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Neurovascular and tendon injuries due to ankle arthroscopy portals: a meta-analysis of interventional cadaveric studies

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Abstract

Neurovascular and tendon structures are considered at risk when performing ankle arthroscopy. Injury rate and distance from portals to such structures varied in the literature. The aim of this meta-analysis is to evaluate the injury risk of these structures in terms of proximity and injury prevalence. Thirteen studies including 184 cadaveric ankle arthroscopy procedures met the inclusion criteria. The antero-central portal exhibited the highest frequencies of nerve/vessel proximity and nerve/vessel missed injuries. Weighted mean distances were as follows: 2.76 ± 2.37 mm for the superficial fibular nerve (SFN) to the antero-lateral portal, 8.13 ± 2.45 mm for the saphenous nerve to the antero-medial portal, 2.1 ± 1.7 mm for the dorsalis pedis artery (DPA) to the antero-central (AC) portal, 6.84 ± 2.59 mm for the sural nerve to the postero-lateral portal. Distances to the postero-medial portal were 7.82 ± 2.98 and 11.03 ± 3.2 mm for the posterior tibial nerve and the posterior tibial artery, respectively. A total of 14 (10.3%) nerve injuries and 17 (12.5%) missed nerve injuries with a cumulative frequency of 22.8% of nerve structure at high risk. The SFN was the most vulnerable (10.3% of injury/missed injury), and it was the closest nerve to a portal. Vascular involvement consisted of 2 (1.5%) injuries and 12 (8.8%) missed injuries with the DPA being the most vulnerable (20%) through the AC portal. Tendon injuries were found in 8.7% procedure acts. The injury rates of extra-articular structures were found to be higher than previously reported in clinical literature. Apart from clinical studies, distance to portals and missed injuries of these structures could be evaluated. This cadaveric meta-analysis yielded more accurate results over the proximity and potential injury risk of ankle noble structure and should incite surgeons for more attention during portal placement. Such anatomical meta-analyses could offer an excellent statistical model of evidence synthesis when assessing injury risk in mini-invasive surgeries.

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References

  1. Acevedo JI, Busch MT, Ganey TM, Hutton WC, Ogden JA (2000) Coaxial portals for posterior ankle arthroscopy: an anatomic study with clinical correlation on 29 patients. Arthroscopy 16:836–842

    Article  CAS  PubMed  Google Scholar 

  2. Balci HI, Polat G, Dikmen G, Atalar A, Kapıcıoğlu M, Aşık M (2016) Safety of posterior ankle arthroscopy portals in different ankle positions: a cadaveric study. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-014-3475-6

    PubMed  Google Scholar 

  3. Başarir K, Esmer AF, Tuccar E, Binnet M, Güçlü B (2007) Medial and lateral malleolar arteries in ankle arthroscopy: a cadaver study. J Foot Ankle Surg 46(3):181–184

    Article  PubMed  Google Scholar 

  4. Barber FA, Click J, Britt BT (1990) Complications of ankle arthroscopy. Foot Ankle 10:263–266

    Article  CAS  PubMed  Google Scholar 

  5. Buckingham RA, Winson IG, Kelly AJ (1997) An anatomical study of a new portal for ankle arthroscopy. J Bone Jt Surg [Br] 79:650–652

    Article  CAS  Google Scholar 

  6. Calder JD, Sexton SA, Pearce CJ (2010) Return to training and playing after posterior ankle arthroscopy for posterior impingement in elite professional soccer. Am J Sports Med 38:120–124

    Article  PubMed  Google Scholar 

  7. de Leeuw PAJ, Golano P, Sierevelt IN, van Dijk CN (2010) The course of the superficial fibular nerve in relation to the ankle position: anatomical study with ankle arthroscopic implications. Knee Surg Sports Tramatol Arthrosc 18:612–617

    Article  Google Scholar 

  8. Feiwell LA, Frey C (1993) Anatomic study of arthroscopic portal sites of the ankle. Foot Ankle 14(3):142–147

    Article  CAS  PubMed  Google Scholar 

  9. Ferkel RD, Hommen JP (2007) Arthroscopy of the ankle and foot. In: Coughlin MJ, Mann RA, Saltzman CL (eds) Surgery of the foot and ankle, ed 8. Mosby Elsevier, Philadelphia, pp 1641–1691

