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Arthroscopy of Ankle and Wrist

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Dr Gandhi Kota

Arthroscopy of the ankle and wrist can be used to diagnose and treat several conditions. For the ankle, common indications for arthroscopy include osteochondral lesions, debridement of post-traumatic synovitis, and resection of bony impingement. Precise portal placement and use of small instruments is important to minimize risks such as nerve injury, vascular injury, and cartilage damage. Wrist arthroscopy indications include treatment of TFCC injuries, excision of ganglia, and assistance in treating fractures. Careful patient positioning and distraction is needed to avoid complications like skin lesions, nerve injuries, and compartment syndrome. Both procedures require expertise to safely access the joint and address underlying pathologies.

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Arthroscopy of Ankle and Wrist By Dr K Gandhi II yr PG Orthopaedics Kamineni Institute of Medical Sciences
ANKLE ARTHROSCOPY The most common current indications for ankle arthroscopy include soft-tissue or bony impingement and treatment of osteochondral lesions of the talus. These patients often have continuing ankle pain after injuries such as a sprain that have not responded to the usual conservative therapy, and tenderness is noted specifically at the ankle joint line on physical examination. A definite diagnosis should be made before arthroscopy is is performed; purely diagnostic arthroscopy has a low success rate.
Indications • Osteochondral lesions of the talus • Microfracture of OCD • Debridement of post-traumatic synovitis • ATFL anterolateral impingement • AITFL anterolateral impingement • Resection of anterior tibiotalar spurs , such as anterior bony impingement • os trigonum excision • Removal of loose bodies • Cartilage debridement in conjunction with ankle fusions
Instrumentation
Arthroscopy of Ankle and Wrist
Joint Distraction
Invasive Distraction
Non-Invasive Distraction
• The patient is positioned supine with the foot 15- 20 cm past the end of the operating table. • A side post of the kind used in knee arthroscopy is mounted lateral to the lower leg. A special leg holder is not required. • This position is advantageous, as it affords access to the ankle from all sides and permits the use of posterior portals.
• A tourniquet is used for all arthroscopic procedures. • Exsanguination is preferred for more complex procedures such as the reattachment of osteochondral fragments, the retrograde cancellous bone grafting of osteo chondral lesions (osteochondritis dissecans ), arthro scopic fracture treatment, and arthroscopic arthrodesis (thigh cuff inflated to 450 mm Hg). Tourniquet
Anterior Portals
Arthroscopy of Ankle and Wrist
Posterior Portals
Arthroscopy of Ankle and Wrist
Transmalleolar and Transtalar Portals
Path of superficial peroneal nerve is marked on ankle.
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Anatomical perspective of the ankle. Arthroscopic views of lateral and medial gutters showed to depict normal appearance (A—lateral gutter and, C—medial gutter), and pathological appearance with a ligament rupture (B, D)
A, Synovitis in lateral ankle. B, After debridement
A, Synovitis in medial ankle. B, After debridement
Vascular injury – Injury to the dorsal pedal artery and an Aneurysm of that vessel (Morgan 1993) have been described. If surgery is performed in a bloodless field (thigh tourniquet or exsanguination), significant bleeding can not be diagnosed intraoperatively. Nerve injury. Nerve lesions have repeatedly been described. Most involve injury to superficial branches of the peroneal or saphenous nerve. Some transient paresthesias have been reported. Intraoperative Local Complications
Cartilage injury - The most frequent intraoperative complication is cartilage injury. Presumably a large percentage of these lesions go undetected. The use of standard portals and small, short instruments is essential for minimizing these complications. Portal placement problems - A nonstandard technique of portal placement can cause unnecessary perforations of the synovium or joint capsule, allowing fluid extravasation into the subcutaneous tissue. This subcutaneous distention can cause significant constriction of the joint cavity. Ligament and tendon injuries - The overaggressive resection of scar tissue can cause the undesired resection of capsulo ligamentous tissue. The surgeon should proceed very carefully, therefore, when significant adhesions are present. Intraoperative Local Complications
Postoperative Local Complications • Synovial fistula. Synovial fistulae have been known to develop at anterior portal sites. • Infection - This is still the most dreaded complication of arthroscopic procedures. • Compartment syndrome (rare). • Reflex sympathetic dystrophy. • Hemarthrosis.
