**2.3.2 Osteoarthritis of the subtalar joint**

Recently, arthroscopic subtalar arthrodesis has been reported as an alternative to traditional open methods for intractable hindfoot disorders, such as subtalar arthritis after fracture of the calcaneus or talus, primary arthritis, talocalcaneal coalition or inflammatory arthritis13-17, because of its advantages, including minimizing invasion to the soft tissue around the hindfoot and preserving blood supply to the talus. Although the lateral approach using anterolateral and posterolateral portals in the supine or lateral decubitus position was initially introduced for arthroscopic subtalar arthrodesis18, 19, the recent trend is the use of

Posterior Ankle and Hindfoot Arthroscopy 299

Fig. 17. Harvesting cancellous bone from the ipsilateral iliac crest using a tube harvester.

Fig. 18. Harvested cancellous bone plug (left) is cut into small bone columns (right).

drilling (Figure 19).

mm are inserted (Figure 21).

Under arthroscopic visualization, two guide wires of the headless cannulated screws (Acutrak plus, Acumed, Hillsboro, Oregon) are inserted from the plantar of the heel to the talus body through the posterior facet of the subtalar joint and was followed by the over-

After autologous bone is grafted to the void after curettage of the posterior facet of the subtalar joint via portals (Fugure 20), the headless cannulated screws with a diameter of 6.5

the posterior two portals with patients in the prone position, permitting surgeons to access the posterior subtalar joint easily, as compared to the lateral approach13, 17. Accompanying techniques, such as the use of a third accessory portal14, 15, 17 or bone substitute for grafting13, 15, have been reported to result in successful prognosis without complications. The author recommends arthroscopic subtalar arthrodesis via a posterior approach using two portals accompanied by grafting of autologous cancellous bone, which is harvested by means of a tube harvester and grafted thorough these arthroscopic portals.

First, the shaver is inserted through the posteromedial portal and the soft tissue is removed until the FHL tendon is identified by arthroscopic visualization. If tenosynovitis is present around the FHL tendon, release of the flexor retinaculum and synovectomy are performed. After identification of the FHL tendon, the soft tissue overlying the posterior facet of the subtalar joint is removed from the lateral field of the FHL tendon. Next, the articular cartilage of the posterior facet of the subtalar joint is removed using a small chisel and a shaver until subchondral bone is exposed (Figure 16).

Fig. 16. Debridement of the subtalar joint with a small chisel.

After curettage of the anterior region of the posterior facet is confirmed arthroscopically, temporary fixation is performed using guide wires with the hindfoot in a neutral position. Subsequently, cancellous autograft bone is harvested from the ipsilateral iliac crest by using a tube harvester (OATS system, Arthrex, Naples, Florida) (Figure 17).

Two or three rigid cancellous bone plugs harvested through an approximately 1.5-cm skin incision are cut by a blade into small bone columns (Figure 18) so that autologous bone grafting is easily performed via arthroscopic portals.

the posterior two portals with patients in the prone position, permitting surgeons to access the posterior subtalar joint easily, as compared to the lateral approach13, 17. Accompanying techniques, such as the use of a third accessory portal14, 15, 17 or bone substitute for grafting13, 15, have been reported to result in successful prognosis without complications. The author recommends arthroscopic subtalar arthrodesis via a posterior approach using two portals accompanied by grafting of autologous cancellous bone, which is harvested by means of a

First, the shaver is inserted through the posteromedial portal and the soft tissue is removed until the FHL tendon is identified by arthroscopic visualization. If tenosynovitis is present around the FHL tendon, release of the flexor retinaculum and synovectomy are performed. After identification of the FHL tendon, the soft tissue overlying the posterior facet of the subtalar joint is removed from the lateral field of the FHL tendon. Next, the articular cartilage of the posterior facet of the subtalar joint is removed using a small chisel and a

tube harvester and grafted thorough these arthroscopic portals.

shaver until subchondral bone is exposed (Figure 16).

