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Arthroscopic Ankle Arthrodesis with Intra-articular Distraction
The Journal of Foot & Ankle Surgery xxx (2014) 1–4
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Tips, Quips, and Pearls “Tips, Quips, and Pearls” is a special section in The Journal of Foot & Ankle SurgeryÒ, which is devoted to the sharing of ideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in the form of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedure a little bit easier, or virtually any other “pearl” that the reader believes will assist the foot and ankle surgeon in providing better care.
Arthroscopic Ankle Arthrodesis with Intra-articular Distraction Hyong Nyun Kim, MD, PhD, June Young Jeon, MD, Kyu Cheol Noh, MD, PhD, Hong Kyun Kim, MD, Quanyu Dong, MD, Yong Wook Park, MD, PhD Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
a r t i c l e i n f o
a b s t r a c t
Keywords: arthritis arthroscope cannula fusion talus tibia trocar
Arthroscopic ankle arthrodesis has shown high rates of union comparable to those with open arthrodesis but with substantially less postoperative morbidity, shorter operative times, less blood loss, and shorter hospital stays. To easily perform arthroscopic resection of the articular cartilage, sufficient distraction of the joint is necessary to insert the arthroscope and instruments. However, sometimes, standard noninvasive ankle distraction will not be sufficient in post-traumatic ankle arthritis, with the development of arthrofibrosis and joint contracture after severe ankle trauma. In the present report, we describe a technique to distract the ankle joint by inserting a 4.6-mm stainless steel cannula with a blunt trocar inside the joint. The cannula allowed sufficient intra-articular distraction, and, at the same time, a 4.0-mm arthroscope can be inserted through the cannula to view the joint. Screws can be inserted to fix the joint under fluoroscopic guidance without changing the patient’s position or removing the noninvasive distraction device and leg holder, which are often necessary during standard arthroscopic arthrodesis with noninvasive distraction. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Ankle arthrodesis has traditionally been the preferred surgical method to treat end-stage ankle arthritis. Open approaches to the ankle joint have traditionally been used; however, arthroscopic arthrodesis has been increasing in popularity, because it is less invasive, offering the advantages of less postoperative pain and fewer wound problems (1–8). Several studies have shown high rates of union with arthroscopic arthrodesis compared with open arthrodesis but with substantially less postoperative morbidity, shorter operative times, less blood loss, and shorter hospital stays (4,7,9). However, nonunion has been reported after arthroscopic arthrodesis (10,11). One of the factors leading to nonunion has been insufficient removal of the articular cartilage from the talus and tibia. To easily perform arthroscopic resection of the articular cartilage, sufficient distraction of the joint is necessary to insert the arthroscope and instruments (12,13). However, sometimes, noninvasive ankle distraction will not be sufficient in post-traumatic ankle arthritis, with the development of arthrofibrosis and joint contracture after severe ankle trauma (12,14,15). In the present report, we have described a technique to Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Yong Wook Park, MD, PhD, Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1, Dalim-1dong, Youngdeungpo-gu, Seoul 150-950 South Korea. E-mail address: [email protected] (Y.W. Park).
