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New concepts (distraction) in ankle arthroscopy
Arthroscopy: The Journal of Arthroscopic and Related Surgery 40):160-167
Published by Raven Press, Ltd. @ 1988 Arthroscopy Association of North America
New Concepts (Distraction) in Ankle Arthroscopy James F. Guhl, M.D.
Summary: Because of the problems inherent in arthroscopic visualization of the ankle, a new distraction technique has been devised to help overcome them. This technique has been used on 131 cases with few and relatively minor complications. It has greatly facilitated visualization of the ankle, and it is now possible to perform certain surgical procedures effectively and safely. Key Words: Talotibial joint--Mechanical distraction--Transmalleolar approach-Posterior approach--Ankle holder.
damage, and fractures at stress risers. These should not occur when the technique is properly employed. Ligament damage has repeatedly proven to be of no concern if proper parameters of technique are followed.
The purpose of the distraction technique of ankle arthroscopy is to facilitate safe and effective diagnostic and operative ankle arthroscopy. The advantages of this method are increased room for visualization, triangulation, and manipulation of instrumentation with elimination of blind spots, especially in the medial and posterqor compartments. Chondral defects can be evaluated, more thoroughly probed, and treated. Loose bodies are retrieved with greater ease and assurance regardless of location. A more complete synovectomy is now possible. Some cases of fibrosis and capsulitis can be treated arthroscopically with distraction, aided by repeated distention of the joint capsule and manipulation. With further knowledge gained by this technique, radiographic correlation is improved relative to use of the bone scan, arthrotomograms, computed tomography (CT) scan, and magnetic resonance imaging (MRI). In addition, there is less articular cartilage scuffing, less fluid extravasation resulting in a potential compartment syndrome, less chance of sinus formation, and subsequent infection. Finally, with use of larger instruments, there is less chance of instrument breakage. Potential complications must be recognized, such as broken pins, pin tract problems, neurovascular
INDICATIONS The indications for arthroscopy and arthroscopic surgery of the ankle are both generalized and localized disease, soft tissue in origin or osteochondral in nature. Specific synovial diseases are rheumatoid arthritis, synovial chondromatoisis, pigmented villonodular synovitis, and infectious arthritis or pyarthrosis. Nonspecific soft tissue lesions include adhesions and chronic posttraumatic synovitis (general or local). Local disease is exemplified by the lateral soft tissue impingement (Figs. 1 and 2) of the lateral talomalleolar joint and its superior synovial recess, secondary to trauma (the meniscoid). There are also distinct posterolateral lesions such as interarticular ganglia of the peroneal tendon sheath and nodules and others of synovial origin. Lesions of the posterior recess (1-3) are the hypertrophied transverse tibiofibular ligament, hypertrophied posterior talofibular ligament, secondary to trauma, a true meniscus of the ankle (seen on rare occasion), and truly pathologic, as well as pathologic labrum lesions, which are seen occasionally.
From St. Francis Hospital, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A. Address correspondence and reprint requests to Dr. James F. Guhl, 5757 W. Oklahoma Ave., Milwaukee, WI 53219, U.S.A.
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DISTRACTION I N A N K L E A R T H R O S C O P Y
FIG. 1. Lateral soft tissue (synovial-capsular) impingement lesion seen in its entirety with distraction. (A) Impingement, left upper corner, (B) Fibula, (C) talus, right upper corner, right ankle.
Osteochondral lesions are perhaps better known. They are osteochondritis dissecans, osteochondral fractures, chondral defects of the dome, and plafond (Fig. 3) osteophytes (interarticular) and intercapsular loose bodies, select cases of posttraumatic and degenerative arthritis, postfracture de-
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FIG. 3. Chrondral defect with loose fragment in the posterolateral corner of the plafond. This was not noted until distraction was applied. Right ankle.
fects, and loose bodies. Some interarticular fractures may be considered for treatment as shown by Ferkel (4). Although many of these diseases and lesions respond to conventional methods, experience with the distraction method appears to show that all of them will respond to a better degree with improved results. CONTRAINDICATIONS
FIG. 2. Same view as Fig. 1 after complete removal of the lesion accomplished best with adequate distraction. Transverse tibiofibular ligament is apparent in the background. Right ankle.
Contraindications include those that are absolute and occur in all joints (generalized infection, local infection, and advanced degenerative arthritis with deformity). Some relative contraindications such as partial ankylosis (severe fibrosis and capsulitis), edema, and poor vascular status can become indications for the distraction method. A contraindication to the distraction technique (and transmalleolar approaches) is sympathetic reflex dystrophy (suspected or demonstrated, and excluding other causes). Open epiphysis should be considered, with some exceptions, such as those that are near closure or those in which transmalleolar drilling with an .062 Kirschner wire is done, if the indications outweigh the disadvantages. Pyarthrosis and chronic infection obviously are absolute contraindications. Loose ankle joints may appear to be a contraindication in many cases, but at times distraction is valuable in maintaining a stable larger
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space for operative instruments depending on the pathology and individual situations.
are not a part of this study, but general improvement appeared obvious during this series.
