in weight bearing during locomotion [2]. Elftmann [3] described that the parallel orientation of the axes of rotation of the talonavicular and calcaneocuboid joints, as happens in foot pronation, results in increased mobility of the transverse tarsal joint, whereas the oblique alignment, as happens in supination, results in increased stability of the joint. During the gait cycle, the increased mobility allows the forefoot to accommodate to uneven terrain and to absorb mediolateral shear forces more easily [4]. The study of contact forces is also important in understanding the pathology at these joints. Kitaoka [5] demonstrated that in an unstable foot, there is a shift in contact distribution toward more dorsal and central regions of the navicular bone. This is evidenced by the clinical pattern of fatigue fractures, acute fractures, and nonunion at the central part of the navicular. Besides abduction and adduction, the talonavicular joint also allows certain degree of dorsiflexion and plantarflexion. Beaudoin [6] reported that the talonavicular contact area decreased in dorsiflexion and increased in plantarflexion.

8.1.1.3 Pathology Arthrodesis is a well-developed method for treating deformities and degenerative diseases of the midtarsal joints. Indications for fusion include posterior tendon deficiency, inflammatory arthritis, residual clubfoot deformity, primary osteoarthritis, and posttraumatic arthritis [7–10]. Mangwani [11] reported the use of arthroscopic debridement to treat talonavicular osteochondral lesion. Besides therapeutic indications, Oloff [12] described that midtarsal arthroscopy can also be used as a diagnostic tool to identify lesions such as osteochondral defects, marginal exostoses, loose cartilaginous or osseous bodies, plica or meniscoid formation with impingement, chronic synovitis, synovial-based neoplasia, and cuboid syndrome. 8.1.1.4 Surgical Approaches The talonavicular joint can be reached by the standard medial approach via an incision from the anterior border of the medial malleolus toward the talonavicular joint, parallel to

8  Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy

and 5 mm above the tibialis posterior tendon [13, 14]. The potential risks of this approach include damage to the saphenous nerve and vein and the superficial peroneal nerve during superficial dissection. The calcaneocuboid joint can be reached by the standard lateral approach via an incision over the calcaneocuboid joint, above the peroneal tendons and sural nerve [15, 16]. The potential risks of this approach include damage to the peroneal tendons and sural nerve. Ollier [17] described an approach for triple arthrodesis using an incision over the dorsolateral aspect of talonavicular joint, extending it obliquely, inferiorly, and posteriorly to 1 inch below the lateral malleolus. The inferior extensor retinaculum is divided in line with the incision and dissection which are made to expose the subtalar, talonavicular, and calcaneocuboid joints. The potential risks of this approach include damage to the peroneal brevis tendon and the extensor digitorum longus tendon. Both the talonavicular and calcaneocuboid joints can also be approached arthroscopically [12, 18–30]. The arthroscopic approaches have the advantages of minimally invasive surgery of better cosmetic results and less surgical trauma. The indication list is expanding.

8.1.2 Indications • Synovitis of the midtarsal joints • Calcaneocuboid impingement

• • • • • •

243

Calcaneonavicular coalition Too-long anterior process (TLAP) of calcaneus Osteoarthritis Triple arthrodesis Osteochondral lesions Repair of torn spring ligament

8.1.3 Contraindications • Acute infection at the portal sites • Lack of expertise • Severely deformed joints

8.1.4 Author-Preferred Technique 8.1.4.1 Preoperative Planning Detailed clinical assessment and proper imaging investigation are important to establish the diagnosis and confirm the indication for midtarsal arthroscopy. 8.1.4.2 Patient Positioning The patient is in supine position with the legs spread. A thigh tourniquet is applied to provide a bloodless operative field. Fluid inflow is by gravity and no arthro-pump is used. A 2.7  mm 30° arthroscope is used for the midtarsal arthroscopy.

244

8.1.4.3 Portal Design Four portals are used for the midtarsal arthroscopy. The lateral midtarsal portal is at the plantar lateral corner of the calcaneocuboid joint. The dorsolateral midtarsal portal is at the junction between the calcaneocuboid and talonavicular joints. The medial midtarsal portal is just above the navicular insertion of the tibialis posterior tendon. The dorsomedial midtarsal portal is at the dorsal talonavicular joint line and midpoint between the dorsolateral and medial midtarsal portals (Fig. 8.1). The calcaneocuboid joint can be approached via the lateral and dorsolateral midtarsal portals. The talonavicular joint can be approached via the medial, dorsomedial, and dorsolateral midtarsal portals.

D. H. Y. Tai et al.

Fig. 8.1  Four portals are used for the midtarsal arthroscopy. The lateral midtarsal portal is at the plantar lateral corner of the calcaneocuboid joint. The dorsolateral midtarsal portal is at the junction between the calcaneocuboid and talonavicular joints. The medial midtarsal portal is just above the navicular insertion of the tibialis posterior tendon. The dorsomedial midtarsal portal is at the dorsal talonavicular joint line and midpoint between the dorsolateral and medial midtarsal portals. (a) lateral midtarsal portal; (b) dorsolateral midtarsal portal; (c) dorsomedial midtarsal portal; (d) medial midtarsal portal

8  Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy

8.1.4.4 Step-by-Step Description of the Technique Calcaneocuboid Arthroscopy • A 3–4 mm incision is made; the lateral midtarsal portal and the subcutaneous tissue are bluntly dissected with a hemostat. • The joint capsule is perforated by the tip of the hemostat. • The lateral gutter of the joint is the working area. • In case of resection of TLAP (too-long anterior process of the calcaneus) lesion, calcaneonavicular coalition, or symptomatic nonunion of the anterosuperior calcaneal process, the lateral midtarsal portal is the viewing portal. The bony lesion is resected with an arthroscopic burr via the dorsolateral midtarsal portal (Fig. 8.2).

