Arthroscopic surgery and tendoscopy are emerging procedures for management of several disorders of the posterior ankle, subtalar joint, and first metatarsophalangeal (MTP) joint. These techniques can be both diagnostic and therapeutic and preserve the soft-tissue envelope to a much greater extent than open surgery. A comprehensive understanding of the regional anatomy is critical to successfully and safely perform these procedures.
Indications for arthroscopic surgery in the posterior ankle and subtalar joint have expanded because of recent advances in arthroscopy. Indications for foot and ankle arthroscopy include posterior bony and soft-tissue impingement, arthrofibrosis, arthritis, osteochondral defects (OCDs), posttraumatic calcifications, and loose bodies.1,2 Additional indications include chronic synovitis, sinus tarsi pain, and hindfoot fracture.3,4 Active infection is an absolute contraindication, and severe edema, vascular dysfunction, and deformity that impedes visualization during arthroscopy are relative contraindications.
The superior articular surface of the calcaneus contains three facets that make up the subtalar joint. The posterior facet is the largest and the major weight-bearing surface of the joint. The middle facet is anteromedial to the sustentaculum tali and is often confluent with the anterior facet. The posterior facet is separated from the anterior and middle facets by the anatomic space composed of the sinus tarsi and tarsal canal. This space contains the interosseous talocalcaneal ligament, roots of the inferior extensor retinaculum, and cervical ligament. Lateral ligamentous support of the subtalar joint arises from the lateral and posterior talocalcaneal ligaments, lateral aspect of the inferior extensor retinaculum, and calcaneofibular ligament. For arthroscopic purposes, posterior facet anatomy forms the basis for portal placement. Unless the interosseous ligament is torn, the anterior and medial facets are largely inaccessible due to the thickness of the ligament filling the tarsal canal.
Posterior Ankle Arthroscopy
Typically, posterior ankle impingement results from trauma or repetitive overuse and commonly occurs in ballet dancers and soccer players.5 It encompasses a broad array of pathology including os trigonum, osteophytes, loose bodies, synovitis, and posttraumatic malunions. Patients most commonly present with generalized hindfoot discomfort and pain during maximal or forced ankle plantar flexion. With the patient sitting and the knee flexed 90°, repetitive plantar flexion with or without rotational stress can reproduce pain, crepitus, or grinding and is helpful for identifying sources of impingement. In addition to a careful physical examination, imaging studies, including weight-bearing radiographs, may reveal bony sources of impingement. MRI and magnetic resonance arthrography also may be of diagnostic value to better delineate hindfoot pathology from normal surrounding structures.
A posterior approach with the patient positioned prone is most commonly used for posterior ankle and subtalar arthroscopy. Portals are placed adjacent to the Achilles tendon posteromedially and posterolaterally6 (Figure 1). A small bump is placed under the distal lower leg to allow ankle motion. The posterior approach minimizes potential damage to the arteries of the tarsal canal and sinus tarsi.7
Portal placement is guided by a straight line drawn from the tip of the lateral malleolus to the Achilles tendon, running parallel to the sole of the foot. The posterolateral portal is made just superior to this line, immediately adjacent to the border of the Achilles tendon. The posteromedial portal is established in the same manner, immediately adjacent to the medial border of the Achilles tendon. Care must be taken to avoid injury to the calcaneal branch of the lateral plantar nerve. The nick and spread technique is used to establish the lateral portal, and subcutaneous dissection is performed with a small hemostat aimed inferiorly toward the first web space. After the hemostat reaches bone, a blunt trochar with an arthroscopic sleeve is inserted. The posteromedial portal is made and a small hemostat is used to dissect soft tissue; the hemostat is advanced anteriorly along the arthroscope toward the posterior subtalar joint until it reaches bone.3 For subtalar arthrodesis, an accessory third portal may be created at the level of the sinus tarsi to introduce a largediameter blunt trocar for distraction.
