Ankle Arthroscopy: A Current Point of View.

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Ankle arthroscopy (AA) is commonly utilized to diagnose and treat intra-articular pathologies of the ankle joint. Arthroscopy can be performed in either the anterior or posterior ankle. In anterior AA, anteromedial (AM) and anterolateral (AL) portals are commonly established to visualize the joint. However, AL portal use is associated with neuropraxic injuries to the superficial peroneal nerve (SPN) as it runs in close proximity to the AL portal site. When AA is combined with additional procedures, such as a Brostrom-Gould ligament repair or open reduction internal fixation (ORIF), the creation of a lateral incision is required. We present a novel approach to performing AA with adjunct procedures and avoiding the use of an AL portal; the AM and lateral incision are used for instrumentation instead. Methods: Following IRB approval, a retrospective review of patients who underwent ankle arthroscopy by a single surgeon at a single institution between January 2020 to October 2024 was conducted. Patients were then assigned to one of three groups: patients who underwent AA only (AA), AA plus Brostrom-Gould repair or ORIF (AA+), or AA plus adjunct procedures using the lateral portal instrumentation method (LP). One hundred fifty-seven patients were initially identified; two were excluded per criteria. Data collected included demographic information, intraoperative details, postoperative complications, and reoperations. Descriptive statistics were used to describe demographics and operative data, and two-tailed Student t-tests were employed to identify statistical differences between group metrics. Results: 155 patients were included, 35 underwent LP, 57 underwent AA+, and 63 underwent AA. There were no significant demographic differences between groups. Mean follow-up was 11.2 months. Increased complication rates were seen in LP (12/35, 34.29%) and AA+ groups (20/57, 35.09%) compared to the AA group (12/63, 19.05%), however, none were statistically significant. SPN neuropathy occurred in two patients in the LP group and one patient in the AA group, all three resolved at follow-up. SPN neuropathy occurred in one patient in the AA+ group, but did not resolve at follow-up. The LP group demonstrated the highest rate of reoperation (11/35, 31.4%), followed by the AA+ group (8/57, 14.1%) and the AA group (2/63, 3.17%); however, none were statistically significant. Conclusion: This is a pilot study demonstrating preliminary data for a far-lateral arthroscopic approach. Our initial data suggests two conclusions: one, that SPN injury risk is not increased with a lateral approach; and two, that the lateral approach does not result in higher complication or reoperation rates than a traditional AA plus adjunct procedures approach. However, as expected, multiple procedures still increase risks versus simple diagnostic AA, which is reflected in the results. Future studies should include a larger sample size with multiple surgeons across multiple sites to validate these results.

Trends in Ankle Arthroscopy and Its Use in the Management of Pathologic Conditions of the Lateral Ankle in the United States: A National Database Study