245

• In case of synovitis of the joint, the portals are interchangeable as the viewing and working portals for synovectomy. The plantar gutter synovitis can be cleared by the arthroscopic shaver via the lateral portal. • In case of calcaneocuboid impingement, the portals are interchangeable as the viewing and working portals. The demarcation between the normal cartilage and the degenerated cartilage of the lateral part of the joint is noted. The lateral bone spurs and the degenerated cartilage are resected with an arthroscopic burr. • In case of calcaneocuboid arthrodesis, the portals are interchangeable as the viewing and working portals. The articular cartilage of the joint is denuded by an arthroscopic osteotome. After all the cartilage of the posterior subtalar joint is removed, the subchondral bone is microfractured with an arthroscopic awl. b

a

c

Fig. 8.2  This is a case of TLAP lesion. (a) Calcaneocuboid arthroscopy is performed with the lateral midtarsal portal as the viewing portal and the dorsolateral portal as the working portal. (b) With the foot in neutral position, the impinged lesion is seen at the navicular bone. (c) With the foot inverted, the anterior calcaneal process impinged on the navicular bone.

d

(d) After resection of the anterior calcaneal process, there is adequate space between the navicular and calcaneus to avoid any impingement, and the space plantar to the bones can be seen. (a) Dorsolateral midtarsal portal; (b) lateral midtarsal portal; (c) calcaneus; (d) cuboid; (e) impinged lesion of the navicular bone; and (f) space plantar to the tarsal bones

246

D. H. Y. Tai et al.

Talonavicular Arthroscopy • The talonavicular joint is a ball-and-socket joint (Fig. 8.3). A different part of the joint is approached via different portals. • The lateral half of the joint is approached via the dorsolateral and dorsomedial midtarsal portals (Fig. 8.4). • The medial half of the joint is approached via the dorsomedial and medial midtarsal portals (Fig. 8.5). • The dorsolateral midtarsal portal is the main working portal for plantar lateral part of the joint. The anterolateral subtalar, dorsomedial midtarsal, and lateral midtarsal portals can be the viewing portals. The medial midtarsal portal can be the working portal for the plantar medial part of the talar head with the dorsomedial midtarsal and medial tarsal canal portals as the viewing portals. Fig. 8.5  The medial half of the talonavicular joint is approached via the dorsomedial (a) and medial (b) midtarsal portals

8.1.4.5 Complications • Lateral midtarsal portal: risks of injury to the peroneal tendons and sural nerve • Dorsolateral midtarsal portal: risks of injury to the long extensor tendons, the lateral branch of the superficial peroneal nerve, and the lateral terminal branch of the deep peroneal nerve [18–20] • Dorsomedial midtarsal portal: potential risks of injury to the intermediate cutaneous branch of the superficial peroneal nerve, the extensor hallucis longus tendon, and the deep peroneal nerve • Medial midtarsal portal: risks of injury to the long saphenous vein and nerve

Fig. 8.3  The talonavicular joint is a ball-and-socket joint with the convex talar head (a) and concave proximal articular surface of the navicular bone (b)

8.1.4.6 Postoperative Care The postoperative rehabilitation plan depends on the procedure performed and will be detailed in the following chapter sessions.

8.1.5 Summary Midtarsal arthroscopy composes of arthroscopy of the talonavicular and calcaneocuboid joint. It can combine with the anterior and posterior subtalar arthroscopy to deal with various hindfoot pathologies.

Fig. 8.4  The lateral half of the talonavicular joint is approached via the dorsolateral (a) and dorsomedial (b) midtarsal portals

8  Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy

8.2

Arthroscopic Management of Talonavicular Osteochondral Defects

Thomas S. Roukis

8.2.1 Introduction Osteochondral defects within the talonavicular joint are rare with fewer than 20 cases published in the literature [31–39]. Although long-term data remains elusive, the first-line treatment for osteochondral lesions of the talar dome remains an arthroscopic debridement with or without microfracture [40]. Oloff et al. [37] in 1996 performed a talonavicular joint arthroscopy of one patient undergoing attempted treatment for an osteochondral lesion of the dorsal navicular. Unfortunately, the procedure could not be completed and required an open arthrotomy with autogenous bone grafting of the lesion, and a good outcome was reported at 6 months follow-up. Ross et al. [38] presented three athletes treated for osteochondral defects of the dorsal navicular with debridement and microfracture under intraoperative distraction with each patient having a successful outcome between 16 and 22 months follow-up. Keller et al. [39] presented a case report of a cystic osteochondral defect of the dorsal navicular successfully treated with a mini-dorsal talonavicular arthrotomy and dry, arthroscopic-assisted debridement, microfracture, and autogenous bone graft backfilling with a successful outcome at 16 months follow-up. Finally, Patel et  al. [41] described one patient with the use of dual medial and lateral pin distractors to assist in performing arthroscopic debridement and microfracture of a talar head osteochondral defect with a successful outcome at 12 months follow-up. It is interesting that, despite being developed more than 20 years ago, this minimally invasive procedure has not become more popular since the only other procedural treatment options reported are open debridement and microfracture with use of autogenous impaction bone grafting and/or supplemental external fixation for arthrodiastasis of the talonavicular joint [31, 32, 34–37].

