Mandrino A, Chabaud B, Moyen B, Brunet-Guedj E
Hôpital E. Herriot, Lyon.
Rev Chir Orthop Reparatrice Appar Mot. 1994;80(4):342-5.
The development of the indications in the arthroscopic surgery of the ankle and the narrowness of this joint impose perfectly adapted portals. Several posterior portals which allow to access to the postero medial corner of the joint have been already described, but are not satisfying. We describe, here, a new postero-medial portal which allows a safe and easy access to the posterior part of the joint.
The arthroscopy is performed with a standard arthroscope (30 degrees, 4.5 mm in diameter) and a lateral ankle distractor. The landmark for this portal is the posterior crest of the medial malleolus. Above the posterior tip of the medial malleolus, this crest is directed up and back, then its direction becomes strictly vertical. The new portal is situated there, 5 millimeters behind the crest (generally 2 centimeters above the posterior tip of the medial malleolus). A needle visualized by the anterior portal is helpful to show the right direction for the portal. After skin incision, a forceps is used to widen the portal. Then the instruments or the arthroscope can be introduced. Posterior tibial artery and nerve are protected by the tendons of tibialis posterior and flexor digitorum longus.
We have used this portal (instrumentation and arthroscope) in four patients (3 osteochondritis dissecans of the medial part of the talus, 1 loose body) without problem.
This portal is safe; it does not intersect the direction of posterior tibial artery and nerve as in the postero-medial portal described by Parisien and avoids in most cases the approach described by Guhl.
Because the medial malleolus is more anterior than the lateral malleolus, it allows a larger approach to the posterior part of the joint than the postero-lateral portal. We recommend it for the arthroscopic treatment of all the lesions of the postero-medial part of the joint.
踝关节镜手术适应证的发展以及该关节的狭窄要求采用完全适配的入路。已经描述了几种可进入关节后内侧角的后入路，但并不令人满意。在此，我们描述一种新的后内侧入路，它能安全、便捷地进入关节后部。
使用标准关节镜（30度，直径4.5毫米）和外侧踝关节撑开器进行关节镜检查。该入路的标志是内踝后嵴。在内踝后尖端上方，此嵴向上向后走行，然后其方向变为严格垂直。新入路位于此处，在嵴后方5毫米处（通常在内踝后尖端上方2厘米）。通过前入路可见的一根针有助于显示入路的正确方向。皮肤切开后，用一把钳子扩大入路。然后可插入器械或关节镜。胫后动脉和神经受到胫后肌腱和趾长屈肌腱的保护。
我们已在4例患者（3例距骨内侧剥脱性骨软骨炎，1例游离体）中使用了该入路（器械和关节镜），未出现问题。
该入路安全；它不像巴黎ien描述的后内侧入路那样与胫后动脉和神经的走行相交，并且在大多数情况下避免了Guhl描述的入路方式。
由于内踝比外踝更靠前，与后外侧入路相比，它能提供更大的空间进入关节后部。我们推荐将其用于关节后内侧部分所有病变的关节镜治疗。
