Hindfoot Arthroscopy

Posterior Ankle Arthroscopy

Indications

  • Posterior ankle impingement syndrome (PAIS)
    • Stieda lesion (symptomatic posterolateral talar process)
    • Os trigonum
    • FHL pathology
  • Peroneal tendon pathology
  • Osteochondral lesions (OCL) and talar bone cysts
  • Subtalar coalitions
  • Haglund lesion with retrocalcaneal bursitis (no associated intratendinous lesions)
  • Posterior tibiotalar or subtalar joint fusion
  • Talus Fractures

Contraindications

  • Local soft tissue infection
  • Severe osteoarthritis

Advantages

  • Less post-operative pain
  • Fewer wound problems
  • Faster rehabilitation

Risks and complications

  • Synovial cutaneous fistula
    • avoid by limiting ankle motion until wounds healed
  • Sural nerve injury (PL portal)
  • Posteromedial neurovascular structures (PM portal)
  • FHL injury (always stay lateral to FHL when shaving)

Instrumentation

  • Thigh tourniquet
  • 30° wide angle 2.7 or 4mm arthroscope
  • 3.5 or 4.5mm shaver
  • Water pump (optional)

Surgical method

  • Patient position is prone or semi prone (affected side down) with the foot hanging over the edge of the bed
  • Posterolateral portal made 1.5 to 2.5 cm proximal to lateral malleolus, 5mm anterior to the medial border of the Achilles tendon (keep ankle in neutral position)
  • Skin incision with blunt dissection using mosquito clamp, aiming for the 1st web space (NB sural nerve); feel ‘divot’ of posterior ankle joint
  • Insert arthroscope sleeve with trocar to ‘divot’ and exchange for arthroscope (bigger scope = better visualization but less manoeuvrability)
  • Posteromedial portal similar 5mm anterior to lateral border of the Achilles tendon
  • Blunt dissection done 90° to the camera scope under direct vision
  • Once mosquito visualised, exchange for 4.5mm shaver and carefully clear fatty/scar tissue from lateral to medial (NB FHL medially)
  • Visualise landmarks and treat pathology

Landmarks and structures

  • Intermalleolar ligament (IML) and superior tibial insertion band of IML divide hindfoot into 4 quadrants:
    • Superolateral
      • Posterior inferior tibiofibular ligament [PITFL]
    • Superomedial
      • Flexor hallucis longus tendon (FHL)
    • Inferomedial
      • FHL retinaculum/ osseous canal
      • Posterolateral talar process (PITFL, posterior talocalcaneal ligament and FHL retinaculum attaches here)
    • Inferolateral
      • Calcaneofibular ligament (CFL)
      • Posterior talofibular ligament

Post-operative treatment

  • Compressive bandage for 72 hours
  • Keep foot elevated as much as possible for 7-10 days
  • Early toe flexion exercises to prevent adhesions of FHL
  • Partial weightbearing progressing to full weightbearing over 1-2 weeks (exception if cartilage procedures were performed)

 

Subtalar Arthroscopy

Introduction

  • First described by Parisien in 1985
  • Complex anatomy of the subtalar joint (STJ) makes it difficult to fully evaluate anterior and / or posterior STJ space even with an extensile approach
  • Although technically challenging, subtalar arthroscopy can provide a comprehensive view of the STJ and address underlying pathology

Indications

  • Evaluation of subtalar instability
  • Debridement of osteochondral lesions
  • Debridement of sinus tarsi syndrome
  • Excision of loose bodies or symptomatic os trigonum
  • Subtalar fusion
  • Evaluation of calcaneal fracture reduction for fixation

Relevant Anatomy

  • Subtalar joint is broadly divided into anterior and posterior joint space
  • The dividing axis runs through sinus tarsi, tarsal canal, talocalcaneal interosseous ligament and inferior extensor retinaculum
    • Contents of anterior joint:
      • Anterior and middle facets
      • Talonavicular joint
      • Spring ligament
    • Contents of posterior joint:
      • Posterior facet (45° lateral to the longitudinal axis of the foot)
      • Capsule
      • Posterior and lateral recess (thickened by calcaneofibular ligament)
      • Calcaneus

