Pearls

The portals should be made in the neutral position or in slight dorsiflexion, to minimize the risk of damage to the underlying structures. The anteromedial portal is regarded to be relatively safe, nevertheless neurovascular complications have been reported.

Introduction of the instruments through the anteromedial and anterolateral portal must be done with the ankle in dorsiflexion. In this position the nerves and vessels are not in tension, resulting in a minimal risk of iatrogenic damage. Moreover this forced dorsiflexed position is the best prevention for iatrogenic cartilage damage.

The superficial peroneal nerve is visible in 40% of patients. To reduce the risk of damage it should be localized when possible (plantarflexion and inversion).

Osteophytes can be removed more easily in dorsiflexion, since it will increase the anterior working area in combination with the saline used for irrigation.

1.   2.   3. 

1. Be Careful

2. Correct introduction of spinal needle. With the ankle in dorsiflexion, the weight-bearing cartilage of the talus cannot be damaged.

3. The superficial peroneal nerve (indicated with arrows (left) and in yellow (right)).

Tips

The saphenous nerve and great sapheneus vein are potentially at risk when making the anteromedial portal. The superficial peroneal nerve is at risk in creating the anterolateral portal. To prevent damage:

1. make the incision through the skin only;

2. use blunt mosquito clamp to spread the soft tissue and to enter the joint cavity;

3. use only blunt instruments to enter the joint cavity;

4. introduce your instruments and scope with the ankle in the slightly or fully dorsiflexed position.