METHODS AND MATERIALS
TECHNIQUE
Eight fresh or thawed frozen amputation specimens were treated with distraction methods and analyzed. After excessive distraction for >1 h and subsequent dissection and inspection, no ligament rupture or damage or increased instability was noted. This was repeated on other specimens during this study with the same conclusions. Sixty-nine cases of ankle arthroscopy were done prior to introduction of the new methods (November 1984). Because of dissatisfaction on many occasions with inadequate ability of diagnostic acumen and surgical instrumentation plus misdiagnosis and repeat procedures, these new techniques were introduced. From November 1984 to February 1987, 131 cases with distraction were employed for ankle arthroscopy. The results of 58 cases, 1984-1986, were reported in a separate publication (5). Experience is now established from 200 cases, including 69 done prior to distraction. The subject of this article is the use of these techniques on 131 patients. Pre- and postoperative stress films were done on most patients. At first, anteroposterior (AP) radiographs with varus-valgus stress were done in 27 cases. Later, lateral views including anterior posteroanterior (PA) stress in flexion and extension were added. Interoperative stress radiographs were done in nine patients while they were still under anesthesia. Direct observation of the anterior talofibular ligament was also done at arthroscopy on many occasions. In some cases, stress radiographs were omitted accidentally. In a few others, radiographs were lost, and several patients from out of town were lost to follow-up. Thus, films were analyzed in 84 cases of 131. In most, there was no difference in the pre- and postoperative stress films except a degree or ~<1 mm. This appeared insignificant or possibly even secondary to the radiograph technique employed. In three cases, there was a slight increase while the patients were still under anesthesia (1 or 2°), which disappeared later. To date, there was no known evidence of objective or subjective signs or symptoms of ligament damage in any patient. Thus, I conclude that this method is safe. End results of treatment
Arthroscopy, Vol. 4, No. 3, 1988
Ankle arthroscopy is done under general (or spinal) anesthesia in a standard hospital operating room or free-standing surgical center. The setup, including the placement of the team, video monitors, and equipment is important for efficiency (Figs. 4 and 5). Selected radiographs are on display for reference. The patient is placed in a supine position on the table. A sandbag may be placed under the buttocks on the involved side to maintain a stable position of the extremitY and avoid external rotation. The hip and knee are flexed 55-60 ° and held in place by a specially designed triangular deflatable beanbag. The foot and ankle are then in place, with the ankle holder in a relative plantar flexed position (Fig. 6). The ball and socket joint of the foot attachment and the swivel action of the support allows for any change of position of the ankle desired for ease of approach and for triangulation by many combinations of portals. The clamp for the ankle holder is sterile and is applied and secured to the side bar of the operating table over the drapes. A tourniquet (if desired) is applied and inflated from 300 to 350 mm Hg. All drapes should be snug around the leg, thigh, and buttocks to allow more room for manipulation of the instruments, arthrom
.
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FIG. 4. Operating room setup. The position of the patient (and extremity) ankle holder, video monitor, surgeon, and assistant are shown. Arthroscope and camera are anterolateral, and basket forceps are placed posterolateral for removal of a loose body from the posterior recess. Left ankle.
DISTRACTION IN A N K L E ARTHROSCOP Y
FIG. 5. Video view from monitor shows forceps entering posterolaterally to grasp the loose body, which could not be easily reached or removed from anteriorly. Distraction made this possible. (A) Forceps, center. (B) Loose body, left. (C) Plafond above. (D) Talus, below. Right ankle.
scope, and camera when the posterior approaches are required. Coban can be wrapped around the foot and leg to accomplish this purpose further. Internal rotation of the foot and ankle allows easier entry of the arthroscope and instruments from posterolateral since the operating table, buttocks, and thighs are well out of the way. Further adjustments can be made to accommodate any required combination of portals for performing surgery as necessary. When prepping and draping have been completed, the anatomic structures are located and drawn on the skin with a marking pencil with the aid of palpation, manipulation of the ankle, and transillumination. The distraction technqiue for arthroscopic sur-
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gery is done in the following manner (Figs. 7-9). A threaded pin (3/16-inch diameter) is placed into the tibia above and into the os calcis below, along the lateral aspect of the extremity. This size is recommended since a more rigid pin of a larger diameter could exert undue force on the ligamentous structures. The upper pin is placed 13/4-2 inches above the ankle joint and drilled just behind the anterior tibial crest away from the anterior tibial artery. The stab wound is made just through the skin in a vertical manner, and the soft tissues are gently spread with a cryle clamp. A handheld cannula is used to protect the soft tissues. This also allows the pin to be set in the power drill, and the proper length can be estimated. It is then inserted perpendicular to the tibia in the medial direction until good purchase is obtained--not through the medial cortex. This can be carefully checked by direct palpation. The fibula should not be used because it can fracture or the pin may cut out. The pin can also slip behind the tibia and potentially cause damage in that area. The lower pin is placed immediately adjacent to the peroneous longus tendon and into the os calcis about one-half inch anterior to the posterior border and one-half inch superior to the inferior border. The border of the calcaneous can be determined or outlined with a hypodermic needle when one is gaining experience. This avoids cutting out when distraction is applied. The skin incision and pin entrance is made in the same manner as in the proximal site. A cannula is again inserted until good purchase is obtained not through the medial cortex. A downward inclination of - 2 0 ° is recommended. The distal pin will then assume a near parallel direction to the proximal pin with the pivot action of the distal end of the distractor when traction is in effect (Fig. 9). If a slight downward angle is necessary, a locking nut is employed to prevent slippage of the distal pin (Figs. 10 and 11). Distraction is then applied slowly up to - 4 - 5 mm separation of the articular surfaces. As the procedure progresses, more distraction is slowly and pe-
I ~,!~'~:!,i!':~
FIG. 6. Patient placement on the operating table with hip and knee flexed over a deftatable beanbag and foot and ankle securely held in a relative plantigrade position by the ankle holder. Left ankle.
