- Email: [email protected]
Ankle arthroscopy: a new technique for non-invasive ankle distraction
Foot and Ankle Surgery 2001
7: 137±139
Ankle arthroscopy: a new technique for non-invasive ankle distraction D . H E D L E Y , N . P .J . GE A R Y A N D P . M ED A Arrowe Park Hospital, Wirral, Merseyside, UK
Summary
Ankle arthroscopy is often complicated by the fact that the ankle joint is a tight space and distraction may be necessary to facilitate access for the arthroscopy equipment. When distraction is not required, it is still necessary to hold the leg stable. This paper describes a technique that uses a standard tibial nailing table to hold the leg and, when necessary, provides distraction during ankle arthroscopy; circumferential access is possible. The equipment is available in most hospitals that treat trauma patients and requires only a disposable ankle sling as an additional piece of equipment. To date, many techniques have been described, and they can be divided into invasive and non-invasive techniques. Criticism of non-invasive techniques is usually aimed at either inadequate distraction or complicated equipment, necessitating the use of invasive methods that have a higher complication rate. We now use this technique for all our ankle arthroscopies, and ®nd it enables excellent distraction and visual access. To date, there have been no complications caused by nerve damage. Keywords: ankle; arthroscopy; distraction; invasive
Introduction Over the last few years, ankle arthroscopy has become a powerful tool in the armamentarium of the orthopaedic surgeon. As advances in arthroscopic equipment have been made, there has been an increase in the range of procedures that can be carried out in the ankle joint [1±4]. In order to do so, it is usually, although not always [5], necessary to achieve suf®cient distraction of the ankle joint [6±9]. Non-invasive methods of external tissue distraction are preferable to those using rigid ®xation because these are associated with more complications, e.g. nerve injury and infection [10, 11]. However, in our practice, we found that many of the commercially Correspondence: Mr David Hedley, 3 Cemeas Close, Lock®elds, Liverpool L5 9RF, UK (e-mail: [email protected]). Ó 2001 Blackwell Science Ltd
available systems [12±14] are inadequate for many reasons: they may provide insuf®cient distraction or be expensive or complicated to use. We have devised a new system of ankle distraction that is easy to use, provides ample distraction, is inexpensive and is available in every hospital that has the use of a standard fracture table.
Methods The patient is placed supine on a standard fracture table with attachments for closed intramedullary tibial nailing. The extra expense involved is a disposable sterile ankle sling (we use the AcufexÒ ankle sling). The contralateral leg is held up out of the way using a well-padded Lloyd-Davies stirrup, held secure with crepe or Velcro straps. The affected leg is positioned with the post behind the thigh so 137
1 38
D . H E D L EY E T A L .
Figure 1 Position of the patient before draping.
that the knee is ¯exed to 90° with the ankle hanging free (Figure 1). The skin is then prepared from the mid-calf to the foot, using whichever antiseptic the surgeon prefers. We prefer to use disposable paper sheets as we ®nd that these easier to modify. The long arm of the fracture table is covered with a sheet, stuck at the proximal end only, and then overwrapped with a sterile crepe bandage, again tied only at the proximal end. This allows extension of the arm without causing shearing or tears. The contralateral leg is covered with a leg bag. We then use a sterile U-drape to cover the upper leg, and fold this over to cover the rest of the patient. Finally, another leg bag covers the traction apparatus. When this has all been done, the ankle sling is wrapped around the foot and connected to the traction apparatus. As this has the inevitable consequence of puncturing the bag, we overwrap this with sterile OptapeÒ. An important technical point is to ensure that the traction bar is well below the ankle distally, i.e. the bar must not be parallel with the leg (Figure 2). This ensures that the traction bar does not interfere with the arthroscopy equipment. The traction can now be applied easily through the bag to the desired level. One bene®t of this method is that it becomes possible to insert a spring balance between the traction lever and the sling. This would allow exact measurement of the distraction force involved, and could be useful for research.
Figure 2 Position of the patient to show draping technique.
