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“Ankle Arthroscopy: No-Distraction and Dorsiflexion Technique Is the Key for Ankle Arthroscopy Evolution”

      We have read with interest the Editorial Commentaries “Ankle Arthroscopy: Correct Portals and Distraction Are the Keys to Success” and “Osteochondral Lesions of the Talus—Are We Going the Wrong Way?” both published by Dr. Richard D. Ferkel in this journal.
      • Ferkel R.D.
      Editorial Commentary: Ankle arthroscopy: Correct portals and distraction are the keys to success.
      • Ferkel R.D.
      Editorial Commentary: Osteochondral lesions of the talus—Are we going the wrong way?.
      In these Editorial Commentaries, Dr. Ferkel made 2 statements that we would like to highlight: (1) “We must continue to push the envelope and develop more arthroscopic techniques in the foot and ankle that benefit our patients and return them back to work and sports more quickly and efficiently,” and (2) “I would encourage the readers to continue to improve their ankle arthroscopy skills by attending hands-on courses at the Orthopaedic Learning Center in Chicago and other venues.”
      • Ferkel R.D.
      Editorial Commentary: Ankle arthroscopy: Correct portals and distraction are the keys to success.
      We deeply agree with him: (1) It is true that new arthroscopic techniques in the foot and ankle would benefit our patients; (2) true, hands-on courses are very important for surgeon formation.
      However, it is difficult to evolve and describe new techniques if a technique such as routine-distraction is the only one used in ankle arthroscopy. This seems to also be the only technique explained in hands-on courses in the United States of America. Likewise, the routine-distraction ankle arthroscopic technique is still promoted in both editorial commentaries, and no comments are made about the dorsiflexion technique for ankle arthroscopy.
      It is interesting to see how the arthroscopic technique has evolved in every joint from diagnostic arthroscopy (first generation) to debridement/resection arthroscopy (second generation) and finally to arthroscopic tissue repair (third generation). Although in the United States of America ankle arthroscopy seems to be anchored in second generation techniques, third generation ankle arthroscopic repair techniques are being commonly described everywhere.
      • Vega J.
      • Golanó P.
      • Pellegrino A.
      • Rabat E.
      • Peña F.
      All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique.
      • Takao M.
      • Matsui K.
      • Stone J.W.
      • et al.
      Ankle Instability Group
      Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle.
      • Pereira H.
      • Vuurberg G.
      • Gomes N.
      • et al.
      Arthroscopic repair of ankle instability with all-soft knotless anchors.
      This is strongly related to the fact that in the USA ankle arthroscopy is commonly performed with routine-distraction, whereas no-distraction and dorsiflexion is the commonest technique almost in the rest of the world. This allows us to perform more advanced techniques. Anatomic reasons support this fact: the ankle joint capsule is inserted at a distance from the articular cartilage; with the no-distraction and dorsiflexion technique, the capsule is relaxed and an anterior working area is created. After serum insufflation, the anterior compartment expands and it is easy to access and observe both the medial and lateral gutters and the talar neck. Using the no-distraction and dorsiflexion technique the lateral and medial collateral ligaments are arthroscopically observed, and when injured, they can be repaired through an all-arthroscopic procedure.
      • Vega J.
      • Golanó P.
      • Pellegrino A.
      • Rabat E.
      • Peña F.
      All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique.

      Vega J, Allmendinger J, Malagelada F, Guelfi M, Dalmau-Pastor M. Combined arthroscopic all-inside repair of lateral and medial ankle ligaments is an effective treatment for rotational ankle instability [published online October 5, 2017]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-017-4736-y.