FIG. 7. Distractor. (A) Strain gauge is proximally located. (B) Distraction knob. (C) Distal pivot attachment. No wrench is necessary.
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ii FIG. 8. Proper pin placement with respect to neurovascular and other anatomic structures from the lateral perspective. Right ankle.
riodicatly applied during surgery until the joint is opened to - 7 - 8 mm beyond normal (Figs. 12 and 13). This should be about the maximum amount of distraction necessary. As distraction time increases under anesthesia, a temporary elastic deformation of the ligaments apparently allows more distraction than was initially obtained. This should not continue beyond minimal bending of the pins or the proper force, as shown by the strain gauge. All distractions are calibrated in pounds of force. The safe range has been determined to be between 30-50 pounds depending on the individual patient's ankle. I suggest that distraction not be maintained any longer than - 4 5 - 6 0 min to avoid excessive and unnecessary stretching of the ligaments. The ankle can be entered immediately as desired or the distraction device can be utilized at the beginning of the p r o c e d u r e . I n j e c t i o n of 0.5% marcaine with epinephrine 1-200,000 is done at the portal sites to reduce interarticular bleeding further. A 16-gauge needle is placed into the joint. Repeated distention is suggested to stretch the capsule and gain more space. The skin incision is then made with a no. 1l-blade knife in a vertical manner, and the tissues are spread accordingly. Protection of the Arthroscopy, Vol. 4, No. 3, 1988
FIG. 9. Anteroposterior view of pin placement showing inclination of distal pin and handheld cannula. Right ankle.
anterior cutaneous branch of the sural nerve on the lateral side and the saphenous vein medially is accomplished by this method, parting the tissues with entry. The distended joint capsule can be easily palpated for reference. With distraction, there is more room to enter the joint safely without doing damage to the articular cartilage. A sharp obturator is initially placed into the cannula, followed by a blunt obturator after the distended capsule is penetrated. With the arthroscope in place, irrigation can be maintained by continuous infusion with a syringe monitored by an assitant, overhead bags aided by gravity or a pressure hand pump, or by the controlled pressure pump system. Marcaine 0.5% with epinephrine 1-200,000 is instilled into the irrigation solution. When the system is complete, viewing of the joint is accomplished. Further portal placement is determined by use of the spinal needle in that area under arthroscopic visualization. In addition, the posterolateral portal can be determined by advancing a Kirschner wire from an anterior portal posteriorly with the ankle joint distended. Probing is done next. An initial synovectomy of the anterior joint compartment may be necessary to obtain a clear view. There are at least eight and possibly 10 portals of
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FIG. 12. Arthroscopic view of medial side of ankle joint including the medial matleolus, before distraction. Left ankle. (A) Plafond. (B) Medial malleolus. (C) Talus.
FIG. 10. Radiograph of distracted ankle with pin placement and distractor. Distal pin has slightly downward angle.
distraction. The anterocentral portal has proven more useful with distraction for passage of operative instruments posteriorly with greater ease. The arthroscope can be inserted in either anterior portal or the posterior approach for triangulation. The posterolateral portal (Figs; 14 and 15) and the posteromedial portals are placed on either side of the Achilles tendon just below the joint line. The latter approach is not generally~ recommended except
approach (to be confirmed by further study for safety). These include three anterior portals: anterolateral, anteromedial, and anterocentral. The first two may utilize an accessory portal at times. The accessory portals have been of less need with
FIG. 11. Locking nut on distal pin held in a slight downward inclination with distractor.
FIG. 13. Arthroscopic view of medial side of ankle joint, including medial matteolus, "after distraction. There is increased room for probing. Left ankle. (A) Plafond. (B) Medial malleolus. (C) Talus. (D) Probe.
