Abstract
Ankle arthroscopy has emerged as a viable treatment option for multiple ankle pathologies and continues to have expanding indications as technology and techniques improve. Historically, ankle arthroscopy used skeletal traction, and it has transitioned to noninvasive soft-tissue distraction because of high rates of iatrogenic complications. Although soft-tissue distraction has decreased complications, it continues to be both cumbersome and time-consuming. Thus we propose a 1-step simple ankle arthroscopy distraction technique that uses an external positioning arm to allow the surgeon to apply manual traction in multiple positions without the use of any reprocessed sterile equipment.
Ankle arthroscopy has emerged as a viable option for multiple ankle pathologies and continues to evolve with expanding indications and new surgical techniques. As the cases broaden and complexity increases, the need for simplification before and during surgery is warranted. The number of ankle arthroscopy cases continues to grow, necessitating a re-evaluation of equipment setup. Because of the convex shape of the talar dome and unique topographic anatomy of the ankle joint, ankle arthroscopy has been deemed unsuitable and the ankle joint is considered one of the most difficult joints on which to safely perform arthroscopy.1 To assist in visualization, early arthroscopists applied skeletal traction through the calcaneus with the use of large external pulleys or cranks often attached to the operating room walls. Although effective, the setup was time-consuming and iatrogenic complication rates of 15% to 17% were documented, with neurologic complications being most common.2, 3, 4, 5 Arthroscopic distraction then transitioned to noninvasive soft-tissue techniques using multiple apparatuses such as a well-leg holder and external bars and clamps in conjunction with padded straps.6 These techniques decreased the iatrogenic complication rate to 8% but required lengthy setup times and several pieces of sterilely processed equipment.7 Thus we propose a 1-step simple ankle arthroscopy distraction technique that uses an external positioning arm to allow the surgeon to apply manual traction in multiple positions without the use of any reprocessed sterile equipment (Table 1).
Table 1.
Tips, Pearls, Pitfalls, Risks, Indications, and Contraindications
| Tips | Pearls | Pitfalls | Risks | Indications | Contraindications |
|---|---|---|---|---|---|
| The external positioning arm should be applied before sterile draping on the ipsilateral side of the patient. | The need for reprocessing equipment is eliminated. The use of a single sterile dressing that is discarded after the procedure is all that is required. | Purchasing enough external fixation arms for both shoulder and ankle procedures | Too much traction placed by the surgeon can lead to neurovascular damage (very uncommon) | Anterior ankle arthroscopy | Any contraindication that would not allow either anterior, posterior, or subtalar ankle arthroscopy |
| The foot pedal for the arm should be positioned before draping. | The setup time and amount of equipment for ankle arthroscopy are reduced. | Posterior ankle arthroscopy | |||
| The external positioning arm should be removed from under the sterile drapes; then, its sterile dressing should be placed just before the procedure. | The technique allows for easy maneuverability of the leg or joint at any time during the procedure. It enables easy removal of the ankle strap and external positioning arm for films to be taken without interfering with the picture. | Subtalar joint arthroscopy | |||
| The risk of neurovascular damage from the leg wall holder commonly used is decreased. | Other procedures in which traction of the ankle is needed |
Surgical Technique
The patient is positioned supine or prone depending on the arthroscopic indications. The following ordered steps are then conducted: (1) A small bump is placed under the patient's ipsilateral hip to align the ankle perpendicular to the table. We use a bump consisting of folded bed sheets or towels. (2) A standard safety strap is applied around the waist, and an additional 4-inch strip of tape is applied around the contralateral padded ankle and bed to decrease movement of the body and contralateral leg during the procedure. Tape is placed over the padding to ensure patient safety and comfort. (3) An external positioning arm—either the Spider (Smith & Nephew, Andover, MA) or Trimono (Arthrex, Naples, FL)—is attached to the ipsilateral surgical side of the bed (Fig 1, Fig 2, Fig 3). The mounting bracket of the external positioning arm is placed at the most distal point of the main bedrail, not the more mobile leg component of the bed. (4) The patient undergoes sterile preparation and draping in the standard fashion. (5) Once the patient and table are fully draped, the external positioning arm is prepared with a disposable clear camera sheath (3M Steri-Drape, 13 cm × 244 cm; 3M, St Paul, MN) standard to most operating room supplies. The external fixation device is now ready to be positioned properly relative to physician preference for the procedure being performed. (6) The ankle is positioned on a soft bump under the distal tibia using sterile towels. The patient should already be marked with all major landmarks and port sites clearly visible for the arthroscopic procedure being performed. (7) The arthroscope and arthroscopic tools (Arthrex) are then inserted. We typically use the dorsiflexion position method3, 4, 5, 8 for introduction of arthroscopic instruments with no distraction to help mitigate iatrogenic injury to the articular surfaces. (8) After completing the most anterior arthroscopic procedures, we then apply a standard padded ankle distraction strap (Arthrex). (9) The strap is positioned around the end of the external positioning arm by simply sliding it over the arm end, requiring no clamps or brackets. The surgeon can then easily apply manual distraction and judge tension before engaging the positioning arm. The bump under the distal tibia may serve as a fulcrum. This in addition to the use of traction will help facilitate the opening of the joint either anteriorly or posteriorly depending on the force vectors. If, during the procedure, visualization is not adequate because of tight spacing, the external fixation arm is gently pulled toward the operating physician. This will provide a larger space for placement of the arthroscope and tools. If an angle needs to be obtained for visualization, the external fixation arm allows for side-to-side or superior-posterior movements depending on the angle needed. The external positioning arm is a single cylinder in a vertical position that allows easy access to all quadrants of the ankle; it also makes incorporation of fluoroscopy positioning much easier, thus limiting radiation exposure to not only the patient but also the medical personnel in the operating room. Video 1 details our technique.
