Arthroscopic Techniques and Anatomy of the Foot and Ankle: A Surgical Atlas

287 Pages·2022·50.821 MB·English

by  Baofu Wei, Alan Y. Yan, Annunziato Amendola

Baofu Wei
Alan Y. Yan
Annunziato Amendola
Arthroscopic Techniques
and Anatomy of
the Foot and Ankle
A Surgical Atlas
123
Arthroscopic Techniques and Anatomy
of the Foot and Ankle
Baofu Wei • Alan Y. Yan • Annunziato Amendola
Arthroscopic Techniques
and Anatomy of the Foot
and Ankle
A Surgical Atlas
Baofu Wei Alan Y. Yan
Hand and Foot Surgery Orthopedic Surgery
Linyi People’s Hospital University of Pittsburgh
Linyi, Shandong, China Pittsburgh, PA, USA
Annunziato Amendola
Orthopedic Surgery
Duke Medical Center
Durham, NC, USA
ISBN 978-3-031-05189-0 ISBN 978-3-031-05190-6 (eBook)
https://doi.org/10.1007/978-3-031-05190-6
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
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To my wife, Yanyan Sun, and our beloved daughter Jairong with love and
your support for me in those years at Durham, North Carolina.
Baofu Wei
To my parents, Xingdi Li and Hongcai Yan, for their unconditional love.
To my wife Vivienne for sticking with me in my rollercoasting lifestyle
throughout the years from our basement in New York City to all the cities we
have lived throughout my training and works, and for my children: Brayden
and River with love and joy in my life.
Alan Y. Yan
To all my fellows and residents who have contributed to this textbook, to my
continuing education and advancing the specialty of orthopedic surgery.
Annunziato Amendola
Preface
Since the late Pau Golano’s landmark works in foot and ankle surgical anatomy, many further
works of detailed surgical anatomies with minimally invasive techniques have continuously
emerged from major study groups mostly in Europe and North America.
Dr. Baofu Wei, one of our editors and main author of this collection, started his detailed
work on surgical anatomy and approaches years ago in China. He subsequently continued his
work in the USA while at Duke. At that time, he was working with some of the leaders in the
field, especially Dr. Amendola, one of the pioneers in foot and ankle sports surgery in the
USA. The collection of the work in the book is to provide a surgical “Google” map in foot and
ankle arthroscopic surgery.
Minimally invasive surgery (MIS) has been met with increasing interest in recent years due
to its presumed faster recovery, decreased trauma, and improved cosmesis. For this reason, an
in-depth understanding is required to perform this type of surgery in an efficient and safe way.
The continuous development of new surgical techniques and instruments has significantly
enlarged our scope of practice and allowed us to improve the outcomes of our patients.
With a complex and relatively small structure consisting of 26 bones, 33 joints, and over
100 muscles, ligaments, and tendons in each foot, the human feet have been the result of an
evolutionary wonder that makes us uniquely human. A lifetime of walking makes each of us
capable of circulating the globe three times over and brings many pathologies to this unique set
of marvelous machinery. This includes a variety of injuries, infection, deformities, and debili-
tating degenerative conditions.
Throughout the last century, safe and efficient open approaches of the forefoot, midfoot,
hindfoot, and ankle have been well explored, developed, and constantly refined. The revolu-
tionary introduction of arthroscopy over the early to mid-twentieth century in orthopedics has
dramatically changed our landscape in orthopedic surgery. Arthroscopy began from early trials
by Nordentoft in Denmark and then the cystoscope trial for the knee in Japan by Takagi.
Takagi’s student, Watanabe, carried on the endeavor using the technological advances in that
golden period in fiberoptics, the modern generation of the camera, and progressing to modern
arthroscopic surgery in orthopedics in the 1950s and ankle arthroscopy in the early 1970s.