Results To date, we have used this technique on 29 ankles. We have been able to inspect all surfaces of the joint and use powered instruments. The procedures we have performed include diagnostic arthroscopy, synovectomy, cheilectomy, arthrodesis and debridement. We have had no problem with skin damage, and encountered no episodes of nerve, tendon or vascular injury. The duration of surgery ranges from 21 min (for a diagnostic arthroscopy) to 134 min (for an arthrodesis).
Discussion This is the best technique of external ankle distraction that we have found to date. Joint access has never been a problem in our experience, and the sling allows for ankle ¯exion and extension during surgery. Our practice revolves around osteoarthritic joints and trauma mainly. We accept the arguments put forward by Graham et al. [15], and in patients with poor-quality skin such as rheumatoid arthritis patients we might need to use pin distraction. However, this can be achieved using the same apparatus to hold the leg and provide distraction if needed. Similar techniques have been described previously, but these tend to involve commercial systems, which, inevitably, are very expensive and therefore Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 137±139
ANKLE ARTHROSCOPY IN NON-INVASIVE ANKLE DISTRACTION
out of reach of many cash-strapped NHS hospitals. As most hospitals will have a fracture table of one sort or another, no additional outlay is required and the only expense is the ankle sling. The bene®t of the traction table is that the ankle is held suspended in the air. This allows for virtually 360° of access to the ankle joint. Many commercial systems actually hold the ankle on the operating table, and this has obvious restrictions to the access that can be achieved. Some ankle arthroscopists argue that traction is not necessary for many procedures. Regardless of one's views on this subject, the ankle still needs to be held still while arthroscopy is performed. Our technique allows this to be done without the aid of an assistant and, furthermore, without the table restricting access. We start with minimal distraction. The sling is just taut at the start of the procedure. Owing to the nature of the draping, the operator can control the distraction during the procedure and alter it with ease, without loss of sterility.
References 1 Kashuk KB, Harmelin E, Holcombe R et al. Arthroscopy of the ankle and subtalar joint. Clin Podiatric Med Surg 2000; 17: 55±79.
Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 137±139
139
2 Jay RM. Clin Podiatric Med Surg 2000; 17: 147±157. 3 Amendola A, Petrik J, Webster-Bogaert S. Ankle arthroscopy: outcome in 79 consecutive patients. Arthroscopy 1996; 12: 565± 573. 4 Sandmeier RH, Renstrom PA. Ankle arthroscopy. Scand J Med Sci Sports 1995; 5: 64±70. 5 van Dijk CN, Scholte D. Arthroscopy of the ankle joint. Arthroscopy 1997; 13: 90±96. 6 Econopouly DS, Perlman MD, Notari MA et al. The use of an ankle joint distractor in ankle arthroscopy. J Foot Surg 1992; 31: 96±99. 7 Takao M, Ochi M, Shu N et al. Bandage distraction technique for ankle arthroscopy. Foot Ankle Int 1999; 20: 389±391. 8 Casteleyn PP, Handelberg F. Distraction for ankle arthroscopy. Arthroscopy 1995; 11: 633±634. 9 Palladino SJ. Distraction techniques for ankle arthroscopy. Clin Podiatric Med Surg 1994; 11: 499±511. 10 Ferkel RD, Heath DD, Guhl JF. Neurological complications of ankle arthroscopy. Arthroscopy 1996; 12: 200±208. 11 Lamy C, Stienstra JJ. Complications in ankle arthroscopy. Clin Podiatric Med Surg 1994; 11: 523±539. 12 Ferkel RD.Arthroscopy of the Foot and Ankle. New York: Lippincott-Raven, 1996. 13 Ferkel RD. Sports medicine. In: Coughlin MJ, Mann RA, Eds, Surgery of the Foot and Ankle. St Louis, MO: Mosby, 1999: 1257±1297. 14 McGinty JB, Gulhl JF. Operative Arthroscopy. New York: Raven Press, 1991. 15 Graham AJ, Hughes S, Cooke PH. Ankle arthroscopy. The use of an Ilizarov half-frame ®xator to distract the ankle joint. Foot Ankle Surg 2000; 6: 55±58.