distract the ankle joint by inserting a large-diameter blunt trocar into the joint. The trocar allows sufficient intra-articular distraction for resection of the articular cartilage. Screws can be inserted to fix the joint under fluoroscopic guidance without changing the patient’s position or removing the noninvasive distraction device and leg holder, which are often necessary during standard arthroscopic arthrodesis with noninvasive distraction. Operative Technique The patient is placed in the supine position with the arthritic ankle (Fig. 1) distal from the operating table (Fig. 2). A pneumatic tourniquet is inflated around the thigh. A skin incision is made medial to the tibialis anterior tendon at the level of the ankle joint for the anteromedial portal. After blunt dissection with a clamp through the skin to the capsule, a 4.6-mm stainless steel cannula with a blunt trocar inside is inserted into the joint under fluoroscopic guidance (Fig. 3). To ease the insertion, a small-diameter (2.5-mm) trocar is inserted first to gradually widen the joint space and distract the soft tissue. Insertion of the cannula with a blunt trocar inside will distract the joint, and, at the same time, a 4.0-mm arthroscope can be inserted through the cannula to view the joint. Another skin incision is made just lateral to the Achilles tendon at the joint line to establish the posterolateral portal. When arthroscopic visualization of the posterior ankle is
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.02.004
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H.N. Kim et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
ligament and intermalleolar ligament under direct visualization through the arthroscope. The mosquito clamp is used to open the joint capsule. To gradually widen the joint capsule and soft tissue, a smalldiameter blunt trocar is inserted first and then substituted with larger ones. Finally, a 4.6-mm stainless steel cannula with a blunt trocar inside is inserted into the joint. When insertion of the cannula under direct visualization with the arthroscope is difficult, the cannula can be inserted under fluoroscopic guidance (Fig. 4). With 2 cannulas inside the joint, they can be used alternatively for maintaining joint distraction. One of the 2 cannulas can be retracted slightly to move freely, and an arthroscope can be inserted through that cannula to examine the joint, with the other cannula used to maintain the joint distraction. Alternatively, 1 of the cannulas can be removed and instruments can be inserted through the same portal, with distraction maintained using the other cannula. A standard anterolateral portal can be established for better instrumentation and visualization. When the arthritic joint distracts easily using this technique, a 5.5-mm disposable plastic cannula (ConMed Linvatech, Largo, FL), which has often been used in shoulder arthroscopy, can be used for distraction of the ankle joint. When a suction tube is connected to the plastic cannula after removing the trocar inside, cartilage debris of various size, which will often clog a shaver, can be resected by a curette and easily flushed out of the joint. Instruments can also be introduced into the joint through the plastic cannula for use. Intra-articular positioning of the cannula can be changed to resect the articular cartilage hidden under the cannula. A blunt trocar can be inserted into the lateral gutter (talofibular space) or medial gutter (medial tibiotalar space) to widen the space to debride the articular cartilage. After thorough removal of the articular cartilage and abrasion of the underlying subchondral bone surface, all the instruments and the arthroscope are removed, and 6.5-mm cannulated screws are inserted to fix the joint under fluoroscopic guidance (Fig. 5). Discussion Fig. 1. Preoperative lateral ankle radiograph showing arthritic change of the articular surface and narrowing of the ankle joint.
possible through the arthroscopic cannula previously introduced to distract the joint, a clamp is inserted anteriorly through the posterolateral incision into the space between the posteroinferior tibiofibular
Unlike hip and knee osteoarthritis, primary degenerative ankle osteoarthritis has rarely been encountered. Also, ankle osteoarthritis is much more likely to be post-traumatic, which accounts for 65% to 80% of ankle osteoarthritis cases (16). In the trauma cases, damage often extends to the soft tissue and leads to joint contracture and
Fig. 2. Fluoroscopic radiographs showing (A) intra-articular ankle distraction by insertion of a large- diameter blunt trocar through the anteromedial portal. (B) Arthroscopic image of the medial ankle visualized from the anterolateral portal showing the blunt trocar inserted through the anteromedial portal and a shaver from the posterolateral portal debriding the articular cartilage.
H.N. Kim et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
3
Fig. 3. Intraoperative image showing the patient in the supine position with the ankle distal from the operating table. A 4.6-mm stainless steel cannula with a blunt trocar inside was inserted into the joint through the anteromedial portal to distract the joint and, at the same time, a 4.0-mm arthroscope can be inserted through the cannula to view the joint. Another 4.6-mm stainless steel cannula was inserted into the joint through the posterolateral portal.
arthrofibrosis after severe ankle pilon fractures. Because of the shape of the talus, joint distraction is necessary for arthroscopic ankle arthrodesis (4). However, in cases with joint contracture and arthrofibrosis, noninvasive ankle distraction might not be sufficient (14,17). Some investigators have advocated invasive skeletal distraction for tight arthritic ankles (12,15). However, possibilities exist for pin breakage, infection, and a risk to neurovascular structures (12,15). We believe inserting an arthroscopic cannula with a blunt trocar inside can be useful to distract the joint intra-articularly when damaging the articular cartilage is not an issue, such as in arthrodesis. Introduction of a blunt trocar into the subtalar joint has been described for arthroscopic subtalar arthrodesis with successful joint distraction (18,19). However, insertion of an arthroscopic cannula for ankle joint distraction during arthroscopic ankle arthrodesis has not been previously described. Intra-articular ankle distraction by inflation of a kyphoplasty balloon placed inside the ankle joint has been discussed (20). We believe this technique is also an option for treatment. However, the inflated balloon can be damaged by sharp instruments during resection of the articular cartilage or it can block vision to certain extent. The cost of the material should also be considered.
