- Email: [email protected]
Arthroscopic Capsular Release of the Talocalcaneonavicular Joint
Technical Note
Arthroscopic Capsular Release of the Talocalcaneonavicular Joint Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S.
Abstract: Arthrofibrosis of the talocalcaneonavicular joint can follow talar neck fracture especially if anterior approaches have been used for fracture fixation. Capsular release of the talocalcaneonavicular joint is indicated if the painful hindfoot stiffness cannot be controlled with conservative treatment. Open capsular release of the talocalcaneonavicular joint demands extensive soft tissue dissection and hinders early postoperative mobilization exercise of the joint. The purpose of this technical note is to describe a minimally invasive approach of arthroscopic capsular release of the talocalcaneonavicular joint that is composed of arthroscopic release of the talonavicular joint and the anterior subtalar joint. This allows immediate postoperative mobilization of the joint.
T
alar neck fracture is an uncommon injury of the foot and ankle. It is associated with high complication rates. Early complications of this injury include skin necrosis, wound dehiscence, and infection.1 Late complications include osteonecrosis, posttraumatic arthritis, osteomyelitis, stiffness, malunion, and nonunion.1-4 Posttraumatic arthritis of the subtalar joint is the most common late complication and can involve the ankle, subtalar, and/or talonavicular joint.2 This can present as pain and stiffness of the involved joint. Limited posterior subtalar motion can occur without radiologic evidence of posttraumatic arthritis or osteonecrosis.5 However, painful stiffness of the talocalcaneonavicular joint after talar neck fracture is rarely mentioned in the literature. The talocalcaneonavicular joint is a ball and socket joint with the talar head seated on the socket formed by the anterior and middle calcaneal facets, the spring ligament, and the posterior articular facet of the navicular. It has a unique capsular lining. Functionally, the talocalcaneonavicular joint is composed of talonavicular articulation, which acts
together with the calcaneocuboid articulation, and the anterior subtalar articulation, which acts together with the talocalcaneal joint.6 Talar neck fracture can result in fibrosis around the fracture site, which may induce capsular fibrosis of the talocalcaneonavicular joint especially if anterior surgical approaches are used for previous fracture management. Open release of the talocalcaneonvicular joint has been proposed for correction of clubfoot or congenital convex pes valgus.7,8 To the best of our knowledge, there is no report in the literature about talocalcaneonavicular release in the management of posttraumatic stiffness of the joint. If the symptoms cannot be controlled with conservative treatment, arthroscopic capsular release of the talocalcaneonavicular joint is indicated. This procedure is contraindicated in other causes of painful stiffness including posttraumatic arthritis, osteonecrosis, and malunion (Table 1). This report describes the technical details of arthroscopic capsular release of the talocalcaneonavicular joint that is composed of arthroscopic release of the talonavicular joint and the anterior subtalar joint.
From the Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received March 17, 2016; accepted July 22, 2016. Address correspondence to Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16233/$36.00 http://dx.doi.org/10.1016/j.eats.2016.07.024
Technique
Arthroscopy Techniques, Vol
-,
Preoperative Planning and Patient Positioning Preoperative assessment of location of pain and the sites of tenderness will determine the extent of arthroscopic release. In this illustrated case, the pain and tenderness is located just above the sustentaculum tali and over the talonavicular joint. There was no lateral heel pain or tenderness. Preoperative radiographs are useful for exclusion of posttraumatic degeneration or
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Table 1. Pearls and Pitfalls of Arthroscopic Capsular Release of the Talocalcaneonavicular Joint Pearls
Pitfalls
1. Preoperative clinical assessment is important to determine the extent of capsular release 2. The spring ligament should be preserved
1. This procedure is not suitable for stiffness due to posttraumatic arthritis 2. This procedure is not suitable for stiffness due to osteonecrosis 3. This procedure is not suitable for stiffness due to malunion
3. Extensive circumferential debridement of the talar neck and head should be avoided
malunion of the talocalcaneonavicular joint. Preoperative magnetic resonance imaging may be needed to exclude posttraumatic arthritis or osteonecrosis (Fig 1). The patient is in supine position with the legs spread. A thigh tourniquet is applied to provide a bloodless operative field. The medial malleolus, tibialis posterior tendon, talar head, sustentaculum tali, and navicular are outlined. The medial, dorsomedial, and dorsolateral midtarsal portals and the medial tarsal canal portal are
marked. A 2.7-mm 30 arthroscope (Henke Sass Wolf GmbH, Germany) is used for this procedure. Portal Placement of Talonavicular Arthroscopy Talonavicular arthroscopy is performed through the medial, dorsomedial, and dorsolateral midtarsal portals.9,10 The medial midtarsal portal is located at the medial corner of the talonavicular joint, just above the insertion of the tibialis posterior tendon. The dorsolateral midtarsal portal is at the junction between the talonavicular and calcaneocuboid joints. The dorsomedial midtarsal portal is at the dorsum of the talonavicular joint, midpoint between the medial and dorsolateral midtarsal portals (Fig 2). In case of significant stiffness of the joint, fluoroscopy may be needed for proper placement of the dorsomedial portal. Incisions of 3 to 4 mm are made at the portal site and the subcutaneous tissue is bluntly dissected down to the joint capsule by a hemostat. The capsule is penetrated by the tip of the hemostat. The portals are interchangeable as the viewing and working portals.
