Arthroscopy is a surgical procedure during which the internal structure of a joint is examined for diagnosis and treatment of problems inside the joint. Ankle Arthroscopy includes the diagnosis and treatment of ankle conditions. In arthroscopic examination, a small incision is made in the patient’s skin through which pencil-sized instruments that have a small lens and lighting system (arthroscope) are passed. Arthroscope magnifies and illuminates the structures of the joint with the light that is transmitted through fiber optics. It is attached to a television camera and the interior of the joint is seen on the television monitor.
Arthroscopic examination of ankle joint is helpful in diagnosis and treatment of the following conditions:
- Inflammation: Synovitis, the inflammation of the lining of the ankle joint
- Acute or chronic injury
- Osteoarthritis: A type of arthritis caused by cartilage loss in a joint
During arthroscopic ankle surgery, either a general or local anesthesia will be given depending on the condition. A small incision of the size of a buttonhole is made through which the arthroscope is inserted. Other accessory incisions will be made through which specially designed instruments are inserted. After the procedure is completed arthroscope is removed and incisions are closed. You may be instructed about the incision care, activities to be avoided and exercises to be performed for faster recovery.
Some of the conditions treated by ankle arthroscopy include:
- Ankle Arthritis
- Unstable ankle
- Ankle fracture
- Osteochondral Defects of the talus
- Undiagnosed ankle pain
Some of the possible complications after arthroscopy include infection, phlebitis (clotting of blood in vein), excessive swelling, bleeding, blood vessel or nerve damage and instrument breakage.
It may take several weeks for the puncture wounds to heal and the joint to recover completely. A rehabilitation program may be advised for a speedy recovery of normal joint function. Your child can resume normal activities and go back to school within a few days.
Common symptoms of an ankle fracture include pain & swelling, bruising, the inability to weight bear and deformity if the injury is severe or the ankle is dislocated.
An ankle fracture can usually be diagnosed with a simple x-ray, however sometimes a CT scan or an MRI may be required to evaluate the fracture pattern or any associated ligament or cartilage injury sustained at the time.
Treatment varies depending on the type and severity of the injury. If the fracture is undisplaced and there is minimal ligamentous damage, the most common method of treatment would be a short leg plaster cast and remaining off your feet with crutches till you can be evaluated with your GP or your surgeon.
If there is significant displacement or the ankle fracture is deemed unstable, you may require surgery to realign the bones. During surgery your doctor may place plates, screws or pins to hold the broken bone until healing happens.
You may then be placed either into a plaster cast or a moonboot after your surgery. Once the fracture has healed, your surgeon will usually recommend Physiotherapy to increase the range of motion and rehabilitate your ankle.
This condition can be particularly debilitating as you gradually lose trust and confidence in your ankle. You may feel particularly unstable initially on uneven ground or when playing sports, progressing to instability even when doing normal activities of daily living. Each ankle sprain will progressively weaken your ligaments, resulting in greater loss of confidence and increased instability.
This instability can clinically be proven when your surgeon examines your ankle and notices increased tilt of the talus (ball joint of the ankle) and also increased laxity to pulling your ankle anteriorly (anterior drawer).
This can be further confirmed by an ultrasound that reveals chronic tears or absence of the ligaments that stabilise the ankle. On occasion your surgeon may order an MRI to exclude any other concomitant pathology within the ankle. Repetitive sprains to the ankle can sometimes cause damage to the cartilage within the ankle joint, called talar osteochondral defects and it is important to identify these if surgery is required, as these can be addressed simultaneously.
Treatment for chronic ankle instability is the same as an acute ankle sprain, which in the initial period of a sprain is still RICE (Rest Ice Compression Elevation), then progressing to physiotherapy to strengthen and improve proprioception and balance in the ankle. Wearing a brace can also help to increase stability and proprioception to the ankle.
Occasionally your surgeon will recommend surgery when non-operative measures have failed or there is other additional damage within the ankle requiring attention. Stabilizing the ligaments is usually done through an open approach on the lateral (outside) aspect of your ankle, where your surgeon will identify the torn or lax ligaments, and tighten and repair them up to the fibula, using sutures, or anchors – which are special screw-like devices with sutures within them. You may be placed into a plaster cast or moonboot while the ligaments repair themselves, and there may be a period of non-weight bearing to allow the wound to heal. After that, you are encouraged to come out of your moonboot/plaster to allow gentle range of motion of the ankle. Once the ligaments are healed, ongoing physiotherapy is encouraged to continue strengthening the ligaments and to obtain adequate range in the ankle.