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FIG. 15. (A) Loose body discovered arthroscopicaUy by posterolateral approach. (B) Talus; loose fragment was pushed forward by a probe from the posteromedial portal and removed from the anterior compartment with a grasping forceps from the anteromedial portal with the arthroscope in the anterolateral approach. Right ankle.
COMPLICATIONS FIG. 14. Anteroposterior radiograph shows apparent loose body in the posteromedial talomalleolar joint. This remained stationary in video record motion studies and was a source of continued disability. Right ankle. Arrow, loose body.
when done by an expert arthroscopist under unusual circumstances, as the case may demand. The transmalleolar approaches (Fig. 16) are employed when access to lesions of the talar dome for drilling or instrumentation cannot be properly accomplished from other approaches. The use of an arthroscopic anterior cruciate ligament guide is helpful for accuracy when the transmalleolar approaches are used. An .062 Kirschner wire is used to begin with or for drilling. Slightly larger holes in the malleolus are suggested through which to pass the .062 Kirschner wires to prevent breakage. The ankle can be flexed and extended for drilling multiple holes. Increasing drill sizes up to 5 mm may be employed for further instrumentation or drilling. The transachilles tendon approach is under development and study in cadavers by R. Ferkel and J. W. Ewing (unpublished observations). Instron testing is being determined to assure safety. I have done a few cases clinically with a spinal needle or probe to date and favor its use in the future. Arthroscopy, Vol. 4, No. 3, 1988
The complications since the introduction of distraction in 131 cases have been documented as follows: missed diagnosis, 1; paresthesias of the sural nerve, 3; neuroma, 1; pin breakage, 2; persistent incisional pain, 3; scarred nodule adjacent to the peroneal tendon sheath, 1 ; cellulitis, 1; infected portal, 1. The paresthesias and neuroma appear to be the most serious problem. They were at the portals for arthroscopy, not those for pin placement. The infected incisional site cleared rapidly with treatment, and the cellulitis was mild and also cleared rapidly, both with no sequelae. These were also at the arthroscopic portals. The persistent incisional pain cleared with time or steroid injections. The broken pins were of no concern. This missed diagnosis was an ankle with an unrecognized aseptic necrosis of the talus. The scarred nodule adjacent to the peroneal tendon was the only complication of distraction and caused some discomfort at the patient's shoe top level. Complications clearly appeared to decrease when the 60 original case series without distraction (19751984) were compared with the series (1984-1986) reported separately, and the third series (1986 to the
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DISCUSSION
FIG. 16. Lesion can be reconstructed through a 5-mm transmalleolar approach. Abrader denudes base of fibrocartilaginous tissue. Drilling was then also done. Final inspection was accomplished with the arthroscope inserted through the transrnalleolar portal. Left ankle. (A) Medial malleolus. (B) Tibia. (C) Abrader. (D) Talus.
present). This appeared to be secondary to experience and the use of distraction. The high incidence of missed diagnoses, poorer results, and repeat surgery seemed to end for the most part with use of distraction. Articular cartilage scuffing, sinus formation, extravasation, and the potential for instrument breakage obviously were significantly reduced or eliminated with distraction. There were no further direct complications of distraction other than the single one reported. Results appeared to improve with time and will be analyzed and reported separately.
Distraction has been tested for safety in the laboratory and utilized under study with clinical and radiographic follow-up in 131 cases to date. Advantages have been stated. Results clearly appear to have improved. Complications were documented and have decreased steadily. No complications were directly related to distraction in I31 cases to date except for the one annoying scar tissue nodule reported. The indications for arthroscopic surgery of the ankle have been determined and enumerated. Prognosis for these indications are falling into place and will be reported separately with results. While arthroscopic ankle surgery can be performed effectively and satisfactorily in some cases without distraction, distraction should be considered in all cases for better diagnostic acumen, improved execution of surgical procedures, reduction of complications, and improved results. REFERENCES 1. Chen Y-C. Soft tissue pathology. In: Guhl JF, ed. Ankle arthroscopy--pathology and surgical techniques. Thoroughfare, New Jersey. Slack Corporation, 1987:81. 2. Ikeuchi H. Soft tissue pathology. In: Guhl JR, ed. Ankle arthroscopy--pathotogy and surgical techniques. Thoroughfare, New Jersey. Slack Corporation, 1987:81. 3. Hamilton WG. Differential diagnosis of ankle problems. In: Guhl JR, ed. Ankle arthroscopy--pathology and surgical techniques. Thoroughfare, New Jersey. Slack Corporation, 1987:71. 4. Ferkel R. Personal communication. In: Ankle arthroscopy-pathology and surgical techniques. Thoroughfare, New Jersey. Slack Corporation, 1987:114. 5. Guhl JF. Ankle arthroscopy--pathology and surgical techniques. Thoroughfare, New Jersey. Slack Corporation, 1987:153.