    Google Scholar 

  10. Ferkel RD, Dalton DH, Guhl JF (1996) Neurological complications of ankle arthroscopy. Arthroscopy 12:200–208

    Article  CAS  PubMed  Google Scholar 

  11. Ferkel RD, Small HN, Gittins JE (2001) Complications in foot and ankle arthroscopy. Clin Orthop Rel Res 391:89–104

    Article  Google Scholar 

  12. Guhl JF (1988) New concepts (distraction) in ankle arthroscopy. Arthroscopy 4:160–167

    Article  CAS  PubMed  Google Scholar 

  13. Guo QW, Hu YL, Jiao C, Ao YF, Tian DX (2010) Open versus endoscopic excision of a symptomatic os trigonum: a comparative study of 41 cases. Arthroscopy 26:384–390

    Article  PubMed  Google Scholar 

  14. Heck J, Mendicino RW, Stasko P, Shadrick D, Catanzariti AR (2012) An anatomic safe zone for posterior ankle arthroscopy: a cadaver study. J Foot Ankle Surg 51(6):753–756

    Article  PubMed  Google Scholar 

  15. Horibe S, Kita K, Natsu-ume T, Hamada M, Mae T, Shino K (2008) A novel technique of arthroscopic excision of a symptomatic os trigonum. Arthroscopy 24:121 e1-e4

    Article  Google Scholar 

  16. Ilyas J (2013) Ankle arthroscopy. In: Bagaria B (ed) Regional arthroscopy. InTech, Croatia, pp 1–21

    Google Scholar 

  17. Jerosh J, Fadel M (2003) Endoscopic resection of a symptomatic os trigonum. Knee Surg Sports Traumatol Arthrosc 14:1188–1193

    Article  Google Scholar 

  18. Lemont H (2007) The branches of the superficial fibular nerve and their clinical significance, 1975. J Am Podiatr Med Assoc 97:319–324

    Article  PubMed  Google Scholar 

  19. Lijoi F, Lughi M, Baccarani G (2003) Posterior arthroscopic approach to the ankle: an anatomic study. Arthroscopy 19:62–67

    Article  PubMed  Google Scholar 

  20. Lui TH, Chan LK (2016) The safety of the posterior ankle arthroscopy in management of posterior ankle impingement: a cadaveric study. Foot (Edinb) 27:4–9

    Article  CAS  Google Scholar 

  21. Martin DF, Baker CL, Curl WW, Andrews JR, Robie DB, Haas AF (1989) Operative ankle arthroscopy. Am J Sports Med 17:16–23

    Article  CAS  PubMed  Google Scholar 

  22. Martin Oliva X, Méndez López JM, Monzo Planella M, Bravo A, Rodrigues-Pinto R (2015) Anatomical relations of anterior and posterior ankle arthroscopy portals: a cadaveric study. Eur J Orthop Surg Traumatol 25:577–581

    Article  Google Scholar 

  23. Marumoto JM, Ferkel RD (1997) Arthroscopic excision of the os trigonum: a new technique with preminary clinical results. Foot Ankle Int 18:777–784

    Article  CAS  PubMed  Google Scholar 

  24. Nickisch F, Barg A, Saltzman CL, Beals TC, Bonasia DE, Phisitkul P, Femino JE, Amendola A (2012) Postoperative complications of posterior ankle and hindfoot arthroscopy. J Bone Jt Surg 94(A):439–446

    Article  Google Scholar 

  25. Noguchi H, Ishii Y, Takeda M, Hasegawa A, Monden S, Takagishi K (2010) Arthroscopic excision of posterior ankle bony impingement for early return to the field: short-term results. Foot Ankle Int 31:398–403

    Article  PubMed  Google Scholar 

  26. Parisien JS, Vangsness T, Feldman R (1987) Diagnostic and operative arthroscopy of the ankle. An experimental approach. Clin Orthop Relat Res 224:228–236

    Google Scholar 

  27. Poggio D, Claret G, López AM, Medrano C, Tornero E, Asunción J (2016) Correlation between visual inspection and ultrasonography to identify the distal branches of the superficial fibular nerve: a cadaveric study. J Foot Ankle Surg 55(3):492–495

