AANA advanced arthroscopy the foot and ankle

AANA Advanced Arthroscopy The Foot and Ankle Series Editor Richard K N Ryu, MD President (2009-2010) Arthroscopy Association of North America Private Practice Santa Barbara, California Other Volumes in the AANA Advanced Arthroscopy Series The Elbow and Wrist The Hip The Knee The Shoulder Chapter X Chapter Title iii AANA Advanced Arthroscopy The Foot and Ankle Annunziato Amendola, MD Professor and Director of University of Iowa Sports Medicine Center Department of Orthopaedics and Rehabilitation University of Iowa Hospital and Clinics Iowa City, Iowa James W Stone, MD Assistant Clinical Professor of Orthopaedic Surgery Medical College of Wisconsin Milwaukee, Wisconsin 1600 John F Kennedy Blvd Ste 1800 Philadelphia, PA 19103-2899 AANA Advanced Arthroscopy: The Foot and Ankle ISBN: 978-1-4377-0662-8 Copyright © 2010 Arthroscopy Association of North America Published by Elsevier Inc All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Permissions may be sought directly from Elsevier’s Rights Department: phone: (ϩ1) 215 239 3804 (US) or (ϩ44) 1865 843830 (UK); fax: (ϩ44) 1865 853333; e-mail: healthpermissions@elsevier.com You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions Notice Knowledge and best practice in this field are constantly changing As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the Authors assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book The Publisher Library of Congress Cataloging-in-Publication Data AANA advanced arthroscopy The foot and ankle / [edited by] Annunziato Amendola, James W Stone 1st ed p ; cm Other title: Advanced arthroscopy Other title: Foot and ankle Includes bibliographical references ISBN 978-1-4377-0662-8 Foot Endoscopic surgery Ankle Endoscopic surgery I Amendola, A (Annunziato) II Stone, James W., 1956- III Title: Advanced arthroscopy IV Title: Foot and ankle [DNLM: Ankle surgery Foot surgery Arthroscopy methods WE 880 A112 2010] RD563.A16 2010 617.5'850597 dc22 2010011087 Publishing Director: Kim Murphy Developmental Editor: Ann Ruzycka Anderson Publishing Services Manager: Frank Polizzano Senior Project Manager: Peter Faber Design Direction: Ellen Zanolle Printed in China Last digit is the print number: DEDICATION To all the residents and fellows I have had the privilege of working with and who have contributed to this work – We have both taught and learned from each other In appreciation Ned Amendola, MD In appreciation to all of the contributors to this volume who have volunteered their time and effort to produce an excellent text and video series which will be an asset to orthopedic surgeons who desire to improve their surgical skills in ankle arthroscopy Your commitment to improving arthroscopic education is inspiring James W Stone, MD This page intentionally left blank Contributors Stephen P Abelow, MD John H Brady, MD Professor Honorífico, Department of Orthopaedic Sports Medicine and Traumatology, Universidad Católica San Antonio de Murcia; Clinica CEMTRO, Madrid, Spain Osteochondral Lesions of the Talar Dome: New Horizons in Cartilage Replacement Orthopedic Surgeon, Intermountain Medical Group, Bountiful, Utah Arthroscopic Fusion for Degenerative Arthritis of the Subtalar Joint Jean-Pascal Allard, MD Assistant Professor, Sherbrooke University; Consultant, Orthopedic Surgery, CHUS-Hôtel-Dieu, Quebec, Canada Osteochondral Lesions of the Talar Dome: Cartilage Replacement Using Osteochondral Autogenous Transplantation and Mosaicplasty Thomas O Clanton, MD Professor of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, Texas; Director, Foot and Ankle Sports Medicine, The Steadman Clinic, Vail, Colorado Osteochondral Lesions of the Talar Dome: Débridement, Abrasion, Drilling, and Microfracture Peter A.J de Leeuw, MD Annunziato Amendola, MD Professor and Director of the University of Iowa Sports Medicine Center, Department Orthopaedic and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Iowa Bony Impingement of the Ankle and Subtalar Joints Champ L Baker, Jr., MD Clinical Assistant Professor of Orthopaedics, Medical College of Georgia, Augusta; Staff Physician, The Hughston Clinic, Columbus, Georgia Soft Tissue Impingement of the Ankle Joint Resident, Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands Tendoscopy John E Femino, MD Associate Clinical Professor, Department of Orthopaedics and Rehabilitation, University of Iowa Carver College of Medicine; University of Iowa Hospitals and Clinics, Iowa City, Iowa Posterior Ankle Arthroscopy for Conditions Causing Ankle Pain: Os Trigonum, Posterior Ankle Soft Tissue Impingement, Flexor Hallucis Longus Stenosis, Haglund’s Deformity, and Other Considerations Timothy C Beals, MD Associate Professor of Orthopaedics, Co-Director, Harold K Dunn Orthopaedic Laboratory, University of Utah School of Medicine, Salt Lake City, Utah Fusion for Degenerative Arthritis of the Ankle Gregory C Berlet, MD Chief, Division of Foot and Ankle Surgery, Ohio University College of Medicine and Public Health, Columbus; Orthopaedic Surgeon, Orthopedic Foot and Ankle Center, Westerville, Ohio Osteochondral Lesions of the Talar Dome: Cartilage Replacement Using Autologous Chondrocyte Implantation and Allografts Carol Frey, MD Assistant Clinical Professor of Orthopaedic Surgery (Volunteer), UCLA David Geffen School of Medicine, Los Angeles; Co-Director, Sports Medicine Fellowship and Family Medicine Sports Medicine Fellowship, West Coast Sports Medicine Foundation and Harbor General Hospital, Manhattan Beach, California Gross Anatomy of the Subtalar Joint vii viii Contributors Eric R Giza, MD Johnny Tak-Choy Lau, MD Assistant Professor of Orthopaedic Surgery, University of California, Davis, School of Medicine; Chief, Foot and Ankle Service, UC Davis Health System, Sacramento, California Osteochondral Lesions of the Talar Dome: Cartilage Replacement Using Autologous Chondrocyte Implantation and Allografts Assistant Professor of Orthopedic Surgery, University of Toronto Faculty of Medicine; Orthopedic Consultant, University Health Network-Toronto Western Division, Toronto, Ontario, Canada Osteochondral Lesions of the Talar Dome: Anatomy, Etiology, and Evaluation; Osteochondral Lesions of the Talar Dome: Cartilage Replacement Using Osteochondral Autogenous Transplantation and Mosaicplasty Mark Glazebrook, MD, PhD Associate Professor of Orthopedic Surgery, Dalhousie University; Orthopedic Consultant, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada Osteochondral Lesions of the Talar Dome: Anatomy, Etiology, and Evaluation; Osteochondral Lesions of the Talar Dome: Cartilage Replacement Using Osteochondral Autogenous Transplantation and Mosaicplasty Sameh A Labib, MD Assistant Professor of Orthopaedic Surgery, Emory University School of Medicine; Emory Sports Medicine Center, Emory Healthcare, Atlanta, Georgia Instability of the Ankle and