Objective To evaluate the clinical value of ankle arthroscopy in diagnosis and treatment of Danis-Weber type B ankle fracture associated with injury to the distal tibiofibular syndesmosis. Methods A retrospective study was conducted of the 35 patients who had been treated at Department of Orthopaedics, Ruijin Hospital North for Danis-Weber type B ankle fracture from February 2014 to December 2016. They were 23 males and 12 females, with an average age of 43.1 years (from 18 to 65 years). Each of them underwent 4 examinations to detect whether injury to the distal tibiofibular syndesmosis was complicated or not: preoperative CT and MRI, C-arm roentgenography and ankle arthroscopy before and after internal fixation of the ankle. The diagnostic rates of the complicated injury by the 4 examinations were compared. The patients complicated with injury to the distal tibiofibular syndesmosis received surgical repair of the injury using TightRope in addition to internal fixation of the ankle, and injury to the deltoid ligament was repaired simultaneously using 3.5 mm anchor nails in case the injury was concomitant. The repair and stability of the distal tibiofibular syndesmosis were observed using ankle arthroscopy again. Results The Cotton and external rotation tests under C-arm roentgenography before surgery and after internal fixation of the ankle demonstrated that 13 cases were complicated with injury to the distal tibiofibular syndesmosis. Of the other 22 patients who had not been diagnosed with the injury by C-arm roentgenography, 6, 13 and 11 were diagnosed with the injury respectively by CT, MRI and ankle arthroscopy. The diagnostic rates of Danis-Weber type B ankle fracture associated with injury to the distal tibiofibular syndesmosis were 37.1% (13/35), 54.3% (19/35), 74.3% (26/35) and 68.6% (24/35) respectively by C-arm roentgenography, CT, MRI and ankle arthroscopy. In the sensitivity to the injury, MRI > ankle arthroscopy > CT > C-arm roentgenography, with significant differences between them (P<0.05). The ankle arthroscopy confirmed the repair efficacy in the 24 patients complicated with injury to the distal tibiofibular syndesmosis and negative results of Cotton and external rotation tests in them. Additionally, ankle arthroscopy revealed 16 cases of injury to the deltoid ligament at the medial ankle. Conclusions Ankle arthroscopy can provide evidence for correct diagnosis and treatment of Type B ankle fracture complicated with injury to the distal tibiofibular syndesmosis, because it allows direct observation of the medial deltoid ligament of the ankle and the distal tibiofibular syndesmosis. It can be also used to assess the stability of the tibiofibular syndesmosis after repair of the injury. Key words: Ankle joint; Fractures, bone; Diagnosis; Ankle arthroscopy; Distal tibiofibular syndesmosis injury

Advances in foot and ankle arthroscopy have allowed surgeons to diagnose and treat a broadening array of disorders that were previously limited to open procedures. Arthroscopy of the posterior ankle, subtalar joint, and first metatarsophalangeal joint and tendoscopy can be used to address common foot and ankle ailments, with the potential benefits of decreased pain, fast recovery, and low complication rates. Posterior ankle and subtalar arthroscopy can be used to manage impingement, arthrofibrosis, synovitis, arthritis, fractures, and osteochondral defects. First metatarsophalangeal joint arthroscopy can address osteophytes, chronic synovitis, osteochondral defects, and degenerative joint disease. Tendoscopy is a minimally invasive alternative for evaluation and débridement of the Achilles, posterior tibial, flexor hallucis longus, and peroneal tendons.

Arthroscopy has many potential complications, whether it is done in the ankle, shoulder, knee, or other joints. Foot and ankle arthroscopy has progressed significantly since its beginning by Burman in 1931. Over the past 2 decades, arthroscopy equipment and instrumentation has improved and newer techniques have been developed. A heightened interest in foot and ankle arthroscopy has grown as diagnostic and imaging capabilities have improved. As the number of arthroscopic procedures of the foot and ankle has increased, so has the opportunity for significant complications.

