Ankle Arthroscopy

Also known as key hole surgery or minimally invasive ankle surgery.   Ankle arthroscopy involves using very small incisions to gain access into the ankle joint.  Each incision is less than 1cm and usually two incisions are required. The ankle joint is relatively small and to allow good surgical access to the joint, its dimensions need temporarily to be increased. This is done using a combination of distraction across the joint together with having a stream of pressurized fluid circulating through the joint which distends it.

The list of conditions below is comprehensive for those disorders in which the technique is useful. The alternative is open ankle surgery which results in larger scars and generally more post-operative pain. For certain cases though this is unavoidable.

The inside of the ankle joint can be inspected using a small camera with operations carried out on the joint using small, specially designed instruments.

The various disorders in which the technique is useful :

- Ankle arthritis
- Footballers ankle (Anterior Ankle Impingement)
- Unstable ankle
- Lateral ligament reconstruction
- Ankle pain following fracture
- Loose bodies within the ankle
- Osteochondral defects of the talus
- Diseases of the synovium
- Undiagnosed ankle pain

Advantage of ankle arthroscopy

The alternative to ankle arthroscopy is open ankle surgery. The very small incisions used result in minimal soft tissue disruption and trauma. This in turn results in:

• Significantly lower pain levels than an open approach

• The ankle is comfortable to weight bear through on the day of surgery

• Most cases can be performed as day cases

• Lower infection rates than open surgery

• Earlier return to work/function/sports

• Little scarring

• Minimal effect if further surgery to the ankle is required

Conditions that can be treated with ankle arthroscopy

Unstable ankle - An ankle may be unstable because it is restraining tissues (bone, tendon) or more commonly the ligaments have been injured and are no longer competent or in the normal position. This is known as mechanical instability and though ankle arthroscopy will not by itself treat this condition, there are often associated problems within the ankle joint which will require an arthroscopy as well as addressing the underlying mechanical problem.

An ankle may also be subjectively unstable. This is when the normal restraints (bone, tendons and ligament) are working fine, but the ankle nevertheless feels unstable. This is usually due to a painful area within the joint such as synovitis injury, a plica, arthrofibrosis or a chondral or osteochondral injury. All of these conditions can be treated arthroscopically.
Anterior ankle synovitis before and after removal with an arthroscopic shaver

Ankle pain following a fracture or sprain
Following an ankle fracture which has healed, there are a number of causes for ongoing pain. If the joint surface has been disrupted and either portions of the joint have been lost or it has not been possible to restore the joint back to its normal dimensions then arthritis may ensue with the symptoms that brings.
Occasionally, the metalwork used to fix an ankle fracture can become prominent or seem to be tender superficially and this would also produce pain. Very rarely, a condition known as a regional pain syndrome may occur, which will produce ongoing pain following ankle fracture.
Generally, any residual symptoms after an ankle fracture stand a chance of improving for twelve to eighteen months following the injury, depending on the underlying diagnosis. If symptoms persist and the preceding conditions have been excluded then there may be problems within the joint itself which are leading to ongoing symptoms. Common findings are either chondral or osteochondral injury, synovitic lesions, loose bodies or post-traumatic plica.

Footballers Ankle
This is a condition which is most often present in those who have engaged in kicking sports for a number of years. Footballers ankle manifests itself with pain at the front part of the ankle joint which remains well localised, often to the outer part of the ankle. It is present during activities which bring the foot closer towards the shin bone also known as the tibia. It is due to spurs of bone on one or other side of the ankle. As these approach each other ie when the foot moves upwards, they trap soft tissue within the ankle joint between them and produce localised pain. A spur of bone at the front of the ankle is also a common finding in ankle arthritis. In ankle arthritis the joint surfaces are not normal. Usually in a footballers ankle the joint surfaces are normal.

An otherwise normal ankle joint with an anterior tibial spur, also known as a Footballers Ankle

Ankle osteoarthritis

Debridement or fusion are the two arthroscopic options.

Loose bodies

Loose bodies are pieces of bone and cartilage which either float freely between a joint or sit loosely attached at the margin of the joint. If these jar between the surfaces of the joint they may cause symptoms of instability or pain. This tends to be intermittent rather than continual. They can also produce symptoms of instability.

Diseases of the synnovium (chondromatosis, early rheumatoid)

The synovial joint lining itself may become diseased as the primary complaint within the ankle joint. Conditions which cause this are diseases such as rheumatoid arthritis or synovial chondromatosis.

Synnovial chondromatosis

After ankle arthroscopy
The first 24 hours
Pain relief
When the patient wakes up after surgery the ankle should feel comfortable. The patient will have had ankle and intra-articular injections of local anaesthetic .

Mobility
After the ankle arthroscopy, once you are back on the ward the physiotherapist will start mobilising you. You may put partial weight through the ankle as is comfortable. The conditions where this is not the case are with an osteo chondral defect and if your arthroscopy has been part of a lateral ligament reconstruction. You will be more comfortable using crutches for a day or two and then these can be discarded.

Your operated leg will need to be elevated when non-weight bearing for the first 24 to 48 hours.

You are encouraged to exercise your ankle within the bandage both by moving it up and down as well as moving it from side to side. This is from as soon as you are able to do this.

Length of stay
Once fully awake and mobile the patient can go in the evening or next day morning.. 

Bandaging after Ankle Arthroscopy
Following an ankle arthroscopy you will have three layers of covering. Closest to the wounds are two small adhesive coverings and these should be kept on for two weeks. Overlying this is a layer of sterile wool and overlying this is a crepe bandage. The dressings should be left intact for the first week. The wounds themselves should be kept dry for two weeks. At one week following the surgery you may remove the outer crepe bandage and the underlying wool. The adhesive dressings over the two arthroscopic portals should be left intact. If these should become loose or dislodged, replace them (without touching the wound) with a good sized adhesive plaster. These can be replaced as often as required, it is important that the wound itself is kept untouched and dry.

Driving after Ankle Arthroscopy
Generally you should be comfortable and safe to drive at one week following your ankle arthroscopy as long as you are permitted to weight bear.

Return to Sport
After ankle arthroscopy you will be back to walking at 1-2 days following your ankle arthroscopy. This will be without use of a crutch. Any sporting activity is best left for at least six weeks following the procedure. Realistically, things can be built up from two weeks post-operatively but will probably take in excess of six weeks before more vigorous sporting activity will be possible.

The bandage worn following ankle arthroscopy