Fig 1. Arthroscopic capsular release of the left talocalcaneonavicular joint. The illustrated case is a case of left talar neck fracture that was treated with anterior screw fixation. The arrow head points to the previous fracture site. Lateral (A) and dorsoplantar (B) foot radiographs before the arthroscopic release showed that there is no radiographic evidence of posttraumatic arthritis of the ankle, subtalar, or talocalcaneonavicular joint. Coronal (C) and sagittal (D) magnetic resonance imaging showed that there is no osteonecrosis.
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Fig 2. Arthroscopic capsular release of the left talocalcaneonavicular joint. (A) Talonavicular arthroscopy is performed through the medial (MMP) and dorsomedial midtarsal (DMMP) portals. (B) Talonavicular arthroscopy is performed through the dorsomedial and dorsolateral midtarsal (DLMP) portals.
Arthroscopic Release of the Dorsomedial Capsule of the Talonavicular Joint The medial midtarsal portal is the viewing portal. The fibrous adhesions medial to the dorsomedial midtarsal portal are released with an arthroscopic shaver (Smith & Nephew, London, UK) via the dorsomedial portal. The debridement should be extended to the dorsum of the talar neck and the navicular bone to achieve an adequate release. The arthroscope is then switched to the dorsomedial midtarsal portal and the release of the dorsomedial capsule of the talonavicular joint is completed by the shaver through the medial midtarsal portal (Fig 3).
midtarsal portal are released with an arthroscopic shaver via the dorsolateral portal (Fig 4). The debridement should be extended to the dorsum of the talar neck and the navicular bone to achieve an adequate release. The arthroscope is then switched to the dorsolateral midtarsal portal and the release of the dorsolateral capsule of the talonavicular joint is completed by the shaver through the dorsomedial midtarsal portal.
Arthroscopic Release of the Dorsolateral Capsule of the Talonavicular Joint The dorsomedial midtarsal portal is the viewing portal. The fibrous adhesions lateral to the dorsomedial
Portal Placement of Medial Subtalar Arthroscopy Medial subtalar arthroscopy is performed through the medial midtarsal portal and the medial tarsal canal portal.11,12 The medial midtarsal portal is located at the medial corner of the talonavicular joint, just above the insertion of the tibialis posterior tendon. The medial tarsal canal portal is over the medial end of the tarsal
Fig 3. Arthroscopic capsular release of the left talocalcaneonavicular joint. The dorsomedial midtarsal portal is the viewing portal. The fibrous adhesions medial to the dorsomedial midtarsal portal is released with an arthroscopic shaver via the medial portal. (Nav, navicular; TH, talar head.)
Fig 4. Arthroscopic capsular release of the left talocalcaneonavicular joint. The dorsomedial midtarsal portal is the viewing portal. The fibrous adhesions lateral to the dorsomedial midtarsal portal is released with an arthroscopic shaver via the dorsolateral portal. (Nav, navicular; TH, talar head.)
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Fig 5. Arthroscopic capsular release of the left talocalcaneonavicular joint. Medial subtalar arthroscopy is performed through the medial midtarsal portal (MMP) and the medial tarsal canal portal (MTCP). The medial midtarsal portal is located at the medial corner of the talonavicular joint, just above the insertion of the tibialis posterior tendon (TPT). The medial tarsal canal portal is over the medial end of the tarsal canal that is just posterior to the tibialis posterior tendon and just above the level of the sustentaculum tali. (MM, medial malleolus; Nav, navicular.)