8.2.2 Indications Osteochondral defects of the talar head and/or navicular can be treated through an arthroscopic approach when they are

247

confined to the dorsal surfaces and can be accessed through standard and/or accessory talonavicular joint arthroscopic portals, when conservative care management efforts have failed and when open approaches are deemed inappropriate. The use of a Weinraub Kirschner-wire distractor (Innomed, Inc., Savannah, GA) [38] or Hintermann distractor (Integra LifeSciences, Plainsboro, NJ) [41] can facilitate distraction of the talonavicular joint and may expand the indications enough to include more plantar osteochondral defects. An additional indication is when ankle joint pathology, such as anteriorlateral soft tissue impingement [42], exists with a concomitant talonavicular joint osteochondral defect. In this situation, the ankle joint arthroscopic debridement and synovectomy would be completed first, and then the soft tissues are released off the talar neck and head until the talonavicular joint is visualized. Standard talonavicular joint arthroscopic portals would then be developed followed by debridement and microfracture of the talar head and/or navicular osteochondral defect. Compared with the isolated talonavicular joint access, this combined approach also has the added benefits of reducing soft tissue restraint about the joint that improves visualization and mobilization within the joint, as well as allowing the use of a 4-mm 30-degree arthroscope that also can deliver a higher rate of fluid compared with a 1.9-mm or 2.7-mm arthroscopes.

8.2.3 Contraindications Contraindications include those germane to any surgery including active infection, active chronic pain syndromes, peripheral vascular disease insufficient to allow healing, lymphedema obscuring soft tissue, and osseous topographic landmarks and restricted range of motion secondary to osseous impingement encountered with advanced degenerative joint disease. Specific to the talonavicular joint hostile or heavily scarred soft tissues, tendons tethered to the underlying capsule and/or osseous structures, extensive degenerative joint changes, and capsular contracture with resultant limited intra-articular working space are all contraindications to arthroscopic debridement and microfracture of talar head and/or navicular osteochondral defects.

248

8.2.4 Author-Preferred Technique 8.2.4.1 Preoperative Planning Proper diagnosis is paramount prior to treating osteochondral defects of the talar head and/or navicular through talonavicular joint arthroscopy. A thorough clinical examination is always important and should include non-weight bearing and weight bearing analysis of the foot with particular attention paid to the entire midtarsal joint complex. Palpation and range of motion of the talonavicular joint are performed with special attention paid to the dorsal, medial, and lateral joint lines. Fullness, induration, pain with palpation, as well as clicking or catching/locking with range of motion are assessed and compared to the contralateral foot. Weight bearing anterior-posterior, medial oblique, lateral oblique, and lateral radiographs should be obtained. These allow rather complete evaluation of the talonavicular joint complex for any contributing osseous pathology, as well as a determination of the overall osseous functional alignment, and complement the clinical exam. Comparison with the contralateral uninvolved foot can be useful if the r­ adiographic findings are otherwise equivocal. A high index of suspicion is required when considering osteochondral defects of the talar head and/or navicular to be the source of pain. Accordingly, computerized tomography without contrast (Fig. 8.6) should be routinely employed to assess for pathology not identified on clinical examination and/or plain film radiographs and plan treatment. 8.2.4.2 Patient Positioning The patient is positioned on the operating room table in the supine position with a gel-positioning roll under their ipsilateral thigh to control physiologic external rotation of their lower extremity. Their heel should partially hang off the end of the table to facilitate drainage of fluid into the arthroscopic drape collection bag, as well as ease mobility of the mini

D. H. Y. Tai et al.

C-arm image intensification should this be required during the procedure. All pertinent equipment should be placed on a large Mayo stand adjacent to the surgeon for easy access. The author prefers the patient to be under general and regional local anesthesia with a thigh tourniquet employed for a bloodless field should this arise. To reduce infection risk, the forefoot is covered with a sterile incise adhesive barrier [43], and the arthroscopic drape collection bag is applied such that the least amount of skin is exposed.

