Instrumentation necessary for arthroscopy of these joints include 1.9-and 2.7-mm 30° arthroscopes, and a shoulder holder and finger traps for the great toe. Distraction of the subtalar joint can be accomplished with noninvasive and invasive methods. The type of distraction chosen depends on the tightness of the joint and location of disease. Distraction of the first metatarsophalangeal joint is done using a modified finger trap suspended from a shoulder holder (Fig 5).
Complications of Foot and Ankle Arthroscopy
Previous complication surveys of arthroscopy have indicated a wide range of complications. An early study of arthroscopic surgery complications was an informal survey in which a low complication rate was reported (< 1%). 41 A large survey reported an incidence of 0.6% complications. 14 However, this retrospective survey was thought by the current authors to underestimate the true complication rate. A later survey reported a similar rate of complications at 0.56%. 50 This study included more advanced procedures such as meniscal repair and anterior cruciate reconstruction; for the first time, the ankle was included with the other arthroscopic procedures.
In a prospective study in which 21 surgeons participated, 51 the overall complication rate was 1.7%; the complication rate of ankle arthroscopy was 0.7%, consisting of one complication (infection) in 146 patients. A complication rate of 14% of 62 ankle arthroscopies, in which distraction techniques were used on most patients, has been reported. 31 Similar complication rates for ankle arthroscopy of 15% (101 patients) 39 and 17% (53 patients) 6 have been reported. In a large series of 518 ankle arthroscopies, the overall complication rate was 9.8%. 22 Complications of arthroscopy of the subtalar and great toe have not been reported previously.
In the current authors’ review of greater than 10 years’ experience, with 612 ankle arthroscopy procedures, the overall complication rate was 9%. The most common complication was neurologic injury, which accounted for 49% of the complications. Males had greater complication rates compared with females. However, women had greater neurologic complications compared with men. The only complication that persisted at 10 years followup was a neurologic injury, specifically, numbness at the incision site. One patient had numbness between the second and third toes and one patient had a neuroma develop. All other complications associated with ankle arthroscopy were temporary and resolved within 6 months. The rate of complications has increased somewhat in the past 10 years, but this is thought by the current authors to be related to the more complicated procedures that have been undertaken.
Types of Complications
Arthroscopic surgery of the foot and ankle has many potential complications. Complications can be categorized as systemic, preoperative, and procedure-related. Systemic complications include those related to anesthesia, stress of injury, illness, and surgery. Cardiopulmonary events, atelectasis, pulmonary embolus, myocardial infarction, and death comprise the majority of systemic complications. Preoperative complications include incorrect diagnosis, lack of preoperative planning, and failure to obtain appropriate preoperative studies (Table 2).
The use of invasive and noninvasive distraction devices can lead to various complications. These complications now will be discussed (Table 3).
The pneumatic tourniquet facilitates arthroscopic surgery of the foot and ankle by providing a bloodless joint and, therefore, improved visibility. There are potential complications with use of a tourniquet and the surgeon must be familiar with its use to minimize their occurrence. Pneumatic tourniquet complications include paresthesias and paresis (either temporary or permanent), thigh pain, and increased intraoperative bleeding (venous tourniquet). An increased risk of thrombophlebitis has been attributed to tourniquet use, but the literature does not support that conclusion. 17 Distal extremity embolization after tourniquet use has been reported in patients with calcified femoral arteries. It has been shown that there is no increase in complications with tourniquet use unless the tourniquet time exceeded 60 minutes. 49 In ankle arthroscopy, complications of tourniquet use were limited to temporary paresthesia that resolved without additional problems. 22 Pneumatic tourniquet complications can be prevented by proper application, appropriate padding, restriction of tourniquet time, and the use of as low a pressure as possible.
Anterocentral and posteromedial portals place the neurovascular structures at an increased risk of damage and therefore should not be used routinely. Transmalleolar portals also are possible, but should be reserved for limited, specific indications because there is a potential for intraoperative or postoperative stress fracture, articular cartilage damage, and cyst formation. Recently, Acevedo et al 1 examined their coaxial portals for posterior ankle arthroscopy to treat patients with hemophilic arthropathy. Posterior capsular synovectomy was achieved in 29 patients without complications after 45-month follow-up. Adherence to strict surgical technique also can limit complications related to portal placement. Incising only the skin when placing portals and then using a mosquito clamp for blunt dissection down to the joint capsule will decrease injuries to nerves, veins, tendons, and other structures. Multiple attempts at portal placement may damage the soft tissues and lead to increased extravasation. Repeated passage of instruments through the portals without the use of a protective cannula can result in increased soft tissue damage and an increased risk of subcutaneous nerve and vessel injury. Cannulae should be used whenever the repeated passage of instrument is predicted and the use of an interchangeable cannulae system can be helpful. The placement of portals too close together may cause skin necrosis and should be avoided.