Technique

  • Patient can be positioned either supine, lateral or prone depending on which part of the joint is being addressed and the need for other procedures
  • If only anterior STJ is to be addressed and other procedures are required, then anterior position is appropriate; however, a comprehensive arthroscopic approach to the STJ will require a prone position and a dual approach as described below
  • 2.7mm 30° short arthroscope is commonly used
  • Non-invasive distraction with hindfoot strap can be helpful
  • Skeletal traction with a 2.0mm calcaneal pin can be used but take care with osteoporotic bone
  • Subtalar joint can be accessed by either lateral and / or posterior approach:

Lateral approach

  • Provides access primarily to the anterior joint
  • 3 Commonly used portals:
  1. Anterolateral portal: 2cms anterior and 1cm distal to tip of distal fibula
    • usually first portal; foot is everted / inverted to identify sinus tarsi
    • 10 mls of saline is injected into the joint prior to introducing trocar
    • arthroscope is then advanced upwards, in line with tarsal canal
    • remaining portals can then be inserted under direct vision (needle guided)
  2. Middle portal: directly over sinus tarsi, 1 cm anterior to tip of fibula
  3. Posterolateral portal: At the level of the fibula tip, close to the Achilles tendon to avoid injury to the sural nerve

Posterior approach

  • Provides access to the posterior joint
  • 2 commonly used portals: 
  1. Posterolateral portal: lateral to Achilles tendon at the level of tip of the fibula
    • arthroscope directed towards interdigital space between 1st and 2nd toes
  2. Posteromedial portal: medial to Achilles tendon at the level same level as the posterolateral portal
    • haemostat used for blunt dissection aimed towards arthroscope

Potential Complications

  • Ranges between 2.6% to 10.2% in the literature
  • Neuritis of branches of superficial peroneal nerve (0.8% to 6.1%)
  • Sural nerve injury (incidence not clearly documented in the literature)
  • Wound complications (0.8% to 4.6%) 
  • Breakage of instrumentation
  • Damage to articular surface

 

Arthroscopic Approaches to the Hindfoot Tendons

Indications

  • Peroneal tendon
    • Tendinopathy and stenosing tenosynovitis
    • Partial tears
    • Subluxation / dislocation (groove deepening)
  • Tibialis posterior tendon
    • Grade 1 (insufficient evidence recommendation for use)
    • Tenosynovitis, tendinopathy, adhesions
  • Achilles tendon
    • Haglund syndrome (with no associated tendon pathology)

Contraindications

  • Local soft tissue infection

Advantages

  • Less post-operative pain
  • Fewer wound problems
  • Faster rehabilitation

Risks and complications

  • Sural nerve injury – peroneal tendoscopy

Instrumentation

  • Thigh tourniquet
  • 30° wide angle 1.9 / 2.7mm short arthroscope (peroneal and tibialis)
  • 30° 4mm standard arthroscope (Achilles)
  • 2.0 / 2.9mm shaver and 3.2mm burr (peroneal)
  • Gravity-fed low pressure, low-flow pump
  • Arthroscopy knives (Smilie blade)

