A minimally invasive technique, arthroscopy is a procedure where a small video camera attached to a fiberoptic lens is inserted into the body. This allows the physician or surgeon a better view of the affected area without making a big incision. Nowadays, arthroscopy is used to evaluate and treat orthopaedic conditions in several different joints of the body. The ankle joint is one of the common joints where arthroscopy is used. In ankle arthroscopy, a thin fibre-optic camera is used to magnify and transmit images of the ankle onto a video screen, so the surgeon can perform the necessary surgical procedures.

In this article, we will cover:

• Parts of the ankle treated during ankle arthroscopy
• Types of conditions treated using ankle arthroscopy
• What to expect before and after ankle arthroscopy

The ankle joint is made up of three bones — the talus, tibia (shinbone) and fibula (small bone of the lower leg). The top of the talus fits inside the socket formed by the lower end of the tibia and fibula, and the bottom of the talus sits on the calcaneus (heel bone).

The tough bands of tissue that connect bones together are called ligaments. There are three ligaments that make up the lateral ligament complex on the side of the ankle that is farthest from the other one. They are the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL).

Two of these ligaments, the ATFL and CFL, are commonly involved in a common ankle sprain or inversion injury to the ankle. Usually, the ATFL prevents the ankle from sliding forward and the CFL prevents it from rolling inward on its side. There is also another ligament on the medial side of the ankle joint called the deltoid ligament.

When the deltoid ligament is torn, it is typically torn in a combination of injuries when the ankle is broken, and is rarely injured alone.

The joint capsule is a water-tight pocket that surrounds the ankle joint. It is made up of ligaments, connective tissue and synovial tissue. Once the joint capsule is filled with sterile saline and is distended, the surgeon will insert the arthroscope into the created pocket. Then, the lights and camera will be turned on to look inside the hip joint. The surgeon will be able to see the surfaces of the distal tibia, fibula, talus and the synovial lining of the joint.

When it first became available, ankle arthroscopy was primarily used to look inside the ankle joint and make a diagnosis. In present times, it is used to perform a large variety of surgical procedures. Some examples include confirming a diagnosis, removing loose bodies and bone spurs, debriding excess inflamed synovial tissue and fixing fractures on the joint surface.

The goal of the surgeon is to fix or improve the patient’s condition by performing an appropriate surgical procedure. An arthroscope helps the surgeon see clearer through a magnified image and perform surgery using much smaller incisions. As a result, there is less damage to the normal tissue and the healing process is shortened. However, it is important to note that the arthroscope is only a tool and results vary according to the condition of the ankle and other efforts to improve the problem.

It is important that both the patient and surgeon make the decision to proceed with the surgery together. The patient should understand the details of the procedure and clarify any concerns with their surgeon.

There are several steps that need to be taken once surgery has been decided on. A full physical examination might be required to ensure that the patient is in the best condition to undergo surgery.

A visit to the physical therapist who will be in charge of the patient’s rehabilitation after surgery might also be needed to get a head start on the recovery process. This is to allow the therapist to record a baseline of information by checking current pain levels and the movement and strength of each ankle. Additionally, this preoperative visit can help the patient prepare for surgery. They will be taught how to use crutches or a walker safely, as well as some post-surgery exercises.

Before the surgical procedure, the patient will be put under general anaesthesia or a form of spinal anaesthesia. There is typically very little space between the tibia and talus. The surgeon will apply traction to widen this space and insert the arthroscope inside. The end of the arthroscope is moved around so the surgeon can look around the joint. Lastly, sterile drapes will be placed to create a sterile environment for the surgeon to work. Around the operating table, there will be a variety of equipment such as surgical instruments, cameras, light sources and TV screens.

To begin the operation, the surgeon makes two to three tiny incisions on the ankle, known as portals. The arthroscope and surgical instruments will be placed inside the ankle through the portals. The surgeon will be careful to protect the nerves and blood vessels nearby. A small metal or plastic tube, known as a cannula, will be inserted through one of the portals to inflate the ankle with sterile saline.

The arthroscope is a small fibre-optic tube that is used to look into and operate inside the joint. This small metal tube has a diameter of ¼ inches and is about 7 inches long. A bright light and TV camera are connected to the outer end of the arthroscope through the fibre optics inside the metal tube. The light will shine into the ankle joint through the fibre optic tube. The TV camera, attached to the lens on the outer end of the arthroscope, projects the image from inside the ankle joint onto the TV screen outside. The surgeon with keep watch on the TV screen while moving the arthroscope around inside the ankle joint.

Several specialised instruments have been developed over the years using the arthroscope to observe what happens during surgery. Now, many surgical procedures that used to require large incisions can be done with much tinier incisions. One such example is where the simple removal of a loose body in the ankle requires only two to three small incisions of ¼ inches. That being said, more extensive surgical procedures may still require larger incisions. During the surgery, the surgeon may decide that a traditional open type operation is needed. If it has already been discussed before the operation, the surgery may be performed on the spot. If not, the arthroscopic procedure will be concluded and a later operation will be planned. The surgeon will then communicate the situation and discuss the details of the next operation with the patient.