Neurovascular structures can be injured via incorrect portal placement, pin placement, prolonged or inappropriate distraction, or the use of a tourniquet. Temporary paresthesias are the most common complications, but permanent paresthesia or paresis is possible. Careful planning and placement of all portals is necessary to prevent neurovascular injury. Anterior portals place the superficial and deep peroneal nerves and the dorsalis pedis artery at risk. There has been one case report of an aneurysm of the dorsalis pedis artery after the use of an anterocentral portal; therefore, this portal should not be used routinely 18 (Figure 6). Recently, pseudoaneurysm of the anterior tibial artery has been reported using the standard anterolateral and anteromedial portals. 38 Neuroma formation after injury to small cutaneous nerves also is possible.
Neurologic injury accounted for 49% of all complications in previous ankle arthroscopy series. 23,34 Specifically, injuries to the superficial peroneal nerve (56%), the sural nerve (22%), the saphenous nerve (18%), and the deep peroneal nerve (4%) were identified. All were direct injuries that occurred by either portal or distractor pin placement. No neurologic injury attributable to tourniquet compression was seen. The same authors found that many nerve injuries were associated directly with the use of the anterolateral portal.
Numerous tendons traverse the ankle and foot. Injuries to the tendons can be avoided by using a meticulous technique in portal placement; for example, the anteromedial portal is established while the index finger is on the anterior tibial tendon so that inadvertent injury cannot occur. With subtalar arthroscopy, extreme caution must be exercised in removing a painful os trigonum to avoid injury to the flexor hallucis longus and posterior neurovascular structures. The transAchilles portal has been abandoned by the senior author (RDF) because of the potential for tendon injury and rupture.
Ligament injury also is possible through inaccurate or inappropriate portal placement, too vigorous debridement of the ankle, and improper distraction techniques. Nevertheless, injury to ligaments during arthroscopy of the foot and ankle is rare. Ankle distraction techniques, either invasive or noninvasive, place the ligaments at risk, but can be minimized by the use of distraction forces of no greater than 50 lb force for no more than 1 to 1.5 hours. Periodically releasing the distraction also will help to minimize complications. A previous study in which stress radiographs obtained after surgery were used has shown no evidence of ligament damage if distraction is used. 31 If distraction techniques are used, the joint should be opened gradually to allow the viscoelastic properties of the ligaments to contribute to maximal joint distraction. Additionally, the use of small pins in mechanical distraction devices will prevent ligament injury by allowing pin bending before ligament failure.
Skin slough, necrosis, seromas, hematomas, and sterile or infected sinus tract formation all are potential wound complications of arthroscopic surgery of the foot and ankle. Wound complications are more common with the anterior portals and may be related to the limited soft tissue envelope. The skin over the anterior ankle is thin and the subcutaneous tissue is minimal.
The risk of skin slough and necrosis may be increased with rough handling of the skin, multiple adjacent portals, lack of appropriate bridging between portals, and repeated passage of instruments. Abnormal skin integrity secondary to previous trauma also may contribute to slough and necrosis. Significant swelling after surgery also can result in excessive tension and increase wound problems around portals that already are traumatized.
Seromas and hematomas are rare but possible after arthroscopic surgery. The minimal subcutaneous tissues and lack of dead space help to prevent these complications.
Sinus tract formation usually occurs after slow healing of a traumatized portal or in cases of postoperative infection. In cases of persistent drainage, the fluid should be cultured, oral antibiotics should be administered, and the joint should be immobilized. If these measures fail to obtain spontaneous closure of the sinus tract, debridement, reclosure over suction drains, and joint immobilization should result in healing of the tract. Failure to treat these problems promptly may result in joint sepsis.