Subtalar Joints Tun Hing Lui, MBBS Jordan L Goldstein, MD Orthopedic Sports Medicine Fellow, Emory School of Medicine, Atlanta, Georgia Instability of the Ankle and Subtalar Joints Department of Orthopaedics and Traumatology, North District Hospital, Sheung Shui, Hong Kong SAR, China Great Toe Arthroscopy Steven Mussett, MB BCh Troy M Gorman, MD Department of Orthopaedics, University of Utah School of Medicine; University Orthopaedic Center, Salt Lake City, Utah Fusion for Degenerative Arthritis of the Ankle Orthopedic Surgeon, Brockville General Hospital, Brockville, Ontario, Canada Osteochondral Lesions of the Talar Dome: Anatomy, Etiology, and Evaluation Isabel Guillén, MD Florian Nickisch, MD Staff Physician and Surgeon, Department of Orthopaedic Sports Medicine and Traumatology, Clinica CEMTRO, Madrid, Spain Osteochondral Lesions of the Talar Dome: New Horizons in Cartilage Replacement Assistant Professor of Orthopaedics, University of Utah School of Medicine; University Orthopaedic Center, Salt Lake City, Utah Fusion for Degenerative Arthritis of the Ankle Marta Guillén, MD Fernando Pena, MD Staff Physician and Surgeon, Department of Orthopaedic Sports Medicine and Traumatology, Clinica CEMTRO, Madrid, Spain Osteochondral Lesions of the Talar Dome: New Horizons in Cartilage Replacement Assistant Professor of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota Gross Anatomy of the Ankle Joint Phinit Phisitkul, MD Pedro Guillén, MD Professor and Chair, Department of Orthopaedic Sports Medicine and Traumatology, Universidad Católica San Antonio de Murcia; Medical Director and Chief Traumatologist, Clinica CEMTRO, Madrid, Spain Osteochondral Lesions of the Talar Dome: New Horizons in Cartilage Replacement W Bryce Henderson, MD Orthopedic Surgeon, Alberta Health Services, Red Deer, Alberta, Canada Osteochondral Lesions of the Talar Dome: Anatomy, Etiology, and Evaluation Beat Hintermann, MD Associate Professor, University of Basel; Chair, Clinic of Orthopaedic Surgery, Kantonsspital, Liestal, Switzerland Ankle Fractures Clinical Professor, Foot and Ankle Surgery, Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa Great Toe Arthroscopy Charles L Saltzman, MD Professor and Chair, Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, Utah Fusion for Degenerative Arthritis of the Ankle David Sitler, MD Orthopedic Surgeon, Foot and Ankle Surgery, Sharp Rees-Stealy Medical Group, San Diego, California Anatomy, Evaluation, and Operative Setup for Posterior Ankle Arthroscopy Contributors ix Bradley E Slagel, MD C Niek van Dijk, MD, PhD Fellow, Orthopaedic Sports Medicine, Fowler Kennedy Sport Medicine Clinic, The University of Western Ontario, London, Ontario, Canada Instrumentation and Operative Setup for Ankle and Subtalar Arthroscopy Professor, University of Amsterdam; Chief of Service, Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands Tendoscopy Maayke N van Sterkenburg, MD James W Stone, MD Assistant Clinical Professor of Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin Diagnostic Arthroscopy for the Ankle and Subtalar Joints Fellow, Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, Netherlands Tendoscopy Brian Weatherby, MD James P Tasto, MD Clinical Professor, University of California, San Diego, School of Medicine; Founder, San Diego Sports Medicine and Orthopaedic Center, San Diego, California Arthroscopic Fusion for Degenerative Arthritis of the Subtalar Joint Orthopedic Surgeon, Steadman Hawkins Clinic of the Carolinas, Greenville, South Carolina Osteochondral Lesions of the Talar Dome: Débridement, Abrasion, Drilling, and Microfracture Kevin R Willits, MD Michael Tucker, MD Staff Physician, The Houston Clinic, Columbus, Georgia Soft Tissue Impingement of the Ankle Joint Associate Professor of Orthopedic Surgery, University of Western Ontario, London, Ontario, Canada Instrumentation and Operative Setup for Ankle and Subtalar Arthroscopy John Louis-Ugbo, MD Orthopedic Resident, Emory School of Medicine, Atlanta, Georgia Instability of the Ankle and Subtalar Joints Tanawat Vaseenon, MD Instructor, Department of Orthopedic Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand Bony Impingement of the Ankle and Subtalar Joints Alastair S.E Younger, MB ChB Associate Professor of Orthopaedics, University of British Columbia; Head, Orthopaedic Research, St Paul’s Hospital, Vancouver, British Columbia, Canada Complex Ankle, Subtalar, and Triple Fusions 194 A AANA ADVANCED ARTHROSCOPY: THE FOOT AND ANKLE B C D E F FIGURE 20-11 Several areas can be visualized from the dorsomedial portal: dorsal metatarsal head (A), dorsolateral metatarsal head (B), lateral gutter (C), lateral metatarsophalangeal compartment (D), central metatarsophalangeal compartment (E), and medial metatarsophalangeal compartment (F) Chapter 20 Great Toe Arthroscopy A B C D E F FIGURE 20-12 Several areas can be visualized from the dorsolateral portal: central metatarsal head and the sagittal sulcus (arrow) (A), dorsomedial metatarsal head and medial gutter (B), dorsocentral metatarsal head (C), dorsolateral metatarsal head (D), lateral gutter (E), and lateral metatarsophalangeal compartment (F) 195 196 AANA ADVANCED ARTHROSCOPY: THE FOOT AND ANKLE C C B A A FIGURE 20-13 Several areas of the metatarsosesamoid compartment can be visualized from the medial portal: medial sesamoid (A), lateral sesamoid (B), and crista of the metatarsal head (C) Arthroscopy-assisted arthrodesis has been described for endstage disease without gross deformity or bone loss.17,18 Dorsomedial, dorsolateral, and medial portals are used together with finger trap traction Residual cartilage is débrided using curettes, shavers, or abraders The preserved subchondral bone is microfractured using a small chondral pick (Fig 20-18) The position of the fusion is 15 degrees of valgus and 20 degrees of dorsiflexion The provisional fixation is made with a Kirschner wire, and the position is confirmed with fluoroscopy When the foot is placed flat on a metal tray, the interphalangeal joint should be slightly elevated from the surface Crossed cannulated screws are inserted under fluoroscopic guidance Chondral and Osteochondral Lesions FIGURE 20-14 Synovial hyperplasia can be seen on the dorsal aspect of the first metatarsophalangeal joint The dorsomedial and dorsolateral portals can be established farther away from the extensor tendons at the dorsomedial and the dorsolateral corners of the joint (see Fig 20-17B) This allows better access for débridement of the osteophytes in the dorsal, medial, and lateral gutters while avoiding crowding of the instruments For example, the medial osteophytes can be débrided with the dorsolateral portal used as the visualization portal and the dorsomedial portals used as the instrumentation portals In the event of a large, overhang osteophyte at the metatarsal head, an accessory proximal dorsal portal can