In the posterior approach, the working space is created by removing the adipose tissue overlying the posterior aspect of the ankle and subtalar joints along with a small portion of the posterior talocalcaneal ligament and posterior joint capsule (Figure 2). The arthroscope can be positioned at the edge of the ankle and subtalar joints to view the articular surfaces. The flexor hallucis longus (FHL) tendon is a critical landmark and should be identified to avoid injury to the neurovascular bundle located medially. Inflammation of the FHL tendon should be investigated routinely.8 To remove an os trigonum, trigonal process, or osteophytes, it is often necessary to partially detach the posterior talofibular ligament, FHL retinaculum, and posterior talocalcaneal ligament. The use of an electrocautery device, burr, or osteotome may help to remove the bony fragment.
van Dijk9 performed 146 arthroscopic hindfoot procedures to manage bony impingement, OCDs, and FHL tendinitis and found that most patients had good outcomes with few complications (1.4% incidence of heel pad numbness). In a study of 12 athletes with posterior subtalar bony impingement treated with arthroscopic excision, Noguchi et al10 reported substantial improvement in American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores and range of motion. The average time to return to sport was 6 weeks. The authors reported one case of transient sural neuritis. Leitze et al11 compared open retrocalcaneal decompression with an arthroscopic technique and found that both procedures resulted in similar improvement in AOFAS ankle-hindfoot scores and required similar rehabilitation time.
In a study of 189 posterior ankle and hindfoot arthroscopy procedures, Nickisch et al12 reported complications after 16 procedures (8.5%), with the most common being plantar numbness, sural nerve dysesthesia, and Achilles tendon tightness. The authors noted that incorrect creation and instrumentation of the posterolateral portal in the prone approach was likely the cause of sural nerve damage. In a review of 246 ankle and 14 subtalar arthroscopic procedures, Deng et al13 reported a 3.5% incidence of cutaneous nerve injury and 3% rate of localized superficial infection.
Subtalar arthroscopy can be performed using regional or general anesthesia. The most common indications for the procedure are subtalar impingement lesions, arthrofibrosis, osteophytes, OCDs, symptomatic coalitions, fractures, and removal of loose bodies. Typically, the patient is placed in the lateral decubitus position. The surgical extremity is draped free with a tourniquet placed on the thigh, the knee is flexed from 40° to 60°, and all bony prominences are padded, including the proximal fibula. A noninvasive ankle strap or transosseous calcaneal wire can be used for distraction as needed.14 The ankle strap also may serve to secure the foot position throughout the procedure and may be attached to the surgeon’s waist or to the table frame with a metal distractor.
Three standard portals (anterior, middle, and posterior) are used to visualize and work in and around the subtalar joint1 (Figure 3). The use of accessory anterior and posterior portals for instrumentation may also be helpful.15 The bony anatomy and Achilles tendon should be marked along with the locations of the superficial peroneal nerve, sural nerve, and dorsalis pedis artery. The anterior portal is located 1 cm anterior and 2 cm distal to the tip of the lateral malleolus at the distal portion of the sinus tarsi. The middle portal is slightly anterior to the tip of the lateral malleolus and immediately anterior to the peroneal tendons. Portal placement can be confirmed with needle localization. The posterior portal is 1 cm proximal to the tip of the lateral malleolus and immediately posterior to the peroneal tendons. Structures at risk of injury during portal creation include the sural nerve branches and peroneal tendons (posterior portal) and the superficial peroneal nerve (anterior portal).2
The joint is insufflated through the anterior portal with 10 mL of normal saline under gravity flow or with an arthroscopic pump, and the nick-and-spread technique is used to create the portal. The subcutaneous tissues are bluntly dissected with a small hemostat, and a blunt trochar is inserted into the joint followed by a 2.3- or 2.7-mm 30° short oblique arthroscope. A 70° arthroscope may provide additional visualization as needed.
The middle and posterior portals are created under direct visualization using an outside-in technique with an 18-gauge needle. For subtalar visualization and instrumentation, it is useful to place the arthroscope in the anterior portal and the instrumentation in the middle or posterior portal. Anterior arthroscope placement permits direct visualization of 90% of the posterior facet.2 The middle and posterior portals serve primarily as instrument portals. Posterior portal instrumentation is useful for managing posterior impingement, débriding synovium, or removing an os trigonum or trigonal process in the posterior compartment.
