When anterior and posterior pathologies appearing in one ankle, through the standard anterior portals, the surgeon performs an anterior ankle arthroscopy supine first, then handle the pathologies of the posterior compartment with the patient prone, as the anterior portals is difficult to examine the pathologies of the posterior ankle.
van Dijk et al advocated a methods double-portal arthroscopic approach using the posteromedial and posterolateral portals is considered reasonable for removal of an os trigonum (13). However, there exists a drawback that patient performed the operation is in the prone position firstly and a change to supine position is necessary for posterior ankle (22).
Here we propose an arthroscopic procedure, with the double posteromedial portals in supine position, the procedure allows the surgeon to access the anterior compartments and the hindfoot, to handle both the anterior and posterior pathologies during the same operation, without any neurovascular or tendons complication.
The study shows that the double posteromedial portals’ ankle anterior arthroscopy time, ankle posterior arthroscopy time are less than standard method. In addition, the double posteromedial portals hasn’t extra time waste, which could reduce the operation time, optimize the procedure and improve the operation efficiency.
Alao, postoperative AOFAS, VAS and KAF score of novel operation method are better than these of standard method one month after operation, which means patients with novel operation methods recover faster than standard group in short-term. And there is no significant difference between traditional way and double posteromedial portals in supine position way in AOFAS, VAS and KAF score in 3, 6 and 12 months, which means our new arthroscopic procedure can reach the same recovery and therapeutic effect as the standard one.
Table 1 shows that the novel method produces about 30 min less operation time. The use of the double posteromedial arthroscopic portals allows full visualization of all the structures in the posterior ankle compartments, both intra-articular and extra-articular. Because it has the advantage of eliminating changing the position during the process, the workload of preparing the operation towel are reduced, the duration of the operation is shortened, which improves the efficiency of operation a lot.
The double posteromedial portals approach which is mentioned above is located in the safe area for the reason that it is anterior to the anterior margin of the Achilles tendon. The neurovascular tibial bundle moves more anteriorly in a safe position by dorsiflexing the ankle. The method makes it possible to view the posterior talotibial, talofibular, and subtalar joints widely. And moreover, it is also permit a wide arthroscopic visualization of the tendons, of the upper calcaneal tuberosity and their sheaths. At the same time, operating with arthroscopic instruments in that region leads to no complication; which means through the double posteromedial portals, arthroscopic and endoscopic management of pathology is completely practicable.
The proximity of the tibialis posterior tendon and of the neurovascular bundle in the posteromedial aspect of the ankle has discouraged some surgeons to try to access this area with surgical instruments.
In this region, other studies have detailed the arthroscopic anatomy, focusing on the relationship between the other anatomic components of the compartment and the posterior tibial neurovascular bundle. It is helpful to avoid the risk of lesion (23).
We admit that our study does have some limitations. First, the double posteromedial portals should be performed by experienced surgeons. However, those departments can improve the proficiency of surgeons by organizing observations of the surgery which is performed by experienced surgeons.