Arthroscopic technique of the retrotalar tunnel
Dr. Vallotton details a specific surgical technique for retrotalar tunnel arthroscopy. He describes the instruments, operative steps, and precautions, emphasizing the importance of proper positioning and precise visualization to avoid complications.
Doctors
Topics
Treatments
Advice
- Dr Jacques Vallotton
- Preparation of the material
- Operating room
- Steps of surgery
- Tunnel visualization
- Precautions and complications
- Retrotibial arthroscopy
- respect for the alignment of the instruments
- visualization of the long flexor tendon
- neurovascular precautions
Posterior ankle impingement: understanding the anatomy of the retrotalar tunnel
Posterior ankle impingement occurs when the tendon and capsulo-ligamentous structures are compressed behind the talus during plantar flexion. The flexor hallucis longus (FHL) tendon passes through a true retrotalar tunnel where a fibrous pulley and the posterior talocalcaneal ligament can thicken and impede gliding. This situation particularly affects athletes exposed to repeated plantar flexion positions, such as dance or football, and results in posterior pain, impingement, and sometimes reduced performance.
The goal of treatment is to restore space and mobility to the FHL while preserving neighboring structures. When conservative measures fail, retrotalar arthroscopy is a minimally invasive option that allows for precise visualization of the posterior subtalar joint, identification of sources of impaction, and release of the tendon in its tunnel to restore smooth propulsion mechanics.
When to consider retrotalar tunnel arthroscopy
The indication is discussed in the presence of persistent posterior pain, increased in plantar flexion, and functional discomfort despite rest, physiotherapy and adaptation of activity. The examination often finds sensitivity to posteromedial palpation and hallux flexion tests. Imaging provides guidance but sometimes remains non-specific; clinical correlation takes precedence.
In active subjects, arthroscopy can rule out associated bone pathology (os trigonum impingement, spurs) and assess subtalar stability. It is part of a graded strategy that aims to quickly relieve pain while preserving tissues and minimizing iatrogenic risks.
The real difficulty is to begin the dissection on the posterior aspect of the talus.
Operative preparation and safety principles
The prone position, careful protection of the bony reliefs and the placement of two posterior portals (medial and lateral) ensure a horizontal and controlled instrument trajectory. Effective irrigation maintains a clear field, a safe condition for progressing in contact with the ligamentous landmarks and the FHL. Navigation is carried out under strict visual control, respecting the axis of the instruments and avoiding any deep penetration towards the posteromedial neurovascular structures.
Before any resection procedure, arthroscopy confirms the exact location of the conflict and checks the relationship between the tendon, the pulley and the posterior subtalar joint.
Key actions: subtalar exposure and release of the FHL
After identification, the fascial fibers are cleaned to expose the posterior plane of the subtalar joint. The reasoned section of the posterior talocalcaneal ligament widens the view and allows identification of the FHL pulley. A progressive release of this pulley reestablishes the tunnel space and allows free sliding of the tendon. Dedicated instruments (shaver, radiofrequency) are used with short strokes, maintaining the horizontal orientation to avoid any deviation towards the vascular-nervous planes.
External mobilization maneuvers confirm at the end of the procedure the restoration of tendon glide.
The horizontality of the instruments must be respected to avoid trajectory errors.
Prevent complications and check critical points
Orientation errors expose the patient to vascular and nervous system injuries and insufficient resection of the pulley. Systematic checks are performed: quality of irrigation, constant identification of the FHL, free sliding test, and, if necessary, radiological control to confirm the level treated. Incomplete resection can allow impingement to persist; conversely, excessive resection poses a risk to the tendon. Technical rigor and careful progression are crucial to achieve a lasting result.
Rehabilitation and resumption of activities
Early rehabilitation promotes recovery: pain and edema management, active mobilizations, and proprioceptive work targeted at the foot-ankle chain. Weight-bearing is gradual, with a return to sports movements guided by the absence of pain and the quality of motor control. The goal is a functional foot, without catching, allowing hallux propulsion and subtalar stability in exposed activities such as dance or football.
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