A diagnostic examination begins by placing the arthroscope in the anterior portal.4 The sinus tarsi ligaments are visualized first, with the deep interosseous ligament filling the tarsal canal located medially. The arthroscope is rotated to visualize the middle facet and the anterior calcaneal process. Rotating 180° allows visualization of the anterior aspect of the posterior facet. The anterolateral corner of the posterior facet is then examined along with the lateral talocalcaneal ligament anterior to the calcaneofibular ligament. The arthroscope can be advanced along the lateral gutter to examine the lateral subtalar capsule and an os trigonum, if present. From the posterior portal, the interosseous ligament can be visualized anteriorly, with the lateral talocalcaneal and calcaneofibular ligaments located laterally. The posterolateral recess, posterolateral corner of the talus, and posterior gutter can be seen with the talus on the superior aspect of the arthroscopic image, and the calcaneus can be seen on the inferior aspect. Following a complete joint examination, pathology can be addressed as appropriate (eg, débridement, decompression, microfracture, removal of loose bodies).
In a study of 49 subtalar arthroscopies performed for a variety of diagnoses, Frey et al16 reported 94% good to excellent results. Most patients with preoperative diagnosis of sinus tarsi syndrome were found to have tears of the interosseous ligaments. The authors noted that “sinus tarsi syndrome” was an inaccurate diagnosis and that subtalar arthroscopy can be used for management of specific diagnoses of subtalar pathology. This conclusion was supported by Lee et al;17 in a series of 33 cases of sinus tarsi syndrome treated with subtalar arthroscopy, the authors found partial tears of the interossoeus talocalcaneal ligament in 29 (88%). Arthroscopic débridement substantially improved AOFAS ankle-hindfoot scores by 43 points, and 87% of cases had a good or excellent outcome.
In a review of outcomes of subtalar arthroscopy performed in 12 patients with symptomatic hindfoot pathology, Goldberger and Conti18 reported good overall patient satisfaction and an increase in AOFAS ankle-hindfoot scores from 60 preoperatively to 71 postoperatively. Three of four patients with lower postoperative scores later required subtalar fusion. The authors noted that subtalar arthroscopy was a more accurate method of diagnosing subtalar articular injury than plain radiographs, bone scan, and MRI. However, they believed that the therapeutic benefit of early management of arthritis with subtalar arthroscopy was limited.
Careful patient selection for arthroscopic subtalar arthrodesis, along with close examination of hindfoot alignment, is critical for optimal outcomes. Patients with subtalar arthritis often have substantial deformity and osteophytes that may interfere with accurate portal placement. Multiplanar deformity with significant bone loss is a relative contraindication to the procedure. Anterior and posterior portals are typically used when the patient is placed in the supine or lateral decubitus position, whereas posteromedial and posterolateral portals are used when the patient is positioned prone. A complete synovectomy and soft-tissue débridement are required to properly visualize the joint so that the articular cartilage can be removed entirely and the subchondral bone prepared adequately.
A hybrid burr that cuts soft tissue and shaves bone can facilitate joint preparation. Approximately 1 to 2 mm of subchondral bone must be removed to expose bleeding cancellous bone (Figure 4). Small, 1- to 2-mm deep holes are then created. Alternatively, a fine osteotome can be used to “fish scale” the subchondral bone. Adequate débridement is critical to obtain good bony contact of the posterior facet. The anterior and medial facets typically are not fused because of their location and thick, ligamentous covering. Autogenous bone graft or allograft substitute can be inserted through an arthroscopic sleeve as needed, based on the amount of bone loss and bony apposition. Guidewires and large (5.5 to 7.0 mm) cannulated compression screws are inserted, with final screw lengths and foot position confirmed with fluoroscopy.
Glanzmann and Sanhueza-Hernandez19 examined outcomes of arthroscopic subtalar arthrodesis performed in 37 patients with symptomatic hindfoot osteoarthritis. They reported a fusion rate of 100% at an average of 11 weeks postoperatively. These findings are supported by more recent series7,20 and are superior to outcomes of an earlier study of open subtalar arthrodesis in which time to union ranged from 10 to 15 weeks, with a nonunion rate of 8% to 29%.21 In a study of 115 patients who underwent subtalar arthroscopy for a variety of diagnoses, including sinus tarsi syndrome, arthritis, hindfoot fracture, arthrofibrosis, and os trigonum, Ahn et al22 reported that AOFAS ankle-hindfoot scores for those who underwent subtalar fusion or other nonfusion procedures improved substantially by 1-year follow-up, with no major complications. The most common nonfusion procedure was arthroscopic synovectomy for synovitis (31 patients). The average preoperative and postoperative AOFAS ankle-hindfoot scores were 69 and 89, respectively. In 26 patients with degenerative arthritis treated with arthroscopic subtalar fusion, the average AOFAS ankle-hindfoot scores improved from 33 preoperatively to 84 postoperatively.
