A Technique for the Reduction of Complications Associated With Anterior Portal Placement During Ankle Arthroscopy Using a Peripheral Vein Illumination Device

Complications of ankle arthroscopy: frequency, prevention, and treatment

The complication rate of ankle arthroscopy (AA) ranges from 3.5% to 14%. To avoid such complications, it is essential to have a thorough understanding of the anatomy of the ankle, to perform the procedure very carefully and with appropriate instrumentation, and to use a non-invasive distraction technique. The most frequent complications are neurological (cutaneous nerve injuries), which are usually caused by direct injury during arthroscopic portals or by a distracting pin when using an invasive distraction technique. They usually resolve spontaneously within a few months. The iatrogenic formation of a pseudoaneurysm is a severe but extremely rare complication (an incidence of 0.008%). There are several treatments for pseudoaneurysms: external compression; direct thrombin injection, surgical intervention (resection of the damaged segment of the artery and reconstruction with a reversed long saphenous vein interposition graft), and endovascular embolisation. Other rare complications include wound infections (localised superficial infection), problems at the portal incisions (prolonged portal drainage, residual pain in the portal, portal scar dehiscence, cyst at the portal site), type I complex regional pain syndrome, instrument breakage, painful scars and nodules, and a number of other rarer complications. In conclusion, when performing AA, it is important to remember the potential complications and try to avoid them. When they do occur, it is essential to diagnose and treat them appropriately.

Safe Insertion Angle of the Suture Button to Avoid Saphenous Structure in Syndesmosis Injury

In placing the medial suture button for syndesmosis injury, the risk of great saphenous vein and saphenous nerve injury has been reported. This study aimed to determine the safe insertion angle of the guide pin to avoid saphenous structure injury during suture button fixation. The incidence of saphenous structure injury was investigated using 8 legs of cadavers. The greater saphenous vein was depicted on the skin using near-infrared light (VeinViewer® Flex) and the distance between the greater saphenous vein and the posterior edge of the tibia at levels of 10, 20, and 30 mm from the joint line of the tibiotalar joint was measured in the 60 legs of healthy participants. On computed tomography (CT) images, the angles between the greater saphenous vein and transmalleolar axis at levels of 10, 20, and 30 mm from the joint line of the tibiotalar joint were measured. The cadaveric study revealed that the percentages of contact with the saphenous nerve were 8.3% to 16.7%. Using near-infrared light, the vein and tibia distance was 32.9 ± 6.8 mm of 10 mm, 26.6 ± 6.4 mm of 20 mm, and 20.4 ± 6.4 mm of 30 mm. The angle between the vein and transmalleolar axis was 1.0° to 9.4°, and more proximal, the angle was smaller. The veins depicted by near-infrared light can be a landmark to identify great saphenous vein, and injury of the saphenous structure can be prevented using VeinViewer Flex or considering the insertion angle defined in this study when placing the suture button for syndesmosis injuries.Level of Evidence: Level IV.

Anterocentral Portal in Ankle Arthroscopy

BACKGROUND

The anterocentral portal is not a standard portal in anterior ankle arthroscopy due to its proximity to the anterior neurovascular bundle. However, it provides certain advantages, including a wide field of vision, and portal changes become redundant. The purpose of this study was to evaluate the neurovascular complications after anterior ankle arthroscopy using the anterocentral portal.

METHODS

We retrospectively identified patients who had undergone anterior ankle arthroscopy with an anterocentral portal at our institution from 2013 to 2018. Medical record data were reviewed and patients were invited for clinical follow-up, where a clinical examination, quantitative sensory testing for the deep peroneal nerve, and ultrasonography of the structures at risk were performed. A total of 101 patients (105 arthroscopies) were identified and evaluated at a mean follow-up of 31.5 ± 17.7 months.

RESULTS

Leading indications to surgery were heterogeneous and included anterior impingement (48.6%), osteochondral lesions of the talus (24.8%), chronic ankle instability (14.3%), and fractures (8.6%). The overall complication rate was 7.6%, and no major complications were observed. In 1.9% (2/105) of the cases, the complications were associated with the anterocentral portal and included injury to the medial branch of the superficial nerve (1/105) and to the deep peroneal nerve (1/105). Injury to the deep peroneal nerve was associated with a loss of detection and nociception. There were no injuries to the anterior tibial artery. In 41.9% (44/105) of the cases, only 1 working portal was used in addition to the anterocentral portal, and in 19% (20/105) the anterolateral portal could be avoided. Ultrasonography confirmed the integrity of the deep peroneal nerve, the medial branch of the superficial peroneal nerve, and the anterior tibial artery in all patients. Patients with nerve injuries associated with the anterocentral portal showed no signs of neuroma or pseudoaneurysm.

CONCLUSION

Using a standardized technique, the anterocentral portal in ankle arthroscopy is safe with a low number of neurovascular injuries and can be recommended as a standard portal. The anterolateral portal remains associated with a high number of injuries to the superficial peroneal nerve.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Application of a peripheral vein illumination device to reduce saphenous structure injury caused by screw insertion during arthroscopic ankle arthrodesis

BACKGROUND

Arthroscopic ankle arthrodesis (AAA) is minimally invasive surgery, whereby percutaneous screw fixation is used through the medial aspect of the distal tibia to fusion the ankle, but it carries the risk of the saphenous vein and nerve injuries. The near-infrared (NIR) vascular imaging system, the VeinViewer^® Flex, projects an image of the vein onto the skin, and the visualization of the vein may reduce the vein and nerve injuries. The purpose of this study is to investigate the risk of the saphenous vein injury by the percutaneous screw insertion during AAA, and to evaluate the effectiveness of the NIR vascular imaging system in the reduction of the saphenous vein injury.

METHODS

Ten patients with the ankle osteoarthritis underwent AAA. Three screw insertion sites (proximal as number 1, anterior distal as number 2, and posterior distal as number 3) were marked and then the vein was depicted on the medial malleolus using the VeinViewer^® Flex. The distance between the screw insertion sites and the closest vein was measured. Additionally, the pattern of the vein course on the medial aspect of the distal tibia was investigated in 32 ankles using the VeinViewer^® Flex.

RESULTS

The distance of number 1, 2, and 3 from the vein was 2.4 ± 1.4 mm (range from 0 to 5 mm), 6.3 ± 6.6 mm (range from 0 to 20 mm) and 3.5 ± 3.1 mm (range from 0 to 11 mm) respectively. In anterior screw insertion site, 3 of 10 cases showed just on the vein. The veins were observed at the anterior region from the center axis of the tibia more than 75% of ankles which was suspected as the greater saphenous vein with closely running of the saphenous nerve, but also other regions had the crossing vein.

CONCLUSIONS

Percutaneous screw fixation during AAA runs the risk of causing the saphenous structure injury. The NIR light imaging system is beneficial in reducing the complications of saphenous structure damage in AAA.