Ankle Arthroscopy

What is ankle arthroscopy?

Ankle arthroscopy is a minimally invasive surgical procedure that orthopaedic surgeons use to treat problems in the ankle joint. Ankle arthroscopy uses a thin fiber-optic camera (arthroscope) that can magnify and transmit images of the ankle to a video screen.

What are the goals of ankle arthroscopy?

The goals of surgery are to reduce ankle pain and improve overall function.

Background

Arthroscopy is an important diagnostic and therapeutic technique for management of disorders of the ankle joint.[1, 2, 3, 4] Ankle arthroscopy can be useful in treating a variety of intra-articular disorders, which may be caused by trauma or by degenerative, inflammatory, or neoplastic conditions. In some cases, the ankle joint disorder is related to extra-articular anomalies, which may be regional (eg, mechanical malalignment in the lower extremity) or systemic (eg, inflammatory arthritis).

As the indications for ankle arthroscopy have increased, so has its usage. The availability of fiberoptic arthroscopy, modern arthroscopic instrumentation, and ankle distraction techniques has allowed orthopedic surgeons to manage a growing of ankle disorders arthroscopically. Surgical procedures of the ankle performed arthroscopically are generally associated with lower morbidity, faster rehabilitation, and better cosmetic results as compared with conventional open surgical methods.[5, 6, 7, 8]

Management of osteochondral defects with autologous cartilage replacement currently requires an open procedure to suture a periosteal patch under which harvested and cultured cells are injected. A biocompatible scaffold for cell proliferation, Hyalograft C, uses laboratory-expanded autologous chondrocytes that are grown on a 3-dimensional graft made of a benzyl ester of hyaluronic acid. The graft is implanted without the need for a periosteal flap and therefore can be implanted arthroscopically.[9]

The role of arthroscopy in the treatment of acute ankle fractures is still unclear; further research is needed. Arthroscopy can assist in reduction and internal fixation of ankle and pilon fractures. It is also useful for treating syndesmosis disruptions, evaluating and treating posterior malleolar fractures of the tibial plafond, and assisting in removal of debris and reduction of talus fractures. Coincidental or concurrent osteochondral lesions can be managed with replacement of fragments or, if this is not feasible, microfracture surgery.

Indications

Arthroscopy is indicated for diagnosis of certain soft tissue disorders when the exact etiology of ankle symptoms remains unclear, as well as for treatment of a variety of ankle disorders, usually after conservative measures have failed.

Indications for diagnostic ankle arthroscopy include the following:

  • Unexplained pain, swelling, stiffness, instability
  • Locking and popping

Indications for therapeutic ankle arthroscopy include the following:

  • Articular injury
  • Soft tissue injury
  • Posttraumatic soft tissue impingement
  • Bony impingement
  • Arthrofibrosis
  • Instability
  • Arthroscopic-assisted fracture fixation
  • Synovitis
  • Loose bodies
  • Intra-articular bands (see the images below)
  • Tendinitis
  • Osteophytes
  • Osteochondral defects (see the image below)
  • Arthrodesis

Synovial inflammation and hypertrophy can result from various conditions, including inflammatory arthritis, infection, crystal arthropathies, degenerative and neuropathic changes, trauma, and overuse. Pigmented villonodularsynovitis is a benign synovial neoplasm that can be either generalized or local. Hemophiliacs often have synovial hypertrophy, and synovial impingement can lead to repeated ankle hemarthrosis.

Inversion injury of the ankle after a single episode or multiple episodes can lead to impingement of the superior portion of the anterior talofibular ligament.

Injury to the inferior tibiofibularsyndesmosis can lead to tearing, scarring, and synovitis in the region of the anteroinferiortibiofibular ligament and impingement of this structure in the tibiofibularsyndesmosis. Increased laxity resulting from torn ankle ligaments allows the talar dome to extrude anteriorly in dorsiflexion and cause soft tissue impingement.[10]

Osteochondral lesions on the dome of the talus can result from acute trauma (eg, from an ankle sprain), degenerative changes, or repetitive trauma. About 10% of lesions are bilateral and are not associated with trauma. Traumatic lesions are mostly anterolateral in location, and degenerative lesions occur on the posteromedial aspect of the talus.

Loose bodies can be chondral or osteochondral in origin and usually result from trauma. They can also occur with synovial chondromatosis or synovial osteochondromatosis and can be free-floating or embedded in synovium or scar tissue.

Anterior osteophytes form over the anterior lip of the distal tibia and corresponding area of articulation on the dorsum of the neck of the talus. These osteophytes or spurs occur because of repetitive and forceful dorsiflexion. Football players and dancers have a high incidence of spurs.

After trauma or degeneration, wear and tear of the cartilage can be responsible for intra-articular adhesions, Loose bodies, and osteophytes. In the late stages, most of the cartilage is denuded, exposing the subchondral bone and cysts.

Intra-articular injury is increasingly being recognized as associated with ankle fractures, but the role of ankle arthroscopy in the evaluation, treatment, and prevention of long-term sequelae is unclear