Distraction-Related Complications Various complications can result from the use of mechanical ankle distractors: • Pin fracture • Pin site infection • Traction injury to tendons, ligaments, nerves, and vessels • Stress fracture
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Contraindications Besides the general contraindications to arthroscopy, advanced degenerative changes in the ankle joint are considered a relative contraindication unless arthrodesis is planned. Acute injuries with massive soft-tissue swelling are another relative contraindication. Edema involving the lower leg or ankle region and advanced stages of arteriovenous occlusive disease also contraindicate arthroscopy. The first priority in these cases is to treat the underlying disease.
ARTHROSCOPY OF THE WRIST From a mostly diagnostic tool, wrist arthroscopy has developed into an effective therapeutic tool, useful for the treatment of a variety of wrist disorders from arthritis to acute fractures.
Indications • TFCC injuries • Interosseous ligament injuries • Anatomic reduction assistance (distal radius, scaphoid fxs) • Ulnocarpal impaction • Debridement of chondral lesions • Removal of loose bodies • Synovectomy • Excision of dorsal wrist ganglia • Assistance in treatment of SNAC and or SLAC wrist • Septic wrist irrigation and debridement • Diagnosis in unexplained mechanical wrist pain
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
POSITIONING AND PREPARATION OF THE PATIENT • Wrist arthroscopy can be done with the patient under regional block anesthesia or general anesthesia. • If multiple procedures are to be done, or if the patient is uncomfortable, a general anesthetic usually is best. • The use of a pneumatic arm tourniquet is optional but may be helpful when treating an intraarticular fracture. • With the patient supine and the shoulder abducted on a hand table, arthroscopy can be done with the elbow flexed and the hand pointing toward the ceiling. • Extension of the elbow (horizontal position) to allow pronation of the forearm may facilitate the treatment of intraarticular fractures.
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Examination of the Radioulnar Joint
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Arthroscopy of Ankle and Wrist
Positioning- and Distraction-Related Complications Excessive finger traction can cause skin lesions on the fingers, compression nerve injury, or traction injury to the metacarpophalangeal joints. If the patient is frail or has skin problems, the traction should be applied through four long fingers rather than two. Another potential complication is skin burns caused by a traction tower that is still hot from sterilization.
Local Complications Portal placement can cause lllJury to subcutaneous nerves, arteries, veins, and extensor tendons. The best prevention is following a systematic placement technique after first marking the anatomic landmarks on the skin. Arthroscopy-Specific Complications Besides instrument breakage, the subcutaneous extravasation of irrigating fluid during the arthroscopic treatment of acute fractures can lead to a compartment syndrome.
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Arthroscopy of Ankle and Wrist

  • 1. Arthroscopy of Ankle and Wrist By Dr K Gandhi II yr PG Orthopaedics Kamineni Institute of Medical Sciences
  • 2. ANKLE ARTHROSCOPY The most common current indications for ankle arthroscopy include soft-tissue or bony impingement and treatment of osteochondral lesions of the talus. These patients often have continuing ankle pain after injuries such as a sprain that have not responded to the usual conservative therapy, and tenderness is noted specifically at the ankle joint line on physical examination. A definite diagnosis should be made before arthroscopy is is performed; purely diagnostic arthroscopy has a low success rate.
  • 3. Indications • Osteochondral lesions of the talus • Microfracture of OCD • Debridement of post-traumatic synovitis • ATFL anterolateral impingement • AITFL anterolateral impingement • Resection of anterior tibiotalar spurs , such as anterior bony impingement • os trigonum excision • Removal of loose bodies • Cartilage debridement in conjunction with ankle fusions
  • 9. • The patient is positioned supine with the foot 15- 20 cm past the end of the operating table. • A side post of the kind used in knee arthroscopy is mounted lateral to the lower leg. A special leg holder is not required. • This position is advantageous, as it affords access to the ankle from all sides and permits the use of posterior portals.
  • 10. • A tourniquet is used for all arthroscopic procedures. • Exsanguination is preferred for more complex procedures such as the reattachment of osteochondral fragments, the retrograde cancellous bone grafting of osteo chondral lesions (osteochondritis dissecans ), arthro scopic fracture treatment, and arthroscopic arthrodesis (thigh cuff inflated to 450 mm Hg). Tourniquet
  • 16. Path of superficial peroneal nerve is marked on ankle.