Fig. 5. Postoperative lateral ankle radiograph showing insertion of cannulated screws for joint fixation.
One advantage of our technique compared with usual noninvasive ankle distraction is that surgeons can move freely around the ankle. Movement will sometimes be limited when the noninvasive
Fig. 4. Fluoroscopic radiographs showing (A) intra-articular ankle distraction by insertion of a large- diameter blunt trocar through the posterolateral portal. (B) Arthroscopic image of the lateral ankle visualized from the anteromedial portal showing the blunt trocar inserted through the posterolateral portal and a curette introduced from the anterolateral portal, resecting the tibial articular cartilage.
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H.N. Kim et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
distraction device is connected to the table. In addition, screws can be inserted under fluoroscopic guidance without having to change the patient’s position or remove the noninvasive distraction device and leg holder. Such steps will often be necessary during standard arthroscopic arthrodesis with noninvasive distraction. We believe our technique allows more powerful distraction compared with the usual noninvasive technique, because it mechanically distracts the joint by directly pushing away the tibial and talar bony structure inside the joint. However, a shortcoming of the technique is that it might not be adequate in an osteoporotic ankle (e.g., in rheumatoid arthritis). The cannula must be held by an assistant such that it does not slip out of the joint, which we believe is not that difficult. We have tried to insert the arthroscopic cannula through the posterolateral portal under fluoroscopic guidance before inserting another cannula through the anteromedial portal. However, insertion of the arthroscopic cannula using that method was more difficult than insertion of an arthroscopic cannula through the anteromedial portal. We believe that was because of the thick ligaments surrounding the posterolateral ankle. Because no ligamentous structure are present around the anteromedial portal area and because an anteromedial notch defined by Harty is present it has been much easier to insert a blunt trocar through the anteromedial portal under fluoroscopic guidance. After joint distraction by the anteromedial cannula, insertion of the cannula through the posterolateral portal will be much easier. We believe this technique should be considered when performing arthroscopic ankle arthrodesis, especially for tight post-traumatic ankle arthritis. References 1. Peterson KS, Lee MS, Buddecke DE. Arthroscopic versus open ankle arthrodesis: a retrospective cost analysis. J Foot Ankle Surg 49:242–247, 2010.
2. Corso SJ, Zimmer TJ. Technique and clinical evaluation of arthroscopic ankle arthrodesis. Arthroscopy 11:585–590, 1995. 3. Dent CM, Patil M, Fairclough JA. Arthroscopic ankle arthrodesis. J Bone Joint Surg Br 75:830–832, 1993. 4. Ferkel RD, Hewitt M. Long-term results of arthroscopic ankle arthrodesis. Foot Ankle Int 26:275–280, 2005. 5. Glick JM, Morgan CD, Myerson MS, Sampson TG, Mann JA. Ankle arthrodesis using arthroscopic method: long-term follow-up of 34 cases. Arthroscopy 12:428–434,1996. 6. Kats J, van Kampen A, de Waal-Malefijt MC. Improvement in technique for arthroscopic ankle fusion: results in 15 patients. Knee Surg Sports Traumatol Arthrosc 11:46–49, 2003. 7. Ogilvie-Harris DJ, Lieberman I, Fitsialos D. Arthroscopic assisted arthrodesis for osteoarthritic ankles. J Bone Joint Surg Am 75:1167–1174, 1993. 8. Stone JW. Arthroscopic ankle arthrodesis. Foot Ankle Clin 11:361–368, 2006. 9. Town D, Silvestro MD, Krause F, Penner M, Younger A, Glazebrook M, Wing K. Arthroscopic versus open ankle arthrodesis: a multicenter comparative case series. J Bone Joint Surg Am 95:98–102, 2013. 10. Abicht BP, Roukis TS. Incidence of nonunion after isolated arthroscopic ankle arthrodesis. Arthroscopy 29:949–954, 2013. 11. Crosby LA, Yee TC, Formanek TS, Fitzgibbons TC. Complications following arthroscopic ankle arthrodesis. Foot Ankle Int 17:340–342, 1996. 12. Kumar VP, Satku K. The A-O femoral distractor for ankle arthroscopy. Arthroscopy 10:118–119, 1994. 13. Miyamoto W, Takao M, Komatu F, Uchio Y. Technique tip: the bandage distraction technique for arthroscopic arthrodesis of the ankle joint. Foot Ankle Int 29:251– 253, 2008. 14. Graham AJ, Hughes S, Cooke PH. Ankle arthroscopy: the use of an Ilizarov halfframe fixator to distract the ankle joint. Foot Ankle Surg 6:55–58, 2000. 