Arthroscopy, Vol. 4, No. 3, 1988
Published by Raven Press, Ltd. @ 1988 Arthroscopy Association of North America
New Concepts (Distraction) in Ankle Arthroscopy James F. Guhl, M.D.
Summary: Because of the problems inherent in arthroscopic visualization of the ankle, a new distraction technique has been devised to help overcome them. This technique has been used on 131 cases with few and relatively minor complications. It has greatly facilitated visualization of the ankle, and it is now possible to perform certain surgical procedures effectively and safely. Key Words: Talotibial joint--Mechanical distraction--Transmalleolar approach-Posterior approach--Ankle holder.
damage, and fractures at stress risers. These should not occur when the technique is properly employed. Ligament damage has repeatedly proven to be of no concern if proper parameters of technique are followed.
The purpose of the distraction technique of ankle arthroscopy is to facilitate safe and effective diagnostic and operative ankle arthroscopy. The advantages of this method are increased room for visualization, triangulation, and manipulation of instrumentation with elimination of blind spots, especially in the medial and posterqor compartments. Chondral defects can be evaluated, more thoroughly probed, and treated. Loose bodies are retrieved with greater ease and assurance regardless of location. A more complete synovectomy is now possible. Some cases of fibrosis and capsulitis can be treated arthroscopically with distraction, aided by repeated distention of the joint capsule and manipulation. With further knowledge gained by this technique, radiographic correlation is improved relative to use of the bone scan, arthrotomograms, computed tomography (CT) scan, and magnetic resonance imaging (MRI). In addition, there is less articular cartilage scuffing, less fluid extravasation resulting in a potential compartment syndrome, less chance of sinus formation, and subsequent infection. Finally, with use of larger instruments, there is less chance of instrument breakage. Potential complications must be recognized, such as broken pins, pin tract problems, neurovascular
INDICATIONS The indications for arthroscopy and arthroscopic surgery of the ankle are both generalized and localized disease, soft tissue in origin or osteochondral in nature. Specific synovial diseases are rheumatoid arthritis, synovial chondromatoisis, pigmented villonodular synovitis, and infectious arthritis or pyarthrosis. Nonspecific soft tissue lesions include adhesions and chronic posttraumatic synovitis (general or local). Local disease is exemplified by the lateral soft tissue impingement (Figs. 1 and 2) of the lateral talomalleolar joint and its superior synovial recess, secondary to trauma (the meniscoid). There are also distinct posterolateral lesions such as interarticular ganglia of the peroneal tendon sheath and nodules and others of synovial origin. Lesions of the posterior recess (1-3) are the hypertrophied transverse tibiofibular ligament, hypertrophied posterior talofibular ligament, secondary to trauma, a true meniscus of the ankle (seen on rare occasion), and truly pathologic, as well as pathologic labrum lesions, which are seen occasionally.
From St. Francis Hospital, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A. Address correspondence and reprint requests to Dr. James F. Guhl, 5757 W. Oklahoma Ave., Milwaukee, WI 53219, U.S.A.
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DISTRACTION I N A N K L E A R T H R O S C O P Y
FIG. 1. Lateral soft tissue (synovial-capsular) impingement lesion seen in its entirety with distraction. (A) Impingement, left upper corner, (B) Fibula, (C) talus, right upper corner, right ankle.
Osteochondral lesions are perhaps better known. They are osteochondritis dissecans, osteochondral fractures, chondral defects of the dome, and plafond (Fig. 3) osteophytes (interarticular) and intercapsular loose bodies, select cases of posttraumatic and degenerative arthritis, postfracture de-
161
FIG. 3. Chrondral defect with loose fragment in the posterolateral corner of the plafond. This was not noted until distraction was applied. Right ankle.
fects, and loose bodies. Some interarticular fractures may be considered for treatment as shown by Ferkel (4). Although many of these diseases and lesions respond to conventional methods, experience with the distraction method appears to show that all of them will respond to a better degree with improved results. CONTRAINDICATIONS
FIG. 2. Same view as Fig. 1 after complete removal of the lesion accomplished best with adequate distraction. Transverse tibiofibular ligament is apparent in the background. Right ankle.
Contraindications include those that are absolute and occur in all joints (generalized infection, local infection, and advanced degenerative arthritis with deformity). Some relative contraindications such as partial ankylosis (severe fibrosis and capsulitis), edema, and poor vascular status can become indications for the distraction method. A contraindication to the distraction technique (and transmalleolar approaches) is sympathetic reflex dystrophy (suspected or demonstrated, and excluding other causes). Open epiphysis should be considered, with some exceptions, such as those that are near closure or those in which transmalleolar drilling with an .062 Kirschner wire is done, if the indications outweigh the disadvantages. Pyarthrosis and chronic infection obviously are absolute contraindications. Loose ankle joints may appear to be a contraindication in many cases, but at times distraction is valuable in maintaining a stable larger
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J. F. G U H L
space for operative instruments depending on the pathology and individual situations.
are not a part of this study, but general improvement appeared obvious during this series.