      However, it is impossible to perform all-arthroscopic ligamentous repair using the distraction technique, because the gutters are collapsed and the ligaments are difficult to observe (Fig 1). On the other hand, with the distraction arthroscopic technique the ligaments are tense, and they need to be relaxed to reinsert them into their correct anatomic position. For these reasons, the no-distraction and dorsiflexion technique is the key for ankle arthroscopy evolution.
      Figure thumbnail gr1
      Fig 1Anatomic osteoarticular dissection and arthroscopic vision of the lateral gutter using the (A) No-Distraction and Dorsiflexion technique and (B) Routine-Distraction. 1: Fibular malleolus. 2: Anterior talofibular ligament (visualized only with the No-Distraction and Dorsiflexion technique). 3: Ankle joint capsule.
      Although the whole talar dome can only be observed with the distraction technique, arthroscopic treatment of an osteochondral defect can be easily performed with both distraction and no-distraction and dorsiflexion techniques. Osteochondral injuries located in talar dome areas
      • Raikin S.M.
      • Elias I.
      • Zoga A.C.
      • Morrison W.B.
      • Besser M.P.
      • Schweitzer M.E.
      Osteochondral lesions of the talus: Localization and morphologic data from 424 patients using a novel anatomical grid scheme.
      1 to 6 are accessible with the no-distraction technique if ankle flexion degree is modified
      • van Bergen C.J.
      • Tuijthof G.J.
      • Maas M.
      • Sierevelt I.N.
      • van Dijk C.N.
      Arthroscopic accessibility of the talus quantified by computed tomography simulation.
      • van Bergen C.J.
      • Tuijthof G.J.
      • Blankevoort L.
      • Maas M.
      • Kerkhoffs G.M.
      • van Dijk C.N.
      Computed tomography of the ankle in full plantar flexion: A reliable method for preoperative planning of arthroscopic access to osteochondral defects of the talus.
      (Fig 2). As reported, osteochondral injury located in the posterior talar dome has to be treated through posterior arthroscopic portals if the distraction technique is being used,
      • Barg A.
      • Saltzman C.L.
      • Beals T.C.
      • Bachus K.N.
      • Blankenhorn B.D.
      • Nickisch F.
      Arthroscopic talar dome access using a standard versus wire-based traction method for ankle joint distraction.
      • Phisitkul P.
      • Akoh C.C.
      • Rungprai C.
      • et al.
      Optimizing arthroscopy for osteochondral lesions of the talus: The effect of ankle positions and distraction during anterior and posterior arthroscopy in a cadaveric model.
      or through hindfoot endoscopic portals, as we perform and recommend.
      Figure thumbnail gr2
      Fig 2Arthroscopic visualization of an osteochondral lesion at the medial talar dome (area 4) in a left ankle. An arthroscope is introduced through the anteromedial portal using the No-Distraction and Dorsiflexion technique. From ankle dorsiflexion (left) to plantarflexion (right).
      The no-distraction and dorsiflexion technique for ankle arthroscopy, popularized by Dr. van Dijk from Amsterdam, is not a new concept,
      • van Dijk C.N.
      Arthroscopy of the ankle.
      and it has allowed expanding the surgical options with numerous new arthroscopic third generation procedures, and reducing the ankle arthroscopy morbidity. In addition, reported complications using the no-distraction and dorsiflexion technique are lower than those reported using routine-distraction.
      • Zengerink M.
      • van Dijk C.N.
      Complications in ankle arthroscopy.
      For these reasons, we can only agree with Dr. Karlsson according to whom routine-distraction for ankle arthroscopy “should be considered a method from the past” because it is “not only unnecessary, but potentially dangerous.”
      • Karlsson J.
      Low risk of complications during ankle arthroscopy.
      Another controversial point is the fact that in the USA the ankle is considered a small joint, and thus a 2.7-mm arthroscope and small joint instruments are used. Although it is certainly possible to use them to perform ankle arthroscopy regardless of the technique used, the use of a 4.0-mm arthroscope and large arthroscopic instruments permits us to be more efficient and faster, and makes it easy to perform advance ankle arthroscopic techniques.
      Opinion leaders should never refuse technical advances, and they must be careful and responsible when providing information in relation to new and emerging procedures. We believe that both of Dr. Ferkel's editorial commentaries
      • Ferkel R.D.
      Editorial Commentary: Ankle arthroscopy: Correct portals and distraction are the keys to success.
      • Ferkel R.D.
      Editorial Commentary: Osteochondral lesions of the talus—Are we going the wrong way?.
      negatively influence the progress and development of ankle arthroscopy third generation procedures in the USA. Some major publications in European journals that support the use of the no-distraction and dorsiflexion technique and large instruments and a 4.0-mm arthroscope are ignored, and this should be alerted. To improve ankle arthroscopic skills and start to perform third generation techniques, we encourage orthopaedic surgeons to start using the no-distraction and dorsiflexion technique and large instruments and a 4.0-mm arthroscope for ankle arthroscopy. A good point to start is attending GRECMIP (Groupe de Recherche et d'Etude en Chirurgie Mini-Invasive du Pied) ankle arthroscopy cadaveric courses in Europe (Barcelona, Spain), and in the USA (Baltimore), or other courses that follow the same principles.

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      References

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        • Golanó P.
        • Pellegrino A.
        • Rabat E.
        • Peña F.
        All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique.
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        • Matsui K.
        • Stone J.W.
        • et al.
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        Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle.
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        • Vuurberg G.
        • Gomes N.
        • et al.
        Arthroscopic repair of ankle instability with all-soft knotless anchors.
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        • Elias I.
        • Zoga A.C.
        • Morrison W.B.
        • Besser M.P.
        • Schweitzer M.E.
        Osteochondral lesions of the talus: Localization and morphologic data from 424 patients using a novel anatomical grid scheme.
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        • Tuijthof G.J.
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        • Saltzman C.L.
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        • Akoh C.C.
        • Rungprai C.
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