Ankle arthroscopy: uses, recovery and risks

What is ankle arthroscopy?

Arthroscopy is a minimally invasive way to see and treat the inside of a joint. The surgeon makes two or three small incisions (portals), inserts a slim camera, and works with small instruments while looking at a monitor. It is a widely used technique for diagnosing and treating problems inside the ankle joint, and because the incisions are small it causes less trauma to the soft tissues than an open approach.^[1]

When it is used

Ankle arthroscopy is considered for problems inside the joint that persist despite non-surgical treatment. Common reasons include:

• Impingement. Bone spurs at the front of the ankle, or thickened soft tissue, can pinch as the ankle bends, particularly in athletes. Arthroscopic treatment removes the spurs or tissue. A systematic review of 20 studies found good results overall, with satisfaction rates of 74% or higher in studies that reported them.^[2,1]
• Cartilage injuries (osteochondral lesions of the talus). These are injuries to the cartilage and underlying bone on the top of the ankle bone (the talus), often after a sprain or fracture. See below.^[1,4]
• Loose bodies and scar tissue, and inflammation of the joint lining (synovitis).^[1]
• Diagnosis when imaging is inconclusive. Arthroscopy can show subtle cartilage damage or synovial disease that MRI or CT doesn’t clearly show.^[1]
• As part of another operation, such as ankle ligament repair, ankle fusion or fracture fixation, to check the joint and prepare its surfaces.^[1,5]
• Selected cases of early arthritis, to clean the joint (debridement).^[6]

Cartilage lesions of the talus

Small cartilage lesions are often treated without surgery first. Surgery is recommended for larger lesions, or when non-surgical treatment has failed.^[4] The choice of operation depends on the size and location of the lesion:

• Bone-marrow stimulation (microfracture, drilling or abrasion) creates tiny channels in the bone beneath the damaged cartilage so that marrow cells can form a repair tissue. It is especially suitable for small lesions and can be done through the arthroscope.^[4]
• Osteochondral grafting replaces the damaged area with a plug of cartilage and bone from another location (autograft) or from a donor (allograft), and is used for larger lesions.^[4]
• Cell-based and scaffold techniques are other options for selected large lesions and are an area of active research.^[4]

An older systematic review found treatment success rates of about 85% for bone-marrow stimulation, 87% for osteochondral transplantation and 76% for cell implantation, and identified bone-marrow stimulation as an effective treatment strategy.^[3] An international group of experts reached consensus statements on debridement, curettage and bone-marrow stimulation for these lesions.^[7]

What the day of surgery involves

Ankle arthroscopy is usually an outpatient procedure. Anesthesia is chosen with the anesthesia team and may include a regional nerve block. A dressing and, depending on what was done, a splint or boot are applied, and your surgeon explains when weight-bearing is allowed.

Recovery

Recovery depends on what was treated: simple debridement or impingement removal usually allows earlier walking than a cartilage procedure, which may require a period of protected weight-bearing to allow the repair to mature. Physical therapy helps restore motion and strength. Full return to sport can take several months. See recovery after foot and ankle surgery.

Risks

Complications of ankle arthroscopy are uncommon but include infection, stiffness, injury to nearby nerves or blood vessels, and persistent pain. Nerve irritation around the incisions can cause numbness or tingling. Some people don’t improve, particularly when cartilage damage is extensive or arthritis is advanced.^[1,2]

Questions to ask before deciding

• What problem inside the ankle is most likely causing my symptoms, and how sure are we?
• Is an MRI or another test needed first?
• What can arthroscopy realistically do for my problem, and what can it not do?
• How long will I be on crutches or in a boot?

When to seek care