Due to the smaller size of the bones and joints of the foot and ankle, as well as the tighter
space, the widespread use of foot and ankle arthroscopy has been relatively delayed compared
to arthroscopy of other larger joints. However, there has been increasing interest and more and
more publications in the recent decades. With the continuous efforts led by some of the pio-
neers and proponents in the field, especially Niek Van Dijk and his group in Amsterdam, as
well as Richard Ferkel in the USA, foot and ankle arthroscopic surgery has become the norm
in managing many foot and ankle surgical pathologies. Furthermore, we are now in the era of
chip-on-tip nanotechnology and needle arthroscopy which further minimize any iatrogenic
injury and represent another paradigm shift moment in foot and ankle surgery.
Several textbooks edited by some of the most experienced pioneering surgeons on foot and
ankle arthroscopy and endoscopy have been published since the early 2000s. These include
Richard Ferkel from the USA, Tung Hing Lui from Hong Kong, China, the Niek van Dijk
vii
viii Preface
group from Amsterdam Foot Ankle School with Pau Golano, James Guhl, Serge Prisien, and
Melbourne Boynton from the USA, James Stone, John Kennedy, and Mark Glazebrook from
North America AANA. However, a detailed surgical Atlas for references has not been
presented.
As one of the pioneers in foot and ankle arthroscopic surgery, Dr. Amendola has been influ-
ential in the development of surgical techniques and clinical applications of foot and ankle
arthroscopic and endoscopic surgery.
Most of the modern-day surgical techniques in minimally invasive surgery have been expo-
nentially and continuously developed in the recent decade. Many of those surgical skills are
not taught during most of the resident training programs or even during fellowships. As sur-
geons either experienced in traditional open approaches or younger generations entering the
practice, the demand of incorporating these newer and safer techniques in surgery will be
extremely beneficial. A comprehensive illustrated surgical atlas aids in the process of acquiring
the skills for these procedures and may assist with getting over the learning curves and benefit
the patients in need.
In this illustrated atlas, we have included the details of local anatomies, preoperative evalu-
ations, and patient position in the operating room including equipment set up. We have also
included the most common approaches with stepwise visual findings of current foot and ankle
arthroscopy and endoscopy to forefoot, midfoot, hindfoot joints, and soft tissues to provide an
educational and practical illustrated guide for medical students, residents, fellows, and attend-
ings with different experience levels in arthroscopic and endoscopic surgery in the foot and
ankle.
Many thanks to some of the most experienced surgeons in this field to edit and review the
topics. Our residents, fellows, and assistants offered much help along the way by collecting
clinical materials and coordinating with our patients during the entire process.
It has been a privilege and great pleasure to advance our understanding in the field of
arthroscopic and endoscopic surgery in this specialty. I believe we will continue making
advances and progress in the future for the best interest of our patients in need.
Pittsburgh, PA, USA Alan Y. Yan
Acknowledgments
Without the persistent effort, support, and hard work of this team of fellows and surgeons, who
have an abundance of experience and leadership in arthroscopic foot and ankle surgery, this
project would not be possible.
Dr. Wei has been a well-published surgeon and scholar with his extraordinary works in
surgical anatomy in foot and ankle surgery throughout his career in China. He was first intro-
duced to me by former AOFAS president Dr. Thomas Lee, who met Dr. Wei and was impressed
by his works while teaching in China. Dr. Wei then continued his works and studies at Duke
University Medical Center, where he carried on his further detailed anatomical studies. During
those few years, Dr. Wei worked with some of the leaders in the field of foot and ankle sur-
geons including Dr. James Nunley, Dr. James DeOrio, Dr. Mark Easley, and Dr. Samuel
Adams. He finally dedicated over 2 years of his time with Dr. Annunziato Amendola to the
anatomy of arthroscopic foot and ankle surgery, thus the creation of this book.
Many fellows of foot and ankle surgery at Duke at that time, followed by teamwork with
some of the leading and most experienced surgeons with deep understanding in minimally
invasive surgery (MIS) and arthroscopic surgery, joined our continuous effort in this important
atlas of surgical techniques in foot and ankle surgery.
