Posterior ankle decompression (open technique) with posterior capsulectomy
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Posterior ankle impingement presents with postero-medial, or occasionally postero-lateral, ankle pain whilst the foot is in positions of full plantar-flexion such as kicking a ball or descending an incline. There may be no symptoms referable to the joint outside these activities.
There are broadly speaking 2 groups of patients who suffer with the problem, professional (or high level recreational) athletes or dancers being one, and anybody else who has sprained their ankle being the other group. Professional Athletes engaged in relevant activities will often have no history of discreet injury, the issue being one of chronic repetition of an “at-risk” activity. The other more numerous group are patients who have suffered an ankle sprain that has failed to settle. It should be remembered that the mechanism of injury with a sprain is not necessarily simply weight bearing and inversion but can include an additional plantar-flexion movement, which is when this posterior compression injury occurs.
If posterior impingement occurs as part of a sprain then other ankle joint symptoms may also exist, such as anteriorly based pain and instability, and these may require treatment also.
Irrespective of whether the MRI findings demonstrate bony impingement it is worth commencing interventional treatment with an ultrasound guided injection into the soft tissue envelope posteriorly. This will target the Flexor Hallucis Longus tendon sheath behind the ankle as well as the posterior ankle joint capsule and joint.
The operation described here is an open one, which gives excellent access to all areas required, but does require careful surgical exposure and meticulous haemostasis. Posterior ankle decompression using an arthroscopic technique is also well established, and described by Nick Cullen FRCS in another of OrthOracles techniques. Even for those experienced with the arthroscopic technique it is useful to know how to perform this operation open for revision cases when the need occurs.
You will need vascular sloops & fine mosquito forceps for this operation, which can be borrowed from Vascular Surgeons who are usually fairly laid back about lending kit. You will also need fine tenotomy scissors and Adsons non-toothed forceps, which are normally under the control of Hand Surgeons, who are much more territorial. The path of least resistance is to have these quietly removed from Hand surgery trays and re-labelled as Foot & Ankle inventory, as they come in useful for lots of other Foot & Ankle operations also.
OrthOracle readers will find the following associated instructional techniques of interest:
Posterior Ankle decompression-Arthroscopic technique
Posterior ankle decompression- Open technique
Ankle arthroscopy using the Smith and Nephew Guhl non-invasive ankle distractor
Ankle fracture: Posterior malleolar fixation using a posteromedial approach
Ankle fracture: Postero-lateral plating of pronation-external rotation ankle fracture (posterior malleolus))
Tarsal tunnel decompression (for tarsal tunnel syndrome)
Author: Mark Herron FRCS
Institution: OrthOracle, London, UK.
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