8.2.4.3 Portal Design As with all foot and ankle arthroscopic approaches, iatrogenic damage to regional nerves, vessels, and tendon structures represents the greatest concern with talonavicular joint arthroscopy. Fortunately, the safety of talonavicular joint arthroscopy portals has been studied in detail [37, 38, 44– 47]. The main portals are the medial, dorsomedial, dorsolateral, and lateral [37, 38, 44–47] with accessory portals possible should adjacent osseous structures and/or articulations require access [18, 22, 25, 26, 48–52]. The arthroscopic portals are universally placed along the talonavicular joint line. The medial portal is located immediately dorsal to the distal insertion of the tibialis posterior tendon and is between 8  mm [46] and 12  mm [44] from the saphenous nerve and vein. The dorsomedial portal, when placed just medial to the tibialis anterior tendon, is between 7-mm [38] and 9-mm from the saphenous nerve and vein [46]. However, when the dorsomedial portal is placed just lateral to the tibialis anterior tendon, it is 4.5 mm from the medial dorsal cutaneous branch of the superficial peroneal nerve and 10.5 mm from the deep peroneal nerve and artery [45]. The dorsolateral portal, when placed just medial to the extensor hallucis longus tendon, is 9  mm from the medial dorsal cutaneous branch of the superficial peroneal nerve and 8 mm from the deep peroneal nerve and artery [46]. However, when the dorsolateral portal is the junction between the

Fig. 8.6  Computerized tomography transverse, coronal and sagittal images (left to right, respectively) from a patient with a symptomatic cystic osteochondral defect within the dorsal navicular

8  Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy

t­alonavicular and calcaneocuboid joints, it is between 4 mm [44] and 6 mm [45] from the lateral branch of the superficial peroneal nerve and 14 mm from the deep peroneal nerve and artery [45]. The lateral portal is located just dorsal to the calcaneocuboid joint and is 12 mm from the intermediate dorsal cutaneous branch of the superficial peroneal nerve [46]. When reviewing the topographic landmarks, proximity to neurovascular structures and portal terminology employed

249

between studies [18, 22, 25, 26, 37, 38, 44–52], it is apparent that three main safe working portals exist. These portals are the medial portal located just dorsal to the tibialis posterior tendon, the dorsomedial portal located just medial to the tibialis anterior tendon, and the dorsolateral portal located just dorsal to the calcaneocuboid joint. Accordingly, these are the portals the author employs for arthroscopy of the talonavicular joint.

250

8.2.4.4 Step-by-Step Description of the Technique Arthroscopy of the talonavicular joint is traditionally performed with 1.9-mm and 2.7-mm 30-degree or similar-sized arthroscopy; however, for practical reasons the author prefers to employ a 4-mm 30-degree arthroscope. First, the field of view is greater, which facilitates identification of intra-­ articular structures and therefore orientation. Second, the equipment is more robust and can sustain more forceful manipulation with less risk of being damaged. Third, the volume of fluid delivered/time is more than with smaller arthroscopic equipment, which is better able to distend the taut capsule and maintain a functional working space. Finally, most facilities have numerous sets of 4-mm 30-degree arthroscopes and equipment, whereas smaller arthroscopes and equipment are in short supply. To identify the medial portal, a line connecting the posterior inferior aspect of the medial malleolus with the superior aspect of the navicular tuberosity is drawn with a surgical scribe and identifies the superior aspect of the tibialis posterior tendon. The medial portal is located just dorsal to the posterior tibial tendon at the level of the navicular tuberosity. The exact location of the medial portal can be confirmed with an 18 guage spinal needle secured to a 35 cc syringe due to the stout features and ability to provide enough pressure to infiltrate the tight talonavicular joint. Although controversial [53, 54], the author prefers bupivacaine 0.25% with 1:200,000 epinephrine to insufflate the talonavicular joint. After verifying the location that affords repeated direct access through the medial portal into the talonavicular joint, a small amount of local anesthesia is deposited directly subcutaneous at this location. The epinephrine creates blanching of the skin and facilitates maintenance of the location identified for the medial incision, which is performed with a No. 11 scalpel blade. This is followed by insertion of a straight hemostat through the soft tissues and capsule in standard “nick-and-­ spread” technique. The hemostat is advanced from medial to lateral across the talonavicular joint while maintaining direct contact with the dorsal navicular to minimize iatrogenic cartilage injury. The hemostat is repeatedly mobilized in a proximal and distal manner similar to how a windshield wiper moves across the windshield to release fibrous adhesions directly off the underlying bone and facilitate creation of a working space within the dorsal capsular recess. A blunt-­ tipped trocar and cannula are inserted through the medial portal employing the same pathway as created with the hemostat. The cannula is maintained in the joint resting on the talar neck after which the trocar is removed. The arthroscope is inserted into the cannula and the joint contents visualized. Next, the dorsomedial portal is identified immediately medial to the anterior tibial tendon, and the location is confirmed through visualization of an 18 guage needle inserted

D. H. Y. Tai et al.

into the talonavicular joint at this location (Fig.  8.7). After verifying the location that affords repeated direct access through the medial portal into the talonavicular joint, a small amount of local anesthesia is deposited directly subcutaneous at this location for the reasons mentioned previously. This is followed by insertion of a straight hemostat through the soft tissues and capsule in standard “nick-and-spread” technique until it comes into view (Fig. 8.8). The image is focused with

Fig. 8.7  Visualization of the 18 guage needle within the talonavicular joint. The 4-mm, 30-degree arthroscope is in the medial portal with the talus proximal, navicular distal, medial to the left and lateral to the right of the image with the needle entering through the planned dorsomedial portal. Note that the orientation remains the same for the arthroscopic images in this chapter