To decrease wound complications, strict adherence to technique is necessary. The use of plastic cannulae for repeated passage of instruments, suturing of portals, and compression dressing and use of a splint after surgery may minimize wound problems. The careful use of motorized arthroscopic instrumentation also is required to prevent injury as the instruments are placed through existing portals.
Infection can occur after any surgery, open or arthroscopic. The infection rate for arthroscopy has been shown to be less than that for open surgery. The infection rate for arthroscopy inclusive of all involved joints is approximately 0.1%, 14,50,51 and the infection rate after ankle arthroscopy is 1.4%. 6 This increased infection rate in the ankle may be attributed to several factors. The minimal subcutaneous tissues and thin skin present around the ankle and foot may predispose them to an increased infection rate. Long and difficult arthroscopic procedures and wound healing problems, as discussed previously, may add to the increased infection rate.
Prophylactic antibiotic administration for patients undergoing routine arthroscopy in joints other than the ankle is controversial. In ankle arthroscopy, the infection rate is higher in patients who do not receive prophylactic antibiotics and in those in whom nonstandard portals are used. 22
Superficial soft tissue infections also are more common in the foot and ankle. Cellulitis after arthroscopic surgery of the ankle also has been reported. 31 The use of absorbable subcutaneous sutures has been implicated in superficial soft tissue infections. 51 Patients with these infections respond well to local wound care, removal of offending sutures, warm compresses, and oral antibiotics.
Intraarticular infections may occur after ankle arthroscopy. 49 Confirmation of a suspected septic joint should be obtained, including joint aspiration, synovial fluid analysis, routine culture, leukocyte count and differential, and erythrocyte sedimentation rate. A bone scan or sonogram may be useful if the diagnosis cannot be confirmed by joint aspiration. For patients in whom the diagnosis of septic joint is suspected or confirmed, repeat arthroscopy is indicated. The diagnosis can be made at the time of arthroscopy, and irrigation and debridement can be done. Suction drains or suction irrigation tubes may be placed under arthroscopic visualization or directly through the arthroscopic cannula. Antibiotics should be initiated immediately after cultures are obtained. When the infecting organism is isolated, appropriate antibiotic coverage should be confirmed.
To reduce the risk of infection after arthroscopy of the foot and ankle, the patient may wash the foot and ankle with an antiseptic scrub brush the morning of surgery. Then at the time of surgery, a 5-to 10-minute iodine scrub is done and antibiotics are given intravenously. Tourniquet times and operative times also are kept to a minimum.
Articular Cartilage Injury
Damage to articular cartilage may be the most frequently unreported complication of arthroscopy of any joint. Small joints such as those of the foot and ankle are much more susceptible to injury because of their narrow confines. Superficial scrapes, nicks, and scuffing should be avoided if possible. More severe damage, including full-thickness injury down to subchondral bone, can occur, and the long-term sequelae of these injuries is unknown.
As the use of arthroscopy of the foot and ankle becomes more widespread and the number and difficulty of procedures increases, the number of complications from articular cartilage injury also may increase. Specific procedures place the articular cartilage at an increased risk. Transmalleolar approaches for osteochondral lesions of the talus can result in articular cartilage damage. Arthroscopically-assisted reconstruction or repair of the anterior talofibular ligament has been attempted using staples and suture anchors. Because penetration of the subtalar joint by staples can occur with resultant articular cartilage damage, extreme caution needs to be exercised when inserting the staples. As in all arthroscopic surgery, gentle technique will reduce damage to the articular surface. Instruments never should be forced into any tight or hard to reach areas; and when necessary, another portal may be added, or a different approach may be used.
Distraction techniques have been developed to increase the joint space for better visibility and ease of instrument use. These techniques have reduced the incidence of articular cartilage damage during ankle arthroscopy. Furthermore, instrumentation specifically designed for use in small joints has led to a decrease in articular cartilage injury.
Small joint instruments are more fragile than large instruments commonly used in the knee. Greater handling care is required during surgery and in the instrument room. Proper care is necessary to prevent catastrophic instrument failure within the joint. All instruments should be inspected before and after each procedure for loose parts, fatigue damage, or other evidence of impending failure. Where appropriate, instruments should be replaced to prevent intraoperative breakage. One-piece instruments may reduce intraarticular breakage, and are recommended.