Arthroscopic-assisted Reduction and Internal Fixation
Restoration of local anatomy and joint articulation with open reduction and internal fixation is the goal of hindfoot fracture management. Arthroscopic-assisted reduction and internal fixation (ARIF) can be used for minimally to moderately displaced talus and calcaneus fractures. Anatomic reduction of the posterior subtalar joint is the most important prognostic indicator after surgery. Joint incongruity of 1 to 2 mm creates substantial increases in articular contact pressure and poor functional outcomes,23 and malreduction of fractures of the posterolateral talar process can cause posterior impingement and ankle pain. Reported benefits of ARIF include decreased soft-tissue exposure, preservation of vascularity, removal of small loose fragments, faster rehabilitation, and improved visualization and reduction of articular cartilage lesions.24 Disadvantages include increased setup and surgical time, soft-tissue swelling caused by fluid extravasation, a steep learning curve for the surgeon, and increased initial cost. Although open reduction and internal fixation remains the standard of care for hindfoot fractures, arthroscopic techniques may help decrease the incidence of wound breakdown, infection, malunion, and posttraumatic arthritis.
Sitte et al25 reported on the use of subtalar arthroscopy with a minimally invasive approach for management of shear fractures of the talar body. The patient was positioned prone and a 2.3- or 2.7-mm arthroscope was moved between posteromedial and posterolateral portals to aid visualization for placement of guidewires. Parallel medial and lateral guidewires were placed to guide insertion of talar body screws. The medial wire was inserted at the lateral talar tubercle, and the lateral wire was placed at the insertion of the posterior talofibular ligament. Guidewire placement was checked under fluoroscopy, and a third wire was placed for temporary stabilization during drilling and placement of 3.5-mm partially threaded screws.
Percutaneous ARIF of intraarticular calcaneal fractures can be performed with the patient in the lateral decubitus position. Fluoroscopy can be used to obtain Broden and axial hindfoot views. The Broden view is a standard radiographic view that demonstrates the articular surface of the posterior subtalar facet. The lower leg and foot are internally rotated 45°, and the central beam is directed toward the lateral malleolus. Radiographs are obtained at 10°, 20°, 30°, and 40° of cephalic tilt.
Anterior and middle subtalar portals are used to visualize the posterior facet without releasing the interosseous ligaments. Fracture hematoma is taken down, and loose bodies and cartilage fragments are removed with a grasper. Kirschner wires are introduced under direct visualization to manipulate the depressed fragments. Screw fixation is then performed.
In a study of 22 patients with Sanders II intra-articular calcaneal fractures treated with ARIF, Woon et al26 found significant correction of the Bohler angle after surgery (P < 0.05) and improved outcome scores at 3 months, with additional improvement noted at 2-year follow-up. These results are comparable to those reported by Gavlik et al27 in a study of 15 patients with calcaneus fractures treated with percutaneous arthroscopic-assisted fixation. In a separate study, the authors found that arthroscopy was also able to detect incongruency of the posterior facet in 12 of 47 (25%) intraarticular calcaneal fractures that appeared to be reduced correctly based on fluoroscopy.28 Finally, Schuberth et al29 reported on a series of 24 cases of calcaneal fracture managed with ARIF, noting no soft-tissue complications and no need for subtalar fusion 1 year after surgery.
First MTP Joint Arthroscopy
Indications and Contraindications
Primary indications for first MTP joint arthroscopy include hallux rigidus, synovitis, loose bodies, OCDs, and arthrofibrosis.30 These conditions may result from acute trauma or repetitive hyperextension/flexion injuries caused by compression of the metatarsal head and proximal phalanx in full extension and flexion. Contraindications include infection and advanced arthritis; deformity and spurs associated with arthritis can prevent adequate visualization of the relevant anatomy. Relative contraindications include severe edema, vascular compromise, and intraarticular pathology that is too large to be addressed arthroscopically. In addition to physical examination, radiographs, and nonsurgical management, diagnostic arthroscopy is warranted in cases of unexplained pain along the joint line with stiffness, swelling, or mechanical symptoms.