Fig 7. Arthroscopic capsular release of the left talocalcaneonavicular joint. The medial tarsal canal portal is the viewing portal. The fibrous tissue at the medial corner of the talonavicular joint is debrided via the medial midtarsal portal. (Nav, navicular; TH, talar head.)
canal that is just posterior to the tibialis posterior tendon and just above the level of the sustentaculum tali (Fig 5). Arthroscopic Release of the Medial Capsule of the Anterior Subtalar Joint The medial midtarsal portal is the viewing portal. The fibrous tissue of the medial gutter of the anterior subtalar joint is debrided and the fibrotic medial capsule is stripped from the sustentaculum tali by an arthroscopic shaver via the medial tarsal canal portal (Fig 6). The arthroscope is switched to the medial tarsal canal portal and the debridement of the medial subtalar gutter is completed by the shaver via the medial midtarsal portal. Arthroscopic Release of the Medial Capsule of the Talonavicular Joint The medial tarsal canal portal is the viewing portal. The fibrous tissue at the medial corner of the talonavicular joint is debrided via the medial midtarsal portal (Fig 7). The release of the fibrous adhesions is then completed from the medial side of the anterior subtalar Table 2. Advantages and Risks of Arthroscopic Capsular Release of the Talocalcaneonavicular Joint Fig 6. Arthroscopic capsular release of the left talocalcaneonavicular joint. The medial midtarsal portal is the viewing portal and the fibrous tissue of the medial gutter of the anterior subtalar joint is debrided and the fibrotic medial capsule is stripped from the sustentaculum tali (ST) by an arthroscopic shaver via the medial tarsal canal portal. (TH,talar head.)
Advantages
Risks
1. Better cosmetic result 2. Less pain 3. Less surgical trauma 4. Early vigorous mobilization
1. Injury to the extraosseous vascular supply surrounding the talar head and neck 2. Damage to the superficial and deep peroneal nerves and tibial nerve
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joint to the medial, dorsal, and lateral sides of the talonavicular joint (Video 1).
technically demanding and should be reserved for the experienced foot and ankle arthroscopists (Table 2).
Discussion
1. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: Results and outcomes. J Bone Joint Surg Am 2004;86:1616-1624. 2. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 2004;86:2229-2234. 3. Dodd A, Lefaivre KA. Outcomes of talar neck fractures: A systematic review and meta-analysis. J Orthop Trauma 2015;29:210-215. 4. Fournier A, Barba N, Steiger V, et al. Total talar fractured Long-term results of internal fixation of talar fractures. A multicentric study of 114 cases. Orthop Traumatol Surg Res 2012;98:S48-S55 (suppl). 5. Comfort TH, Behrens F, Gaither DW, Denis F, Sigmond M. Long-term results of displaced talar neck fractures. Clin Orthop 1985;199:81-87. 6. Seringe R, Wicart P. French Society of Pediatric Orthopaedics. The talonavicular and subtalar joints: The “calcaneopedal unit” concept. Orthop Traumatol Surg Res 2013;99:S345-S355 (suppl). 7. Palovcic V, Pecak F. Surgical treatment of clubfoot: The significance of talocalcaneonavicular malposition correction. J Pediatr Orthop B 1999;8:1-4. 8. Yen CC, Huang SC. Surgical treatment of congenital convex pes valgus. J Formos Med Assoc 1997;96:424-428. 9. Lui TH, Chan LK. Safety and efficacy of talonavicular arthroscopy in arthroscopic triple arthrodesis. A cadaveric study. Knee Surg Sports Traumatol Arthrosc 2010;18:607-611. 10. Lui TH. New technique of arthroscopic triple arthrodesis. Arthroscopy 2006;22:464.e1-464.e5. 11. Lui TH, Chan LK, Chan KB. Medial subtalar arthroscopy: A cadaveric study of the tarsal canal portal. Knee Surg Sports Traumatol Arthrosc 2013;21:1279-1282. 12. Lui TH. Medial subtalar arthroscopy. Foot Ankle Int 2012;33:1018-1023. 13. Lui TH, Chan KB, Chan LK. Portal safety and efficacy of anterior subtalar arthroscopy: A cadaveric study. Knee Surg Sports Traumatol Arthrosc 2010;18:233-237. 14. Lui TH. Clinical tips: Anterior subtalar (talocalcaneonavicular) arthroscopy. Foot Ankle Int 2008;29:94-96. 15. Lui TH. Arthroscopic subtalar release of post-traumatic subtalar stiffness. Arthroscopy 2006;22:1364.e1-1364.e4.