If an instrument breaks within a joint, the outflow should be stopped immediately and the arthroscope position should be fixed to avoid losing the fragment within the joint. Small instrument fragments may migrate into the medial or lateral recesses or to the posterior aspects of the ankle, making them very difficult to retrieve (Fig 7). If visualization of the fragment is lost, a careful systematic search of the entire ankle should be done. Once the fragment is found, magnetic instruments such as the Golden Retriever TM (Instrument Makar, Inc, Okemos, MI) or a small grasper may be used to retrieve the broken part. If a broken piece of instrument cannot be found within a reasonable time, surgery should be stopped. The broken instrument piece then is best located by the use of plain radiography or fluoroscopy.
The use of nonmagnetic arthroscopic instruments should be discouraged in small joints because of the difficulty in finding and retrieving such instruments. When motorized instruments such as burrs or shavers are used within the ankle or other small joints, extreme care must be taken. These instruments may destroy the metallic ends of the arthroscope, other instruments, or cannulae resulting in metallic debris or instrument fragments remaining within the joint.
Fluid Management Complications
Arthroscopy of any joint depends on good visualization, which is affected by the quality of camera equipment, arthroscope, and joint clarity. Intraarticular bleeding must be controlled through good fluid management, local control, and use of the tourniquet. Fluid inflow may be through a separate posterolateral portal, with outflow via the arthroscope. Three-liter bags, elevated at least 1 m above joint level, usually will provide enough gravity pressure to distend the joint and control bleeding. A syringe and catheter or a commercially available arthroscopic fluid pump also may be used for fluid delivery. In most cases, a pump has not been necessary; however, it can be particularly useful in decreasing bleeding when the tourniquet is not used. If a commercial arthroscopic pump is used, proper operation is required. Care should be taken to avoid high distention pressures to minimize extravasation.
If intraarticular bleeding is excessive, inflow pressure or volume may be increased to assist in clearing the blood. If this fails, local infiltration of the area of bleeding with a small volume of epinephrine solution may help control bleeding, but this is only rarely necessary. If visualization remains difficult, the tourniquet may be inflated. When all attempts to control bleeding fail and visualization remains impaired, the procedure should be stopped and the situation should be reassessed. Occasionally, the source of bleeding will be the subcutaneous tissue of the portal. In this case, small veins may be cauterized and larger veins and arteries may be ligated. In this situation, as with all surgery, careful neurovascular assessment should be done as soon as the patient is awake after the procedure. A suction drain may prevent a hematoma after surgery in patients in whom excessive bleeding occurred, or in patients in whom extensive synovectomy, abrasion arthroplasty, or excision of osteophytes may have resulted in increased bleeding. However, routine use of an intraarticular drain after surgery is not necessary.
Compartment ischemia during or after arthroscopy of the foot and ankle can lead to serious complications. Fortunately, the most severe of these, compartment syndrome, is rare after arthroscopic surgery. Ischemia results from tourniquet use, excessive extravasation, and compartment syndrome. Ischemia from the tourniquet usually has little morbidity, but long tourniquet times may result in slower rehabilitation, permanent muscle damage, or may lead to development of a compartment syndrome. 9
Excessive extravasation may increase the risk of compartment syndrome. Extravasation may occur during arthroscopy, although complications of fluid extravasation in arthroscopy of the foot and ankle have not been common in the authors’ experience. Compartment pressure can rise significantly with the use of an arthroscopic fluid pump; therefore, great care must be used with these devices. If extravasation during a procedure is worse than normal, then surgery should be halted. In most cases, compartment pressures rapidly decrease to normal after completion of the procedure and deflation of the tourniquet (based on the senior author’s personal experience). Compression, ice, and elevation assist in preventing additional swelling. In all cases, the patient should be monitored carefully to recognize an evolving compartment syndrome and to prevent its potential sequelae.
Effusions After Surgery
Effusions of the foot and ankle after surgery are rare and are a result of bleeding or synovitis. Careful systematic inspection of the joint at the time of arthroscopy and irrigation at the end of the procedure to remove all intraarticular debris may result in a decreased incidence of an effusion after surgery. A recurrent effusion may be aspirated with appropriate synovial fluid analysis and cultures taken, if the condition persists for greater than 4 weeks postoperatively. Occasionally, injection of intraarticular steroids may improve a recurrent or persistent effusion, but this treatment may be complicated by chondrocalcinosis or infection.