  • 19. Anatomical perspective of the ankle. Arthroscopic views of lateral and medial gutters showed to depict normal appearance (A—lateral gutter and, C—medial gutter), and pathological appearance with a ligament rupture (B, D)
  • 20. A, Synovitis in lateral ankle. B, After debridement
  • 21. A, Synovitis in medial ankle. B, After debridement
  • 22. Vascular injury – Injury to the dorsal pedal artery and an Aneurysm of that vessel (Morgan 1993) have been described. If surgery is performed in a bloodless field (thigh tourniquet or exsanguination), significant bleeding can not be diagnosed intraoperatively. Nerve injury. Nerve lesions have repeatedly been described. Most involve injury to superficial branches of the peroneal or saphenous nerve. Some transient paresthesias have been reported. Intraoperative Local Complications
  • 23. Cartilage injury - The most frequent intraoperative complication is cartilage injury. Presumably a large percentage of these lesions go undetected. The use of standard portals and small, short instruments is essential for minimizing these complications. Portal placement problems - A nonstandard technique of portal placement can cause unnecessary perforations of the synovium or joint capsule, allowing fluid extravasation into the subcutaneous tissue. This subcutaneous distention can cause significant constriction of the joint cavity. Ligament and tendon injuries - The overaggressive resection of scar tissue can cause the undesired resection of capsulo ligamentous tissue. The surgeon should proceed very carefully, therefore, when significant adhesions are present. Intraoperative Local Complications
  • 24. Postoperative Local Complications • Synovial fistula. Synovial fistulae have been known to develop at anterior portal sites. • Infection - This is still the most dreaded complication of arthroscopic procedures. • Compartment syndrome (rare). • Reflex sympathetic dystrophy. • Hemarthrosis.
  • 25. Distraction-Related Complications Various complications can result from the use of mechanical ankle distractors: • Pin fracture • Pin site infection • Traction injury to tendons, ligaments, nerves, and vessels • Stress fracture
  • 36. Contraindications Besides the general contraindications to arthroscopy, advanced degenerative changes in the ankle joint are considered a relative contraindication unless arthrodesis is planned. Acute injuries with massive soft-tissue swelling are another relative contraindication. Edema involving the lower leg or ankle region and advanced stages of arteriovenous occlusive disease also contraindicate arthroscopy. The first priority in these cases is to treat the underlying disease.
  • 37. ARTHROSCOPY OF THE WRIST From a mostly diagnostic tool, wrist arthroscopy has developed into an effective therapeutic tool, useful for the treatment of a variety of wrist disorders from arthritis to acute fractures.
  • 38. Indications • TFCC injuries • Interosseous ligament injuries • Anatomic reduction assistance (distal radius, scaphoid fxs) • Ulnocarpal impaction • Debridement of chondral lesions • Removal of loose bodies • Synovectomy • Excision of dorsal wrist ganglia • Assistance in treatment of SNAC and or SLAC wrist • Septic wrist irrigation and debridement • Diagnosis in unexplained mechanical wrist pain
  • 42. POSITIONING AND PREPARATION OF THE PATIENT • Wrist arthroscopy can be done with the patient under regional block anesthesia or general anesthesia. • If multiple procedures are to be done, or if the patient is uncomfortable, a general anesthetic usually is best. • The use of a pneumatic arm tourniquet is optional but may be helpful when treating an intraarticular fracture. • With the patient supine and the shoulder abducted on a hand table, arthroscopy can be done with the elbow flexed and the hand pointing toward the ceiling. • Extension of the elbow (horizontal position) to allow pronation of the forearm may facilitate the treatment of intraarticular fractures.
  • 52. Examination of the Radioulnar Joint
  • 60. Positioning- and Distraction-Related Complications Excessive finger traction can cause skin lesions on the fingers, compression nerve injury, or traction injury to the metacarpophalangeal joints. If the patient is frail or has skin problems, the traction should be applied through four long fingers rather than two. Another potential complication is skin burns caused by a traction tower that is still hot from sterilization.
  • 61. Local Complications Portal placement can cause lllJury to subcutaneous nerves, arteries, veins, and extensor tendons. The best prevention is following a systematic placement technique after first marking the anatomic landmarks on the skin. Arthroscopy-Specific Complications Besides instrument breakage, the subcutaneous extravasation of irrigating fluid during the arthroscopic treatment of acute fractures can lead to a compartment syndrome.