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Ankle arthroscopy is a widely performed procedure for diagnosing and treating ankle pathologies. While generally safe, surgical site infections (SSIs) remain a concern, with reported incidences ranging from 0.13% to 3.08%. Although relatively uncommon, SSIs can delay rehabilitation, increase healthcare costs, and lead to severe complications like septic arthritis. Identifying predictors of infection is crucial to improving surgical outcomes. Previous studies suggest that diabetes mellitus (DM) and high body mass index (BMI) may be associated with increased infection risk, but data remain limited. This 8-year retrospective study aimed to determine the incidence of postoperative infections in ankle arthroscopy and identify significant predictors of SSI, using a multivariate analysis of demographic and clinical risk factors. Methods: This retrospective cohort study included 321 patients who underwent ankle arthroscopy between 2014 and 2022. Patients were excluded if they had pre-existing infections, open fractures, or incomplete medical records. Demographic and clinical data, including age, sex, BMI, smoking status, diabetes mellitus (DM), hypertension (SAH), and ASA score, were collected. The primary outcome was SSI incidence, with infections classified as superficial (managed conservatively) or deep (requiring surgical debridement or implant removal). Multivariate logistic regression was performed to identify independent predictors of infection, controlling for potential confounders. Statistical significance was set at p &lt; 0.05. This study provides one of the largest long-term analyses on infection risk factors in ankle arthroscopy, offering critical insights into patient selection and perioperative management strategies. Results: The overall SSI incidence was 2.5% (8/321 patients), with 6 superficial and 2 deep infections requiring further surgery. Diabetes mellitus (DM) and high BMI emerged as independent predictors of infection. Patients with BMI ≥40 kg/m² had a 50% infection rate (p = 0.008), while DM patients had an 11.8% infection rate (p = 0.013). No significant associations were found with hypertension (p = 0.862), smoking (p = 0.254), ASA score (p = 0.616), or sex (p = 0.075). The most common indications for arthroscopy were synovectomy, impingement, and loose body removal (48.3%), followed by osteochondral defect treatment (16.8%) and ligament repair (12.8%). These findings suggest that BMI and DM should be considered in preoperative risk stratification. Conclusion: This 8-year study confirms that BMI and diabetes mellitus are independent predictors of postoperative infection in ankle arthroscopy, while other demographic factors, including hypertension, smoking, and ASA score, showed no significant correlation. Although the overall infection rate was low (2.5%), deep infections requiring surgical intervention reinforce the importance of early recognition and risk-based perioperative management. These findings support the implementation of targeted infection prevention strategies, particularly in patients with high BMI and diabetes, to optimize surgical outcomes and minimize complications. Preoperative screening and tailored postoperative care are essential to reducing infection risk in this patient population. Fisher’s Exact Test Results for Risk Factors Associated with Infection in Ankle Arthroscopy This table presents the association between clinical and demographic risk factors and surgical site infections (SSIs) following ankle arthroscopy. Diabetes mellitus (p = 0.013) and BMI (p = 0.008) were significantly associated with infection, indicating their role as independent risk factors. Other variables, including hypertension, smoking, gender, ASA score, and type of surgical procedure, did not show statistically significant associations (p &gt; 0.05).

Category:Arthroscopy; Ankle; Sports; OtherIntroduction/Purpose:Opioids can be an important tool in the management of postoperative pain, however, increased prescribing of these medications following orthopaedic procedures has significantly contributed to the current opioid crisis. Post- operative opioid utilization and duration varies greatly among surgeons, procedures, and patients. We sought to investigate patterns of opioid prescription following ankle arthroscopy and determine patient factors associated with increased postoperative opioid prescribing.Methods:A national claims-based database was queried for patients undergoing first-time ankle arthroscopy. Only patients with continuous database inclusion for at least one year prior to and one year after index ankle arthroscopy were included. Patients carrying an International Classification of Diseases (ICD)-9 or ICD-10 code(s) for diagnosis of septic ankle joint or a CPT code for total ankle arthroplasty prior to index ankle arthroscopy were excluded from the study. Patients who filled at least 1 opioid prescription between 1 and 4 months prior to surgery were defined as preoperative opioid-use group. Monthly relative risk ratios for filling an opioid prescription were calculated for the first year after surgery. Multiple logistic regression analysis was performed to identify factors associated with opioid prescription refills at 3, 6, 9, and 12 months after ankle arthroscopy. For analysis, P<0.05 was defined as significant.Results:We identified 6,039 patients who underwent primary ankle arthroscopy. The preoperative opioid-use group consisted of 1,514 patients (25.1%), of which 24 (1.6%) filled opioid prescriptions at 6 months postoperatively compared to 39 (0.9%) of opioid-naive patients (relative risk [RR], 1.84 95% confidence interval [CI], 1.11-3.05). Multivariate analysis determined that the preoperative opioid-use group was at increased risk of filling prescriptions at 3 (odds ratio [OR], 2.22; 95% CI 1.42-3.48) and 6 months (OR, 1.74; 95% CI, 1.01-2.95) postoperatively. Patients with Body Mass Index (BMI) > 30 were also at increased risk at 3 months (OR, 1.65; 95% CI, 1.04-2.62) and 6 months (OR, 2.01; 95% CI, 1.17-3.49) postoperatively. Comorbidities such as diabetes, hypertension, fibromyalgia, alcohol, and tobacco abuse were not associated with opioid filling (P>0.05).Conclusion:Preoperative opioid prescription filling and BMI 30 were associated with an increased risk of extended opioid prescription utilization following ankle arthroscopy. Overall, prolonged opioid prescribing was not widespread in either group postoperatively. This may represent the indications and outcomes of ankle arthroscopy. Patients presenting with preoperative opioid-use and increased BMI may benefit from multimodal pain management and additional perioperative education around non- pharmacologic pain-management strategies to decrease risk of prolonged opioid use.