Achilles Tendon Rupture
Usually patients report a loud pop or snap that then causes the inability to weight bear associated with severe pain & swelling. Upon presentation to your GP or surgeon, they may notice a gap or depression in the tendon, just above the heel bone.
The rupture can usually be diagnosed either clinically, or with an ultrasound, though on occasion your surgeon may order an MRI to delineate the severity of the tear further.
The Achilles rupture can be treated either conservatively, or with surgery. Conservative management usually involves placing you into a plaster cast initially, then transitioning you into a moonboot. You may be allowed progressive weight bearing along with physiotherapy to encourage healing of the rupture.
Surgical repair of the Achilles can either be done through a small cut, or even percutaneously, to expose the rupture and suture the ends of the tendon together. Surgery has the added benefit of reducing the risk of re-rupture, increasing the push off power of the Achilles and increasing return to sport.
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Initial symptoms of bruising and swelling can be severe therefore it is important to present to your GP for initial investigation, which will usually include an x-ray and an ultrasound. You may require crutches initially, and your GP may either use a compression stocking to control your pain & swelling, or a moonboot.
To aid the swelling & bruising, the mnemonic RICE consisting of Rest, Ice, Compression & Elevation is important to be adhered to. It can take anywhere up to 2 weeks or more for the symptoms to settle.
The x-ray is usually normal, or may reveal small avulsion flakes of bone off the tip of the fibula which can represent ligaments of the ankle that have pulled off these small flecks of bone. The ultrasound report can also sound daunting, reporting ruptures of ligaments such as the ATFL and the CFL. Despite this, many ankles go on to recover well, as these ligaments are anatomically very weak, and are commonly ruptured with a simple ankle sprain.
Upon presentation to your surgeon, they will examine you to ensure you do not have any other serious injuries that may have occurred during the sprain. Although it is tempting to perform an MRI, an ankle sprain is usually diagnosed clinically, or with the initial x-ray and ultrasound. The only reason to perform and MRI would be to exclude other injuries within the ankle that do not appear to be settling after 4-6 weeks.
If your surgeon or GP diagnoses an ankle sprain, initial treatment once pain & swelling settles will be to gradually increase the range of motion in your ankle with simple flexion & extension exercises of the ankle, and to slowly increase the amount of weight you can put through the ankle. Your surgeon will encourage you to wean yourself out of your moonboot and perhaps recommend an ankle brace temporarily until you regain strength & confidence in the ankle. They will also refer you to a physiotherapist, who will be able to guide you through exercises necessary to regain range of motion, strength and proprioception in your ankle.
Depending on the severity of your injury, it can take up to 6 weeks or more to recover from an ankle sprain, and sometimes up to 3 months before you can return to sport. The most common reasons your surgeon would recommend surgery would be:
- There is other pathology within the ankle as a result of the sprain that requires surgery
- Ongoing pain, likely due to chronic inflammation & scar causing impingement within the ankle joint
- Chronic instability or frequent giving way of the ankle (ankle instability)
A simple x-ray will usually confirm the diagnosis – there can be evidence of loss of joint space, osteophytes (bony spurs), increased sclerosis (opacity of the bones close to the joint) and development of cysts later on.
Initially, non-operative management such as simple analgesia, anti-inflammatories, activity modification or braces can help, but as symptoms progress and begin to interfere with your activities of daily living or mobility, your surgeon may recommend surgery.
Surgical options mainly involve either replacing the joint, or fusing the joint together. An ankle replacement involves removing the worn surfaces off the tibia and talus, placing a metal cap on both ends with a sophisticated polyethylene spacer in between. This will allow maintenance of range of motion, however ankle replacement systems are still evolving, long term results are not yet proven, and therefore criteria to meet the surgical requirements for an ankle replacement are still limited. Your surgeon can explain more and determine whether you are suitable.
An ankle fusion will involve also removing the worn surfaces off the tibia & talus, compressing the joint and holding it with metal pins or plates. Depending on the level of deformity, this can either be done arthroscopically or through an open cut. While ankle replacements continue to evolve, this is still the more common procedure performed. There may be a period of 6-8 weeks where your surgeon may recommend either a plaster cast or moonboot and remain non weight bearing while the fusion takes.
Contrary to belief, despite the ankle being fused, you can still walk normally and complete all activities of daily living with minimal compromise. Most do not notice a significant difference, as the arthritis causes stiffness within the ankle anyway, and more importantly, there is relief from the pain.