References Arthrofibrosis of the talocalcaneonavicular joint can affect the motion of the subtalar joint and midtarsal joint. This can result in painful stiffness of the hindfoot. Arthoscopic release of the joint can restore the motion and relieve the hindfoot pain. Before conducting this procedure, other causes of stiffness should be excluded. The extent of release should be governed by preoperative clinical assessment including the subjective localization of pain by the patient and localization of the tender spots. Theoretically, complete release of the joint is possible because the capsular boundary can be approached by a combination of medial subtalar arthroscopy,11,12 talonavicular arthroscopy,9,10 and anterior subtalar arthroscopy.13,14 In this reported technique, the spring ligament is preserved to maintain the stability of the talocalcaneonavicular joint. The fibrous adhesion between the talar head and the spring ligament can be debrided through the medial and anterior subtalar arthroscopies that can approach the medial and lateral side of the plantar gutter, respectively.11-13 The lateral capsule of the joint can be released through anterior subtalar arthroscopy.13,14 Lateral capsular release is indicated if there is lateral heel pain and tenderness over the lateral side of the talar head together with painful limitation of hindfoot inversion. Extensive circumferential release of the talar neck should be avoided to preserve the anastomotic ring of the extraosseous vascular supply surrounding the talar head and neck.3 If there is associated arthrofibrosis of the posterior subtalar joint, arthroscopic subtalar release can also be performed.15 Arthroscopic capsular release of the talocalcaneonavicular joint has the advantages of better cosmetic result, less pain, less surgical trauma, and early vigorous mobilization allowed. The potential risks of this technique include injury to the extraosseous vascular supply surrounding the talar head and neck and damage to the superficial and deep peroneal nerves and tibial nerve. This technique is
Arthroscopic Capsular Release of the Talocalcaneonavicular Joint Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S.
Abstract: Arthrofibrosis of the talocalcaneonavicular joint can follow talar neck fracture especially if anterior approaches have been used for fracture fixation. Capsular release of the talocalcaneonavicular joint is indicated if the painful hindfoot stiffness cannot be controlled with conservative treatment. Open capsular release of the talocalcaneonavicular joint demands extensive soft tissue dissection and hinders early postoperative mobilization exercise of the joint. The purpose of this technical note is to describe a minimally invasive approach of arthroscopic capsular release of the talocalcaneonavicular joint that is composed of arthroscopic release of the talonavicular joint and the anterior subtalar joint. This allows immediate postoperative mobilization of the joint.
T
alar neck fracture is an uncommon injury of the foot and ankle. It is associated with high complication rates. Early complications of this injury include skin necrosis, wound dehiscence, and infection.1 Late complications include osteonecrosis, posttraumatic arthritis, osteomyelitis, stiffness, malunion, and nonunion.1-4 Posttraumatic arthritis of the subtalar joint is the most common late complication and can involve the ankle, subtalar, and/or talonavicular joint.2 This can present as pain and stiffness of the involved joint. Limited posterior subtalar motion can occur without radiologic evidence of posttraumatic arthritis or osteonecrosis.5 However, painful stiffness of the talocalcaneonavicular joint after talar neck fracture is rarely mentioned in the literature. The talocalcaneonavicular joint is a ball and socket joint with the talar head seated on the socket formed by the anterior and middle calcaneal facets, the spring ligament, and the posterior articular facet of the navicular. It has a unique capsular lining. Functionally, the talocalcaneonavicular joint is composed of talonavicular articulation, which acts
together with the calcaneocuboid articulation, and the anterior subtalar articulation, which acts together with the talocalcaneal joint.6 Talar neck fracture can result in fibrosis around the fracture site, which may induce capsular fibrosis of the talocalcaneonavicular joint especially if anterior surgical approaches are used for previous fracture management. Open release of the talocalcaneonvicular joint has been proposed for correction of clubfoot or congenital convex pes valgus.7,8 To the best of our knowledge, there is no report in the literature about talocalcaneonavicular release in the management of posttraumatic stiffness of the joint. If the symptoms cannot be controlled with conservative treatment, arthroscopic capsular release of the talocalcaneonavicular joint is indicated. This procedure is contraindicated in other causes of painful stiffness including posttraumatic arthritis, osteonecrosis, and malunion (Table 1). This report describes the technical details of arthroscopic capsular release of the talocalcaneonavicular joint that is composed of arthroscopic release of the talonavicular joint and the anterior subtalar joint.