15. Guhl JF. New techniques for arthroscopic surgery of the ankle: preliminary report. Orthopedics 9:261–269, 1986. 16. Chou LB, Coughlin MT, Hansen S Jr, Haskell A, Lundeen G, Saltzman CL, Mann RA. Osteoarthritis of the ankle: the role of arthroplasty. J Am Acad Orthop Surg 16:249–259, 2008. 17. Waseem M, Barrie JL. A new distraction method in difficult ankle arthroscopy. J Foot Ankle Surg 41:412–413, 2002. 18. Beimers L, de Leeuw PA, van Dijk CN. A 3-portal approach for arthroscopic subtalar arthrodesis. Knee Surg Sports Traumatol Arthrosc 17:830–834, 2009. 19. Lee KB, Saltzman CL, Suh JS, Wasserman L, Amendola A. A posterior 3-portal arthroscopic approach for isolated subtalar arthrodesis. Arthroscopy 24:1306–1310, 2008. 20. Aydin AT, Ozcanli H, Soyuncu Y, Dabak TK. A new noninvasive controlled intraarticular distraction technique on a cadaver model. Arthroscopy 22:905.e1–905.e3, 2006.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Tips, Quips, and Pearls “Tips, Quips, and Pearls” is a special section in The Journal of Foot & Ankle SurgeryÒ, which is devoted to the sharing of ideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in the form of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedure a little bit easier, or virtually any other “pearl” that the reader believes will assist the foot and ankle surgeon in providing better care.
Arthroscopic Ankle Arthrodesis with Intra-articular Distraction Hyong Nyun Kim, MD, PhD, June Young Jeon, MD, Kyu Cheol Noh, MD, PhD, Hong Kyun Kim, MD, Quanyu Dong, MD, Yong Wook Park, MD, PhD Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
a r t i c l e i n f o
a b s t r a c t
Keywords: arthritis arthroscope cannula fusion talus tibia trocar
Arthroscopic ankle arthrodesis has shown high rates of union comparable to those with open arthrodesis but with substantially less postoperative morbidity, shorter operative times, less blood loss, and shorter hospital stays. To easily perform arthroscopic resection of the articular cartilage, sufficient distraction of the joint is necessary to insert the arthroscope and instruments. However, sometimes, standard noninvasive ankle distraction will not be sufficient in post-traumatic ankle arthritis, with the development of arthrofibrosis and joint contracture after severe ankle trauma. In the present report, we describe a technique to distract the ankle joint by inserting a 4.6-mm stainless steel cannula with a blunt trocar inside the joint. The cannula allowed sufficient intra-articular distraction, and, at the same time, a 4.0-mm arthroscope can be inserted through the cannula to view the joint. Screws can be inserted to fix the joint under fluoroscopic guidance without changing the patient’s position or removing the noninvasive distraction device and leg holder, which are often necessary during standard arthroscopic arthrodesis with noninvasive distraction. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Ankle arthrodesis has traditionally been the preferred surgical method to treat end-stage ankle arthritis. Open approaches to the ankle joint have traditionally been used; however, arthroscopic arthrodesis has been increasing in popularity, because it is less invasive, offering the advantages of less postoperative pain and fewer wound problems (1–8). Several studies have shown high rates of union with arthroscopic arthrodesis compared with open arthrodesis but with substantially less postoperative morbidity, shorter operative times, less blood loss, and shorter hospital stays (4,7,9). However, nonunion has been reported after arthroscopic arthrodesis (10,11). One of the factors leading to nonunion has been insufficient removal of the articular cartilage from the talus and tibia. To easily perform arthroscopic resection of the articular cartilage, sufficient distraction of the joint is necessary to insert the arthroscope and instruments (12,13). However, sometimes, noninvasive ankle distraction will not be sufficient in post-traumatic ankle arthritis, with the development of arthrofibrosis and joint contracture after severe ankle trauma (12,14,15). In the present report, we have described a technique to Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Yong Wook Park, MD, PhD, Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 948-1, Dalim-1dong, Youngdeungpo-gu, Seoul 150-950 South Korea. E-mail address: [email protected] (Y.W. Park).