Fig 1.
Right anterior ankle arthroscopy setup before sterile field application with the patient supine and the external positioning arm (Spider) on the ipsilateral side on the most distal portion of main bed frame. The photograph highlights the simple setup for anterior ankle arthroscopy, with the external positioning arm attached to the main bedrail, allowing for ample distraction as well as correct patient setup before the surgical approach.
Fig 2.
Standard anterior ankle arthroscopy sterile setup with the patient supine and with the external positioning arm (Spider) in place. The patient is prepared and an ipsilateral hip bump is placed before setup. Sterile towels are then placed beneath the tibia to be used as a fulcrum when needed. The patient is marked appropriately for the procedure; our port sites are also marked. The photograph shows the incorporation of the standard ankle strap (Arthrex), which is placed around the ankle with the padded portion on the dorsum of the foot and with a sterile camera sheath (3M Steri-Drape, 13 cm × 244 cm) in place over the external positioning arm. Once the ankle strap is placed over the ankle and external positioning arm as shown, the operating surgeon can apply ample traction when needed.
Fig 3.
Standard prone posterior ankle arthroscopy sterile setup with the external positioning arm (Spider) in place. The patient is in the prone position with a bump under the ipsilateral hip to help with proper alignment. Sterile towels are placed underneath the tibia to be used as a fulcrum. As shown, the ankle is marked to indicate the correct procedure and the locations for port placement. The setup shows the incorporation of the standard ankle strap (Arthrex), with the padded portion placed around the calcaneus and a sterile camera sheath in place.
Discussion
Using our 1-step ankle distraction setup may decrease surgical setup times, reduce overall costs, and minimize the burden on central sterilization and operative equipment. The surgical setup time is decreased when the ancillary staff prepositions the external positioning arm on the operative bedrail as described earlier. This single step eliminates the need for the surgeon to position, pad, and secure the well-leg holder. By not using the well-leg holder, the potential neurovascular injury from sustained pressure on the popliteal fossa is also eliminated.3, 4, 7 Moreover, this method removes all reprocessed sterile equipment, thus cutting costs and the burden regarding the sterilization process and operating room staff. The external positioning arm is commonplace in operating rooms in which shoulder arthroscopy is performed; in most cases the burden of purchasing the equipment has already been met.
Potential safety improvements associated with our technique include elimination of reprocessed sterile bed clamps that may perforate the sterile field as they attach over the sterile drapes. Our technique may also help prevent traction injuries because the surgeon can easily gauge tension applied to the ankle and easily maintain it well below the established tension level of 30 lb considered safe for ankle arthroscopy.3 In addition, the ease of positioning may potentially decrease the amount of fluoroscopy time and radiation exposure to the patient and the surgical team. In conclusion, using an external positioning arm to provide ankle distraction can be completed in 1 step while reducing operative costs and improving patient positioning and surgeon comfort.
Footnotes
The authors report that they have no conflicts of interest in the authorship and publication of this article.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defense or the US government. The authors are employees of the US government.
Supplementary Data
The patient in placed in the supine position to undergo anterior ankle arthroscopy. An already sterile field is shown, including the sterile dressing on the external positioning arm (Spider). We show how the standard heel strap (Arthrex) is placed on and off the patient. We also show not only how the arm can be moved to position the patient with traction during anterior ankle arthroscopy but also how it can be placed to the side when films that must be obtained during the procedure are taken.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The patient in placed in the supine position to undergo anterior ankle arthroscopy. An already sterile field is shown, including the sterile dressing on the external positioning arm (Spider). We show how the standard heel strap (Arthrex) is placed on and off the patient. We also show not only how the arm can be moved to position the patient with traction during anterior ankle arthroscopy but also how it can be placed to the side when films that must be obtained during the procedure are taken.