Ankle Arthroscopy From a Posterior Approach

Indications

Isolated posterior ankle pathology such as flexor hallucis longus (FHL) tendonitis, posterior impingement from a Stieda process, an os trigonum, or soft tissue
Posterior osteochondral defects
Ankle fusion, or combined ankle and subtalar fusion
Typically posterior ankle arthroscopy is performed in the prone position, although a full lateral position can be used on occasion, or two posterior portals in the supine position using a leg holder

Indications Pitfalls

Anterior ankle pathology that requires treatment at the same time
Open procedures not easily performed in the prone position such as lateral ligament reconstruction

Indications Controversies

A clear distinction between an osteochondral lesion that can be approached from the anterior as opposed to the posterior side cannot easily be made and depends on surgeon comfort with both approaches.
Sometimes anterior ankle pathology can be reached in the prone position with the leg flexed up.

A typical patient history will reveal complaints of posterior ankle pain on activity. Clinical examination will usually reveal posterior ankle tenderness, possible loss of plantar flexion range, or pain on resisted flexion of the FHL tendon. Fig. 47.1 shows the prominent Stieda process in a ballet dancer and the typical location of the pain.
Magnetic resonance imaging (MRI) will often demonstrate fluid in the FHL sheath, edema in the posterior talus, a bony prominence, or soft tissue impingement. Fig. 47.2 shows the MRI of the same patient as seen in Fig. 47.1 .
A computed tomography scan is a good way to assess the bone pathology ( Fig. 47.3 ).
On occasion for dancers, a lateral x-ray in the pointe position will allow assessment of the posterior ankle bony impingement.

Treatment Options

Activity modification and changes in training regimen. Many patients with posterior ankle impingement are athletes or dancers.
Nonsteroidal antiinflammatory drugs and physiotherapy can allow resolution of symptoms.
Steroid injection into the posterior ankle structures (not the tendons or tendon sheaths) to reduce inflammation.

The annotated MRI shows the structures in the posterior ankle and how they relate. The neurovascular bundle must be avoided by staying lateral to the FHL tendon ( Fig. 47.4 ).

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