be established at the proximal end of the osteophyte If adequate débridement is not possible arthroscopically, the decision should be made to perform an open débridement Chondral and osteochondral lesions have been successfully treated arthroscopically, and the benefits included less pain, less stiffness, and reduced rehabilitation time (Fig 20-19).13,14,16 In cases with cartilage lesions, the aims are to remove the source of pain, stimulate fibrocartilaginous regeneration, and eliminate mechanical symptoms Partial-thickness cartilage injury can be treated with a radiofrequency probe to provide smooth edges We recommend a microfracture technique using a small joint microfracture probe or a Kirschner wire for a full-thickness cartilage loss or an osteochondral defect For the in situ osteochondral lesion, the overlying cartilage may look deceptively normal, but with careful palpation with a probe, the lesion can be identified A curette can be used to remove the osteochondral fragments, although we have found the 2.0-mm probe causes less trauma to the surrounding tissue Softened cartilage can be easily penetrated and cut with the tip of the probe The probe can then be used as a hook to pull the fragment loose The fragment can be débrided with a shaver or removed with hemostats The defect is further débrided until fresh cancellous surface is uncovered Microfracture is then performed The joint is mobilized through range of motion, and any potential location that can provide mechanical catching is smoothed with a radiofrequency probe A corresponding lesion Chapter 20 Great Toe Arthroscopy A 197 B FIGURE 20-15 A, The radiograph shows osteophytes on the dorsal aspect of the metatarsal head and the base of the proximal phalanx B, The arthroscopic view shows an instrument interposed between the osteophytes FIGURE 20-16 Anteroposterior (A) and lateral (C) radiographs of a foot with moderate osteoarthritis show dorsal osteophytes and loose bodies at the first metatarsophalangeal joint Eburnation of the cartilage is seen on the dorsal aspect of the metatarsal head (B) A C B FIGURE 20-17 A, The periosteal elevator is used to strip the dorsal capsule from the dorsal osteophytes B, The arthroscopic cannula localizes the dorsolateral and dorsomedial portals, which are slightly far from the extensor tendons A B A B FIGURE 20-18 The metatarsal (A) and proximal (B) phalangeal facets have been prepared by cartilage débridement and microfracture of subchondral bone A B C FIGURE 20-19 A full-thickness cartilage lesion on the dorsum of the metatarsal head is visualized before (A) and after (B) débridement A kissing lesion (C) can be seen in the metatarsosesamoid compartment Chapter 20 Great Toe Arthroscopy that may manifest on the proximal phalangeal base should be observed and treated.27 Arthrofibrosis Arthroscopic lysis of the MTP-1 arthrofibrosis has been reported.19,26 It has the potential advantage of early postoperative rehabilitation, because there is less pain associated with the procedure Arthroscopic visualization in the joint can be limited by advanced arthrofibrosis The routine dorsomedial and dorsolateral portals are employed for the débridement of the dorsal, medial, and lateral gutters At the initial portal placement, the trocar should be used to free the dorsal fibrotic tissue by sweeping in a back-and-forth fashion Soft tissue release can involve stripping the medial capsule from the metatarsal head if overplication has occurred from a hallux valgus reconstruction The sesamoid apparatus can be examined from the medial portal, and a plantar medial working portal is created under direct visualization for the débrider (Fig 20-20) Plantar flexion of the joint opens the metatarsosesamoid compartment for easier instrumentation Manual manipulation to achieve maximum range of motion is usually performed after the release 199 Gouty Tophi Percutaneous soft tissue shaving of gouty tophi has produced good aesthetic results in 17 patients, with patients having partial skin necrosis and no reported nerve injuries.23 An endoscopy-assisted technique has been described to minimize wound breakdown and persistent drainage.22 A study by Wang and colleagues5 showed superior reduction in the number of acute attacks (5.4 vs 1.9) and an increase in the American Orthopaedic Foot and Ankle Society (AOFAS) score (20.9 vs 4.0) after endoscopic débridement (n ϭ 15) compared with medication alone (n ϭ 13) at a minimum of years’ follow-up Two portals are localized at the proximal and distal ends of the tophi (Fig 20-21) A trocar is used to make a tunnel Sesamoidectomy The medial and lateral sesamoids can be accessed from the combination of dorsomedial, dorsolateral, medial, and plantar medial portals.24 The evidence is limited, with only case reports presented in the literature The lateral sesamoid has been removed using the medial portal or the toe web portal for visualization and the plantar medial portal for instrumentation.25 The medial sesamoid has been removed using the dorsolateral portal for visualization and the medial portal for instrumentation.24 The sesamoid can be excised in piecemeal with a pituitary rongeur or a 2.0-mm, round abrader The ligamentous attachments are preserved Van Dijk and colleagues found the medial sesamoid excision to be less successful, and an open excision was used in all three cases in their series.13 Excision of both sesamoids is not recommended because of the risk of a cock-up deformity FIGURE 20-20 The arthroscopic view demonstrates complete release of the metatarsosesamoid compartment FIGURE 20-21 A, The patient has difficulty with shoewear because of large tophi overlying the first metatarsophalangeal joint B, Débridement is performed using two medial portals A B 200 AANA ADVANCED ARTHROSCOPY: THE FOOT AND ANKLE FIGURE 20-22 A, The plantar portal is established inside-out from the toe web portal B, The arthroscope is positioned through the plantar portal while the intermetatarsal ligament is being released with a retrograde knife from the toe web portal A B through the tophi that joins both portals The portals can be used interchangeably for visualization or instrumentation The tophaceous material is removed with a shaver, progressing from the tunnel toward the pseudocapsule at the periphery Part of the medial capsule may need to be removed Great care is used to avoid injury to the dorsomedial hallucal nerve superficial to the pseudocapsule The dorsolateral portal can be added for intra-articular débridement The use of warm irrigation fluid is recommended to increase the solubility of the urate and prevent the system from clogging.23 Postsurgical gout attack can be prevented by presurgical control of serum uric acid and prophylactic perioperative administration of colchicine.28,29 Hallux Valgus Patients with hallux valgus can develop pain at the joint line without bunion pain or