7: 137±139
Ankle arthroscopy: a new technique for non-invasive ankle distraction D . H E D L E Y , N . P .J . GE A R Y A N D P . M ED A Arrowe Park Hospital, Wirral, Merseyside, UK
Summary
Ankle arthroscopy is often complicated by the fact that the ankle joint is a tight space and distraction may be necessary to facilitate access for the arthroscopy equipment. When distraction is not required, it is still necessary to hold the leg stable. This paper describes a technique that uses a standard tibial nailing table to hold the leg and, when necessary, provides distraction during ankle arthroscopy; circumferential access is possible. The equipment is available in most hospitals that treat trauma patients and requires only a disposable ankle sling as an additional piece of equipment. To date, many techniques have been described, and they can be divided into invasive and non-invasive techniques. Criticism of non-invasive techniques is usually aimed at either inadequate distraction or complicated equipment, necessitating the use of invasive methods that have a higher complication rate. We now use this technique for all our ankle arthroscopies, and ®nd it enables excellent distraction and visual access. To date, there have been no complications caused by nerve damage. Keywords: ankle; arthroscopy; distraction; invasive
Introduction Over the last few years, ankle arthroscopy has become a powerful tool in the armamentarium of the orthopaedic surgeon. As advances in arthroscopic equipment have been made, there has been an increase in the range of procedures that can be carried out in the ankle joint [1±4]. In order to do so, it is usually, although not always [5], necessary to achieve suf®cient distraction of the ankle joint [6±9]. Non-invasive methods of external tissue distraction are preferable to those using rigid ®xation because these are associated with more complications, e.g. nerve injury and infection [10, 11]. However, in our practice, we found that many of the commercially Correspondence: Mr David Hedley, 3 Cemeas Close, Lock®elds, Liverpool L5 9RF, UK (e-mail: [email protected]). Ó 2001 Blackwell Science Ltd
available systems [12±14] are inadequate for many reasons: they may provide insuf®cient distraction or be expensive or complicated to use. We have devised a new system of ankle distraction that is easy to use, provides ample distraction, is inexpensive and is available in every hospital that has the use of a standard fracture table.
Methods The patient is placed supine on a standard fracture table with attachments for closed intramedullary tibial nailing. The extra expense involved is a disposable sterile ankle sling (we use the AcufexÒ ankle sling). The contralateral leg is held up out of the way using a well-padded Lloyd-Davies stirrup, held secure with crepe or Velcro straps. The affected leg is positioned with the post behind the thigh so 137
1 38
D . H E D L EY E T A L .
Figure 1 Position of the patient before draping.
that the knee is ¯exed to 90° with the ankle hanging free (Figure 1). The skin is then prepared from the mid-calf to the foot, using whichever antiseptic the surgeon prefers. We prefer to use disposable paper sheets as we ®nd that these easier to modify. The long arm of the fracture table is covered with a sheet, stuck at the proximal end only, and then overwrapped with a sterile crepe bandage, again tied only at the proximal end. This allows extension of the arm without causing shearing or tears. The contralateral leg is covered with a leg bag. We then use a sterile U-drape to cover the upper leg, and fold this over to cover the rest of the patient. Finally, another leg bag covers the traction apparatus. When this has all been done, the ankle sling is wrapped around the foot and connected to the traction apparatus. As this has the inevitable consequence of puncturing the bag, we overwrap this with sterile OptapeÒ. An important technical point is to ensure that the traction bar is well below the ankle distally, i.e. the bar must not be parallel with the leg (Figure 2). This ensures that the traction bar does not interfere with the arthroscopy equipment. The traction can now be applied easily through the bag to the desired level. One bene®t of this method is that it becomes possible to insert a spring balance between the traction lever and the sling. This would allow exact measurement of the distraction force involved, and could be useful for research.
Figure 2 Position of the patient to show draping technique.
