Authors: Kevin Lehane, James J. Butler, Dylan Lowe, Alan P. Samsonov, Sebastian Krebsbach, Jose Perez, David A. Bloom, John G. Kennedy
Categories: Technical Note
Source: Arthroscopy Techniques
Authors: Kevin Lehane, James J. Butler, Dylan Lowe, Alan P. Samsonov, Sebastian Krebsbach, Jose Perez, David A. Bloom, John G. Kennedy
Anterior ankle arthroscopy is an important diagnostic and therapeutic tool in the treatment of pathologies of the ankle joint. In a series of 7 articles, the basics of ankle arthroscopy are reviewed. In this article (part 1), patient positioning, tourniquet placement, and draping for anterior ankle joint arthroscopy are reviewed.
Anterior ankle arthroscopy is a commonly performed procedure to address and diagnose a litany of pathologies of the ankle joint.^1^ Indications for anterior ankle arthroscopy include diagnostic arthroscopy, anterior ankle impingement resection, bone marrow stimulation for osteochondral lesions of the talus, loose body removal, arthroscopically assisted ankle fracture fixation, and ligament reconstruction.2, 3, 4 In a series of 7 articles, the basics of ankle arthroscopy are reviewed. In this article (part 1), patient positioning, tourniquet placement, and surgical draping for anterior ankle joint arthroscopy are reviewed; these are demonstrated in Video 1. Proper positioning of the patient on the operating table allows for efficient and effective manipulation of the lower leg for arthroscopic access to the compartments of the ankle.
The patient is positioned supine on a standard operating theater table with the heels at the end of the operating table to facilitate ease of access by the surgeon and assistant (Fig 1). Next, the thigh is abducted and the knee is flexed, resting against the surgeon’s chest. Two to three layers of cotton cast padding are wrapped around the thigh, with caution taken to avoid wrinkles. A nonsterile tourniquet is placed circumferentially around the proximal aspect of the thigh and subsequently tightened and secured. The tourniquet is connected to the associated tourniquet inflation system. The pressure is typically set to 250 mm Hg. A nonsterile gauze roll is used to hang the operative leg from the ankle and is secured from an intravenous pole stand (Fig 2). A nonsterile sheet is placed over the contralateral leg, and the sheet is secured by taping it down over the leg with silk tape. The leg is painted with 2 sterile 2% wt/vol chlorhexidine gluconate solution applicator sticks and is left to dry for a minimum of 3 minutes. With the help of a sterile assistant, the surgeon places a three-quarter drape below the leg. The surgeon then places a three-quarter drape above the knee. Next, a sterile blue operating room towel is placed underneath the operative foot, and a sterile Kocher device is used to free the gauze roll from underneath the ankle, which is then handed off to a nonsterile assistant. A sticky U drape can be applied with the tails facing up, followed by a stockinette, according to surgeon preference. Finally, the leg is placed through the hole in the extremity drape and handed off to the anesthesiologist, and this is subsequently secured from intravenous poles. If a 2.7-mm 30° arthroscope (Arthrex, Naples, FL) is being used, a sterile soft-tissue distractor is then placed over the foot and the lower extremity is placed into traction (Fig 3). Finally, the foot is elevated on a sterile bump. The height of the operating theater table is then adjusted to the desired height of the surgeon.Fig 1Patient positioned supine with feet resting at edge of operating table.Fig 2Right operative extremity hanging from nonsterile gauze roll wrapped around intravenous pole.Fig 3Soft-tissue distractor over right foot.
Anterior ankle arthroscopy is a powerful diagnostic and therapeutic modality for orthopaedic foot and ankle surgeons.^1^ Fastidious patient positioning, tourniquet placement, sterile preparation, and draping are vital to ensure reproducibility in the setup. Crucial points during the preoperative setup include ensuring the feet are positioned just at the edge of the operating table, placement of the tourniquet at the proximal aspect of the thigh, and diligent preparation of the extremity with chlorhexidine application sticks, particularly between the toes, to ensure robust sterilization (Table 1).Table 1Pearls and PitfallsPearlsPitfallsPosition the patient supine with the heels at the edge of the operating table to allow ease of access.Failing to properly position the patient can restrict access and lead to discomfort for both the surgeon and the assistant.Wrap the thigh with 2-3 layers of cotton cast padding to protect the skin from pressure injuries.Not ensuring smooth, wrinkle-free padding can result in skin complications or uneven pressure distribution.Ensure the foot is elevated on a sterile bump, and adjust the table height to the surgeon’s preference.Failure to adjust the table height appropriately can lead to poor ergonomics, increasing the surgeon’s fatigue and risk of procedural errors.
Distraction of the ankle joint is accomplished by either noninvasive or invasive methods. Invasive distractors are rarely used in modern arthroscopy owing to the complications associated with these methods, including fracture of the fibula and/or tibia, pin breakage, pin-track infection, ligament damage, and neurovascular injury.^5^ Two noninvasive methods of ankle distraction are distraction with a sterile soft-tissue strap and the dorsiflexion method. When using a standard 2.7-mm 30° arthroscope, noninvasive distraction with a sterile soft-tissue strap improves visualization of the central and posterior aspects of the ankle, whereas the dorsiflexion method facilitates good visualization of the anterior compartment and lateral gutter.^6^ A major advantage of using a 1.9-mm 0° arthroscope (Arthrex) is that it circumvents the need for both invasive distraction and noninvasive distraction.^7^ The benefits and drawbacks associated with both the 2.7-mm 30° arthroscope and the 1.9-mm 0° arthroscope are discussed in depth in part 2.
The authors declare the following financial interests/personal relationships which may be considered as potential competing J.G.K. is a consultant for In2Bones and Arthrex and receives financial support from the Ohnell Family Foundation, Mr. Winston Fisher, and Ms. Tatiana Rybak. All other authors (K.L., J.J.B., D.L., A.P.S., S.K., J.P., D.A.B.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.