Ankle arthroscopy

Introduction

Arthroscopy is a surgical procedure used by orthopaedic surgeons to visualize, diagnose and treat problems inside a joint. In an arthroscopic examination, the doctor makes a small incision in the patient’s skin and inserts a pencil-sized instrument that contains a small lens and lighting system to magnify and illuminate the structures inside the joint. Arthroscopy is now used to evaluate and treat orthopedic problems in many different joints of the body. The ankle joint is one of the most common joints where arthroscopy is used to assess and treat certain problems.

The following guide will help you understand about:

– What parts of the ankle are treated during an ankle arthroscopy
– What types of surgeries are treated with an ankle arthroscopy
– What to expect before and after ankle arthroscopy

Anatomy

Which parts of the ankle are involved?
The ankle joint is formed by the connection of three bones. The ankle bone is called the talus; the upper side of the talus fits into a socket formed by the lower ends of the tibia and fibula (the thin bone of the calf); the lower side of the talus sits on the heel bone called the calcaneus. The talus works like a hinge in its place to allow the foot to move up (dorsiflexion) and down (plantar flexion).
Ligaments are soft tissues that bind bones together. They are similar to tendons, except that tendons attach muscles to bones. Three ligaments make up the lateral ligament complex, on the lateral side of the ankle, at the furthest distance from the other ankle (lateral means further than the center of the body). These include the anterior talofibular ligament, the calcaneofibular ligament and the posterior talofibular ligament. A thick ligament called the deltoid ligament supports the ankle medially (on the side closest to the other ankle).

The ligaments surrounding the ankle help form the joint capsule. A joint capsule is a waterproof sac that forms around any joint. It is made up of the ligaments around the joint and the soft tissue between the ligaments, which fills the spaces left by the ligaments to form a sac.

If the joint capsule is filled with sterile saline and is swollen, the surgeon can insert the arthroscope into this pocket to see inside the joint. The surgeon can see the structures that are inside the ankle joint, including the articular surfaces of the tibia, fibula and talus as well as the synovial tissue.

Arguments

Ankle arthroscopy was originally used to look inside the ankle and establish a diagnosis. Today, ankle arthroscopy is used to perform a wide range of surgical procedures, including confirming a diagnosis, removing osteophytes, removing excess inflamed synovial tissue, visualizing fractures of the articular surface, etc.
The surgeon’s goal is to repair or ameliorate your problem by performing an appropriate surgical procedure; the arthroscope is an instrument that enhances the surgeon’s ability to perform this procedure. The arthroscope’s image is magnified and allows the surgeon good and clear visibility. The arthroscope allows the surgeon to visualize and perform surgery through smaller incisions.

Training

What do you need to know before surgery?
The patient together with the orthopaedic surgeon will decide for this type of surgery. The patient should understand as much as possible about the procedure. If the patient has any doubts and questions, he or she should make sure that he or she gets all the information from the doctor.
Once the decision for this surgery has been made, other measures such as a complete physical examination will have to be taken.

Also, the patient will need a therapist for post-operative recovery. One of the aims of this pre-operative visit is to build up a base of information about the current level of pain, the ability to perform normal physical activities, movements and last but not least information about ankle stability.

A second purpose of the pre-operative visit is to prepare you for surgery. The therapist will teach the patient how to walk safely using a crutch or cane. The patient will also learn some exercises to use during recovery after surgery.

On the day of surgery, the patient will probably be called in the morning at the hospital or orthopedic clinic and will be asked not to eat or drink anything after midnight the night before the operation.

Surgical procedure

What happens during ankle arthroscopy?
A general anesthesia or spinal/regional anesthesia will be performed before the operation. The ankle joint is very tight, with little space between the tibia and talus. By placing traction, the surgeon is able to widen this space and allow the arthroscope to penetrate into the joint.The arthroscope tip will be moved into this space to visualize the entire joint. Finally, sterile drapes are placed over the leg to create a sterile environment for the surgeon when operating. There is a lot of equipment surrounding the operating table, including the high performance monitor, camera, light sources and surgical instruments.
The surgeon begins the operation by making two or three small incisions in the ankle, called portals (SFs J ). Through these portals, arthroscopic and surgical instruments are inserted into the ankle. Great care is taken to protect the surrounding nerves and blood vessels. A small plastic or metal tube (cannula) will be inserted through one of the portals to inflate the ankle with sterile saline.
The arthroscope is a pencil-sized instrument that contains a small lens and illumination system to magnify and illuminate the structures inside the joint. Light is transmitted through fiber optics to the end of the arthroscope inserted into the joint. By attaching the arthroscope to a miniaturized video camera, the doctor is able to examine through this very small incision the entire interior of the joint in detail – unlike the large incision used in traditional surgery. The miniaturized video camera attached to the arthroscope displays images of the joint magnified approximately 12 times on a high-definition monitor, allowing the doctor to examine, test and treat all the structures inside the ankle joint.