Results To date, we have used this technique on 29 ankles. We have been able to inspect all surfaces of the joint and use powered instruments. The procedures we have performed include diagnostic arthroscopy, synovectomy, cheilectomy, arthrodesis and debridement. We have had no problem with skin damage, and encountered no episodes of nerve, tendon or vascular injury. The duration of surgery ranges from 21 min (for a diagnostic arthroscopy) to 134 min (for an arthrodesis).
Discussion This is the best technique of external ankle distraction that we have found to date. Joint access has never been a problem in our experience, and the sling allows for ankle ¯exion and extension during surgery. Our practice revolves around osteoarthritic joints and trauma mainly. We accept the arguments put forward by Graham et al. [15], and in patients with poor-quality skin such as rheumatoid arthritis patients we might need to use pin distraction. However, this can be achieved using the same apparatus to hold the leg and provide distraction if needed. Similar techniques have been described previously, but these tend to involve commercial systems, which, inevitably, are very expensive and therefore Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 137±139
ANKLE ARTHROSCOPY IN NON-INVASIVE ANKLE DISTRACTION
out of reach of many cash-strapped NHS hospitals. As most hospitals will have a fracture table of one sort or another, no additional outlay is required and the only expense is the ankle sling. The bene®t of the traction table is that the ankle is held suspended in the air. This allows for virtually 360° of access to the ankle joint. Many commercial systems actually hold the ankle on the operating table, and this has obvious restrictions to the access that can be achieved. Some ankle arthroscopists argue that traction is not necessary for many procedures. Regardless of one's views on this subject, the ankle still needs to be held still while arthroscopy is performed. Our technique allows this to be done without the aid of an assistant and, furthermore, without the table restricting access. We start with minimal distraction. The sling is just taut at the start of the procedure. Owing to the nature of the draping, the operator can control the distraction during the procedure and alter it with ease, without loss of sterility.
References 1 Kashuk KB, Harmelin E, Holcombe R et al. Arthroscopy of the ankle and subtalar joint. Clin Podiatric Med Surg 2000; 17: 55±79.
Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 137±139
139
2 Jay RM. Clin Podiatric Med Surg 2000; 17: 147±157. 3 Amendola A, Petrik J, Webster-Bogaert S. Ankle arthroscopy: outcome in 79 consecutive patients. Arthroscopy 1996; 12: 565± 573. 4 Sandmeier RH, Renstrom PA. Ankle arthroscopy. Scand J Med Sci Sports 1995; 5: 64±70. 5 van Dijk CN, Scholte D. Arthroscopy of the ankle joint. Arthroscopy 1997; 13: 90±96. 6 Econopouly DS, Perlman MD, Notari MA et al. The use of an ankle joint distractor in ankle arthroscopy. J Foot Surg 1992; 31: 96±99. 7 Takao M, Ochi M, Shu N et al. Bandage distraction technique for ankle arthroscopy. Foot Ankle Int 1999; 20: 389±391. 8 Casteleyn PP, Handelberg F. Distraction for ankle arthroscopy. Arthroscopy 1995; 11: 633±634. 9 Palladino SJ. Distraction techniques for ankle arthroscopy. Clin Podiatric Med Surg 1994; 11: 499±511. 10 Ferkel RD, Heath DD, Guhl JF. Neurological complications of ankle arthroscopy. Arthroscopy 1996; 12: 200±208. 11 Lamy C, Stienstra JJ. Complications in ankle arthroscopy. Clin Podiatric Med Surg 1994; 11: 523±539. 12 Ferkel RD.Arthroscopy of the Foot and Ankle. New York: Lippincott-Raven, 1996. 13 Ferkel RD. Sports medicine. In: Coughlin MJ, Mann RA, Eds, Surgery of the Foot and Ankle. St Louis, MO: Mosby, 1999: 1257±1297. 14 McGinty JB, Gulhl JF. Operative Arthroscopy. New York: Raven Press, 1991. 15 Graham AJ, Hughes S, Cooke PH. Ankle arthroscopy. The use of an Ilizarov half-frame ®xator to distract the ankle joint. Foot Ankle Surg 2000; 6: 55±58.