Hemarthrosis After Surgery
In arthroscopy of the foot and ankle, the incidence of hemarthrosis has been much less than in the knee. 22 Hemarthrosis after arthroscopy may be a result of the specific procedure (chondroplasty, synovectomy) or failure of local hemostasis during the procedure. Bleeding may be aggravated by the use of aspirin or other nonsteroidal antiinflammatory medication; therefore, these medications should be discontinued before the procedure.
Signs and symptoms of hemarthrosis include pain, swelling, decreased range of motion (ROM), and occasionally, low-grade fever. Aspiration is indicated if the patient has marked pain, or if the swelling limits the ROM and strengthening program.
Thrombophlebitis and Pulmonary Embolism
Thrombophlebitis and pulmonary embolism can be serious complications. They have been reported in open and arthroscopic procedures of the foot and ankle. 30 Patients who have a previous history of thrombophlebitis or pulmonary embolism should be treated with prophylactic anticoagulation as soon as possible. Prophylaxis is a controversial topic and the particular method used is determined by surgeon preference and experience. Another controversial issue is whether the use of the tourniquet increases the incidence of thrombophlebitis or protects against it. If thrombophlebitis or pulmonary embolism is suspected in the postoperative period, the patient should undergo diagnostic studies such as ultrasonography or venography; if positive, treatment may include anticoagulation.
Reflex Sympathetic Dystrophy
Reflex sympathetic dystrophy can occur after arthroscopy. The etiology of reflex sympathetic dystrophy is not understood. It may occur in the preoperative and postoperative periods. In patients who are not treated, the condition may become chronic and resist all forms of therapy.
Rarely, arthroscopic surgery of the ankle may assist in the treatment of reflex sympathetic dystrophy. Primarily, it is useful to rule out other intraarticular causes of pain that may mimic reflex sympathetic dystrophy. If reflex sympathetic dystrophy is superimposed on an intraarticular problem, arthroscopic removal of a chronic irritant from within the ankle may facilitate treatment of reflex sympathetic dystrophy.
Stress Fractures After Surgery
In cases where transmalleolar portals were used or invasive distraction techniques were used, stress fractures may result after surgery (Fig 8). Bicortical pin placement during distraction may increase the risk of a fracture. In patients who complain of pain for more than 4 weeks after surgery, especially at the transmalleolar portal or pin insertion site, a stress fracture should be included in the differential diagnosis. Plain radiography, bone scanning, tomography, and computed tomography scanning sometimes are necessary to confirm the diagnosis. In a previous report of ankle ar-throscopy, stress fractures after surgery were attributed only to the use of invasive distraction. 31 Stress fractures have not been reported secondary to the use of transmalleolar portals, but with greater use of this portal, this complication might be anticipated. 6,51
Treatment for stress fractures may include limited or nonweightbearing status, and the use of a brace, splint, or cast. Rarely, bone grafting may be necessary to obtain union.
Incisional pain also can complicate arthroscopic procedures. Normal immediate postoperative incisional pain should resolve quickly. Continued or chronic pain after arthroscopy may be related to formation of neuromas of the superficial skin nerves at the arthroscopic portals. Some patients may respond to superficial injection of local anesthetic and corticosteroids.
Foreign bodies remaining in the subcutaneous tissues surrounding the portals also may be a cause of persistent local pain. Osseous and chondral debris and broken instrumentation may cause discomfort and inflammatory foreign body reaction. In these patients, a second procedure to remove the foreign body from the portal area may be required.
Arthroscopy has become an important tool in the evaluation and treatment of disorders of the foot and ankle. Previous assumptions that arthroscopic surgery of the foot and ankle had minimal complications has been refuted in the literature. 6,22,30,39,51
A thorough understanding of foot and ankle anatomy is critical before attempting any arthroscopic procedures. Experience gained in the arthroscopy of larger joints, including the shoulder and knee, is beneficial before undertaking arthroscopy of the smaller joints, including the ankle and other joints of the foot. Because procedures attempted with arthroscopy have increased in complexity, the potential for complications has increased. Invasive distraction techniques also have increased the potential for complications. A 9% complication rate has been reported for ankle arthroscopy. 22 Although most of these complications are of little morbidity, additional refinements in technique and instrumentation may decrease this complication rate (Table 4).
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Osaretin B. Idusuyi, MD; and G. James Sammarco, MD, Guest Editors© 2001 Lippincott Williams & Wilkins, Inc.