Has plantarflexion any positive impact on the clinical risk of vascular injury during ankle arthroscopy ?

Ankle arthroscopy has evolved as a diagnostic and therapeutic tool. Traditionally, it is performed with traction because of the tight ankle joint space. Original traction techniques were invasive but have progressed to the commonly used noninvasive modalities. Recent reports have suggested traction may be unnecessary. The purpose of this study was to compare prospectively ankle arthroscopy with and without traction in terms of ease of visualization of anatomic structures according to the Ferkel's ankle arthroscopy criteria. Under Institutional Review Board approval, 103 patients received ankle arthroscopies, first with noninvasive traction and subsequently without traction. An independent observer scored each arthroscopy based on the 21-point Ferkel's criteria. For each structure adequately visualized, one point was given. Inadequate visualization was defined as excessive force or as visible cartilage scuffing. The maximum possible score was 21 points and the lowest was zero. Fifty-five females and 48 males, average age 35 (range, 16 to 71) years, participated in the study. Noninvasive traction facilitated visualization of all structures of the anterior ankle in more than 90% of cases except for the anterior compartment and lateral gutters, which were better visualized without traction with the ankle in dorsiflexion. No difference was seen when visualizing the talus. Traction arthroscopy performed better when evaluating the central and posterior ankle. The mean score difference was statistically significant, 11.2 versus 18.5 points, favoring noninvasive traction arthroscopy. The complication rate was 4%. Noninvasive traction facilitated complete ankle arthroscopy. Dorsiflexion improved visualization of the anterior compartment and lateral ankle gutter. The authors recommend noninvasive traction when performing ankle arthroscopy.

Category:ArthroscopyIntroduction/Purpose:While there has been an increasing emphasis on assessing resident competency, little has been published on how to best evaluate competency for ankle arthroscopy. The purpose of this study was to design and validate an objective model for assessing basic ankle arthroscopy knowledge and surgical skills on a cadaveric ankle.Methods:The Basic Ankle Arthroscopy Skills Scoring System was adapted from previously validated assessment tools for knee arthroscopy. The scoring system includes (1) an oral questionnaire (0-23 points), (2) a surgical task-specific checklist (0-19 points), and (3) a global surgical skills rating (12-60 points). Ten medical students and twenty-three residents participated. All participants performed a diagnostic ankle arthroscopy on a cadaveric ankle and were assessed by a single observer. Six participants were tested by two evaluators to determine inter-observer reliability.Results:There was strong correlation between educational level and scores on the global surgical skills rating scale (r=0.967, p<0.0001), task-specific checklist (r=0.815, p<0.815), and oral questionnaire (r=0.896, p<0.0001). The global surgical skills scores were significantly different over multiple trainee levels but most notably between post graduate year (PGY) 1 and 2 (p<0.01) and between PGY 2 and 3 (p<0.05) [Figure 1a]. Oral questionnaire and task-specific checklists were significantly lower for medical students than PGY1 residents (p<0.001) [Figure 1b-c]. There was significant improvement in the oral questionnaire between senior and junior residents (p<0.05). There was a moderate correlation between number of ankle arthroscopy cases and scores on the global surgical skills score (r=0.7019, p<0.0001). Inter-observer reliability was high for the global surgical skills scores (ICC=0.89).Conclusion:The Basic Ankle Arthroscopy Skills Scoring System is a valid measure to objectively assess trainees’ ankle arthroscopy clinical knowledge and surgical skills in a bioskills laboratory. This tool will allow residency programs to evaluate competency and track individual progress over time.

