Arthroscopy of the Foot & Ankle

ARTHROSCOPY OF THE FOOT AND ANKLE
By:  Robert H. Sheinberg, D.P.M., D.A.B.F.A.S., F.A.C.F.A.S.

Foot and ankle injuries are very common in sports or in general activities of daily living.  Many structures including bone, ligament, cartilage and joint lining may be injured.  Injuries may occur from a single traumatic event or from overuse.  Injuries may occur during the teenage years that may manifest themselves later on. 

Symptoms:

These injuries may cause stiffness and pain in the foot or the ankle joints, especially after getting out of bed first thing in the morning to walk.  This stiffness and pain will be present for a proportional period of time usually to the degree of joint injury.  With weightbearing the joint usually loosens and the person is able to ambulate.  This stiffness and pain will redevelop if the person sits for a period of time and tries to get up and walk.  As the day goes on the foot or ankle may ache, especially with excessive weightbearing.  Swelling may be present over the area that is injured.  Instability  may develop if the ligaments have been injured causing the foot or ankle to constantly twist. 

When these injuries are unresponsive to conservative treatment which may include orthotics, medication or rehabilitation, arthroscopic surgery may be necessary to remove the damaged tissue in the foot and ankle.

A miniature camera is placed into the injured joint allowing an image to be seen on a television screen.  The joint is visualized and small instruments, including laser, are introduced into the joint to clean out and repair the damage.  Fragments of bone and cartilage are often removed.  Suctioning of debris and smoothing rough surfaces will often allow a joint to resume its normal gliding motion.

CONDITIONS TREATED:                                                   ADVANTAGES:

1.  chronic joint pain and swelling                                    1.  faster recovery
2.  arthritis and bone spurs                                              2.  less pain and swelling
3.  loose bone and cartilage fragments                           3.  avoids large incisions
4.  stiff, scarred joints                                                       4.  low risk of infection
5.  chronic instability                                                        5.  outpatient procedures
6.  ankle fractures that have not completely                    6.  quicker return to activities.
     recovered.

Joints are designed to give our bodies freedom of movement.  Wear and tear of a joint due to injury or due to aging may alter the lifestyle of an individual.  When conservative treatments fail to alleviate the pain and deformity of a joint, arthroscopic surgery should be considered.  The surgery is especially helpful for a fracture that has occurred to the ankle even after the ankle has been fixed surgically.  The cartilage in the ankle joint may have been damaged during the injury causing chronic stiffness and pain that may be mild but never goes away completely.  Patients often think that this is a very livable condition.  However, once treated arthroscopically a full return to activity may be possible.  

Fibrous Bands in the ankle

 

 

Defect in the cartilage of the Talar dome is debrided of loose and/or damaged cartilage and drill holes are placed into and through the subchondral bone plate to allow bleeding into the area from the bone to allow healing of the area with fibrocartilage which is the cartilaginous version of scar tissue.

Ankle Spur Before and After Resection

Loose bodies within the ankle joint discovered to the arthroscopy procedure are removed to eliminate irritants in the joint space that lead to swelling and pain.

       

These are pictures of a Pilon fracture that was performed by a different surgeon.  The anterior tibial plate was placed too distal and invaded the patient's joint.  These injuries often cause post-traumatic arthritis regardless of the fixation. The plate was removed and the patient had some relief.  Approximately 1 year later, the patient underwent a successful arthroscopic fusion.

S/P Pilon with anterior plate too distal

After removal of the plate prior to arthroscopic fusion

 

After arthroscopic fusion

 

Bone and Cartilage fragment removed from ankle joint

 

   

     

Pics of Microfracture for Talus OCD Below

   

 

Below, OCD can be seen as the rise in cartilage that causes pain in the ankle. The dmaged cartilage is removed and Microfracture is performed.

 

    

 

Below, OCD is debrided and microfracture performed of defect.

  

Tibial Spur

Microfracture of OCD

 

A series of intraop ankle arthroscopy pics of synovial chondromatosis with OCD talus and tibia and microfracture

Pic of one of the nodules inside the ankle join

Pic of an OCD in the talar dome due to pressure from the nodule

Pic after microfracture and debridement of above OCD

Pic during microfracture of tibial OCD

Pics of Loose Bodies During Ankle Arthroscopy Below

The loose bodies caused depressions in the cartilage of the talus due to constant pressure with range of motion as seen below.

More Loose bodies in the ankle

 

Pics of Loose Bodies removed during scope.  A seperate incision had to be made to remove the bodies due to the size. Below

 

Fibrous Band in ankle joint

 

Intraop arthroscopy pic of OCD afer debridement and during Microfracture

Intraop Pictures of OCD of the talus after debridement and during microfracture

Series of OCD with Microfracture

Scar tissue in the ankle causing pain and an impingement before and after debridement

OCD before and after Microfracture

Impingement at the lateral aspect of the ankle joint with scar tissue on the intra-articular portion of the AITFL. This causes irritation in the joint with range of motion.

The impingement is at the upper right hand corner. The instrument is shaving it down

 

After removal of the impingement

Pic of synovitis and Villi impinging the ankle joint

 

Series of Pics of Microfracture of large OCD of the Talar Dome

Pic of OCD after preparation and debridement 

Measuring the size and depth of the OCD

 

Action shot of Microfracture of Talus OCD

 

Bleeding of OCD after Microfracture

 

OCD in Ankle Joint with Microfracture

We are curreting the OCD to debride the defect

The defect is debrided to bone below

Microfracture is performed with a Pic

Bleeding can be seen in the defect

More Bleeding from the defect

OCD of the medial talar dome. The cartilage is frayed and can be seen at the OCD

After debridement, we are measuring the size of the OCD

 

Cutting of Tibial Spur with Blade

Posterior arthroscopy

Scar tissue in the back of the ankle

After debridement, the FHL can be on the right hand side

The ankle joint can be seen at the top of the screen clear of any scar tissue or debris

 

Posterior scope with removal ganglion cysts

The ganglion is the mass with the reddish hue inside the back of the joint

The ankle and subtalar joint visualized post debridement

A portion of the posterior ankle ligament complex

The cleaned out ankle joint

The cleaned out ankle and subtalar joint easily visualized.  The FHL tendon is noted at the top right of the picture

The FHL tendon after debridement

 

Intraoperative subtalar joint arthroscopy pics

Scarring in the subtalar joint

Scar tissue at the middle facet

Cleaned out middle facet

Scar tissue and fibrous band in the subtalar joint

Cleaning out the joint

Scar tissue around thePosterior facet

Cleaned out posterior facet

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