From the Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received March 17, 2016; accepted July 22, 2016. Address correspondence to Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16233/$36.00 http://dx.doi.org/10.1016/j.eats.2016.07.024
Technique
Arthroscopy Techniques, Vol
-,
Preoperative Planning and Patient Positioning Preoperative assessment of location of pain and the sites of tenderness will determine the extent of arthroscopic release. In this illustrated case, the pain and tenderness is located just above the sustentaculum tali and over the talonavicular joint. There was no lateral heel pain or tenderness. Preoperative radiographs are useful for exclusion of posttraumatic degeneration or
No
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(Month), 2016: pp e1-e5
e1
e2
T. H. LUI
Table 1. Pearls and Pitfalls of Arthroscopic Capsular Release of the Talocalcaneonavicular Joint Pearls
Pitfalls
1. Preoperative clinical assessment is important to determine the extent of capsular release 2. The spring ligament should be preserved
1. This procedure is not suitable for stiffness due to posttraumatic arthritis 2. This procedure is not suitable for stiffness due to osteonecrosis 3. This procedure is not suitable for stiffness due to malunion
3. Extensive circumferential debridement of the talar neck and head should be avoided
malunion of the talocalcaneonavicular joint. Preoperative magnetic resonance imaging may be needed to exclude posttraumatic arthritis or osteonecrosis (Fig 1). The patient is in supine position with the legs spread. A thigh tourniquet is applied to provide a bloodless operative field. The medial malleolus, tibialis posterior tendon, talar head, sustentaculum tali, and navicular are outlined. The medial, dorsomedial, and dorsolateral midtarsal portals and the medial tarsal canal portal are
marked. A 2.7-mm 30 arthroscope (Henke Sass Wolf GmbH, Germany) is used for this procedure. Portal Placement of Talonavicular Arthroscopy Talonavicular arthroscopy is performed through the medial, dorsomedial, and dorsolateral midtarsal portals.9,10 The medial midtarsal portal is located at the medial corner of the talonavicular joint, just above the insertion of the tibialis posterior tendon. The dorsolateral midtarsal portal is at the junction between the talonavicular and calcaneocuboid joints. The dorsomedial midtarsal portal is at the dorsum of the talonavicular joint, midpoint between the medial and dorsolateral midtarsal portals (Fig 2). In case of significant stiffness of the joint, fluoroscopy may be needed for proper placement of the dorsomedial portal. Incisions of 3 to 4 mm are made at the portal site and the subcutaneous tissue is bluntly dissected down to the joint capsule by a hemostat. The capsule is penetrated by the tip of the hemostat. The portals are interchangeable as the viewing and working portals.
Fig 1. Arthroscopic capsular release of the left talocalcaneonavicular joint. The illustrated case is a case of left talar neck fracture that was treated with anterior screw fixation. The arrow head points to the previous fracture site. Lateral (A) and dorsoplantar (B) foot radiographs before the arthroscopic release showed that there is no radiographic evidence of posttraumatic arthritis of the ankle, subtalar, or talocalcaneonavicular joint. Coronal (C) and sagittal (D) magnetic resonance imaging showed that there is no osteonecrosis.
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Fig 2. Arthroscopic capsular release of the left talocalcaneonavicular joint. (A) Talonavicular arthroscopy is performed through the medial (MMP) and dorsomedial midtarsal (DMMP) portals. (B) Talonavicular arthroscopy is performed through the dorsomedial and dorsolateral midtarsal (DLMP) portals.