METHODS AND MATERIALS
TECHNIQUE
Eight fresh or thawed frozen amputation specimens were treated with distraction methods and analyzed. After excessive distraction for >1 h and subsequent dissection and inspection, no ligament rupture or damage or increased instability was noted. This was repeated on other specimens during this study with the same conclusions. Sixty-nine cases of ankle arthroscopy were done prior to introduction of the new methods (November 1984). Because of dissatisfaction on many occasions with inadequate ability of diagnostic acumen and surgical instrumentation plus misdiagnosis and repeat procedures, these new techniques were introduced. From November 1984 to February 1987, 131 cases with distraction were employed for ankle arthroscopy. The results of 58 cases, 1984-1986, were reported in a separate publication (5). Experience is now established from 200 cases, including 69 done prior to distraction. The subject of this article is the use of these techniques on 131 patients. Pre- and postoperative stress films were done on most patients. At first, anteroposterior (AP) radiographs with varus-valgus stress were done in 27 cases. Later, lateral views including anterior posteroanterior (PA) stress in flexion and extension were added. Interoperative stress radiographs were done in nine patients while they were still under anesthesia. Direct observation of the anterior talofibular ligament was also done at arthroscopy on many occasions. In some cases, stress radiographs were omitted accidentally. In a few others, radiographs were lost, and several patients from out of town were lost to follow-up. Thus, films were analyzed in 84 cases of 131. In most, there was no difference in the pre- and postoperative stress films except a degree or ~<1 mm. This appeared insignificant or possibly even secondary to the radiograph technique employed. In three cases, there was a slight increase while the patients were still under anesthesia (1 or 2°), which disappeared later. To date, there was no known evidence of objective or subjective signs or symptoms of ligament damage in any patient. Thus, I conclude that this method is safe. End results of treatment
Arthroscopy, Vol. 4, No. 3, 1988
Ankle arthroscopy is done under general (or spinal) anesthesia in a standard hospital operating room or free-standing surgical center. The setup, including the placement of the team, video monitors, and equipment is important for efficiency (Figs. 4 and 5). Selected radiographs are on display for reference. The patient is placed in a supine position on the table. A sandbag may be placed under the buttocks on the involved side to maintain a stable position of the extremitY and avoid external rotation. The hip and knee are flexed 55-60 ° and held in place by a specially designed triangular deflatable beanbag. The foot and ankle are then in place, with the ankle holder in a relative plantar flexed position (Fig. 6). The ball and socket joint of the foot attachment and the swivel action of the support allows for any change of position of the ankle desired for ease of approach and for triangulation by many combinations of portals. The clamp for the ankle holder is sterile and is applied and secured to the side bar of the operating table over the drapes. A tourniquet (if desired) is applied and inflated from 300 to 350 mm Hg. All drapes should be snug around the leg, thigh, and buttocks to allow more room for manipulation of the instruments, arthrom
.
-
,
t,y/ ! f/ L{
t
FIG. 4. Operating room setup. The position of the patient (and extremity) ankle holder, video monitor, surgeon, and assistant are shown. Arthroscope and camera are anterolateral, and basket forceps are placed posterolateral for removal of a loose body from the posterior recess. Left ankle.
DISTRACTION IN A N K L E ARTHROSCOP Y
FIG. 5. Video view from monitor shows forceps entering posterolaterally to grasp the loose body, which could not be easily reached or removed from anteriorly. Distraction made this possible. (A) Forceps, center. (B) Loose body, left. (C) Plafond above. (D) Talus, below. Right ankle.
scope, and camera when the posterior approaches are required. Coban can be wrapped around the foot and leg to accomplish this purpose further. Internal rotation of the foot and ankle allows easier entry of the arthroscope and instruments from posterolateral since the operating table, buttocks, and thighs are well out of the way. Further adjustments can be made to accommodate any required combination of portals for performing surgery as necessary. When prepping and draping have been completed, the anatomic structures are located and drawn on the skin with a marking pencil with the aid of palpation, manipulation of the ankle, and transillumination. The distraction technqiue for arthroscopic sur-
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163
gery is done in the following manner (Figs. 7-9). A threaded pin (3/16-inch diameter) is placed into the tibia above and into the os calcis below, along the lateral aspect of the extremity. This size is recommended since a more rigid pin of a larger diameter could exert undue force on the ligamentous structures. The upper pin is placed 13/4-2 inches above the ankle joint and drilled just behind the anterior tibial crest away from the anterior tibial artery. The stab wound is made just through the skin in a vertical manner, and the soft tissues are gently spread with a cryle clamp. A handheld cannula is used to protect the soft tissues. This also allows the pin to be set in the power drill, and the proper length can be estimated. It is then inserted perpendicular to the tibia in the medial direction until good purchase is obtained--not through the medial cortex. This can be carefully checked by direct palpation. The fibula should not be used because it can fracture or the pin may cut out. The pin can also slip behind the tibia and potentially cause damage in that area. The lower pin is placed immediately adjacent to the peroneous longus tendon and into the os calcis about one-half inch anterior to the posterior border and one-half inch superior to the inferior border. The border of the calcaneous can be determined or outlined with a hypodermic needle when one is gaining experience. This avoids cutting out when distraction is applied. The skin incision and pin entrance is made in the same manner as in the proximal site. A cannula is again inserted until good purchase is obtained not through the medial cortex. A downward inclination of - 2 0 ° is recommended. The distal pin will then assume a near parallel direction to the proximal pin with the pivot action of the distal end of the distractor when traction is in effect (Fig. 9). If a slight downward angle is necessary, a locking nut is employed to prevent slippage of the distal pin (Figs. 10 and 11). Distraction is then applied slowly up to - 4 - 5 mm separation of the articular surfaces. As the procedure progresses, more distraction is slowly and pe-
I ~,!~'~:!,i!':~
FIG. 6. Patient placement on the operating table with hip and knee flexed over a deftatable beanbag and foot and ankle securely held in a relative plantigrade position by the ankle holder. Left ankle.