The patient is positioned supine under general, regional, or local anesthesia. A sterile finger trap attached to a standing pole is placed on the hallux distal to the first MTP joint and suspended for noninvasive distraction. Self-adherent wrap may also be used to hold the hallux in place. An Esmarch bandage is used to exsanguinate the foot and serve as an ankle tourniquet. Inflow pressure under gravity is often sufficient to control intra-articular bleeding.
The three commonly used portals for first MTP joint arthroscopy are the direct medial, dorsomedial, and dorsolateral portals (Figure 5). The dorsomedial and dorsolateral portals are established after marking the joint line and borders of the extensor hallucis longus tendon. A 22-gauge spinal needle is inserted from the medial or lateral border of the tendon, and the joint is insufflated with 2 to 5 mL of saline. A 4-mm longitudinal incision is made, and the subcutaneous tissue is bluntly dissected with a mosquito clamp. A blunt trochar with an interchangeable cannula is inserted into the joint, followed by a 1.9- or 2.3-mm short oblique wideangle 30° arthroscope. Once the joint is visualized, the remaining two portals are created in the same manner under direct visualization. The medial portal is medial and inferior to the terminal branch of the superficial peroneal nerve. The dorsomedial portal provides good visualization of the dorsal aspect of the joint, and the medial portal provides a view of the sesamoids.
Instruments (eg, small shavers, probes, graspers, baskets, curets) are used to address intra-articular pathology. If an OCD is found, a 0.035-inch Kirschner wire is used for microfracture of the subchondral bone. It may be necessary to remove traction before intraarticular examination of the sesamoid complex to decrease capsular tightness and improve visualization.
Osteophytes and inflamed synovium can be removed arthroscopically if they are small, but open cheilectomy and débridement are recommended for large bone spurs (ie, >5 mm) secondary to inadequate working space.30 Visualization is best through the dorsolateral portal, with the dorsomedial and medial portals used for instrumentation. Osteophytes should be removed with a burr from medial to lateral in a distal to proximal fashion to evenly remove bone. The dorsal synovial fold may block spur removal, and care must be taken not to injure the dorsal cutaneous nerve. Fluoroscopy can help guide bony resection to ensure adequate decompression. Evaluation of the medial and lateral sesamoids is achieved with the hallux plantarflexed and the arthroscope placed in the dorsolateral and dorsomedial portals, respectively.
In a series of 24 patients treated with first MTP joint arthroscopy for a variety of pathology, van Dijk et al31 reported good or excellent results in 14 patients. One patient had transient loss of sensation in the medial hallux and another had loss of sensation laterally. In a study of 20 patients with degenerative joint disease treated with first MTP joint arthroscopy, Debnath et al32 reported that 95% of patients were pain free at 2 years postoperatively. Recently, Ahn et al33 reported on a series of 59 first MTP joint arthroscopies performed for a variety of diagnoses, including hallux valgus, hallux rigidus, gouty arthritis, sesamoid fracture nonunion, septic arthritis, and OCD. The authors reported a 95% rate of patient satisfaction and significant improvement in AOFAS hallux MTP scores at 2-year follow-up (69 preoperatively, 92 postoperatively; P < 0.05). Complications included one case of superficial wound infection and one case of transient dorsolateral digital nerve injury. Overall, limited data exist to support the long-term benefits of first MTP joint arthroscopy compared with those of open procedures, but the potential for decreased soft-tissue damage and faster rehabilitation warrant further research into this technique.
Iatrogenic damage to the articular surface as a result of the small working space and stiffness of the joint is a complication associated with this procedure.31 Noninvasive distraction and joint distension with normal saline are critical to allow adequate space for scope insertion and instrumentation. Additional potential complications include nerve injury and tendon laceration; the risk of these complications increases with incorrect portal placement.
Indications and Contraindications
Primary indications for tendoscopy about the foot and ankle are symptomatic tenosynovitis and small tears.34 Tendoscopy can be used for evaluation and management of disorders of the Achilles, posterior tibial, FHL, and peroneal tendons. Absolute contraindications include tendon injury that requires open resection, infection, and severe edema that prevents tendon localization and accurate portal placement. Relative contraindications include extensive scarring, poor tissue quality, and vascular compromise.