Arthroscopic Release of the Dorsomedial Capsule of the Talonavicular Joint The medial midtarsal portal is the viewing portal. The fibrous adhesions medial to the dorsomedial midtarsal portal are released with an arthroscopic shaver (Smith & Nephew, London, UK) via the dorsomedial portal. The debridement should be extended to the dorsum of the talar neck and the navicular bone to achieve an adequate release. The arthroscope is then switched to the dorsomedial midtarsal portal and the release of the dorsomedial capsule of the talonavicular joint is completed by the shaver through the medial midtarsal portal (Fig 3).
midtarsal portal are released with an arthroscopic shaver via the dorsolateral portal (Fig 4). The debridement should be extended to the dorsum of the talar neck and the navicular bone to achieve an adequate release. The arthroscope is then switched to the dorsolateral midtarsal portal and the release of the dorsolateral capsule of the talonavicular joint is completed by the shaver through the dorsomedial midtarsal portal.
Arthroscopic Release of the Dorsolateral Capsule of the Talonavicular Joint The dorsomedial midtarsal portal is the viewing portal. The fibrous adhesions lateral to the dorsomedial
Portal Placement of Medial Subtalar Arthroscopy Medial subtalar arthroscopy is performed through the medial midtarsal portal and the medial tarsal canal portal.11,12 The medial midtarsal portal is located at the medial corner of the talonavicular joint, just above the insertion of the tibialis posterior tendon. The medial tarsal canal portal is over the medial end of the tarsal
Fig 3. Arthroscopic capsular release of the left talocalcaneonavicular joint. The dorsomedial midtarsal portal is the viewing portal. The fibrous adhesions medial to the dorsomedial midtarsal portal is released with an arthroscopic shaver via the medial portal. (Nav, navicular; TH, talar head.)
Fig 4. Arthroscopic capsular release of the left talocalcaneonavicular joint. The dorsomedial midtarsal portal is the viewing portal. The fibrous adhesions lateral to the dorsomedial midtarsal portal is released with an arthroscopic shaver via the dorsolateral portal. (Nav, navicular; TH, talar head.)
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Fig 5. Arthroscopic capsular release of the left talocalcaneonavicular joint. Medial subtalar arthroscopy is performed through the medial midtarsal portal (MMP) and the medial tarsal canal portal (MTCP). The medial midtarsal portal is located at the medial corner of the talonavicular joint, just above the insertion of the tibialis posterior tendon (TPT). The medial tarsal canal portal is over the medial end of the tarsal canal that is just posterior to the tibialis posterior tendon and just above the level of the sustentaculum tali. (MM, medial malleolus; Nav, navicular.)
Fig 7. Arthroscopic capsular release of the left talocalcaneonavicular joint. The medial tarsal canal portal is the viewing portal. The fibrous tissue at the medial corner of the talonavicular joint is debrided via the medial midtarsal portal. (Nav, navicular; TH, talar head.)
canal that is just posterior to the tibialis posterior tendon and just above the level of the sustentaculum tali (Fig 5). Arthroscopic Release of the Medial Capsule of the Anterior Subtalar Joint The medial midtarsal portal is the viewing portal. The fibrous tissue of the medial gutter of the anterior subtalar joint is debrided and the fibrotic medial capsule is stripped from the sustentaculum tali by an arthroscopic shaver via the medial tarsal canal portal (Fig 6). The arthroscope is switched to the medial tarsal canal portal and the debridement of the medial subtalar gutter is completed by the shaver via the medial midtarsal portal. Arthroscopic Release of the Medial Capsule of the Talonavicular Joint The medial tarsal canal portal is the viewing portal. The fibrous tissue at the medial corner of the talonavicular joint is debrided via the medial midtarsal portal (Fig 7). The release of the fibrous adhesions is then completed from the medial side of the anterior subtalar Table 2. Advantages and Risks of Arthroscopic Capsular Release of the Talocalcaneonavicular Joint Fig 6. Arthroscopic capsular release of the left talocalcaneonavicular joint. The medial midtarsal portal is the viewing portal and the fibrous tissue of the medial gutter of the anterior subtalar joint is debrided and the fibrotic medial capsule is stripped from the sustentaculum tali (ST) by an arthroscopic shaver via the medial tarsal canal portal. (TH,talar head.)
Advantages
Risks
1. Better cosmetic result 2. Less pain 3. Less surgical trauma 4. Early vigorous mobilization
1. Injury to the extraosseous vascular supply surrounding the talar head and neck 2. Damage to the superficial and deep peroneal nerves and tibial nerve
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joint to the medial, dorsal, and lateral sides of the talonavicular joint (Video 1).
technically demanding and should be reserved for the experienced foot and ankle arthroscopists (Table 2).