difficulties due to the deformity In a case series of 30 feet, arthroscopic synovectomy through the standard dorsomedial and dorsolateral portals achieved complete pain relief in 22, significant pain relief in 5, and persistent pain in at years’ follow-up.20 Five patients developed bunion pain and required further arthroscopy-assisted correction For patients with a painful joint line and a hallux valgus requiring correction, synovectomy performed through the described portals can be used in conjunction with deformity correction The arthroscopy-assisted correction of hallux valgus deformity has been reported by Lui and associates in a series of 94 patients with reducible 1-2 intermetatarsal angle and normal distal metatarsal articular angle.8 The average hallux valgus angle improved from 33 ± degrees to 14 ± degrees, and the intermetatarsal angle improved from 14 ± degrees to ± degrees° The postoperative AOFAS score was 93, and the satisfaction rate was 95.7% Complications included hallux varus, skin impingement, screw breakage, and MTP-1 stiffness FIGURE 20-23 The exostectomy is performed through the medial and proximal medial portals The lateral release is performed through the toe web and the plantar portals Under arthroscopic visualization through the plantar portal, the intermetatarsal ligament, adductor hallucis tendon, and lateral capsule are released with a retrograde knife (Fig 20-22) Manipulation is performed to bring the toe to at least neutral alignment The sesamoid reduction can be evaluated from the toe web portal or the medial portal The medial portal and the proximal medial portal are used interchangeably for the arthroscope and the round abrader for the medial exostectomy (Fig 20-23) The sagittal sulcus is a landmark that can be visualized from the dorsolateral portal Through the medial and proximal medial portals, the medial capsule is percutaneously plicated with a no PDS suture to pull the distal plantar part toward the proximal dorsal part The intermetatarsal angle is manually closed, and fixation with a 4.0 cannulated screw is performed under fluoroscopic guidance (Fig 20-24).30 The PDS suture is tied afterward (Fig 20-25) Chapter 20 Great Toe Arthroscopy A 201 B FIGURE 20-24 A cannulated screw is placed to stabilize the first and second metatarsals A, The guide pin is placed into the center of the second metatarsal from the lateral aspect B, Satisfactory reduction of the intermetatarsal angle is demonstrated ● ● ● Joint distraction may be used as needed for work that must be done between the articular facets, such as fusion of an osteochondral lesion When the arthroscope is superficial, it is held such that one of the surgeon’s fingers sits on the cannula at the skin level of the portal to prevent pistoning or dislodgment of the arthroscope Percutaneous suture technique is performed by passing the curved eyed-needle through a portal into a structure and out through the intact skin for both ends of the suture The suture ends are then retrieved from the plane just superficial to that structure with small, curved hemostats Both suture ends are used to anchor to another structure in the same way before tying PITFALLS ● FIGURE 20-25 The PDS suture is used to plicate the medial capsule The suture is tied from the proximal medial portal under proper tension to achieve further correction of the valgus and pronation deformity ● ● PEARLS& PITFALLS PEARLS ● All portals are made carefully with a sharp incision through only the skin Small, curved hemostats should be used to spread the soft tissue, puncture the joint capsule, feel the joint and the cartilage, dilate the portals, and occasionally strip the fibrotic joint capsule ● The MTP-1 joint can sometimes be so stiff and fibrotic that arthroscopic maneuvers can harm by damaging the articular cartilage or the instruments Consent must be obtained from patients, who must be informed that an open procedure may be required as a backup plan Small joint arthroscopy has steep learning curve Arthroscopic laboratory training can be helpful Superficial nerves, especially the dorsomedial hallucal nerve can be injured from portal placement, instrument passing, or suture placement The surgeon should be aware of the location of the nerve and possible anatomic variations For the lateral release in treating hallux valgus, the retrograde knife should be introduced through the toe web portal only, without passing through the plantar portal The retrograde knife and the shaver should be kept away from the fat tissue plantar to the intermetatarsal ligament 202 AANA ADVANCED ARTHROSCOPY: THE FOOT AND ANKLE Postoperative Rehabilitation Protocol Bulky dressing and a postoperative shoe are routinely used for to days Bearing weight on the heel is allowed The patient gradually increases weight bearing and range of motion as tolerated For a hallux valgus correction, a toe web spacer is used, and the screw is removed at week under local anesthesia For an arthrodesis, full weight bearing in a stiff-sole shoe is allowed after crossing of the trabeculae at to weeks Swelling can persist for a few months but usually to a lesser degree than with open procedures For a medial sesamoid excision, the hallux is strapped into slight varus for weeks to prevent hallux valgus deformity CONCLUSIONS Arthroscopy can be helpful in selected cases of MTP-1 pathologies Because of the steep learning curve for the technique, basic small joint arthroscopic skills and some laboratory training are recommended Considered as an alterative to open procedures, MTP-1 arthroscopy allows magnified visualization, minimally invasive treatment, and diminution of postoperative pain and scarring Familiarity with the topographic anatomy of the forefoot and awareness of nerve variations can minimize complications Because of the limited amount of information about MTP-1 arthroscopy, evidence-based recommendations and guidelines must be developed REFERENCES Watanabe M Selfox-Arthroscope (Wantantabe No 24 Arthroscope) Tokyo, Japan: Teishin Hospital, 1972 Lidtke RH, George J Anatomy, biomechanics, and surgical approach to synovial folds within the joints of the foot J Am Podiatr Med Assoc 2004;94:519-527 Solan MC, Lemon M, Bendall SP The surgical anatomy of the dorsomedial cutaneous nerve of the hallux J Bone Joint Surg Br 2001;83: 250-252 Ferkel R Great-toe arthroscopy In: Whipple T, ed Arthroscopic Surgery: The Foot & Ankle Philadelphia, PA: Lippincott-Raven; 1996:255-272 Wang CC, Lien SB, Huang GS, et al Arthroscopic elimination of monosodium urate deposition of the first metatarsophalangeal joint reduces the recurrence of gout Arthroscopy 2009;25:153-158 Browne K, Lee J The appreciation of passive movement of the metatarsophalangeal joint of the great toe in man J Physiol 1954;123:10-1P Michelson J, Dunn L Tenosynovitis of the flexor hallucis longus: a clinical study of the spectrum of