A very special thanks to Kristopher Spring who recognized the unique role of this collec-
tion of works and for his continuous support throughout the process. I am indebted to Mr. Lee
Klein, our editor, in his prompt and tireless efforts to make this project a reality.
Many thanks to my staff, my fellows, and my residents, and especially my assistant Kristi
Price for keeping my daily schedule up-to-date and helping with editing every step of the way.
Alan Y. Yan
ix
Contents
1 Gross Anatomy of the Ankle Joint for Arthroscopy. . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Skin and Landmarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Ankle Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2.1 Ankle Mortise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2.2 The Inferior Syndesmosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Anatomy of the Talus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.4 Anatomy of the Subtalar Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.5 The Capsule of the Ankle Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.6 The Ligaments Around the Ankle Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.6.1 Medial Ligament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.6.2 Lateral Ligament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.6.3 Posterior Intermalleolar Ligament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.7 Deep Fascia Layer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.7.1 Anterior Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.7.2 Posterior Superficial Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.7.3 Posterior Deep Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.7.4 Lateral Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.7.5 Medial Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.8 Superficial Nerves and Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.8.1 Superficial Peroneal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.8.2 Sural Nerve and Lesser Saphenous Vein . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.8.3 Saphenous Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2 Arthroscopy Instruments and Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.1 Arthroscopic Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.1.1 Arthroscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.1.2 Trocar, Obturator, and Cannula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.2 Camera, Video Monitor, and Printer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
2.2.1 Camera Control Unit and Camera Head . . . . . . . . . . . . . . . . . . . . . . . . . 28
2.2.2 Video Monitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
2.2.3 Printer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
2.3 Light Source and Cable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.4 Motorized Instrument . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.4.1 Energy System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.4.2 The Soft Tissue Shaver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.4.3 The Arthroscopic Burr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.4.4 Footswitch Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.5 Irrigation Equipment and Suction System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.6 Special Instrument . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
2.6.1 Arthroscopic Probe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
2.6.2 Arthroscopic Osteotome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
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2.6.3 Arthroscopic Elevator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.6.4 The Closed-Cup Curette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.6.5 The Open Curette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.6.6 The Chondro-Picks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.6.7 The Grasper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.6.8 The Straight Punch Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.6.9 MicroVector Drill Guide System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.6.10 Basic Surgical Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.7 Noninvasive and Invasive Distraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.8 Other Accessory Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.8.1 The Thigh Tourniquet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.8.2 Prevention of Deep Vein Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3 Anterior Arthroscopy of the Ankle Joint: General Principles
and Arthroscopic Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.2 Regional Anatomy of the Anterior Ankle Joint . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.3 Indications and Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.3.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.3.2 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.4 Procedural Setup and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.5 Anterior Portals/Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3.5.1 Anteromedial Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3.5.2 Anterolateral Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3.5.3 Anterocentral Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3.5.4 Accessory Anteromedial Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3.5.5 Accessory Anterolateral Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
3.6 Establishing the Portals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3.7 Diagnostic Arthroscopic Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
4 Posterior Arthroscopy of the Ankle and Subtalar Joint:
General Principles and Arthroscopic Examination . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.2 Regional Anatomy of the Posterior Ankle Joint . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.3 Indications and Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.3.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.3.2 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.4 Anesthesia, Tourniquet, Position, and Distraction . . . . . . . . . . . . . . . . . . . . . . . . 51
4.5 Posterior Portals/Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4.5.1 Posterolateral Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4.5.2 Posteromedial Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4.5.3 Accessory Posterolateral Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4.5.4 Accessory Posteromedial Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4.6 Creating the Pathway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.7 Diagnostic Arthroscopic Examination: Posterior Ankle Examination . . . . . . . . . 57
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
5 Osteochondral Lesions of Talus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.2 Anatomy of the Articular Cartilage of the Talus . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.3 Symptoms, Physical Examination, and Radiographic Evaluation . . . . . . . . . . . . 66
5.3.1 Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5.3.2 Physical Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66