Portals are placed anywhere along the length of the tendon of interest. To evaluate the Achilles tendon and paratenon, patients are positioned prone, and posteromedial and posterolateral portals are created on either side of the tendon. A small shaver is used to débride fat, synovitis, and diseased tendon. For noninsertional disease, resection of the paratenon is performed on the anterior aspect of the tendon at the area of nodular swelling and pain. Tendoscopy cannot be used to manage insertional calcifications of the Achilles tendon without detaching a portion of the tendon in the process.
Tendoscopy of the posterior tibial tendon can be performed anywhere along the tendon from its insertion on the navicular to 6 cm above the medial malleolus. Great care must be taken to protect the neurovascular bundle. A distal portal is made 2 cm distal and anterior to the medial malleolus, and a proximal portal is created 2 cm posterior and superior to the medial malleolus. Arthroscopic débridement of FHL tenosynovitis is performed, following the tendon through its course behind the ankle joint and proceeding distally.
For peroneal tendoscopy, portals are placed proximal and distal to the central area of diseased tendon35 (Figure 6). An 18-gauge spinal needle is inserted into the tendon sheath and the proximal portal is made under direct visualization. During portal placement and tendon inspection, there is considerable risk of injury to the sural nerve. Inspection of the peroneus brevis and longus tendons begins approximately 6 to 8 cm proximal to the tip of the lateral malleolus and proceeds distally through the fibroosseous tunnel, with the sheath and each tendon examined for tenosynoitis, tears, or adhesions (Figure 7). The peroneal groove is inspected, as well, especially in cases of subluxation. Tenosynovitis of the peroneus brevis and peroneus longus tendons is débrided and adhesions are released. A low peroneus brevis or peroneus quartus in which the tendon runs more distally than normal (and thus is more prone to subluxation and synovitis) can be removed. In patients with extensive tenosynovitis or tearing, conversion to open débridement or repair through one of the portal sites is often necessary.36
Steenstra and van Dijk37 treated 20 patients with endoscopic débridement for noninsertional Achilles tendinopathy combined with paratendinopathy and reported that all patients had substantial pain relief and returned to sport 4 to 8 weeks after surgery. In a series of eight patients with chronic symptomatic tenosynovitis secondary to rheumatoid arthritis, Bulstra et al38 performed endoscopic synovectomy of the posterior tibial tendon. At 1-year follow-up, four patients had no recurrence of synovitis and were satisfied with the procedure; two patients had recurrence without tendon rupture that required further endoscopic débridement. The final two patients were less satisfied after surgery; one underwent hindfoot arthrodesis after 2.5 years to address hindfoot arthritis, and the other had recurrent pain but chose not to pursue further surgery. In a series of six patients with stage I tendon dysfunction, Chow et al39 performed posterior tibial tendoscopy with synovectomy and noted that all patients were pain free, with normal tendon strength at 2 months postoperatively. No patients progressed to stage II or greater tendon dysfunction. Average time to return to work was 10 weeks.
Vega et al40 reported on a series of seven patients with chronic subluxation of the peroneal tendons and pain in the lateral retromalleolar area treated with tendoscopy. In all patients, tendoscopic deepening of the peroneal groove was performed without superior peroneal retinaculum repair. At an average final follow-up of 15.4 months, no patients had recurrent subluxation and AOFAS scores increased from 75 preoperatively to 93 postoperatively.
Advances in foot and ankle arthroscopy have improved diagnosis and management of a broad array of disorders. Arthroscopy of the posterior ankle, subtalar joint, and first MTP joint and tendoscopy are techniques that may reduce soft-tissue complications, postoperative morbidity, and rehabilitation time compared with traditional open approaches. A thorough knowledge of forefoot, midfoot, and hindfoot anatomy and surgical technique, along with careful patient selection, is critical to safely and successfully perform these advanced arthroscopic procedures. Additional prospective, randomized clinical trials of these arthroscopic techniques are needed to clarify the indications, outcomes, and overall utility of these procedures.
Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, reference 11 is a level II study. References 6 and 25 are level V expert opinion. The remainder of the references are level IV studies.
References printed in bold type are those published within the past 5 years.
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