presentation and treatment Foot Ankle Int 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J Am Podiatr Med Assoc 2005;95:221-228 Masih S, Antebi A Imaging of pigmented villonodular synovitis Semin Musculoskelet Radiol 2003;7:205-216 Fessell DP, van Holsbeeck M Ultrasound of the foot and ankle Semin Musculoskelet Radiol 1998;2:271-282 Iqbal MJ, Chana GS Arthroscopic cheilectomy for hallux rigidus Arthroscopy 1998;14:307-310 van Dijk CN, Veenstra KM, Nuesch BC Arthroscopic surgery of the metatarsophalangeal first joint Arthroscopy 1998;14:851-855 Bartlett DH Arthroscopic management of osteochondritis dissecans of the first metatarsal head Arthroscopy 1988;4:51-54 Borton DC, Peereboom J, Saxby TS Pigmented villonodular synovitis in the first metatarsophalangeal joint: arthroscopic treatment of an unusual condition Foot Ankle Int 1997;18:504-505 Debnath UK, Hemmady MV, Hariharan K Indications for and technique of first metatarsophalangeal joint arthroscopy Foot Ankle Int 2006;27:1049-1054 Carro LP, Vallina BB Arthroscopic-assisted first metatarsophalangeal joint arthrodesis Arthroscopy 1999;15:215-217 Stroud CC Arthroscopic arthrodesis of the ankle, subtalar, and first metatarsophalangeal joint Foot Ankle Clin 2002;7:135-146 Lui TH Arthroscopic release of first metatarsophalangeal arthrofibrosis Arthroscopy 2006;22:906.e1-4 Lui TH First metatarsophalangeal joint arthroscopy in patients with hallux valgus Arthroscopy 2008;24:1122-1129 Lui TH, Ng S, Chan KB Endoscopic distal soft tissue procedure in hallux valgus surgery Arthroscopy 2005;21:1403 Lui TH Endoscopic resection of the gouty tophi of the first metatarsophalangeal joint Arch Orthop Trauma Surg 2008;128:521-523 Lee SS, Lin SD, Lai CS, et al The soft-tissue shaving procedure for deformity management of chronic tophaceous gout Ann Plast Surg 2003; 51:372-375 Perez Carro L, Echevarria Llata JI, Martinez Agueros JA Arthroscopic medial bipartite sesamoidectomy of the great toe Arthroscopy 1999; 15:321-323 Chan PK, Lui TH Arthroscopic fibular sesamoidectomy in the management of the sesamoid osteomyelitis Knee Surg Sports Traumatol Arthrosc 2006;14:664-667 Ferkel R, Buecken KV Great toe arthroscopy: indications, technique and results Presented at the Arthroscopy Association of North America, April, 1991; San Diego, CA Shonka TE Metatarsal phalangeal joint arthroscopy J Foot Surg 1991; 30:26-28 Kang EH, Lee EY, Lee YJ, et al Clinical features and risk factors of postsurgical gout Ann Rheum Dis 2008;67:1271-1275 Linton RR, Talbott JH The surgical treatment of tophaceous gout Ann Surg 1943;117:161-182 Friscia DA Distal soft tissue correction for hallux valgus with proximal screw fixation of the first metatarsal Foot Ankle Clin 2000;5:581-589 Index Note: Page numbers followed by f refer to figures; page numbers followed by b refer to boxes A Achilles tendon, 3f, Aiming devices, 24 Anesthesia, 19, 22 Ankle anatomy of, 2-10, 40, 89 anterior, 2-3, 2f, 3f arthroscopic See Ankle arthroscopy (diagnostic) axial, 78, 78f ligamentous, 78-80, 79f posterior, 3-4, 3f, 4f topographic, 2-4, 2f, 3f, 4f arthroscopy of See Ankle arthroscopy (diagnostic); Ankle arthroscopy (therapeutic) degenerative arthritis of, 157 arthrodesis for See Ankle arthrodesis imaging of, 159, 159f nonoperative treatment of, 159 pathogenesis of, 157-158, 158f patient history in, 158-159 physical examination in, 158-159 fracture of See Ankle fracture instability of See Ankle instability soft spot of, 2-3 Ankle arthrodesis, 157-169, 157f See also Triple arthrodesis anatomy for, 157-158 anterior, 157-169 alignment in, 160, 162 care after, 164 case study of, 160, 161f, 164, 164f, 165f complications of, 167 fixation in, 162-164, 162f, 163f indications for, 160 joint preparation for, 161-162, 162f results of, 160, 166-167, 168t setup for, 160-161, 161f complex, 177-185 bone deformity in, 178-179 contraindications to, 178 evaluation for, 177-178 imaging for, 178 indications for, 178 osteophytes in, 179, 179f tight joint and, 179, 179f subtalar arthrodesis with, 165-166, 165f, 166f, 167f, 179-180, 180f, 181f Ankle arthroscopy (diagnostic), 4-10, 10b, 18, 27b, 29-32 accessory anteromedial portal for, 7, 8f, 28f anterolateral portal for, 5-6, 7f, 28f syndesmosis on, anteromedial portal for, 4-5, 4f, 5f, 7f, 28f anterolateral corner on, 5f lateral aspect on, 5f lateral gutter on, medial gutter on, 5, 6f, 7f posterolateral corner on, 6f posteromedial corner on, 6f syndesmosis on, 5, 5f in fracture See Ankle fracture, arthroscopic evaluation of interosseous ligament complex on, 29-30, 30f lateral gutter on, 5, 53 medial gutter on, 5, 6f, 7f, 29, 29f medial malleolus on, 29, 29f, 30f portal creation for, 27-28, 27-28b, 28f, 29f positioning for, 26-27, 26f, 27f posterior, 34-35, 35b, 35f portals for, 34, 34f, 35f positioning for, 34, 34f posterolateral portal for, 7, 8f, 9f, 28f, 29f posteromedial portal for, 9f, 10, 28f talar dome on, 29, 30-31, 30f talar neck on, 30-31, 31f tibiofibular ligament on, 29-31, 30f, 31f Ankle arthroscopy (therapeutic) anesthesia for, 19, 22 in anterior soft tissue impingement, 54-56, 55f, 55t, 56f in arthrodesis See Ankle arthrodesis; Subtalar joint arthrodesis; Triple arthrodesis assessment for, 18-19, 24b in bony impingement, 41, 47-48 distraction for, 20-22, 21f, 22b in flexor hallucis longus tendon stenosis, 73, 73b, 73f in flexor hallucis longus tenosynovitis, 64f, 153-155, 153f, 154f, 155f instrumentation for, 22-24, 23f, 24f operating setup for, 18b, 19f, 22 positioning for, 19, 19f, 20f, 22, 22f posterior, 58-64, 64b anatomy for, 58-59, 58f bone scan before, 61-62 Ankle arthroscopy (therapeutic) (Continued) cannulas for, 62, 62f, 64 capsule excision for, 62-63, 63f care after, 64 cartilage excision for, 63, 63f clinical evaluation for, 59-60 computed tomography before, 60, 60f in flexor hallucis longus stenosis, 73, 73b, 73f flexor hallucis tendon in, 63-64, 64f in Haglund’s deformity, 74-76, 74f, 75f, 76b, 76f magnetic resonance imaging before, 60-61, 61f medial portal for, 62, 62f os trigonum removal in, 59, 63, 63f, 64f, 65-69 See also Os trigonum positioning for, 62, 62f posterolateral portal for, 62, 62f radiography before, 60, 60f in soft tissue impingement, 71, 71b surface markings for, 62, 62f Ankle fracture, 88-96 arthroscopic evaluation of, 89-90 cartilage lesions on, 90, 91f contraindications to, 89 fracture pattern on, 90, 94f, 95f grade lesion on, 90 grade lesion on, 90, 91f grade lesion on, 90, 91f grade lesion on, 90, 91f indications for, 89 ligament assessment on, 90, 91f, 92f, 93f portal for, 89, 90f positioning for, 89, 90f imaging in, 89 nonoperative treatment of, 89 open reduction and internal fixation for, 89 patient history in, 89 physical examination in, 89 rehabilitation after, 90 Ankle impingement Bassett’s ligament, 42-43, 52, 53f bony, 38-51 anatomy of, 40 anterior, 39t, 40-43, 40f, 49b arthroscopic treatment of, 41 differential