Discussion
1. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: Results and outcomes. J Bone Joint Surg Am 2004;86:1616-1624. 2. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 2004;86:2229-2234. 3. Dodd A, Lefaivre KA. Outcomes of talar neck fractures: A systematic review and meta-analysis. J Orthop Trauma 2015;29:210-215. 4. Fournier A, Barba N, Steiger V, et al. Total talar fractured Long-term results of internal fixation of talar fractures. A multicentric study of 114 cases. Orthop Traumatol Surg Res 2012;98:S48-S55 (suppl). 5. Comfort TH, Behrens F, Gaither DW, Denis F, Sigmond M. Long-term results of displaced talar neck fractures. Clin Orthop 1985;199:81-87. 6. Seringe R, Wicart P. French Society of Pediatric Orthopaedics. The talonavicular and subtalar joints: The “calcaneopedal unit” concept. Orthop Traumatol Surg Res 2013;99:S345-S355 (suppl). 7. Palovcic V, Pecak F. Surgical treatment of clubfoot: The significance of talocalcaneonavicular malposition correction. J Pediatr Orthop B 1999;8:1-4. 8. Yen CC, Huang SC. Surgical treatment of congenital convex pes valgus. J Formos Med Assoc 1997;96:424-428. 9. Lui TH, Chan LK. Safety and efficacy of talonavicular arthroscopy in arthroscopic triple arthrodesis. A cadaveric study. Knee Surg Sports Traumatol Arthrosc 2010;18:607-611. 10. Lui TH. New technique of arthroscopic triple arthrodesis. Arthroscopy 2006;22:464.e1-464.e5. 11. Lui TH, Chan LK, Chan KB. Medial subtalar arthroscopy: A cadaveric study of the tarsal canal portal. Knee Surg Sports Traumatol Arthrosc 2013;21:1279-1282. 12. Lui TH. Medial subtalar arthroscopy. Foot Ankle Int 2012;33:1018-1023. 13. Lui TH, Chan KB, Chan LK. Portal safety and efficacy of anterior subtalar arthroscopy: A cadaveric study. Knee Surg Sports Traumatol Arthrosc 2010;18:233-237. 14. Lui TH. Clinical tips: Anterior subtalar (talocalcaneonavicular) arthroscopy. Foot Ankle Int 2008;29:94-96. 15. Lui TH. Arthroscopic subtalar release of post-traumatic subtalar stiffness. Arthroscopy 2006;22:1364.e1-1364.e4.
References Arthrofibrosis of the talocalcaneonavicular joint can affect the motion of the subtalar joint and midtarsal joint. This can result in painful stiffness of the hindfoot. Arthoscopic release of the joint can restore the motion and relieve the hindfoot pain. Before conducting this procedure, other causes of stiffness should be excluded. The extent of release should be governed by preoperative clinical assessment including the subjective localization of pain by the patient and localization of the tender spots. Theoretically, complete release of the joint is possible because the capsular boundary can be approached by a combination of medial subtalar arthroscopy,11,12 talonavicular arthroscopy,9,10 and anterior subtalar arthroscopy.13,14 In this reported technique, the spring ligament is preserved to maintain the stability of the talocalcaneonavicular joint. The fibrous adhesion between the talar head and the spring ligament can be debrided through the medial and anterior subtalar arthroscopies that can approach the medial and lateral side of the plantar gutter, respectively.11-13 The lateral capsule of the joint can be released through anterior subtalar arthroscopy.13,14 Lateral capsular release is indicated if there is lateral heel pain and tenderness over the lateral side of the talar head together with painful limitation of hindfoot inversion. Extensive circumferential release of the talar neck should be avoided to preserve the anastomotic ring of the extraosseous vascular supply surrounding the talar head and neck.3 If there is associated arthrofibrosis of the posterior subtalar joint, arthroscopic subtalar release can also be performed.15 Arthroscopic capsular release of the talocalcaneonavicular joint has the advantages of better cosmetic result, less pain, less surgical trauma, and early vigorous mobilization allowed. The potential risks of this technique include injury to the extraosseous vascular supply surrounding the talar head and neck and damage to the superficial and deep peroneal nerves and tibial nerve. This technique is