. Ankle arthroscopy is increasingly being utilized for disorders previously limited to management with open surgery. Despite uniformly good results and few complications, little is known regarding national trends in ankle arthroscopy. This study sought to investigate changes in the use of inpatient and ambulatory ankle arthroscopy in the United States. . The National Survey of Ambulatory Surgery and the National Hospital Discharge Survey were used to identify cases of ankle arthroscopy. The data were analyzed for trends in demographics, treatment, and use. Between 1994 and 2006, the population-adjusted rate of ankle arthroscopy increased by 65% (4.9/100 000 capita to 8.1/100 000 capita). The rate of ambulatory procedures increased by 80%, whereas the rate of inpatient procedures decreased by 95%. Sex-adjusted rates increased by 90% for males and 32% for females. The largest increases in age-adjusted rates were among patients 35 to 54 years of age. The proportion of procedures performed in freestanding ambulatory facilities increased from 15% to 49%. Use of peripheral nerve blocks during ambulatory procedures increased from 6% to 26%. Private insurance was the largest compensator at all times, and the proportion of workers' compensation payments increased from 8% to 22% during the study period. . Results from the most recently available Centers for Disease Control and Prevention data demonstrated that rates of ambulatory ankle arthroscopy increased, whereas rates of inpatient ankle arthroscopy decreased dramatically between 1994 and 2006. Understanding national practice patterns can aid policy makers and surgeons in allocating health care resources, so as to ensure quality patient care. N/A (descriptive epidemiology study).

Arthroscopic diagnosis of tibiofibular syndesmosis disruption

There is increasing emphasis on assessing resident competency, but little has been published on how to best evaluate trainee competency for ankle arthroscopy. The purpose of this study was to validate an objective model for assessing basic ankle arthroscopy knowledge and operative skills on a cadaveric ankle. The Diagnostic Ankle Arthroscopy Skills Scoring System was adapted from previously validated assessment tools for knee arthroscopy. The scoring system included (1) an oral questionnaire (0-23 points), (2) an operative task-specific checklist (0-19 points), and (3) a global operative skills rating (12-60 points). Thirty-three trainees consisting of orthopedic residents and medical students performed a diagnostic ankle arthroscopy on a cadaveric ankle and were assessed by a single observer, while a subset were tested by 2 evaluators to determine interobserver reliability. There was strong correlation between educational level and scores on the global operative skills rating scale (r = 0.967, P < .0001), task-specific checklist (r = 0.815, P < .815), and oral questionnaire (r = 0.896, P < .0001). The global operative skills scores significantly improved with training level, and the largest difference was between medical students and senior residents. The most notable year-to-year increases in skill were between postgraduate year (PGY) 1 and 2 (P < .01) and between PGY2 and PGY3 (P < .05). Oral questionnaire and task-specific checklists were significantly lower for medical students than PGY1 residents (P < .001). There was also significant improvement in the oral questionnaire between senior and junior residents (P < .05). There was a moderate correlation between number of self-reported ankle arthroscopy cases and scores on the global operative skills score (r = 0.7019, P < .0001). Interobserver reliability was high for the global operative skills scores (interclass correlation coefficient = 0.89). The study revealed a valid measure to objectively assess trainees' ankle arthroscopy clinical knowledge and operative skills in a bioskills laboratory. This tool should enable residency programs to evaluate competency and track individual trainee progress over time.

