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An arthroscopy is a keyhole operation to access the inside of the ankle cavity. This is to make a diagnosis and to provide minimally invasive treatment. It can be done through the front or the back of the ankle depending on where the pathology is. The inside of the joint is then seen via a small camera that is projected onto TV screens.
What happens during the operation?
The operation is done through two or three very small incisions of around 5mm in length each. These are either at the front of the ankle, Anterior Ankle Arthroscopy or at the back of the ankle Posterior Ankle Arthroscopy. The incisions are used to introduce a camera (Arthroscope) into the ankle cavity which then projects the picture onto the TV screen. I can then introduce special instruments; motorised shavers; or drills into the ankle to perform the necessary operation.
Depending on the findings various treatments can then be provided. Most commonly soft tissue scarring, loose bone or cartilage fragments and bone spikes or spurs can be removed from the ankle.
Cartilage defects can also be treated by making small holes in the exposed underlying bone. This will then encourage bleeding from the bone which in turn can form a clot. This then turns into a special scar type cartilage (Fibrocartilage). This technique is known as Microfracture treatment.
The exact procedure is normally planned before the surgery. Sometimes it can be decided during the operation that something new is needed or that what was planned preoperatively is no longer appropriate.
What are the alternative treatments?
An ankle Arthroscopy is recommended normally when all non-operative measures to control your pain have being tried. These include taking pain medications, including anti-inflammatory medications; having physiotherapy; or using shoe inserts or braces. Injections into the ankle or the area where the pain is occurring can also be tried. It is important to note that the treatment is mainly for pain relief and if you can cope with your pain then it is possible to have no surgery at all.
What happens on the day of surgery?
The operation is done under general anaesthetic and as a day case procedure which means you will go home on the same day.
You will be asked to attend the hospital early in the morning so that the necessary checks are undertaken and will be asked to change into the hospital gown. You will be seen by the nurse, physio, and the medical teams before being taken to the operating room.
A cannula is placed in your arm to administer the anaesthetic before putting you under and asleep. Following the surgery, you will have big bulky bandaging around your ankle. You would have been given a local anaesthetic around your ankle so you will not feel much pain.
After returning to your hospital room, you will be met by the physiotherapist who will ensure you can safely get around using crutches. You are likely to be given a flat sandal to wear over your bandages and most patients can fully weight bear on the operated foot following an ankle Arthroscopy. If you have had a micro fracture treatment, then you may be asked to remain non weight bearing and, in those cases, you will rely on the crutches to take your weight.
What is the recovery after an Ankle arthroscopy?
This is a general timeline of recovery after this type of surgery. Depending on how much work has been done at surgery and depending on your individual circumstances the recovery may vary from patient to patient.
If you have had a microfracture treatment, then the period of non-weight bearing may be extended to up to four weeks. Otherwise you can fully weight bear from the 1st post-operative day.
Week 1
During this time, the local anaesthetic given to you at the end of the surgery will start to wear off. this normally happens within the first 12 to 24 hours. You may require to take some painkillers at this stage which would have been provided to you.
You must take it easy be sure to spend time to elevate your leg and use ice to control any swelling. You should also be able to get around to move the ankle within the confines of the bandaging. You may see some bruising or minor bleeding around the bandaging. By the end of the first week, you should feel reasonably recovered from the operation on the pain levels will be very low. You can at this stage remove the bandaging down to sticky dressings that would have been applied to the front or back of your ankle. This will mean that you can now easily fit into your own shoes and I would recommend that you wear some trainers at this stage.
You can start exercising the ankle by moving it up and down, and specific instructions will be given to you. If you have had micro fracture treatment, then you must continue using crutches and not bearing weight otherwise you should be mobile and without crutches at this stage.
Week 2
You will continue to progress during this week and can start going for longer walks outside but must refrain from doing any high impact activity or prolonged walking. The ankle will continue to swell at this point, and you must continue with regular elevation and icing to control this.
I will review you at the end of the two weeks. To ensure that the progress has been satisfactory and to give any specific instructions. If there are any sutures to be removed, they will be removed at this stage and the wound dressing changed.
Physiotherapy can then commence at this stage. Occasionally physiotherapy at an earlier stage may be indicated and we can discuss this.
Weeks 2-6
There will be continuous improvement over this. The range of motion will increase, and the swelling will improve gradually. You may need to continue to elevate however the need for doing so will gradually diminish in this. You may start doing some gentle exercises such as longer walks and exercise bike or swimming if the wounds are completely healed. You may be able to commence higher impact exercise towards the end of this and most patients can resume running and jumping activities from six weeks onwards.
If you have had microfracture treatment, then weight bearing will be delayed until week 4 but you must continue doing range of motion exercises most sitting or lying on a bed. You can then start walking normally from four weeks have avoid high impact activity until six weeks post-surgery.
I routinely see patients at six weeks following surgery and normally this will be the final visit before you are discharged to the care of the physiotherapists.
Months 2-6
Things will gradually return to normal in this period. You can resume all your usual activities although high impact sports should be introduced gradually and in increments of 10% per week. You may note some residual swelling specially after activity, but this should slowly improve towards the end of this period.
What are the risks associated with an Ankle Arthroscopy?
This information should be read in conjunction with the information on general complications of foot and ankle surgery.
Some of the risks specific to an ankle arthroscopy is detailed below.
Injury to superficial nerves during arthroscopy can lead to numbness or a sensitive neuroma formation. I take care in looking for an even marking out the nerves with a marker pen prior to the operation to avoid inadvertent injury. Despite this a small proportion of patients may be affected. The main nerve to the foot (tibial nerve) is at risk during posterior ankle arthroscopy.
The blood vessels supplying the foot pass in front and behind the ankle and during anterior and posterior ankle arthroscopy are at risk of injury. This is normally very rare indeed but may result in bleeding and the need for additional surgery to repair the blood vessel. Occasionally it may lead to formation of a swelling in the blood vessel that can present a few days after the surgery.
Tendons that lift the ankle and the toes are at risk during an anterior ankle arthroscopy and the tendon to the big toe that bends it down can be injured during a posterior ankle arthroscopy. Rates of tendon injury are very low and if they occur and are noted at the time of surgery can be repaired at the same time.
When can I resume my routine?
If you drive an automatic car then you can start driving within a few days of surgery if the operation was on your left foot. If surgery was on your right foot or you drive a manual car then it may not be possible to safely drive for the first two- or three-weeks following surgery. As a rule of thumb when the bandaging is removed, and you have a pain free range of ankle motion and you have been walking unaided then you can consider driving. You must be safe and in control of the car and be able to perform an emergency stop. It is your responsibility to inform your insurer so that you are covered in the event of an accident.
Most sedentary work can commence after a few days and when the post-operative pain has settled. If your work involves significant amounts of walking or standing or you work in a heavy manual profession, then you may wish to delay work for two weeks from the operation and in some cases up to four weeks depending on the type of work that you do.
The wounds will be fresh and covered in the first two weeks and you must avoid getting them wet in that time. The sticky dressings are normally waterproof however we do recommend that the bandaging is kept dry and you may have to have a shower whilst protecting the bandaging with a bag or a special device. After two weeks if the wounds have healed well then you can remove the dressing and get them wet.
