One-Step Anterior and Posterior Ankle Arthroscopy by Double Postero-Medial Portals: 6 Years Follow-Up Prospective Study (SS-64)

Abstract

By anterior approaches is not possible to explore posterior ankle compartment and to check any posterior hindfoot problem. Patients who present both anterior and posterior ankle disorders, must presently postpone further treatment to prone position in second surgery. Maintaining supine patient's assessment, after anterior step, two postero-medial portals permit to reach posterior ankle and subtalar joint for treating topic lesions. In period January2001-January2007, on 88 ankle submitted to arthroscopic treatment with both side pathology, 46ones were operated in supine position with double postero-medial approach, permitting to treat patients both with anterior and posterior compartment pathology, through one-step surgery. The procedure reproduces the same posterior portals in prone assessment rotating the peroneal one 90° medially: placing the first one 1cm. anteriorly to Achilles' tendon at medial malleolus tip level, the second approach is opened 5cm superiorly to former one. Flexor hallucis longus tendon represents medial landmark to prevent damage to tibial bundle. The mosquito's gentle use in portals widening prevents the compression of any nervous branch. Treatment of both anterior and posterior ankle disorders in supine position lead good patient's improvement in our 6years follow-up (Kitaoka preop:57, postop:87) (p<0,02) compared to control group, without any neurovascular complication and with good posterior compartment visualization. The FHL tendon, easy to check and to respect: protecting it the risk of lesions of tibial neurovascular bundle is very low, permitting a safe surgery in posterior compartment. None patient reported any neurological problem nor to posterior tibial nerve territory or to medial talus skin sensitivity. Because the presence of varicose veins, 3patients presented swelling and oedema of posterior ankle for 3 weeks. None patient have been submitted to new surgical procedure for the same disorder. These portals and positioning have not been described in literature. Compared to open surgery, the limit of arthroscopic procedure has been to treat contemporarily anterior and posterior compartments in those cases where surgery was necessary to address in both sides of the joint. The previous supine assessment made impossible to reach both the joint spaces without its intra-operative change. Maintaining supine position, two postero-medial portals permit to reach lesions in posterior ankle compartment, after anterior pathology treatment by standard portals, without any risk of neurovascular lesions. Authors demonstrate the procedure is safe and reproducible respecting the anatomical landmarks and they suggest to use it routinely to check always ankle posterior side.