When the surgical procedure is done, surgical staples or sutures will be used to close the portals and incisions. The patient may be placed in a large compressive bandage and splint from the knee to the toes. This is to immobilise and provide the ankle with protection. Alternatively, the patient may be placed in compression stockings if the surgeon does not see a need for a bulky bandage and splint. Compressive bandages or stockings are used to reduce swelling and prevent blood clots from forming in the leg. Finally, the patient will be escorted to the recovery room.

As with all major surgeries, complications may arise during ankle arthroscopy. Below are some of the more common complications that may occur:

• anaesthesia complications
• infection
• thrombophlebitis
• equipment failure
• slow recovery

Anaesthesia complications

Most surgeries require some form of anaesthesia to be done beforehand. Most patients do not have any problems with anaesthesia. However, a small number run into complications such as reactions to anaesthesia, the drugs used and problems related to other medical complications. Patients are advised to discuss the risks and concerns with their anesthesiologist.

Infection

It is possible for a postoperative infection to occur after ankle arthroscopy. However, it is very uncommon and only happens in less than 1% of cases. Patients may experience increased pain, swelling, fever and redness or drainage from the incisions. One should alert their surgeon immediately if they suspect they are developing an infection.

There are two types of infections, superficial or deep. A superficial infection may occur in the skin around the portals or incisions. Superficial infections do not extend into the joint and can typically be treated simply using antibiotics. However, if the ankle joint itself becomes infected, it will become a serious compilcation and may require another surgical procedure on top of antibiotics to drain the infection.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, also known as deep venous thrombosis (DVT), is prone to occur following any operation. However, it is more likely to occur on the hip, pelvis and knee area. DVT occurs when blood clots form in the large veins of the leg. This can lead to swelling in the leg and it may become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung and lodge in the capillaries, cutting off blood supply to a part of the lung. This is called pulmonary embolism. This name is derived from pulmonary which means lung, and embolism which refers to something travelling through the vascular system. DVT is something that surgeons go to great lengths to prevent. There are several ways to reduce the risk of DVT, but the most effective method is possibly getting the patient to move as soon as possible after surgery. Other preventive measures include wearing pressure stockings to keep the blood in the legs moving and using medications that thin the blood and prevent the formation of blood clots.

Equipment failure

Several instruments used by surgeons in ankle arthroscopy are fragile and small. These instruments may break, and as a result, leave a piece of instrument floating inside the joint. Normally, this breakage does not cause any damage to the joint. Such broken pieces are typically easy to locate and remove, but this may prolong the duration of the operation.

During and after arthroscopy, several kinds of devices such as pins, screws and suture anchors are used to hold tissue in place. There is a possibility of these devices causing problems. For example, if one device breaks, the free-floating piece may hurt other parts of the joint, particularly the articular cartilage. The anchor at the end of the tissue may poke too far through the tissue, rubbing and irritating the nearby tissues. As such, a second surgery may be needed to remove the device and fix the problems caused.

Slow recovery

Not all patients are able to resume their normal routine activities shortly after ankle arthroscopy. Smaller incisions used in arthroscopy does not always mean that a more minor surgery is done. It is possible to perform a great deal of reconstructive surgery inside the ankle joint via small incisions through an arthroscope. The speed of recovery is affected by the kind of surgery performed inside the ankle. It usually takes a shorter amount of time to recover if only a simple procedure was done. Patients who have suffered extensive damage to the articular cartilage in the ankle joint tend to require more complex and extensive surgical procedures. Extensive reconstructive surgeries like these will take a longer time to heal and have a slower recovery process. Patients are advised to discuss expectations following ankle arthroscopy.

Ankle arthroscopy is typically done on an outpatient basis. This means that patients can go home on the same day as their surgery. However, more complex reconstructions where bones are altered and larger incisions are required may require a short stay in the hospital. The purpose of this is to better control the pain and monitor the condition. One may also begin physical therapy while in the hospital.

The portals are covered using surgical strips, while sutures or surgical staples may have been used for larger incisions. Crutches are also commonly used after ankle arthroscopy and may only be needed for one or two days for simple procedures.

It is important to follow the surgeon’s instructions regarding placing weight on the foot while walking and standing. Be careful not to avoid doing too much too quickly. Patients may also be instructed to use a cold pack on the ankle, and also to keep the leg supported and elevated.

Rehabilitation is determined based on the kind of surgical procedure performed. Formal physical therapy may not be required if the procedure was a simple one, like a simple debridement. Simple instructions may be given to do some exercises as a part of a home rehabilitation program.

Most patients will be asked to take part in formal physical therapy following ankle arthroscopy. In general, rehabilitation programs tend to be longer and more involved if the surgery had been more complex. The initial physical therapy treatments are structured to help control pain and swelling after the surgery. Patients will also be taught how to place a safe amount of weight on their affected leg.

In the present day, arthroscopy is used to perform complex and major reconstructive surgery using only tiny incisions. It is important to remember that small incisions on the outside do not mean that there is not much healing to be done on the inside of the ankle joint. Patients of major reconstructive surgery can expect recovery to take several months. The goal of a physical therapist is to help keep pain under control while improving motion and strength of the ankle. After the ankle is in a stable condition and is recovering well, regular therapist visits will no longer be required. However, it is still the patient’s responsibility to complete their exercises as part of their home rehabilitation program.