FIG. 7. Distractor. (A) Strain gauge is proximally located. (B) Distraction knob. (C) Distal pivot attachment. No wrench is necessary.
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ii FIG. 8. Proper pin placement with respect to neurovascular and other anatomic structures from the lateral perspective. Right ankle.
riodicatly applied during surgery until the joint is opened to - 7 - 8 mm beyond normal (Figs. 12 and 13). This should be about the maximum amount of distraction necessary. As distraction time increases under anesthesia, a temporary elastic deformation of the ligaments apparently allows more distraction than was initially obtained. This should not continue beyond minimal bending of the pins or the proper force, as shown by the strain gauge. All distractions are calibrated in pounds of force. The safe range has been determined to be between 30-50 pounds depending on the individual patient's ankle. I suggest that distraction not be maintained any longer than - 4 5 - 6 0 min to avoid excessive and unnecessary stretching of the ligaments. The ankle can be entered immediately as desired or the distraction device can be utilized at the beginning of the p r o c e d u r e . I n j e c t i o n of 0.5% marcaine with epinephrine 1-200,000 is done at the portal sites to reduce interarticular bleeding further. A 16-gauge needle is placed into the joint. Repeated distention is suggested to stretch the capsule and gain more space. The skin incision is then made with a no. 1l-blade knife in a vertical manner, and the tissues are spread accordingly. Protection of the Arthroscopy, Vol. 4, No. 3, 1988
FIG. 9. Anteroposterior view of pin placement showing inclination of distal pin and handheld cannula. Right ankle.
anterior cutaneous branch of the sural nerve on the lateral side and the saphenous vein medially is accomplished by this method, parting the tissues with entry. The distended joint capsule can be easily palpated for reference. With distraction, there is more room to enter the joint safely without doing damage to the articular cartilage. A sharp obturator is initially placed into the cannula, followed by a blunt obturator after the distended capsule is penetrated. With the arthroscope in place, irrigation can be maintained by continuous infusion with a syringe monitored by an assitant, overhead bags aided by gravity or a pressure hand pump, or by the controlled pressure pump system. Marcaine 0.5% with epinephrine 1-200,000 is instilled into the irrigation solution. When the system is complete, viewing of the joint is accomplished. Further portal placement is determined by use of the spinal needle in that area under arthroscopic visualization. In addition, the posterolateral portal can be determined by advancing a Kirschner wire from an anterior portal posteriorly with the ankle joint distended. Probing is done next. An initial synovectomy of the anterior joint compartment may be necessary to obtain a clear view. There are at least eight and possibly 10 portals of
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FIG. 12. Arthroscopic view of medial side of ankle joint including the medial matleolus, before distraction. Left ankle. (A) Plafond. (B) Medial malleolus. (C) Talus.
FIG. 10. Radiograph of distracted ankle with pin placement and distractor. Distal pin has slightly downward angle.
distraction. The anterocentral portal has proven more useful with distraction for passage of operative instruments posteriorly with greater ease. The arthroscope can be inserted in either anterior portal or the posterior approach for triangulation. The posterolateral portal (Figs; 14 and 15) and the posteromedial portals are placed on either side of the Achilles tendon just below the joint line. The latter approach is not generally~ recommended except
approach (to be confirmed by further study for safety). These include three anterior portals: anterolateral, anteromedial, and anterocentral. The first two may utilize an accessory portal at times. The accessory portals have been of less need with
FIG. 11. Locking nut on distal pin held in a slight downward inclination with distractor.
FIG. 13. Arthroscopic view of medial side of ankle joint, including medial matteolus, "after distraction. There is increased room for probing. Left ankle. (A) Plafond. (B) Medial malleolus. (C) Talus. (D) Probe.
