Ankle arthroscopy is a minimally invasive surgical technique that utilizes the technology of fiber optics magnifying lenses, and digital video monitors to allow the surgeon to directly visualize the inside of an ankle through small incisions.
Several incisions, (1/2 a centimeter in length) are fashioned about the ankle to allow for the insertion of a small fiber optic video camera, and/or special arthroscopic instruments. Sterile fluid is also circulated through the ankle to distend the joint, creating more space for the arthroscope and instruments. This also allows for better visibility within the ankle, space to maneuver instruments, and clearance of debris.
How is Ankle Arthroscopy Performed?
Ankle arthroscopy is generally performed as an outpatient surgery under general anesthesia with or without a regional pain block or epidural anesthetic with sedation. After adequate anesthesia is established, a tourniquet is applied to the leg and the leg is prepped and draped in a sterile fashion. Incisions are made in the front or back of the ankle to serve as entry points into the ankle, or portals, for the arthroscopic camera and instruments. These portals are placed strategically in an effort to avoid vessels and nerves. Sterile fluid is then allowed to flow through the ankle to further open the joint. At the completion of the procedure, small sutures are placed in the skin to close the portals. The patient is usually discharged home the same day with specific weight bearing and dressing care instructions.
Ankle arthroscopy can treat several ankle joint disorders:
- Osteochondral defect of the talus (also referred to as osteochondritis dessicans, OCDs, osteochondral fractures)
This includes acute ankle sprains and repetitive ankle injuries caused by chronic instability. Patients often complain of persistent and progressive ankle pain and swelling. This can be associated with mechanical symptoms of catching, clicking, or popping, and decreased range of motion. The diagnosis is made with the combination of physical exam and diagnostic imaging including x-rays, MRI, and/or CT scan. After the diagnosis is made arthroscopically, treatment options include micro fracture subchondral drilling, abrasion arthroplasty, fragment fixation, and bone grafting procedures. Thorough discussion with your surgeon is necessary to determine which option is most appropriate for you.
- Anterior Ankle Impingement (also referred to as “athlete’s ankle” or “footballer’s ankle”) and Anterolateral Ankle Impingement
These occur when either bone and soft tissue of the anterior (the “front” of) ankle joint becomes inflamed due to repetitive stress or irritation. This will cause pain in the ankle joint, swelling, and can limit motion of the ankle, especially dorsiflexion (loss of the ability to bend your “toes towards your nose”). The diagnosis of anterior ankle impingement can be made by identifying osteophytes, or “bone spurs,” on standard x-rays of the ankle. Sometimes a MRI is necessary if bone spurs are not present. MRI can identify redundant and inflamed soft tissue in the anterolateral gutter of the ankle not seen with standard x-rays. This is considered anterolateral ankle impingement. If nonoperative measures fail to relieve symptoms of either of these conditions, ankle arthroscopy can be used to shave away redundant soft tissues and/or bone spurs.
- Posterior Ankle Impingement
This occurs when the bone and soft tissue of the hind foot (the “back” of the ankle) becomes inflamed due to repetitive stress. This will cause pain in the ankle joint, swelling, and often times limited motion of the ankle, especially plantarflexion (loss of the ability to “press on the gas”). Like anterior ankle impingement, it is usually associated with bone issues, in the posterior part of the ankle (the “back” of the ankle). It can also be associated with an accessory bone, which is not found in all patients that is referred to as an os trigonum. Surgical treatment involves placing arthroscopic incisions in the back of the ankle to access the painful area. Bone spurs, inflamed soft tissue, and if present, the os trigonum, can then be removed arthroscopically.
Synovitis is inflammation of the soft tissue lining of the ankle joint (synovium) that will often manifest as pain, swelling, and loss of motion. This can occur due to an acute trauma, inflammatory arthritis (i.e. rheumatoid arthritis), overuse, and degenerative joint disease (osteoarthritis). If nonsurgical treatment options fail to provide relief, ankle arthroscopy can be used to surgically remove inflamed synovium.
- Loose Bodies
Articular cartilage and/or scar tissue following trauma to the ankle can become free floating in the joint and form what is referred to as a “loose body”. These can also occur with in the setting of a condition called synovial chondromatosis, where the lining of the joint becomes redundant for unexplained reasons. These loose bodies can cause problems such as clicking, catching, and frank locking that often lead to pain, swelling, and loss of motion. Occasionally loose bodies can be identified with standard x-rays or a CT scan, but frequently require an MRI is needed to visualize the culprit. Ankle arthroscopy can be used to find and remove the loose body.