diagnosis of, 41 loose bodies in, 40, 40f 203 204 Index Ankle impingement (Continued) nonoperative treatment of, 41 physical examination in, 41 radiography in, 41 recurrent inversion sprain and, 41 anterocentral, 42 anterolateral, 42-43 anteromedial, 41-42, 42f Bassett’s ligament, 42-43, 52, 53f classification of, 39, 39t, 40f etiology of, 38-39, 39f historical perspective on, 38 lateral, 43 medial, 43, 44f osteophytes in, 38-39, 39f, 40f posterior, 44-48, 45f, 46f, 47t anatomy of, 44 anomalous muscles in, 46 arthroscopic treatment of, 47-48 computed tomography in, 44 differential diagnosis of, 45-46 vs flexor hallucis longus tendonitis, 47, 47t magnetic resonance imaging in, 44, 45-46, 45f, 47, 48f physical examination in, 45, 47 radiography in, 44-45, 45f posterolateral, 44-46, 45f posteromedial, 46-48, 47f, 48f soft tissue anterior, 52-57, 56b arthroscopic treatment of, 54-56, 55f, 55t, 56f computed tomography arthrography in, 54 imaging in, 53-54 magnetic resonance imaging in, 54 meniscoid-type lesion in, 52, 52f nonoperative treatment of, 54 pathoanatomy of, 53 patient history in, 53 physical examination in, 53, 54f rehabilitation for, 56 posterior, 69-72 anatomy of, 69-70, 70f arthroscopic treatment of, 71, 71b contraindications to, 71 indications for, 71 rehabilitation after, 72 imaging in, 70-71 magnetic resonance arthrography in, 67f, 70-71 magnetic resonance imaging in, 70-71 nonoperative treatment of, 71 patient history in, 70 physical examination in, 70 radiography in, 70-71 ultrasonography in, 70-71 synovial, 43, 52 Ankle instability, 78-80 anatomy of, 78-80, 78f, 79f, 80f anterior drawer test in, 81, 81f functional, 80 hindfoot varus in, 81, 81f, 86 mechanical, 80 mechanisms of, 80 patient history in, 81 physical examination in, 81, 81f radiography in, 81-82, 82f surgical treatment of, 82-87, 87b anatomic, 82-83 Brostrom-Gould repair in, 82-85, 84f, 85f, 86f contraindications to, 82 hindfoot varus and, 86 indications for, 82 Ankle instability (Continued) nonanatomic, 82-83 os subfibulare and, 81, 81f, 86, 86f peroneal pathology and, 86 portals for, 83 positioning for, 83, 83f rehabilitation after, 87 results of, 82 talar tilt test in, 81, 81f Ankle sprain, lateral, 52-53, 78 See also Ankle impingement, soft tissue; Ankle instability Anterior drawer test, 81, 81f Anterolateral corner compression syndrome, 52 Anterolateral synovial impingement, 43, 52 Arthrodesis See Ankle arthrodesis; Subtalar joint arthrodesis; Triple arthrodesis Arthrofibrosis, first metatarsophalangeal joint, 187-188t, 199, 199f Arthroscope, 22-23, 23f Arthroscopy See Ankle arthroscopy; Subtalar joint arthroscopy Autologous matrix-induced chondrogenesis, 144 Awls, 24, 24f B Bassett’s ligament impingement, 42-43, 52, 53f Bioseed-C, 144 Bone scan in os trigonum syndrome, 61-62 in osteochondral talar lesion, 61-62, 100, 118 Brostrom-Gould procedure, 83-85 anterior talofibular ligament transection in, 83-85, 85f inferior extensor retinaculum in, 83, 84f landmarks for, 83, 84f negative gravity test in, 85, 86f peroneal sheath incision for, 83-85, 84f positioning for, 83, 83f rehabilitation after, 87 results of, 82-83 suture placement in, 85, 85f C Calcaneocuboid joint arthrodesis of, 183 fixation of, 184 Calcaneofibular ligament, 53, 79, 79f in ankle fracture, 90, 92f injury to, 80 See also Ankle instability Calcaneotibial ligament, 79 Chevron medial malleolar osteotomy, 128 Chondrocelect, 144 Co.don chondrosphere, 144 Collagen-covered autologous chondrocyte implantation, 136 Computed tomography (CT) in first metatarsophalangeal joint disorders, 188 in os trigonum syndrome, 60 in osteochondral talar lesion, 60, 60f, 99-101, 100f, 118 in posterior ankle impingement, 44 Computed tomography arthrography (CTA), in anterolateral ankle impingement, 54 Curettes, 23, 23f D Dancer’s tendinitis, 43, 46-47, 47f, 48f, 59-60 See also Flexor hallucis longus tenosynovitis Deltoid ligament, 79 See also Calcaneotibial ligament; Tibionavicular ligament; Tibiotalar ligament in ankle fracture, 90, 92f, 95f Distraction, 20-22, 24b complications of, 21, 22b contraindications to, 21-22, 22b force for, 21 invasive, 20-21, 22b noninvasive, 20, 22b controlled, 20-21, 21f semicontrolled, 20, 21f Double arthrodesis, 183 E Extensor digitorum longus tendon, Extensor hallucis longus tendon, 3, 5, 6f F Fibular tip, avulsion fracture of, 43 First metatarsophalangeal joint disorders See Great toe, first metatarsophalangeal joint disorders of Flexor hallucis longus tendon, 4, 9f, 16, 16f, 58, 58f, 152 Flexor hallucis longus tendon stenosis, 72-74 anatomy of, 72, 72f arthroscopic treatment of, 73, 73b, 73f contraindications to, 72-73 indications for, 72-73 rehabilitation after, 73 imaging in, 72 nonoperative treatment of, 73 patient history in, 72 physical examination in, 72 Flexor hallucis longus tendonitis, 43, 46-47, 47f, 48f See also Flexor hallucis longus tenosynovitis magnetic resonance imaging of, 61, 61f vs posterior ankle impingement, 47, 47t Flexor hallucis longus tenosynovitis, 59-60, 151-155 anatomy of, 152 arthroscopic treatment of, 60, 63-64, 64f, 153-155 portals for, 153-154, 154f positioning for, 153, 153f rehabilitation after, 155 release technique for, 154, 155f conservative management of, 153 imaging in, 152-153, 153f nonoperative treatment of, 60 open treatment of, 60 patient history in, 152 physical examination in, 152, 152f posterior ankle impingement and, 152, 152f Forceps, basket, 23, 23f Fracture See Ankle fracture Fresh osteochondral allograft transplantation, 131-132, 132f G Gout, first metatarsophalangeal joint, 187-188t, 199-200, 199f Graspers, 23, 24f Great toe anatomy of, 186, 187f first metatarsophalangeal joint disorders of, 187-188t arthrofibrotic, 187-188t, 199, 199f arthroscopic treatment of, 190-202, 201b cannula in, 192, 193f contraindications to, 190 examination for, 192, 193f, 194f, 195f, 196f indications for, 190 Index Great toe (Continued) instruments in, 190, 190b, 191f portals for, 191-192, 192f positioning for, 190, 190f rehabilitation after, 202 traction in, 190, 192, 192f chondral, 187-188t, 196-199, 198f gouty, 187-188t, 199-200, 199f imaging in, 188, 189f nonoperative treatment for, 190 osteoarthritic, 187-188t, 193-196, 197f, 198f osteochondral, 187-188t, 196-199, 198f osteophyte, 187-188t, 193, 197f patient history in, 188 physical examination in, 188 rigidus, 187-188t, 193, 197f sesamoid, 187-188t, 199 synovial, 187-188t, 192-193, 196f valgus, 187-188t, 200-201, 200f, 201f H Haglund’s deformity, 74-76, 74f anatomy of, 74 arthroscopic treatment of, 74-76, 75f, 76b, 76f contraindications to, 74 indications for, 74 imaging in, 74 nonoperative treatment of, 74 patient history in, 74 physical examination in, 74 Hallux rigidus, 187-188t, 193, 197f Hallux valgus, 187-188t, 200-201, 200f, 201f evaluation of, 188 Harty, notch of, 2-3 Hemophilia, 178, 181f Hindfoot varus, 81, 81f, 86 Hyalograft