Separate to the Achilles tendon rupture, Achilles tendinopathy is gradual degeneration & inflammation of the Achilles tendon, causing pain, swelling and limited mobility.
- Insertional Achilles tendinopathy occurs at the insertion of the Achilles onto the heel (calcaneus), and is an enthesopathy – inflammation or degeneration of a tendon at its insertion onto bone. It typically affects overweight, middle aged male athletes, though it can also be associated with repetitive strain to the Achilles, or a tight gastrocnemius (calf) muscle. Insertional Achilles tendinopathy can also be associated with a heel spur (pump bump), or a Haglunds deformity – overgrowth of bone in front of the Achilles tendon.
As opposed to non-insertional Achilles tendinopathy, insertional Achilles tendinopathy can be quite recalcitrant to non-operative measures, though it is still worth a trial of at least 3-6 months. Heel lifts, Physiotherapy to perform eccentric calf stretches and occasionally shockwave therapy can be recommended by your GP or surgeon to help.
If all these measures fail, then your surgeon may recommend surgery – occasionally this can be performed arthroscopically, but the majority of the time if there is degeneration within the substance of the Achilles tendon itself, then your surgeon will recommend opening up the tendon, debriding the degenerative portion, removing the heel spur &Haglunds, and re-attaching the tendon back to bone. You will then be placed into a plaster cast, and transitioned into a moonboot, though your weight bearing will be limited for about 8 weeks, and with the help of progressive Physiotherapy, it can take up to 6-9 months before you can return to sport.
- Non-insertional Achilles tendinopathy occurs approximately 2-6cm above the insertion of the Achilles tendon onto the heel. This is a watershed area of vascular supply which is generally quite poor, hence the common location for degeneration & inflammation of the tendon here. Though it can affect the same group of patients and your symptoms may be the same, the treatment is quite different.
With non-insertional Achilles tendinopathy, non-operative measures actually work far better than for insertional tendinopathy. Heel lifts, Physiotherapy for eccentric calf stretches and shockwave therapy are still recommended, however they have a much higher rate of success than for insertional tendinopathy. You will still need to persist with these measures for at least 3-6 months however to notice a benefit.
Surgery can still be recommended for non-insertional tendinopathy that has failed a trial of non-operative treatment. This can usually be done through smaller, percutaneous incisions or arthroscopically, with much quicker recovery rates, however again – if there is substantial degeneration within the substance of the tendon, there may be a small cut required to debride the tendon and repair it.
Osteochondral Defects of the Talus
The talus is the ball joint of the ankle, that articulates with the tibia and allows you to range your ankle joint. An osteochondral defect presents as damage to articular cartilage of the dome of the talus, usually the result of injury.
Flat Foot Deformity (pes planus)
On occasion the flat foot can cause pain – and the symptoms and location can be varied. Most commonly this causes pain around the region of the tibialis posterior tendon – which is located around the inside (or medial aspect) of your ankle radiating down to the instep of your arch.
Sometimes it can also cause pain on the outside of your ankle, just below the tip of your fibula, as this is your subtalar joint – the joint below your ankle joint. This can be because of inflammation that is radiating through from the inside to outside of the joint, or because of impingement from the progressive flat foot deformity.
The tibialis posterior tendon is a very important tendon that maintains the arch of your foot and is a powerful inverter and plantar flexor of your foot (it turns your foot in and helps you to push off). If the tendon becomes frayed or inflamed over time, this can cause ongoing pain and also worsen the flat foot deformity.
Initially this can be offloaded or supported with orthotics to reduce the inflammation and take the pressure of the tibialis posterior tendon, however on occasion, surgery may be required to repair or replace the tendon, and also to correct the shape of your foot.
Fracture of the Calcaneus
These fractures are usually of high energy and thus can cause the heel bone to fracture into multiple fragments. The principle of treating fractures of the calcaneus is to maintain alignment of the bone and to prevent further arthritis in future.
Again if the fractures are overall in good alignment, these can be treated in plaster or a moon boot remaining non-weight bearing for approximately 8 weeks. If however the fractures are displaced or alter the alignment of the heel, then surgery is recommended to prevent further repercussions in future.
If surgery is required, all attempts are made to minimise soft tissue damage, as there are increased chances of skin incisions not healing well with long cuts in the calcaneus, therefore we attempt to fix the fractures through smaller cuts or percutaneous/keyhole placements of screws or plates.