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FIG. 15. (A) Loose body discovered arthroscopicaUy by posterolateral approach. (B) Talus; loose fragment was pushed forward by a probe from the posteromedial portal and removed from the anterior compartment with a grasping forceps from the anteromedial portal with the arthroscope in the anterolateral approach. Right ankle.
COMPLICATIONS FIG. 14. Anteroposterior radiograph shows apparent loose body in the posteromedial talomalleolar joint. This remained stationary in video record motion studies and was a source of continued disability. Right ankle. Arrow, loose body.
when done by an expert arthroscopist under unusual circumstances, as the case may demand. The transmalleolar approaches (Fig. 16) are employed when access to lesions of the talar dome for drilling or instrumentation cannot be properly accomplished from other approaches. The use of an arthroscopic anterior cruciate ligament guide is helpful for accuracy when the transmalleolar approaches are used. An .062 Kirschner wire is used to begin with or for drilling. Slightly larger holes in the malleolus are suggested through which to pass the .062 Kirschner wires to prevent breakage. The ankle can be flexed and extended for drilling multiple holes. Increasing drill sizes up to 5 mm may be employed for further instrumentation or drilling. The transachilles tendon approach is under development and study in cadavers by R. Ferkel and J. W. Ewing (unpublished observations). Instron testing is being determined to assure safety. I have done a few cases clinically with a spinal needle or probe to date and favor its use in the future. Arthroscopy, Vol. 4, No. 3, 1988
The complications since the introduction of distraction in 131 cases have been documented as follows: missed diagnosis, 1; paresthesias of the sural nerve, 3; neuroma, 1; pin breakage, 2; persistent incisional pain, 3; scarred nodule adjacent to the peroneal tendon sheath, 1 ; cellulitis, 1; infected portal, 1. The paresthesias and neuroma appear to be the most serious problem. They were at the portals for arthroscopy, not those for pin placement. The infected incisional site cleared rapidly with treatment, and the cellulitis was mild and also cleared rapidly, both with no sequelae. These were also at the arthroscopic portals. The persistent incisional pain cleared with time or steroid injections. The broken pins were of no concern. This missed diagnosis was an ankle with an unrecognized aseptic necrosis of the talus. The scarred nodule adjacent to the peroneal tendon was the only complication of distraction and caused some discomfort at the patient's shoe top level. Complications clearly appeared to decrease when the 60 original case series without distraction (19751984) were compared with the series (1984-1986) reported separately, and the third series (1986 to the
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DISCUSSION
FIG. 16. Lesion can be reconstructed through a 5-mm transmalleolar approach. Abrader denudes base of fibrocartilaginous tissue. Drilling was then also done. Final inspection was accomplished with the arthroscope inserted through the transrnalleolar portal. Left ankle. (A) Medial malleolus. (B) Tibia. (C) Abrader. (D) Talus.
present). This appeared to be secondary to experience and the use of distraction. The high incidence of missed diagnoses, poorer results, and repeat surgery seemed to end for the most part with use of distraction. Articular cartilage scuffing, sinus formation, extravasation, and the potential for instrument breakage obviously were significantly reduced or eliminated with distraction. There were no further direct complications of distraction other than the single one reported. Results appeared to improve with time and will be analyzed and reported separately.
Distraction has been tested for safety in the laboratory and utilized under study with clinical and radiographic follow-up in 131 cases to date. Advantages have been stated. Results clearly appear to have improved. Complications were documented and have decreased steadily. No complications were directly related to distraction in I31 cases to date except for the one annoying scar tissue nodule reported. The indications for arthroscopic surgery of the ankle have been determined and enumerated. Prognosis for these indications are falling into place and will be reported separately with results. While arthroscopic ankle surgery can be performed effectively and satisfactorily in some cases without distraction, distraction should be considered in all cases for better diagnostic acumen, improved execution of surgical procedures, reduction of complications, and improved results. REFERENCES 1. Chen Y-C. Soft tissue pathology. In: Guhl JF, ed. Ankle arthroscopy--pathology and surgical techniques. Thoroughfare, New Jersey. Slack Corporation, 1987:81. 2. Ikeuchi H. Soft tissue pathology. In: Guhl JR, ed. Ankle arthroscopy--pathotogy and surgical techniques. Thoroughfare, New Jersey. Slack Corporation, 1987:81. 3. Hamilton WG. Differential diagnosis of ankle problems. In: Guhl JR, ed. Ankle arthroscopy--pathology and surgical techniques. Thoroughfare, New Jersey. Slack Corporation, 1987:71. 4. Ferkel R. Personal communication. In: Ankle arthroscopy-pathology and surgical techniques. Thoroughfare, New Jersey. Slack Corporation, 1987:114. 5. Guhl JF. Ankle arthroscopy--pathology and surgical techniques. Thoroughfare, New Jersey. Slack Corporation, 1987:153.
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