Master Techniques in Orthopaedic Surgery: The Foot and Ankle

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43 Arthroscopic-Assisted Open Reduction and Internal Fixation Ankle

FIGURE 43.2 A-C. Radiographic images demonstrating left ankle fracture treated with external fixation.

for arthroscopy. Surgeon preference dictates whether the patient is then placed in a well-leg holder in order to allow for counter pressure when a noninvasive distractor is used for the ankle (Fig. 43.4). While it is reasonable to use an ankle distractor, the authors find that the ankle joint is readily acces sible without distraction in patients with unstable ankle fractures. Regardless of whether distraction is used or not, a pad or blankets are placed under the operative leg to allow for unobstructed lateral fluoroscopic images. The leg is then sterilely prepared and draped followed by exsanguination and inflation of the tourniquet. The arthroscopic portion of the case commences prior to fixation of the fracture. The anterome dial portal is established, just medial to the anterior tibial tendon at the level of the joint. A 2.7-mm 30° arthroscope is placed through the anteromedial portal. The anterolateral portal may then be established (Fig. 43.5). Care should be taken to avoid the superficial peroneal nerve as this portal is established in the “soft spot” lateral to the peroneus tertius. Proper placement of the portal can be confirmed with direct visualization from the anteromedial portal by first inserting a needle at the intended site. A shaver may then be inserted through the anterolateral working portal. With regard to arthroscopic fluid management, either a low flow and pressure (25 to 35 mm Hg) automated system or gravity flow may be used. This is to minimize fluid extravasation into tissues that may already be compromised. With portals now established, the fracture hematoma that is frequently encountered may be evac uated. The ankle is then inspected, performing a standard 21-point diagnostic arthroscopy. 8 Any

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FIGURE 43.3 A, B. Postreduction computed tomography status post left ankle external fixation.