Fig. 16. Debridement of the subtalar joint with a small chisel.

grafting is easily performed via arthroscopic portals.

a tube harvester (OATS system, Arthrex, Naples, Florida) (Figure 17).

After curettage of the anterior region of the posterior facet is confirmed arthroscopically, temporary fixation is performed using guide wires with the hindfoot in a neutral position. Subsequently, cancellous autograft bone is harvested from the ipsilateral iliac crest by using

Two or three rigid cancellous bone plugs harvested through an approximately 1.5-cm skin incision are cut by a blade into small bone columns (Figure 18) so that autologous bone

Fig. 17. Harvesting cancellous bone from the ipsilateral iliac crest using a tube harvester.

Fig. 18. Harvested cancellous bone plug (left) is cut into small bone columns (right).

Under arthroscopic visualization, two guide wires of the headless cannulated screws (Acutrak plus, Acumed, Hillsboro, Oregon) are inserted from the plantar of the heel to the talus body through the posterior facet of the subtalar joint and was followed by the overdrilling (Figure 19).

After autologous bone is grafted to the void after curettage of the posterior facet of the subtalar joint via portals (Fugure 20), the headless cannulated screws with a diameter of 6.5 mm are inserted (Figure 21).

Posterior Ankle and Hindfoot Arthroscopy 301

Fig. 21. Lateral view of the standard X-ray of the ankle before surgery (left) and after surgery

After surgery, operated feet are not placed in casts, and active range-of-motion exercise of the talocrural joint is allowed the next day. Partial weight-bearing is allowed six weeks after surgery and full weight- bearing is permitted after a bridging callus is confirmed between

Since 1997, the author has performed about 300 hindfoot endoscopic procedures utilizing posterior two portals without any complications. The patients complained of less pain after surgery and recovered earlier than those who underwent open surgery. The author believes that hindfoot endoscopic surgery, performed by an experienced arthroscopist who has enough knowledge for local anatomy and become skillful in this art, is safe and reliable

[1] Van Dijk, CN.; Scholten, PE. & Krips, R. (2000). A 2-portal endoscopic approach for

[2] Parisien, JS. & Vangsness, T. (1985). Arthroscopy of the subtalar joint: An experimental

[3] Van Dijk, CN. (2006). Hindfoot endoscopy for posterior ankle pain. *Instr Course Lect,*

[4] Takao, M; Ochi, M; Shu, N; Naito, K; Matsusaki, M; Tobita, M & Kawasaki, K. (1999).

[5] Golano, P; Vega, J; de Leeuw, PA; Malagelada, F; Manzanares, MC; Gotzens V & van

diagnosis and treatment of posterior ankle pathology. *Arthroscopy,* Vol.16, pp. 871-

Bandage distraction technique for ankle arthroscopy. *Foot Ankle Int,* Vol. 20, pp.

Fijk, CN. (2010). Anatomy of the ankle ligaments: a pictorical essay. *Knee Surg* 

(right).

**3. Conclusion** 

**4. References** 

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389-91.

posterior facets by radiological investigation.

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*Sports Traumatol Arthrosc,* Vol. 18, pp. 557-569.

Fig. 19. Inserted guide wire through the subtalar joint (left, arrow) followed by the over drilling (right, arrowhead).

Fig. 20. Grafted cancellous bone on the subtalar joint (arrow).

Fig. 19. Inserted guide wire through the subtalar joint (left, arrow) followed by the over

Fig. 20. Grafted cancellous bone on the subtalar joint (arrow).

drilling (right, arrowhead).

Fig. 21. Lateral view of the standard X-ray of the ankle before surgery (left) and after surgery (right).

After surgery, operated feet are not placed in casts, and active range-of-motion exercise of the talocrural joint is allowed the next day. Partial weight-bearing is allowed six weeks after surgery and full weight- bearing is permitted after a bridging callus is confirmed between posterior facets by radiological investigation.
