SLR - January 2020 - Ben Palmer
Reference: Ahn JH, Park D, Park YT, Park J, Kim Y. What Should We Be Careful of Ankle Arthroscopy? J Orthop Surg (Hong Kong). 2019 July 30; 27(3) 1-9Scientific Literature Review
Reviewed By: Ben Palmer, DPM
Residency Program: AMITA Health, St. Joseph Hospital – Chicago, IL
Podiatric Relevance: Ankle arthroscopy has been widely used as a tool for various ankle disorders since 1972. This technique can be used to treat many disorders of the ankle joint such as osteochondral lesions of the talus (OLT), excision of bone spurs, arthrodesis, and much more. However, complications can arise and the most common of these are neurological injuries. Recently there has been a shift from invasive to noninvasive distraction because the noninvasive distraction is much safer and effective for the patient.
Methods: Between March 2003 and February 2011, 514 patients underwent ankle arthroscopy and were included in this study. A total of 941 arthroscopic procedures were performed. Exclusion criteria consisted of acute ankle fracture, systemic inflammatory arthritis, long standing neuromuscular disease, or peripheral vascular disease. The mean follow-up was 33 months. The arthroscopic procedures were performed with noninvasive distraction as well as without the use of a thigh tourniquet. The distraction device was applied with the patient in a supine position with the hip and knee flexed at a 45 degree angle with a padded thigh holder. The anteromedial, anterolateral, and posterolateral portals were the most commonly used with care taken to avoid damage to the nerve branches. In all the procedures a 2.4 millimeter or 2.7 millimeter 30 degree arthroscope was utilized. After the arthroscopic procedures were performed the distraction devices were removed and other open procedures were performed with a thigh tourniquet, as needed, set to 280-300 mmHg.
Results: The most common arthroscopic procedure performed was an ankle synovectomy in 382 cases followed by marrow stimulation in 177, bony spur excision in 151 and loose body removal in 87. Average arthroscopy time was 47 minutes. Complications arose in 14 of 514 patients (2.7 percent). Neuropraxia occurred in eight cases (1.6 percent) and only in one case did the neuropraxia last longer than six months. Superficial peroneal nerve (SPN) paresthesia occurred in six cases (1.2 percent), one case of deep peroneal nerve injury (0.2%), and one case of sural nerve dysesthesia occurred (0.2 percent). There were also three patients (0.6 percent) who experienced skin necrosis of the posterior thigh due to distraction time plus the tourniquet time exceeding 120 minutes.
Conclusions: Noninvasive distraction during ankle arthroscopy has become the standard surgical tool for various ankle disorders. Even though the noninvasive approach has shown to be safe and effective in this study, when combined with a thigh tourniquet for additional open procedures the results not only show that neurological complications are possible but skin and soft tissue injuries can occur as well due to high pressure on the posterior thigh. Further, this begs the question as to whether it is the ankle distraction of merely the placement of the arthroscope or instrumentation in close proximity to the SPN during the procedure itself that leads to these reported complications.