distract the ankle joint by inserting a large-diameter blunt trocar into the joint. The trocar allows sufficient intra-articular distraction for resection of the articular cartilage. Screws can be inserted to fix the joint under fluoroscopic guidance without changing the patient’s position or removing the noninvasive distraction device and leg holder, which are often necessary during standard arthroscopic arthrodesis with noninvasive distraction. Operative Technique The patient is placed in the supine position with the arthritic ankle (Fig. 1) distal from the operating table (Fig. 2). A pneumatic tourniquet is inflated around the thigh. A skin incision is made medial to the tibialis anterior tendon at the level of the ankle joint for the anteromedial portal. After blunt dissection with a clamp through the skin to the capsule, a 4.6-mm stainless steel cannula with a blunt trocar inside is inserted into the joint under fluoroscopic guidance (Fig. 3). To ease the insertion, a small-diameter (2.5-mm) trocar is inserted first to gradually widen the joint space and distract the soft tissue. Insertion of the cannula with a blunt trocar inside will distract the joint, and, at the same time, a 4.0-mm arthroscope can be inserted through the cannula to view the joint. Another skin incision is made just lateral to the Achilles tendon at the joint line to establish the posterolateral portal. When arthroscopic visualization of the posterior ankle is
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.02.004
2
H.N. Kim et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
ligament and intermalleolar ligament under direct visualization through the arthroscope. The mosquito clamp is used to open the joint capsule. To gradually widen the joint capsule and soft tissue, a smalldiameter blunt trocar is inserted first and then substituted with larger ones. Finally, a 4.6-mm stainless steel cannula with a blunt trocar inside is inserted into the joint. When insertion of the cannula under direct visualization with the arthroscope is difficult, the cannula can be inserted under fluoroscopic guidance (Fig. 4). With 2 cannulas inside the joint, they can be used alternatively for maintaining joint distraction. One of the 2 cannulas can be retracted slightly to move freely, and an arthroscope can be inserted through that cannula to examine the joint, with the other cannula used to maintain the joint distraction. Alternatively, 1 of the cannulas can be removed and instruments can be inserted through the same portal, with distraction maintained using the other cannula. A standard anterolateral portal can be established for better instrumentation and visualization. When the arthritic joint distracts easily using this technique, a 5.5-mm disposable plastic cannula (ConMed Linvatech, Largo, FL), which has often been used in shoulder arthroscopy, can be used for distraction of the ankle joint. When a suction tube is connected to the plastic cannula after removing the trocar inside, cartilage debris of various size, which will often clog a shaver, can be resected by a curette and easily flushed out of the joint. Instruments can also be introduced into the joint through the plastic cannula for use. Intra-articular positioning of the cannula can be changed to resect the articular cartilage hidden under the cannula. A blunt trocar can be inserted into the lateral gutter (talofibular space) or medial gutter (medial tibiotalar space) to widen the space to debride the articular cartilage. After thorough removal of the articular cartilage and abrasion of the underlying subchondral bone surface, all the instruments and the arthroscope are removed, and 6.5-mm cannulated screws are inserted to fix the joint under fluoroscopic guidance (Fig. 5). Discussion Fig. 1. Preoperative lateral ankle radiograph showing arthritic change of the articular surface and narrowing of the ankle joint.