Fig. 8.8  Visualization of the small straight hemostat within the talonavicular joint. The 4-mm, 30-degree arthroscope is in the medial portal and the hemostat through the dorsomedial portal

8  Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy

the focal point being the hemostat itself. The hemostat is moved in dorsal-plantar and proximal-distal directions, and these motions are compared with what is shown on the video screen. The camera is rotated until the motions of the hemostat and those shown on the video screen are identical, thereby achieving proper orientation. The light cord is rotated as needed to keep the instrumentation and areas of interest in view. Next, the hemostat is withdrawn, and an arthroscopic small joint full-radius shaver or radiofrequency wand is inserted into the joint and employed to resect acute and chronic synovitis, as well as fibrotic tissues (Fig. 8.9). If the visualization is suboptimal, the use of a pin distractor can be employed to create distraction of the talonavicular joint [38, 41]. Careful pin placement to avoid regional neurovascular structures while simultaneously avoiding blocking access to the working portals is an important consideration. Finally, the dorsolateral portal is identified immediately superior to the calcaneocuboid joint, and the location is confirmed through visualization of an 18 guage needle inserted into the talonavicular joint at this location. After verifying the location that affords repeated direct access through the dorsolateral portal into the talonavicular joint, a small amount of local anesthesia is deposited directly subcutaneous at this location for the reasons mentioned previously. Portal creation and orientation and soft tissue resection are performed as described for the other portals. Soft tissue resection continues until the entire talonavicular joint from dorsomedial to dorsolateral is visualized (Fig. 8.10).

a

251

The osteochondral defect is identified through visualization of friable, diseased cartilage in the region of the pathology noted on plain film and computerized tomographic images (Fig. 8.11). It can be difficult to clearly visualize the osteochondral defect. If this occurs, gentle palpation along the dorsal navicular cartilage with a blunt probe or small chondral pick systematically advanced across the field of view can be helpful in identifying the pathology (Fig. 8.12). Once identified, a small backward-facing angled curette is employed to perform debridement of the osteochondral defect (Fig. 8.13), which is continued until healthy cancellous bone substrate is visualized throughout (Fig.  8.14). Dense fibrotic tissues, especially at the inferior aspect of the osteochondral defect, are best resected with a small joint full-radius shaver since the shield can protect the adjacent normal articular cartilage from iatrogenic injury (Fig.  8.15). Microfracture with a small chondral pick is employed if the sclerotic bone remains; otherwise the procedure is completed when viable cancellous bone substrate is visualized throughout the osteochondral defect (Fig.  8.16). Although reported [39], the author does not perform bone graft backfill of the osseous defect following arthroscopic debridement of osteochondral defects within the talonavicular joint. After removal of the arthroscopic equipment, the incisions are closed in two layers, specifically the subdermal tissues with absorbable suture and the skin edges with nonabsorbable sutures.

b

Fig. 8.9  Intraoperative image intensification image (a) and arthroscopic visualization (b) of the radiofrequency wand employed for soft tissue resection about the dorsal talonavicular joint. The 4-mm, 30-degree

arthroscope is in the medial portal and the radiofrequency wand through the dorsomedial portal

252

Fig. 8.10  Arthroscopic visualization of the dorsal talonavicular joint following soft tissue resection. The 4-mm, 30-degree arthroscope is in the medial portal and the small joint full-radius shaver is through the dorsolateral portal

D. H. Y. Tai et al.

Fig. 8.12  Arthroscopic visualization of a blunt probe used to identify the osteochondral defect within the dorsal navicular. The 4-mm, 30-degree arthroscope is in the medial portal and the blunt probe through the dorsomedial portal

ognizing situations that are not amenable to an arthroscopic approach preoperatively, employing strategically placed pin distractors or converting to an open approach intraoperatively once recognized. Iatrogenic cartilage injury is possible especially during the index soft tissue resection when visualization is the most compromised and during debridement of the osteochondral defect but is minimized through meticulous technique. Finally, incision-healing problems leading to tethering of tendons to the skin or delayed wound healing can occur with improper portal location and excessive manipulation of the soft tissue envelope about the dorsal midfoot.

Fig. 8.11 Arthroscopic visualization of the osteochondral defect within the dorsal navicular directly inferior to the small joint full-radius shaver. The 4-mm, 30-degree arthroscope is in the medial portal and the small joint full-radius shaver through the dorsolateral portal

8.2.4.5 Complications and Management The most common complication following arthroscopic debridement of osteochondral defects within the talonavicular joint is neurological injury that can have an unpredictable course but usually resolves without intervention. Failure to access and/or achieve complete debridement of the osteochondral defect is possible but preventable by properly rec-

8.2.4.6 Postoperative Care A Sir Robert Jones compression dressing is applied to control edema and immobilize the foot until suture removal [55]. Once the sutures are removed at 2–3 weeks postoperative, the patient is enrolled into a structured physiotherapy program to achieve functional restoration of the talonavicular joint range of motion. However, a period of non-weight bearing is recommended to allow the blood clot within the osteochondral defect to stabilize and mature without exposure to joint compression forces. This is usually 4–6 weeks but will vary based on patient compliance, foot structure, and complexity of the osteochondral defect treated. Thereafter, progressive weight bearing and return to activities occur using pain and swelling as a guide for when to reduce these activities.