Sometimes previous trauma, prior ankle surgery, infections of the ankle joint, and inflammatory arthritides such as rheumatoid arthritis predispose patients to the development of scar tissue, or arthrofibrosis. Ankle arthroscopy can be used to identify this scar tissue and remove it.
Septic arthritis, or infection of the joint space, can not be treated effectively with antibiotics alone. It often necessitates an urgent surgery to wash out the joint. This can be done as an open procedure or with an arthroscopy. Although infections of the skin and soft tissue around the ankle joint preclude ankle arthroscopy in most settings, septic arthritis, can be an indication for ankle arthroscopy. The decision of whether or not an infection is amenable to arthroscopic surgery is determined by many factors. Only you and your surgeon can determine whether or not it is appropriate for you.
Ankle arthroscopy also be used along with conventional techniques of fracture repair to ensure that normal anatomic alignment of cartilage within the ankle is restored. This is done to help minimize the risk of future post traumatic arthritis.
- Unexplained Ankle Symptoms
Occasionally patients develop symptoms such as pain, swelling, locking, catching, grinding, or popping that cannot be explained with diagnostic techniques such as x-rays, CT scans, MRIs, or bone scans. When nonoperative measures have been exhausted, ankle arthroscopy can be used to diagnose lesions within the ankle joint. It provides the opportunity to look directly into the joint, identify potential problems, and definitively treat many of them.
- Tibiotalar Arthritis
Ankle fractures, infection, osteonecrosis, and arthritis may eventually lead to chronic pain and stiffness that can not be controlled with non-operative measures. Ankle fusion is a treatment option appropriate for many patients in this situation. When performed by an experienced surgeon, ankle arthroscopy offers a minimally invasive way to perform ankle fusion that may yield results that are equal to or better than conventional open techniques. Your surgeon can determine if this procedure is appropriate option for you.
Recovery: How do I Care for my Ankle after Surgery?
This will ultimately depend on the type of problem and nature of the arthroscopic procedure used to treat the problem. Patients can expect pain and swelling following surgery that necessitates elevation of the leg and oral pain medication for at least several days. The type of procedure performed will determine whether or not your ability to bear weight on the affected leg will be restricted after surgery. This can range from progressive immediate weight bearing with crutches, to a period of strict non-weight bearing for one to two months. Your dressing will be left in place until follow-up with your surgeon, and sutures will be removed one to two weeks after surgery. Active range of motion is generally allowed immediately. After the swelling and soft tissue reaction subsides, a progressive strengthening routine may be implemented. It will be up to your surgeon when each of these activities is allowed and whether or not a formal physical therapy referral is necessary.
Many factors will contribute to the outcome of your ankle arthroscopy procedure. These include, but are not limited to: your expectations, the severity of your condition, complexity of the procedure performed, as well as postoperative compliance, rehabilitation and motivation.
Advantages of Ankle Arthroscopy
Ankle arthroscopy makes possible direct visualization of the inside of the ankle without large cosmetically unsightly scars. It minimizes other problems encountered with large incisions around the ankle such as pain, bleeding, wound breakdown, and infection. The procedure can be performed as an outpatient because of its minimally invasive nature. Patients may be able to begin rehabilitation sooner, rehabilitate more functionally, and return to high level activities such as sports.
Who is NOT Eligible for Ankle Arthroscopy?
Patients with severe arthritic changes with loss of the joint space are not good candidates for arthroscopic debridement procedures. Patients with severe peripheral vascular disease, peripheral neuropathy, reflex sympathetic dystrophy/complex regional pain syndrome, and edema may not be eligible for ankle arthroscopy. It is important to thoroughly discuss your individual risks, potential benefits, and the alternatives to ankle arthroscopy with your surgeon.
Potential complications of ankle arthroscopy include, but are not limited to, injury to nerves, vessels, tendons, ligaments or cartilage about the ankle, deep and superficial infections, scarring, reflex sympathetic dystrophy/complex regional pain syndrome, missed diagnoses, broken instruments, and anesthetic complications. It is important to attend follow-up appointments with your surgeon following surgery as recommended.
The following symptoms should be urgently reported to your surgeon, as they may be an indication of a complication:
- Pain not controlled by pain medication.
- Constitutional symptoms including nausea, vomiting, fevers, or chills.
- Wound redness, swelling, warmth or drainage.
- New numbness, weakness, or tingling.