    Article  PubMed  Google Scholar 

  28. Scheibling B, Koch G, Clavert P (2017) Cadaver study of anatomic landmark identification for placing ankle arthroscopy portals. Orthop Traumatol Surg Res 103(3):387–391

    Article  CAS  PubMed  Google Scholar 

  29. Schneider T, Hoffstetter I, Menke W, Schulitz KP (1996) Arthroscopy of the ankle joint. A list of indications and realistic expectations. Foot Ankle Surg 2:189–193

    Article  Google Scholar 

  30. Scholten PE, Siereve IN, van Dijk CN (2008) Hindfoot endoscopy for posterior ankle impingement. J Bone Jt Surg 90(A):2665–2672

    Article  CAS  Google Scholar 

  31. Sim JA, Lee BK, Kwak JH (2006) New posteromedial portal for ankle arthroscopy. Arthroscopy 22:799e1–e2

    Article  Google Scholar 

  32. Sitler DF, Amendola A, Bailey CS, Thain LM, Spouge A (2002) Posterior ankle arthroscopy: an anatomic study. J Bone Jt Surg [Am] 84:763–769

    Article  Google Scholar 

  33. Sprague NF III, Guhl JF, Olson DW (1989) Specific complications: elbow, wrist, hip, and ankle. In: Spraque, NF III (eds) Complications in arthroscopy. 1. Raven Press, New York, pp 199–224

    Google Scholar 

  34. Tryfonidis M, Whitfield CG, Charalambous CP, Baraza WK, Zubairy AI, Blundell CM (2008) Posterior ankle arthroscopy portal safety regarding proximity to the tibial and sural nerves. Acta Orthop Belg 74:370–373

    PubMed  Google Scholar 

  35. Van Dijk CN, Scholten PE, Krips R (2000) A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthroscopy 16:871–876

    Article  PubMed  Google Scholar 

  36. Voto SJ, Ewing JW, Fleissner PR Jr, Alfonso M, Kufel M (1989) Ankle arthroscopy: neurovascular and arthroscopic anatomy of standard and trans-achilles tendon portal placement. Arthroscopy 5:41–46

    Article  CAS  PubMed  Google Scholar 

  37. Wang L, Gui J, Gao F, Yu Z, Jiang Y, Xu Y, Shen H (2007) Modified posterior portals for hindfoot arthroscopy. Arthroscopy 23:1116–1123

    Article  PubMed  Google Scholar 

  38. Woo SB, Wong TM, Chan WL, Yen CH, Wong WC, Mak KL (2010) Anatomic variations of neurovascular structures of the ankle in relation to arthroscopic portals: a cadaveric study of Chinese subjects. J Orthop Surg (Hong Kong) 18:71–75

    Article  Google Scholar 

  39. Yamada T, Gloviczki P, Bower TC, Naessens JM, Carmichael SW (1993) Variations of the arterial anatomy of the foot. Am J Surg 166:130–135

    Article  CAS  PubMed  Google Scholar 

  40. Yammine K (2014) Evidence-based anatomy. Clin Anat 27:847–852

    Article  PubMed  PubMed Central  Google Scholar 

  41. Zengerink M, van Dijk CN (2012) Complications in ankle arthroscopy. Knee Surg Sports Traumatol Arthrosc 20:1420–1431

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We are thankful to Dr Anthony V. D’Antoni for reviewing the English of the initial draft of this paper.

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Authors and Affiliations

  1. Department of Orthopedics, Lebanese American University-Rizk Hospital, Achrafieh, P. O. Box: 11-3288, Beirut, Lebanon

    Kaissar Yammine & Chahine Assi

  2. Center for Evidence-Based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon

    Kaissar Yammine

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  1. Kaissar Yammine
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  2. Chahine Assi
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Protocol/project development: KY. Data collection and appraisal: KY and CA. Data analysis: KY. Manuscript writing/editing: KY and CA.

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Correspondence to Kaissar Yammine.

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Yammine, K., Assi, C. Neurovascular and tendon injuries due to ankle arthroscopy portals: a meta-analysis of interventional cadaveric studies. Surg Radiol Anat 40, 489–497 (2018). https://doi.org/10.1007/s00276-018-2013-5

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  • DOI: https://doi.org/10.1007/s00276-018-2013-5

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