C, 143-144 Hyper-plantar flexion test, 152, 152f I Impingement See Ankle impingement; Subtalar joint impingement Inflow system, 23 Instrumentation, 18b, 19f, 23f handheld, 23-24, 23f, 24f motorized, 24, 24f retrieval of, 24 Interosseous ligament complex, 29-30, 30f L Lateral gutter, 53 Loose bodies, in ankle impingement, 40, 40f, 70-71, 71f M Magnetic resonance arthrography (MRA) in flexor hallucis longus stenosis, 72 in osteochondral talar lesion, 99, 101f in posterior ankle soft tissue impingement, 70-71 in synovial impingement, 43 Magnetic resonance imaging (MRI) in anterolateral ankle impingement, 54 in anteromedial ankle impingement, 42 in first metatarsophalangeal joint disorders, 188, 189f in flexor hallucis longus tendonitis, 61, 61f in Haglund’s deformity, 74f in os trigonum syndrome, 61, 61f, 66, 66f Magnetic resonance imaging (MRI) (Continued) in osteochondral talar lesion, 60-61, 61f, 99-101, 100f, 101f, 118, 126, 135f in posterior ankle impingement, 44, 45-46, 45f, 47, 48f in posterior ankle soft tissue impingement, 70-71 in posterior tibial tendon dysfunction, 150 in retrocalcaneal bursitis, 61 in synovial impingement, 43 Malleolus lateral, medial, 2-3, 2f, 4, 4f, 9f arthroscopic evaluation of, 29, 29f, 30f Matrix-based chondrocyte implantation, 129-130, 130f Maxtrix/membrane-induced autologous chondrocyte implantation, 136-138, 136f arthroscopic technique of, 138, 139f, 140f, 141f, 142f, 143f instruments for, 138, 141f open technique of, 136-137, 137f, 138f Medial gutter, 29, 29f Metatarsophalangeal joint disorders See Great toe, first metatarsophalangeal joint disorders of N Nonsteroidal anti-inflammatory drugs, in degenerative ankle arthritis, 159 Notch of Harty, 2-3 O Operating room, 18, 18b, 19f Os calcis fracture, 43 Os subfibulare, 43, 81, 81f surgical treatment of, 86, 86f Os trigonum, 59, 65-69 anatomy of, 16, 16f, 65 arthroscopic removal of, 63, 63f, 64f, 66-69, 69b contraindications to, 66 fibrous junction mobilization in, 67-69, 68f flexor hallucis longus tendon in, 46, 46f, 67-69, 68f flexor hallucis longus tunnel release in, 67-69, 67f hemostat for, 67-69, 68f indications for, 66 osteotome in, 69 portals for, 66, 66f, 67f posterior tibiofibular ligament in, 67-69, 67f, 68f rehabilitation after, 69 results of, 59 talar exposure after, 67-69, 69f bone scan in, 61-62 computed tomography of, 60 vs flexor hallucis longus tendinitis, 151-152 magnetic resonance imaging of, 61, 61f, 66, 66f nonoperative treatment of, 59, 66 open removal of, 46 pain with, 59 patient history in, 65-66 physical examination in, 65-66 in posterior impingement, 44-46, 46f vs posterior talar process, 153, 153f radiography of, 60, 60f, 153f Osteochondral lesions first metatarsophalangeal joint, 187-188t, 196-199, 198f talar dome See Talar dome, osteochondral lesions of 205 OsteoCure, 131 Osteophytes in ankle impingement, 38-39, 39f, 40f in anterior ankle impingement, 40, 40f in anterocentral ankle impingement, 42 in anteromedial ankle impingement, 41-42, 42f in arthrodesis procedures, 179, 179f in first metatarsophalangeal joint, 187-188t, 193, 197f in medial ankle impingement, 43, 44f Osteotomes, 24, 24f P Patient positioning, 19, 19f, 20f, 22, 22f Peroneal nerve, 3, 3f Peroneal tendinopathy anatomy of, 146-147 arthroscopic treatment of, 147-149, 147f, 149b groove deepening in, 148 inspection for, 148, 148f portals for, 147-148, 147f, 148f rehabilitation after, 149 conservative management of, 147 evaluation of, 147 imaging of, 147 Peroneal tendon, 80 in ankle instability, 86 Pigmented villonodular synovitis, first metatarsophalangeal joint, 187-188t, 192-193 Platelet-rich plasma, 144 Posterior neurovascular bundle, 3, 3f, 4f Posterior tibial tendon dysfunction, 149-151 anatomy of, 149 arthroscopic treatment of, 150-151, 151b portals for, 150-151, 150f synovectomy in, 151, 151f conservative management of, 150 evaluation of, 149-150 imaging in, 150 intra-articular lesions in, 150 patient history in, 149-150 physical examination in, 149-150, 150f rehabilitation after, 151 Probes, 23, 23f R Radiography in anterior ankle impingement, 41 in anteromedial ankle impingement, 42, 42f in bony ankle impingement, 39, 39f, 39t, 40f in degenerative ankle arthritis, 159, 159f, 164 in first metatarsophalangeal joint disorders, 188, 189f in flexor hallucis longus tenosynovitis, 152-153, 153f in lateral ankle instability, 81-82, 82f in medial ankle impingement, 43, 44f in os trigonum syndrome, 60, 60f, 66, 153f in osteochondral talar lesion, 99-100, 99f, 118 in posterior ankle impingement, 44-45, 45f in posterior tibial tendon dysfunction, 150 in retrocalcaneal bursitis, 59 in synovial impingement, 43 Rasps, 23 Rehabilitation after ankle fracture, 90 after anterior soft tissue impingement treatment, 56 after Brostrom-Gould repair, 87 after flexor hallucis longus tendon stenosis treatment, 73 after flexor hallucis longus tenosynovitis treatment, 155 206 Index Rehabilitation (Continued) after Haglund’s deformity treatment, 76 after lateral ankle instability treatment, 87 after os trigonum removal, 69 after osteochondral talar dome lesion treatment, 103, 114-115, 115b, 123 after peroneal tendinopathy treatment, 149 after posterior soft tissue ankle impingement, 72 after subtalar arthrodesis, 174 Retrocalcaneal bursa, 58 Retrocalcaneal bursitis, 59 arthroscopic treatment of, 58-59, 64 magnetic resonance imaging of, 61 nonoperative treatment of, 59 Rheumatoid arthritis, 178 S Saphenous vein, 13 Sesamoids, 186 removal of, 199 Sinus tarsi syndrome, 48 Snow-boarder’s fracture, 43 Stem cells, in osteochondral talar lesions, 144 Stieda’s process, 16, 16f, 44 Subtalar joint anatomy of, 11-12, 170-171, 170f, 171f anterior (talocalcaneonavicular), 11-12, 11f, 13f axial, 78, 78f ligamentous, 11, 12f posterior (talocalcaneal), 11-12, 11f, 14f arthroscopy of See Subtalar joint arthroscopy degenerative arthritis of arthrodesis for See Subtalar joint arthrodesis conservative management of, 172 imaging of, 171 patient history in, 171 physical examination in, 171 pain in, 177 Subtalar joint arthrodesis, 170-176 See also Triple arthrodesis ankle arthrodesis with, 165f, 166f, 179-180, 180f, 181f arthroscopic, 170-171, 174b advantages of, 176 ankle arthrodesis with, 165f, 166f cartilage removal in, 172, 173f complications of, 174-175 contraindications to, 171-172 débridement in, 172, 172f, 173f guidewire in, 173-174, 174f indications for, 171-172 vs open arthrodesis, 175 portals for, 172, 172f rehabilitation after, 174 results of, 174-175, 176 screw insertion in, 173-174, 174f spot-welding in, 173, 173f technique of, 172-174, 172f open, 170, 175 Subtalar joint arthroscopy See also Ankle arthroscopy diagnostic, 32-33, 33b anterolateral portal for, 32, 32f, 33f central portal for, 32 positioning for, 32 posterior, 34-35, 34f, 35b, 35f posterolateral portal for, 32, 32f portals for, 12-16 accessory, 13 anterior, 12, 14f, 15f