Over the years, since the invention of arthroscopy, numerous surgical instruments have been developed to perform different types of arthroscopic surgeries and to see what happens while the instruments are in use. Today, many surgical procedures are performed through small incisions. More extensive surgical procedures may require large incisions. The surgeon may further decide if traditional open surgery is needed and/or a traditional open surgery. If this has been discussed before the surgery, then the surgery can be done immediately, if not, the arthroscopic procedure will be terminated and a traditional open type surgery will be planned later. The surgeon will discuss all the details that were discovered during the arthroscopy and what needs to be done next.
Once surgery is completed, the arthroscopic portals and surgical incisions will be closed with sutures or surgical staples. There is a possibility that the patient will have large sterile bandages applied and splinting from the knee to the toes. The splint and bandage are used to immobilize and protect the ankle. If the surgeon feels that the patient does not need a bulky bandage and splint, then the joint could be placed in a compression stocking. A compression bandage (or stocking) reduces swelling and helps prevent venous thrombosis.

Complications

As with all major surgeries, complications can occur during ankle arthroscopy. This article does not provide a complete list of possible complications, but highlights some of the most common problems. Some of the most common complications after ankle arthroscopy are:
– anesthesia complications
– thrombophlebitis
– infection
– equipment failure
– slow recovery

Complications of anesthesia

Most surgical procedures require some type of anesthesia. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications and problems due to anesthesia. Be sure to discuss any risks that may occur during anesthesia with your anesthesiologist.

Thrombophlebitis (blood clots)

Thrombophlebitis, sometimes called deep vein thrombosis (DVT), can occur after any surgery, but is more likely to occur after hip, pelvic, or knee surgery. DVT occurs when blood clots form in large veins in the leg. This can cause the leg to swell, get warm and become painful to the touch. If the blood clots in the veins break, they can migrate to the lungs, where they settle in the capillaries and cut off the blood supply to part of the lung. This is called a pulmonary embolism. Most surgeons take DVT very seriously. There are several ways to reduce the risk of DVT, but probably the most effective is to mobilize the patient as soon as possible after surgery. Two other preventive measures are:

– compression stockings to keep the blood moving in the legs
– drugs that thin the blood and prevent clots (anticoagulants)

Infection

Following ankle arthroscopy, postoperative infection is possible. This is very uncommon and occurs in less than 1% of cases. The patient may have pain, swelling, fever and redness or discomfort from the incisions. The patient should inform the surgeon immediately of any symptoms that occur.

Infections are of two types: superficial or deep. A superficial infection can occur on the skin around incisions or portals. A superficial infection does not spread into the joint and can usually be treated with antibiotics. If the ankle joint becomes infected, this is a serious complication and will require antibiotics and possibly another surgical procedure to drain the infection.

Equipment / instrument failure

Many of the instruments used by the surgeon to perform ankle arthroscopy are small and fragile. These instruments can break resulting in a piece floating inside the joint. The broken piece is usually easy to locate and remove, but this may result in a longer duration of surgery than originally planned. There is usually no damage to the joint due to broken instrumentation.

Slow recovery

Not all patients can return to routine activities quickly after ankle arthroscopy. . The arthroscope allows doctors to perform reconstructive surgery inside the ankle joint without making large incisions. How quickly the ankle recovers after arthroscopy depends on the type of ankle injury. Simple problems that need simple procedures using arthroscopy generally recover better and faster. Patients with extensive damage to the articular cartilage in the ankle tend to require more complex and extensive surgical procedures. These more extensive reconstructions may require longer healing time and have a slower recovery. You should discuss this with your doctor and make sure you have realistic expectations after arthroscopic ankle surgery.

After surgery

What happens after an ankle arthroscopy?
Ankle arthroscopy is usually done in the operating room, with patients being discharged 24 hours after surgery. More complex reconstructions that require large incisions and more complex surgery may require a short stay in hospital to better control pain and to follow the progress closely. You can also start physiotherapy while you are hospitalized.

Portals are covered with surgical tapes, larger incisions can be repaired with either staples or surgical sutures. Splints are commonly used after ankle arthroscopy. They may only be needed for one or two days after simple procedures.

Follow your surgeon’s instructions about how much weight you can leave on the operated leg while walking. Avoid overexertion. You may be instructed to apply ice to the ankle and keep the leg elevated.

Recover

How is recovery done?
Patient recovery depends on the type of surgery used. Officially, you do not need physiotherapy after simple surgery.
Many surgeons refer patients for physiotherapy after any type of ankle arthroscopy. Generally speaking, more complex surgeries involve a longer recovery. The first few sessions of physiotherapy are designed to help control pain and swelling secondary to surgery.
Remember, just because you have small incisions on the outside, there may be long-term tissue healing on the inside of the ankle joint. If you have had major reconstructive surgery, you should expect a full recovery after several months. The goal of the therapist is to help keep pain under control and improve ankle movement and stability.