8  Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy

a

b

253

c

Fig. 8.13  Intraoperative anterior-posterior (a) and lateral (b) image intensification views, as well as arthroscopic visualization (c), demonstrating use of a small forward-angled curette for debridement of the

osteochondral defect within the dorsal navicular. The 4-mm, 30-degree arthroscope is in the medial portal and the curette through the dorsomedial portal

Fig. 8.14  Arthroscopic visualization following debridement of the osteochondral defect within the dorsal navicular. The 4-mm, 30-degree arthroscope is in the medial portal. Note the residual dense fibrotic tissue within the base and perimeter of the defect

Fig. 8.15  Arthroscopic visualization during debridement of the fibrotic tissues within the base of the osteochondral defect using a small joint full-radius shaver. The 4-mm, 30-degree arthroscope is in the medial portal and the small joint full-radius shaver through the dorsomedial portal

8.2.4.7 Outcome Except for surgical technique description, limited data beyond generalizations provided in small case reports/series [37–39, 41] exists specific to arthroscopic debridement of osteochondral defects within the talonavicular joint. What has been published is generally favorable with resolution of pain and meaningful improvement in function occurring, and this parallels the author’s experience.

8.2.5 Summary Arthroscopic treatment of osteochondral defects within the talonavicular joint was first described 20 years ago. Despite talonavicular joint arthroscopy being safely performed, either in isolation or combined with arthroscopy of adjacent osseous and/or articular structures, it is interesting that it has not become more popular for the treatment of symptomatic

254

D. H. Y. Tai et al.

osteochondral defects within the talonavicular joint. While the available literature is favorable, due to the paucity of published comparative effectiveness data, the clinical outcomes following arthroscopic treatment of osteochondral defects

within the talonavicular joint remain a matter for conjecture. As with all arthroscopic procedures, strict adherence to proper portal development and the principles of arthroscopic joint debridement is obligatory.

DISTAL

MEDIAL

LATERAL

PROXIMAL

Fig. 8.16  Montage of intra-articular talonavicular joint arthroscopic images following debridement of a dorsal navicular osteochondral defect

8  Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy

8.3

Arthroscopic Decompression of Calcaneocuboid Joint

Amanda Slocum and Tun Hing Lui

8.3.1 Introduction Calcaneocuboid joint pathology is often poorly understood, easily overlooked, and difficult to diagnose [56, 57]. They may present with diffuse lateral foot pain and localized tenderness at the calcaneocuboid joint on clinical examination. “Cuboid syndrome” is a nonspecific term frequently used to describe symptoms associated with this condition [57]. Pathologies that can occur in the calcaneocuboid joint are similar to those of other joints. Chronic synovitis and impingement syndrome involving the calcaneocuboid joint may result from arthritic erosions and spur formation at the joint. This may be caused by systemic diseases, such as rheumatic joint disease, primary degenerative joint disease, or secondary to complications from inflammatory conditions or trauma, including osteochondral lesions, loose bodies, and lateral impingement syndrome resulting from fractures in this region [56–60]. Calcaneocuboid joint involvement has been found to occur in 68% of patients in a study involving 104 patients with calcaneal fractures [60]. In another study of 24 patients with calcaneal fractures, 8 were found to have calcaneocuboid joint osteoarthritis [61]. Lateral calcaneocuboid impingement syndrome is a known complication after calcaneal fracture. It is due to lateral cortical bulging from the impaction of the talar body onto the calcaneus. Residual bone may overhang from the displaced anterolateral calcaneal wall. This leads to loss of motion at the calcaneocuboid joint, causing pain over the joint and increased stress to the adjacent joints [59–62]. Calcaneocuboid joint arthritis is frequently asymptomatic [63]. Hence, careful history taking and clinical examination are essential to confirm the calcaneocuboid joint as the source of pain [12, 56, 62]. Once the calcaneocuboid joint is identified as the primary source of pain, a trial of non-­operative management can be considered. This includes physiotherapy and use of anti-inflammatory medications, orthotics, and steroid injection. Operative treatment is indicated if conservative treatment fails to relieve the symptoms.

255

Clare et al. suggested that both the overhang and the lateral fourth at the distal aspect of the calcaneus should be removed in case of lateral calcaneocuboid impingement syndrome, as the articulation of this lateral portion with the cuboid is almost always arthritic [64]. This is commonly performed open using the lateral approach. Calcaneocuboid arthroscopy has recently been developed and provides a minimally invasive approach to the calcaneocuboid joint [12, 56]. In the past, calcaneocuboid joint arthroscopy was mainly for diagnostic purpose, due to limitations by anatomic space constraint. With the development of smaller and more sophisticated instrumentation, therapeutic arthroscopy of the calcaneocuboid joint is becoming a more viable option in tackling calcaneocuboid joint pathology. Recently, calcaneocuboid joint arthroscopy has been used to decompress the calcaneocuboid joint in cases of lateral calcaneocuboid impingement syndrome. Aside from removal of the overhang, arthroscopic synovectomy, resection of scar tissue, and debridement of damaged cartilage can be performed in the same setting [62, 65]. In addition to the advantage of minimally invasive surgery including smaller wounds, better cosmetic result, and less surgical soft tissue trauma, it also allows focused examination of the degenerative parts of the joint. Therefore, the amount of bone resection can be titrated according to the extent of degeneration. This can prevent excessive resection of the joint and accelerated degeneration of the remaining part of the calcaneocuboid joint.