possible through the arthroscopic cannula previously introduced to distract the joint, a clamp is inserted anteriorly through the posterolateral incision into the space between the posteroinferior tibiofibular
Unlike hip and knee osteoarthritis, primary degenerative ankle osteoarthritis has rarely been encountered. Also, ankle osteoarthritis is much more likely to be post-traumatic, which accounts for 65% to 80% of ankle osteoarthritis cases (16). In the trauma cases, damage often extends to the soft tissue and leads to joint contracture and
Fig. 2. Fluoroscopic radiographs showing (A) intra-articular ankle distraction by insertion of a large- diameter blunt trocar through the anteromedial portal. (B) Arthroscopic image of the medial ankle visualized from the anterolateral portal showing the blunt trocar inserted through the anteromedial portal and a shaver from the posterolateral portal debriding the articular cartilage.
H.N. Kim et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
3
Fig. 3. Intraoperative image showing the patient in the supine position with the ankle distal from the operating table. A 4.6-mm stainless steel cannula with a blunt trocar inside was inserted into the joint through the anteromedial portal to distract the joint and, at the same time, a 4.0-mm arthroscope can be inserted through the cannula to view the joint. Another 4.6-mm stainless steel cannula was inserted into the joint through the posterolateral portal.
arthrofibrosis after severe ankle pilon fractures. Because of the shape of the talus, joint distraction is necessary for arthroscopic ankle arthrodesis (4). However, in cases with joint contracture and arthrofibrosis, noninvasive ankle distraction might not be sufficient (14,17). Some investigators have advocated invasive skeletal distraction for tight arthritic ankles (12,15). However, possibilities exist for pin breakage, infection, and a risk to neurovascular structures (12,15). We believe inserting an arthroscopic cannula with a blunt trocar inside can be useful to distract the joint intra-articularly when damaging the articular cartilage is not an issue, such as in arthrodesis. Introduction of a blunt trocar into the subtalar joint has been described for arthroscopic subtalar arthrodesis with successful joint distraction (18,19). However, insertion of an arthroscopic cannula for ankle joint distraction during arthroscopic ankle arthrodesis has not been previously described. Intra-articular ankle distraction by inflation of a kyphoplasty balloon placed inside the ankle joint has been discussed (20). We believe this technique is also an option for treatment. However, the inflated balloon can be damaged by sharp instruments during resection of the articular cartilage or it can block vision to certain extent. The cost of the material should also be considered.
Fig. 5. Postoperative lateral ankle radiograph showing insertion of cannulated screws for joint fixation.
One advantage of our technique compared with usual noninvasive ankle distraction is that surgeons can move freely around the ankle. Movement will sometimes be limited when the noninvasive
Fig. 4. Fluoroscopic radiographs showing (A) intra-articular ankle distraction by insertion of a large- diameter blunt trocar through the posterolateral portal. (B) Arthroscopic image of the lateral ankle visualized from the anteromedial portal showing the blunt trocar inserted through the posterolateral portal and a curette introduced from the anterolateral portal, resecting the tibial articular cartilage.
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H.N. Kim et al. / The Journal of Foot & Ankle Surgery xxx (2014) 1–4
distraction device is connected to the table. In addition, screws can be inserted under fluoroscopic guidance without having to change the patient’s position or remove the noninvasive distraction device and leg holder. Such steps will often be necessary during standard arthroscopic arthrodesis with noninvasive distraction. We believe our technique allows more powerful distraction compared with the usual noninvasive technique, because it mechanically distracts the joint by directly pushing away the tibial and talar bony structure inside the joint. However, a shortcoming of the technique is that it might not be adequate in an osteoporotic ankle (e.g., in rheumatoid arthritis). The cannula must be held by an assistant such that it does not slip out of the joint, which we believe is not that difficult. We have tried to insert the arthroscopic cannula through the posterolateral portal under fluoroscopic guidance before inserting another cannula through the anteromedial portal. However, insertion of the arthroscopic cannula using that method was more difficult than insertion of an arthroscopic cannula through the anteromedial portal. We believe that was because of the thick ligaments surrounding the posterolateral ankle. Because no ligamentous structure are present around the anteromedial portal area and because an anteromedial notch defined by Harty is present it has been much easier to insert a blunt trocar through the anteromedial portal under fluoroscopic guidance. After joint distraction by the anteromedial cannula, insertion of the cannula through the posterolateral portal will be much easier. We believe this technique should be considered when performing arthroscopic ankle arthrodesis, especially for tight post-traumatic ankle arthritis. References 1. Peterson KS, Lee MS, Buddecke DE. Arthroscopic versus open ankle arthrodesis: a retrospective cost analysis. J Foot Ankle Surg 49:242–247, 2010.