Background: Ankle arthroscopy is indicated for both diagnosis and treatment of a large spectrum of common ankle disorders. It has certain advantages over the open procedure; however, it is important to recognize that there are some complications associated with it. Infections after this procedure are quite uncommon, with an overall estimated incidence of 2%. Given the low incidence of infections after ankle arthroscopy, not a great deal of literature on the topic has been published. The present review aims to provide an overview of the incidence, diagnosis, and treatment of infections after ankle arthroscopy. Methods: A systematic review of the literature indexed in the PubMed, MEDLINE, and Cochrane Library databases using search term "ankle arthroscopy infections" was performed in November 2023. No restrictions were applied concerning the date of publication. The Preferred reporting items for systematic reviews and meta-analyses (PRISMA) were followed. Among all surgical operations for the treatment of ankle and foot pathologies, we included articles with a described superficial or deep infection after ankle arthroscopy. Results: The search resulted in 201 studies. Only 21 studies met our inclusion criteria, and they were included in this systematic review. We evaluated 1706 patients who underwent 1720 arthroscopic tibiotalar procedures at an average age of 42 years old. Out of the 1720 procedures, 41 (2%) were complicated by infection. We divided infectious complications into superficial (68%; 28/41) and deep (32%; 13/41) infections. The most common pathogen isolated was Staphylococcus aureus. Arthroscopic arthrodesis was found to be the most affected by deep infections. Conclusions: Infection after ankle arthroscopy is an uncommon complication. Superficial infections were successfully treated with antibiotics, while surgical debridement, arthroscopic drainage, and intravenous antibiotics were necessary in cases of deep infections. Considering the amount of information on pathogens associated with knee and shoulder infections, there is still a lack of literature on pathogens associated with ankle infections, which makes their management difficulty.

Background:Ankle arthroscopy (AA) is a commonly used operative technique to diagnose and treat a variety of intraarticular pathologies of the ankle joint. In AA, 2 portals are commonly established to achieve visualization of the joint: the anteromedial (AM) and anterolateral (AL) portals. However, the superficial peroneal nerve (SPN) runs near the anterolateral portal site; thus, creation of the AL portal is associated with neuropraxic injuries to the SPN.When AA is combined with additional procedures, such as a Brostrom-Gould ligament repair or open reduction internal fixation (ORIF), the use of a direct lateral incision is required. We present a novel approach to combining AA with lateral adjunct procedures which avoids creation of the AL portal; the AM portal and lateral incision are used for instrumentation instead. The primary objective of this study is to compare complication rates, such as SPN injury, between the lateral incision (LI) approach and conventional arthroscopy plus a lateral incision approach.Methods:Following IRB approval, a retrospective chart review was conducted spanning a time frame from January 2020 to October 2024. Patients were included if they underwent AA plus either a Brostrom-Gould repair or ORIF (AA+) or if they underwent AA plus adjunct procedures using the lateral portal instrumentation method (LI). Ninety-four patients were initially identified; 2 were excluded per criteria. Demographic information, intraoperative details, and any postoperative complications or reoperations were recorded. Descriptive statistics were used to describe demographics and operative data, and 2-tailed Student t tests were used to identify statistical differences between group metrics.Results:Ninety-two patients were included in the study. No statistical differences were observed between cohorts in either of the intraoperative metrics considered (procedural duration and tourniquet duration; P = .44 and .89, respectively). In addition, complication and reoperation rates were not statistically different between the LI and AA+ groups (P = .94 and .40, respectively). The rate of SPN neuropathy or neurapraxia were also compared between groups, resulting in no statistical differences (P = .37).Conclusion:In this retrospective cohort study, we observed no differences when only anteromedial and lateral portals are used for an ankle arthroscopy with adjunct procedures compared with the traditional 3-incision approach. We hypothesize that instances of infection or wound dehiscence would decrease given a large enough cohort because of the creation of 1 fewer portal. However, given the small, underpowered sample, we cannot determine whether the lateral approach alters complication risk; larger multicenter studies are needed.Level of Evidence:Level III, retrospective cohort study.