8.3.2 Indications • Symptomatic lateral calcaneocuboid impingement that is recalcitrant to conservative treatment [12, 56, 57, 62]

8.3.3 Contraindications • Calcaneocuboid joint is not the source of pain. • Extensive damage of cartilage or advanced degeneration of the calcaneocuboid joint. • Active infection at the operative site. • Lack of expertise. • Lack of proper-sized instruments.

256

8.3.4 Author-Preferred Technique 8.3.4.1 Preoperative Planning It is important to delineate properly the source of the pain as it may not originate solely from the calcaneocuboid joint. Frequently, the lateral heel pain after calcaneal fractures can be multifactorial. Causes include calcaneofibular impingement, posterior subtalar arthritis, anterolateral calcaneal impingement, sinus tarsi syndrome, anterior subtalar arthritis, sural nerve neuritis, and peroneal tendon impingement [62]. Identifying the sources of pain correctly allows the surgeon to formulate a surgical plan that is most suited to the patient. Local tenderness is the most important clinical examination to locate the source of pain. Dorsolateral and oblique X-rays of the foot can show the lateral bone spur and degeneration of the lateral fourth of the calcaneocuboid joint (Fig. 8.17). CT can help to delineate osteochondral lesions, loose bodies, and the location and extent of bone spur and degeneration of the calcaneocuboid joint. Further work-up with MRI may help rule out occult pathologies of the calcaneocuboid joint and adjacent structures, e.g., peroneal tendons and talocalcaneonavicular joint [56].

Fig. 8.17  Preoperative dorsoplantar radiograph shows lateral bone spur of the calcaneocuboid joint

D. H. Y. Tai et al.

8.3.4.2 Patient Positioning The patient can be positioned lateral, supine, or prone, depending on the concomitant surgical procedures that are planned. If calcaneocuboid arthroscopy is the only procedure planned, lateral position of the patient is preferred. A 2.7-­ mm 30° arthroscope is used for this procedure. A thigh tourniquet is applied to provide a bloodless operative field. Fluid inflow is by gravity and no arthro-pump is needed.

8  Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy

8.3.4.3 Portal Design Calcaneocuboid arthroscopy is performed via the lateral and dorsolateral midtarsal portals (Fig. 8.18). The lateral midtarsal portal is located at the plantar lateral corner of the calcaneocuboid joint. The dorsolateral midtarsal portal is at the junction between the calcaneocuboid joint and talonavicular

Fig. 8.18  Calcaneocuboid arthroscopy is performed via the lateral and dorsolateral midtarsal portals

257

joint. Portal sites can be modified according to the location and span of the overhang. They should be placed at the dorsal and plantar ends of the overhang. Fluoroscopy is helpful for locating the portal sites, especially if the joint line is obscured by the bony overhang.

258

8.3.4.4 Step-by-Step Description of the Technique • Three to 4 mm incisions are made at the portal sites. The subcutaneous tissue is bluntly dissected to the underlying bone using a hemostat. • The capsule is incised and stripped from the joint and surrounding bones by a small periosteal elevator. The stripping can be guided by fluoroscopy. This creates the working space for calcaneocuboid arthroscopy. • The lateral and dorsolateral midtarsal portal sites can be used interchangeably as the working and viewing portals.

D. H. Y. Tai et al.

• Any inflamed synovium and scar tissue should be resected to improve the arthroscopic visual field. The overhang is removed with an arthroscopic burr or acromionizer. The amount of resected bone should be checked frequently with fluoroscopy to avoid uneven or excessive bone resection (Fig. 8.19). • After removal of the overhang, the calcaneocuboid joint can be examined for any cartilage damage (Fig.  8.20). The joint pathology can then be treated arthroscopically. The extent of joint resection is titrated according to the extent of cartilage damage (Fig. 8.21).

a

b

c

d

Fig. 8.19 Arthroscopic views of the calcaneocuboid joint. (a) Dorsolateral midtarsal portal is the viewing portal. There is S: inflamed synovium covering the plantar lateral part of the calcaneocuboid joint. (b) Lateral midtarsal portal

is the viewing portal. The interface between the overhang and normal articular cartilage (arrow) can be determined. (c) The overhang is removed with an arthroscopic acromionizer. (d) The normal articular cartilage is preserved

8  Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy

a

259

b

Fig. 8.20 (a) Dorsolateral midtarsal portal is the viewing portal. The overhang is resected. (b) The articular cartilage is examined for any lesion. (a) cuboid and (b) calcaneus

peroneal nerve, and the lateral terminal branch of the deep peroneal nerve • Excessive bone resection and accelerated degeneration of the calcaneocuboid joint • Incomplete resection of the overhang leading to residual impingement pain

8.3.4.6 Postoperative Care The patient is advised to adhere to non-weight bearing walking for 2 weeks after the operation and then weight bearing walking as tolerated after that. Passive mobilization exercise of the joint is encouraged.