Surgical method

  • Peroneal tendoscopy – foot plantarflexed (straight line of tendons)
    • Lateral or supine position
      • Portal 1: 20mm distal to fibula tip (proximal to tubercle)
        • 2-5 ml Saline can be injected into sheath to assist scope placement
      • Portal 2: 10mm proximal to fibula tip (posterior)
        • use 22G needle under direct vision
    • Accessory portals
      • Portal 3: 5-6 cm proximal to fibula tip (at musculotendinous junction)
        • often see vinculum between brevis and longus
      • Portal 4: distal to peroneal tubercle
        • for release of inferior retinaculum and tubercle excision
  • Tibialis tendoscopy
    • Supine position
      • Portal 1: 15-20 mm distal to posterior edge of medial malleolus
      • Portal 2: 15-20 mm proximal to posterior edge of medial malleolus
  • Achilles tendoscopy
    • Haglund excision
    • Prone position
      • Portal 1: superior border of calcaneus slightly anterior and lateral to tendon (blunt dissection to prevent sural nerve injury)
      • Portal 2: medial portal similar under direct vision
  • Non-insertional Achilles tendinopathy
    • Prone position
      • Portal 1: lateral distal aspect 2-3cm distal to pathological thickening
      • Portal 2: medial proximal aspect 2-4cm proximal to thickening

Landmarks and structures

  • Peroneal tendoscopy
    • Zone A – superior peroneal retinaculum
      • stenosing tenosynovitis, peroneus quartus, peroneus brevis hypertrophy
    • Zone B – inferior peroneal retinaculum and tubercle
      • stenosis or degenerative tear
    • Zone C – osseous groove lateral cuboid (not for tendoscopy)
    • Zone D – distal to metatarsal base (not for tendoscopy)

Post-operative treatment

  • Dictated by specific treatment
  • Compressive bandage for 72 hours
  • Keep foot elevated as much as possible for 7-10 days
  • Partial weightbearing progressing to full weightbearing over 1-2 weeks

 

References

Ögüt T, Yontar NS. Treatment of hindfoot and ankle pathologies with posterior arthroscopic techniques. EFORT open reviews. 2017;2(5):230-40

Smyth NA, Zwiers R, Wiegerinck JI, Hannon CP, Murawski CD, van Dijk CN, et al. Posterior hindfoot arthroscopy: a review. The American journal of sports medicine. 2014;42(1):225-34

Zengerink M, van Dijk CN. Complications in ankle arthroscopy. Knee Surgery, Sports Traumatology, Arthroscopy. 2012;20(8):1420-31

van Dijk CN. Hindfoot endoscopy. Foot and ankle clinics. 2006;11(2):391-414, vii

Muñoz G and Eckhol S. Subtalar Arthroscopy: Indications, Technique and Results. Foot and Ankle Clinics. 2015;20(1):93-108. Doi: 10.1016/j.fcl.2014.10.010

Williams MM and Ferkel RD. Subtalar arthroscopy: indications, technique, and results. Arthroscopy. 1998;14(4):373-381. Doi: 10.1016/S0749-8063(98)70004-0

Oliva XM, Rios JM and Guelfi M. Arthroscopy of Subtalar Joint. In: Randelli P, Dejour D, van Dijk C et al. (eds). Arthroscopy. Springer, Berlin, Heidelberg. 2016. Doi: 10.1007/978-3-662-49376-2_91

Cychosz CC, Phisitkul P, Barg A, Nickisch F, van Dijk CN, Glazebrook MA. Foot and ankle tendoscopy: evidence-based recommendations. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2014;30(6):755-65

Smyth NA, Zwiers R, Wiegerinck JI, Hannon CP, Murawski CD, van Dijk CN, et al. Posterior hindfoot arthroscopy: a review. The American journal of sports medicine. 2014;42(1):225-34

Kennedy JG, van Dijk PA, Murawski CD, Duke G, Newman H, DiGiovanni CW, et al. Functional outcomes after peroneal tendoscopy in the treatment of peroneal tendon disorders. Knee Surgery, Sports Traumatology, Arthroscopy. 2016;24(4):1148-54

van Dijk CN, Kort N, Scholten PE. Tendoscopy of the posterior tibial tendon. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 1997;13(6):692-8

Carreira D, Ballard A. Achilles tendoscopy. Foot and ankle clinics. 2015;20(1):27-40

Sammarco VJ. Peroneal tendoscopy: indications and techniques. Sports medicine and arthroscopy review. 2009;17(2):94-9