2. Corso SJ, Zimmer TJ. Technique and clinical evaluation of arthroscopic ankle arthrodesis. Arthroscopy 11:585–590, 1995. 3. Dent CM, Patil M, Fairclough JA. Arthroscopic ankle arthrodesis. J Bone Joint Surg Br 75:830–832, 1993. 4. Ferkel RD, Hewitt M. Long-term results of arthroscopic ankle arthrodesis. Foot Ankle Int 26:275–280, 2005. 5. Glick JM, Morgan CD, Myerson MS, Sampson TG, Mann JA. Ankle arthrodesis using arthroscopic method: long-term follow-up of 34 cases. Arthroscopy 12:428–434,1996. 6. Kats J, van Kampen A, de Waal-Malefijt MC. Improvement in technique for arthroscopic ankle fusion: results in 15 patients. Knee Surg Sports Traumatol Arthrosc 11:46–49, 2003. 7. Ogilvie-Harris DJ, Lieberman I, Fitsialos D. Arthroscopic assisted arthrodesis for osteoarthritic ankles. J Bone Joint Surg Am 75:1167–1174, 1993. 8. Stone JW. Arthroscopic ankle arthrodesis. Foot Ankle Clin 11:361–368, 2006. 9. Town D, Silvestro MD, Krause F, Penner M, Younger A, Glazebrook M, Wing K. Arthroscopic versus open ankle arthrodesis: a multicenter comparative case series. J Bone Joint Surg Am 95:98–102, 2013. 10. Abicht BP, Roukis TS. Incidence of nonunion after isolated arthroscopic ankle arthrodesis. Arthroscopy 29:949–954, 2013. 11. Crosby LA, Yee TC, Formanek TS, Fitzgibbons TC. Complications following arthroscopic ankle arthrodesis. Foot Ankle Int 17:340–342, 1996. 12. Kumar VP, Satku K. The A-O femoral distractor for ankle arthroscopy. Arthroscopy 10:118–119, 1994. 13. Miyamoto W, Takao M, Komatu F, Uchio Y. Technique tip: the bandage distraction technique for arthroscopic arthrodesis of the ankle joint. Foot Ankle Int 29:251– 253, 2008. 14. Graham AJ, Hughes S, Cooke PH. Ankle arthroscopy: the use of an Ilizarov halfframe fixator to distract the ankle joint. Foot Ankle Surg 6:55–58, 2000. 15. Guhl JF. New techniques for arthroscopic surgery of the ankle: preliminary report. Orthopedics 9:261–269, 1986. 16. Chou LB, Coughlin MT, Hansen S Jr, Haskell A, Lundeen G, Saltzman CL, Mann RA. Osteoarthritis of the ankle: the role of arthroplasty. J Am Acad Orthop Surg 16:249–259, 2008. 17. Waseem M, Barrie JL. A new distraction method in difficult ankle arthroscopy. J Foot Ankle Surg 41:412–413, 2002. 18. Beimers L, de Leeuw PA, van Dijk CN. A 3-portal approach for arthroscopic subtalar arthrodesis. Knee Surg Sports Traumatol Arthrosc 17:830–834, 2009. 19. Lee KB, Saltzman CL, Suh JS, Wasserman L, Amendola A. A posterior 3-portal arthroscopic approach for isolated subtalar arthrodesis. Arthroscopy 24:1306–1310, 2008. 20. Aydin AT, Ozcanli H, Soyuncu Y, Dabak TK. A new noninvasive controlled intraarticular distraction technique on a cadaver model. Arthroscopy 22:905.e1–905.e3, 2006.