Patient positioning is usually based on surgeon preference. Patients can be placed in a supine position with the leg supported on the table or the leg can be placed in a leg holder and allowed to fall free. Some surgeons use the lateral decubitus position with the patient supported on a beanbag, and some surgeons recommend the prone position when the primary pathology is posterior and posterior portals are planned15 (Fig. 67-5). A standard 4.0-mm 30-degree arthroscope is usually sufficient, but a 2.7-mm 30-degree arthroscope may allow easier maneuverability within the ankle joint. Prior to beginning an ankle arthroscopy, the surface landmarks should be delineated with a marking pen. The dorsalis pedis artery should be palpated and marked, and the saphenous vein and accompanying nerve can be marked just anterior to the medial malleolus. In some patients, the terminal branches of the superficial peroneal nerve can be visualized by grasping the fourth toe and bringing the foot into a plantarflexed and adducted position. Prior to starting the procedure, 10 to 15 mL of saline is injected into the ankle through the anteromedial side of the joint. Invasive or noninva-sive distraction devices may be used to improve the visualization in the joint depending on the needs of the procedure. The anteromedial portal is more reproducible and usually established first. A vertical skin incision is made through the skin medial to the tibialis anterior tendon at or just above the joint line. A
Figure 67-6 A, The eight-point anterior examination of the ankle through the arthroscope. B, The seven-point posterior examination of the ankle through the arthroscope. (From Ferkel TD, Scranton PR: Current concepts review: Arthroscopy of the foot and ankle. J Bone Joint Surg Am 1993;75:1233-1242.)
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hemostat or blunt obturator is used to dissect through the capsule. The anterolateral portal is then established with the aid of the arthroscope. The skin is transilluminated to look for branches of the superficial peroneal nerve and traversing veins, and a skin incision is made just lateral to the peroneus tertius tendons at or just above the joint line. A central anterior portal has been described, but it engenders unnecessary risk to the anterior tibial artery and deep peroneal nerve and should be avoided.2 Posterior portals include the posterolateral and posteromedial portals. The posterolateral portal is usually considered the "safe" portal and can be established with the use of the arthroscope through one of the anterior portals. The postero-lateral portal is made just lateral to the Achilles tendon at the level of the joint line. An 18-gauge needle can be used to localize the correct placement under direct arthroscopic visualization, or alternatively a switching stick can be used through one of the anterior portals. Once this portal is established, it can be used for gravity inflow or as a working portal for posterior pathology.2 The posteromedial portal has not gained wide acceptance due to the risk of damage to the nearby posterior neurovascular bundle. A recent anatomic study has described the safe use of posterolateral and posteromedial arthroscopic portals with the patient in the prone position.15 This allows excellent visualization of the posterior half of the tibiotalar joint, the subtalar joint, and the flexor hallucis longus tendon if posterior ankle joint pathology is to be addressed. Once the portals are established, a systematic diagnostic arthroscopy following an eight-point examination, as described by Ferkel and Scranton,2 is performed to thoroughly evaluate the ankle (Fig. 67-6).
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