Fig. 8.21  Postoperative dorsoplantar radiograph shows that lateral bone spur of the calcaneocuboid joint is resected

• After the procedure, the joint should be thoroughly irrigated to remove all the bone debris.

8.3.4.5 Complications • Lateral midtarsal portal: risks of injury to the peroneal tendons and sural nerve • Dorsolateral midtarsal portal: risks of injury to the long extensor tendons, the lateral branch of the superficial

8.3.5 Summary Arthroscopic decompression of the calcaneocuboid joint is a feasible minimally invasive approach in managing patients with symptomatic lateral calcaneocuboid impingement. It allows concurrent management of other pathologies related to lateral calcaneocuboid impingement. The amount of joint resection can be titrated according to the extent of degeneration of the lateral part of the joint, and this helps avoid excessive bone resection.

260

8.4

D. H. Y. Tai et al.

Endoscopic Treatment of Calcaneonavicular Coalition

Thomas Bauer and Tun Hing Lui

8.4.1 Introduction Calcaneonavicular coalition is a congenital anomaly characterized by an abnormal connection between the calcaneus and the navicular. It is classified into syndesmosis, synchondrosis, and synostosis according to different tissues bridging between the bones [66, 67]. The typical presentation is persistent anterolateral ankle pain, rigid flatfoot, and repeated ankle sprains in an adolescent between 8 and 14 years old [68–71]. Calcaneonavicular coalition is an entity of prevalence of 5%. Only one fourth of the cases becomes symptomatic [66, 70]. Resection of the calcaneonavicular coalition is indicated if non-operative treatment cannot relieve the symptoms. Extensor digitorum brevis muscle interposition can be performed together with coalition resection in order to prevent recurrence of the bone bar and prolong the pain relief period [72–75]. Classically, resection of the coalition is performed with an open approach. Mubarak et  al. [76] reported significant functional improvement, full recovery in sports activities, and low rate of recurrent ossification after resection of calcaneonavicular coalition and fat graft interposition. Cadaveric study has also been conducted and demonstrated a mean 10-mm plantar gap unfilled after resection of the coalition and extensor digitorum brevis interposition and fat graft achieved a better filling of the resection area. Good to excellent functional outcomes are expected if the operation is performed in young patients before degenerative changes occur [73, 77–85]. Residual heel pain or disability on walking may occur if resection of the coalition is performed in adults because of arthritis of the adjacent joints. Lui [86] first described the surgical

technique of an arthroscopic resection of calcaneonavicular coalition in a 14-year-old boy with symptomatic too long anterior process (TLAP). After that, there are reports of successful resection of the calcaneonavicular coalition under endoscopic control [79, 81–89]. The key of success of endoscopic resection of calcaneonavicular coalition is precise location of the portals. In order to achieve complete resection of the coalition, both viewing and working portals must be accurately located around the coalition under fluoroscopy. Moreover, location of the working portal must be modified according to the location of the superficial peroneal nerve in order to prevent nerve injury during the resection. Molano et al. [79] proposed that the safest technique of endoscopic calcaneonavicular coalition resection should be a 2-portal technique with the viewing portal at the level of the anterior process of the calcaneus and the working portal distal and medial to the bone bar. During calcaneonavicular coalition resection, the surgeon should make sure that the resection is complete especially on the medial and plantar part of the bar. This region is deep and sometimes difficult to access endoscopically. Incomplete resection will result in persistent pain or recurrence of the bone bar. The technical details to overcome these problems are described here.

8.4.2 Indications • Symptomatic calcaneonavicular coalition or • Symptomatic calcaneal too long anterior process (TLAP) with syndesmosis or synchondrosis, or • Painful nonunion of anterior calcaneal process [88] that is recalcitrant to conservative treatment.

8.4.3 Contra-Indications • Local soft tissue infection around the portal sites. • Other source of midfoot pain, e.g. midtarsal arthritis.

8  Midtarsal Arthroscopy: Talonavicular Joint (TNJ) Arthroscopy and Calcaneocuboid Joint (CCJ) Arthroscopy

8.4.4 Author Preferred Technique 8.4.4.1 Preoperative Planning Diagnosis is suspected clinically and confirmed with iconography (oblique views on foot X-rays, CT scan, and MRI) (Fig. 8.22). For painful TLAP, a cortisone injection is always performed before surgery to confirm the source of the midfoot pain.

261

8.4.4.2 Patient Positioning The patient is in a supine position with a support under the ipsilateral buttock. A pneumatic thigh tourniquet is applied to provide a bloodless operative field. 8.4.4.3 Portal Design The superficial peroneal nerve must be identified with foot inversion. The viewing portal is identified under fluoroscopic control. An oblique view of the foot is taken and the portal is located dorsal to the angle of Gissane. The portal is created with skin incision followed by blunt dissection of the subcutaneous tissue with a mosquito clamp till the underlying bone is reached. A 4.0-mm arthroscope is introduced via the viewing portal. Under fluoroscopy, position of the arthroscope is checked and confirmed to be at the dorsal surface of the anterior calcaneal process and at the proximal lateral end of the bone bar in contact with the navicular bone. The working portal is at the distal medial end of the bone bar. It is located with a needle under fluoroscopy. At this point the working portal is