anterolateral, 32, 32f, 33f confirmation of, 32 lateral approach, 12-13, 14f, 15f Subtalar joint arthroscopy (Continued) middle, 12, 14f posterior, 12-13, 14f, 15f posterior approach, 15, 15f posterolateral, 15, 15f, 32, 32f posteromedial, 15, 15f Subtalar joint impingement, 48-49, 49f Sural nerve, 3, 3f, 13, 58, 58f in posterior ankle impingement, 46 Synovial impingement, 43, 52 Synovitis See also Flexor hallucis longus tenosynovitis first metatarsophalangeal joint, 187-188t, 192-193, 196f T Talar compression syndrome, 44-48, 45f, 46f, 47t Talar dome anatomy of, 97, 125 arthroscopic evaluation of, 29, 30-31, 30f, 107, 121, 121f osteochondral lesions of, 97-104, 103b, 132b anatomy of, 97, 125 anterolateral tibial osteotomy for, 128 arthroscopic treatment of, 63, 63f, 107-114, 107b, 114b, 126-127 age and, 106 ankle instability and, 106 antegrade drilling in, 109-110, 111f, 112f bone grafting in, 110-111, 113-114, 113f contraindications to, 105-107, 106t in cystic lesion, 111, 113-114, 113f, 114f débridement in, 102-103, 107-108, 108f, 109f, 111, 113f, 114f, 126-127 indications for, 105-107, 106t loose fragment removal in, 107-108, 108f microfracture in, 107-109, 110f, 111f, 126-127, 127f, 128f patient weight and, 106 rehabilitation after, 103, 114-115, 115b, 132-133 results of, 101-102, 106 retrograde drilling in, 110-111, 112f, 113f setup for, 127f trephination in, 107-108, 109f autologous chondrocyte implantation for, 103, 128-129, 129f autologous matrix-induced chondrogenesis for, 144 Bioseed-C for, 144 bone scan in, 61-62, 100, 118 chevron medial malleolar osteotomy for, 128 Chondrocelect for, 144 classification of, 98, 98t, 117, 125, 125t Co.don chondrosphere for, 144 collagen-covered autologous chondrocyte implantation for, 136 computed tomography in, 60, 60f, 99-101, 100f, 118 cystic, 106, 106t arthroscopic treatment of, 111, 113-114, 113f, 114f epidemiology of, 98, 117 etiology of, 117 fresh osteochondral allograft transplantation for, 131-132, 132f Hyalograft C for, 143-144 large, 135, 135f locations of, 98 magnetic resonance arthrography in, 99, 101f magnetic resonance imaging in, 60-61, 61f, 99-101, 100f, 101f, 118, 126, 135f Talar dome (Continued) matrix/membrane-induced autologous chondrocyte implantation for, 129-130, 130f, 136-138, 136f arthroscopic technique of, 138, 139f, 140f, 141f, 142f, 143f open technique of, 136-137, 137f, 138f mosaicplasty osteochondral autogenous transplantation for, 117-124, 123b, 130-131, 131f advantages of, 120 complications of, 123 contraindications to, 120 disadvantages of, 120 evidence-based studies of, 118-120, 119t graft harvest in, 120, 122 graft placement in, 122-123, 123f graft size in, 121-122, 122f historical perspective on, 118 indications for, 120 instruments for, 121, 122f lateral approach to, 121, 122f medial approach in, 121, 121f pain after, 123 rehabilitation after, 123 technique of, 121-123, 121f, 122f, 123f natural history of, 101-103 nonoperative treatment of, 101-102, 107, 126 open treatment of, 113-114, 127-128 osteochondral autograft transplantation for, 130-131, 131f pathology of, 97-98 patient history in, 98, 117-118, 126 physical examination in, 99, 117-118, 126 platelet-rich plasma for, 144 radiography in, 99-100, 99f, 118 staging of, 125, 125t stem cells for, 144 synthetic osteochondral graft for, 131 terminology for, 97 tissue transplantation for, 103 treatment of, 101-103, 102t See also specific treatments Talar neck, arthroscopic evaluation of, 30-31, 31f Talar tilt test, 81, 81f Talofibular ligament anterior, 53, 79, 79f arthroscopic evaluation of, 31, 31f in ankle fracture, 90, 91f injury to, 80 See also Ankle instability posterior, 53, 79, 79f arthroscopic evaluation of, 31 rupture of, 79-80, 80f Talonavicular joint arthrodesis of, 177, 182-183, 182f, 183f pain in, 177 Talus See also Talar dome lateral process of, 16 medial tubercle of, 16 posterior lateral tubercle of, 16, 16f Tendoscopy, 146-156 flexor hallucis longus, 151-155, 152f, 153f, 154f, 155f peroneal tendon, 146-149, 147f, 148f posterior tibial tendon, 149-151, 150f, 151f Tibia, 30-31, 31f Tibial ligament, transverse, 29-30, 30f Tibial osteotomy, anterolateral, 128 Tibial plafond fracture, 94f See also Ankle fracture Tibialis tendon, 4, 4f Tibiofibular ligament anterior, arthroscopic evaluation of, 90, 93f anterior-inferior, 5, 5f arthroscopic evaluation of, 30-31, 31f Index Tibiofibular ligament (Continued) anteroinferior, thickened distal fascicle of, 39f, 41, 42-43 posterior, arthroscopic evaluation of, 90, 93f posterior-inferior, 5, 6f, 8f, 9f arthroscopic evaluation of, 29-30, 30f Tibionavicular ligament, 79 Tibiotalar ligament, 79 Triple arthrodesis, 180-185, 184-185b calcaneocuboid fusion in, 183 care after, 185, 185f Triple arthrodesis (Continued) contraindications to, 178 evaluation for, 177-178 fixation in, 183-185, 184f imaging for, 178 indications for, 177-178 instrumentation for, 180-182 subtalar fusion in, 182 talonavicular fusion in, 182-183, 182f, 183f 207 U Ultrasonography in flexor hallucis longus stenosis, 72 in posterior ankle soft tissue impingement, 70-71 in posterior tibial tendon dysfunction, 150 V Video camera, 23 Volkmann fragment, 94f Chapter Chapter Title Video Contributor Video Title Diagnostic Arthroscopy of the Ankle and Subtalar Joints James W Stone, MD Ankle and Subtalar Joint Arthroscopy: Set Up, Portals, Diagnostic Arthroscopy Soft Tissue Impingement Lesions of the Ankle Joint Michael Tucker, Jr., MD and Champ L Baker, Jr., MD Management of Soft Tissue Impingement Lesions of the Ankle and Subtalar Joints Anatomy, Operating Room Set-Up, and Diagnostic Arthroscopy for Posterior Ankle Arthroscopy David Sitler, MD Treatment of Posteromedial Soft Tissue Impingement Instability of the Ankle and Subtalar Joints Sameh A Labib, MD Brostrum Repair Sameh A Labib, MD Repair of Os Subfibulare 10 Ankle Fractures Beat Hinterman, MD Ankle Arthroscopy in Acute Ankle Fracture 12 Osteochondral Lesions of the Talar Dome: Debridement, Abrasion, Drilling, and Microfracture Thomas O Clanton, MD Curettage, Drilling and Microfracture for Osteochondral Lesions of the Talus 14 Osteochondral Lesions of the Talar Dome: Cartilage Replacement Using Autologous Chondrocyte Implantation and Allografts Gregory C Berlet, MD, FRSC(C) Chevron Malleolar Osteotomy and OATS 16 Tendoscopy Prof Dr C.N van Dijk, P.A.J de Leeuw, MSc and Drs M.N van Sterkenburg Testing Flexor Hallucis Longus Prof Dr C.N van Dijk, P.A.J de Leeuw, MSc and Drs M.N van Sterkenburg Endoscopic Treatment of FHL Tendinopathy Prof Dr C.N van Dijk, P.A.J de Leeuw, MSc and Drs M.N van Sterkenburg Endoscopic Release of Flexor Hallucis Longus Troy Gorman, MD Anterior Ankle Arthroscopy for Fusion Troy Gorman, MD Posterior Ankle Arthroscopy for Fusion: Setup Phinit Phisitkul, MD Great Toe Arthroscopy for Soft Tissue Impingement 17 20 Degenerative Arthritis Ankle: Fusion Great Toe Arthroscopy