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Ankle arthroscopy

126 citationsUpdated Oct 2026

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Overview

Ankle arthroscopy is a safe, minimally invasive procedure with a low overall complication rate that offers decreased morbidity and faster recovery times compared with open arthrotomy [12, 14]. Adequate evidence-based literature supports the technique for most generally accepted indications, yielding good results when used appropriately [1, 2]. The procedure is most commonly performed in patients younger than 50 years and is performed more frequently in female patients [3]. While the number of indications for anterior ankle arthroscopy is rising, with open surgery increasingly replaced by arthroscopic techniques for anterior pathology [9], posterior ankle arthroscopy also demonstrates promising outcomes in young populations and serves as a powerful diagnostic and therapeutic modality for posterior ankle pathology [5, 7, 8].

The procedure is particularly effective for alleviating ankle pain when indications are fulfilled [26]. Arthroscopic treatment of anterolateral ankle soft-tissue impingement is a very safe procedure when indicated [27], and posterior ankle arthroscopy is a safe and effective surgical procedure for posterior ankle impingement [37]. In the management of lateral ankle instability, there has been a significant increase in the use of ankle arthroscopy [3]. Arthroscopic treatment of ankle instability is emerging as the potential gold standard technique, offering the advantage of addressing both instability and associated intra-articular pathology in a single procedure with excellent results [176]. Combining ankle arthroscopy with a modified Brostrom procedure provided significantly improved ankle hindfoot scores at an average of 35 months follow up [34].

Despite these benefits, surgical practices in ankle instability remain heterogeneous, with the least consensus in specific clinical situations [31]. Operative procedures that only focus on part of the pathology should be approached with caution until assessment of a patient with ankle instability defines all deficiencies [4]. Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes [30]. Further studies are needed in the area of ankle arthroscopy indications [2]. With sound knowledge regarding the indications, merits, and potential risks of new techniques, they will be powerful tools in foot and ankle surgery [15]. Two-millimetre diameter operative arthroscopy of the ankle may hold the potential to make ankle arthroscopy less invasive and more accessible [20].

Anatomy & Pathophysiology

Bony Anatomy

The ankle mortise is formed by the tibial plafond, medial malleolus, and lateral malleolus, which articulates with the dome of the talar body [88]. The talar dome is wider anteriorly and narrower posteriorly [88]. During motion from plantar flexion to dorsiflexion, the ankle mortise widens 1 to 1.5 mm [88]. Consequently, medial and superior clear spaces appear wider with the foot in plantar flexion [88]. The distal fibula features a convex medial surface that articulates with the concave incisura fibularis of the distal lateral tibia [88]. The fibula rotates approximately 2 degrees within the incisura during ankle motion and ambulation [88]. Ankle dorsiflexion results in external rotation and proximal translation of the fibula [88].

Radiographic assessment relies on specific measurements. The talocrural angle is approximately 83 degrees and symmetrical with the contralateral ankle [97]. The medial clear space should be less than 5 mm and no more than 2 mm greater than the tibiotalar clear space [97]. The tibiofibular clear space (syndesmosis A), measured 10 mm above the joint line, should be greater than 5 mm [97]. The tibiofibular overlap (syndesmosis B), measured 10 mm above the joint line, should be less than 5 mm on AP view and less than 1 mm on the mortise view [97]. Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space [109]. The size of the medial clear space more than doubles depending upon the rotational position of the limb [97]. There is a significant increase in medial clear space with ankle plantarflexion [97].

Ligamentous Anatomy

The lateral collateral ligaments function as restraints to varus and inversion forces at the ankle [88]. The anterior talofibular ligament (ATFL) originates from the anteroinferior aspect of the lateral malleolus, 1 cm proximal to its tip, and extends to the lateral aspect of the talar neck [88]. The ATFL is the weakest ankle ligament [88]. The calcaneofibular ligament (CFL) extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus [88]. The posterior talofibular ligament (PTFL) extends from the posterior lateral malleolus to the posterolateral talus [88]. The PTFL is the strongest ankle ligament [88]. The ATFL inferior fascicle is connected to the calcaneofibular ligament [158]. The ATFL superior fascicle is an intra-articular structure [158].

The distal tibiofibular joint (ankle syndesmosis) and fibula provide stability against lateral talar translation [88]. The deltoid ligament complex is the primary ankle stabilizer during stance [88]. The deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body [88]. It functions primarily to resist lateral talar translation and external rotation [88]. The posterior deep deltoid is the most important component of the deep deltoid ligament [88]. The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament [88]. It functions primarily to resist valgus and eversion ankle forces [88].

The deltoid ligament consists of superficial and deep layers, with at most six bands, of which only three are constant: the tibionavicular ligament, tibiospring ligament, and deep posterior tibiotalar ligament [94]. The tibiocalcaneal portion of the superficial deltoid ligament is the strongest component and resists eversion of the calcaneus [94]. The deep portion of the deltoid ligament is organized into two short, thick, discrete bands: the anterior and posterior deep tibiotalar ligaments [94]. The anterior and posterior deep tibiotalar ligaments are intra-articular but extrasynovial [94]. The deep posterior band comprises the largest band of the deltoid complex [94]. The deep deltoid ligament has the highest load to failure at 713.8 N ± 69.3 compared with the lateral collateral ligaments [94]. The dominant mode of failure for the deep deltoid ligament is an intrasubstance rupture near its talar insertion [94]. The dominant mode of failure for the superficial deltoid ligament is at its insertion on the anterior malleolus [94].

The deltoid ligament has a rich vascular supply from three separate extraosseous sources: the medial tarsal artery, the posterior tibial artery, and the tibialis anterior artery [94]. There is also a component of intraosseous vascular supply to the deltoid ligament from either the talus or the medial malleolus [94]. The accessory anteroinferior tibiofibular ligament is a normal anatomical finding that could lead to anterolateral impingement in cases with coexistent ankle instability [41].

Joint Kinematics and Biomechanics

The ankle joint is responsible for most sagittal plane motion of the foot and ankle [88]. Ankle range of motion includes 23 to 48 degrees of plantar flexion [88]. Ankle range of motion includes 10 to 23 degrees of dorsiflexion [88]. The ankle joint also contributes to inversion, eversion, and rotation [88]. The dynamic congruency of the joint, influenced by ligamentous integrity, is the main anatomical component in mechanical ankle instability [91]. Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus [147]. The greatest increases in laxity after sectioning the ATFL occurred in ankle positions and loads corresponding to common modes of injury [118]. Most studies found distinct characteristics of the incisura fibularis morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement [130].

Pathophysiology of Instability and Injury

More than 75% of ankle ligament injuries involve the lateral ligament complex, particularly the ATFL and CFL [53]. Medial ligament injuries are usually seen in association with a fracture or joint injury [53]. Syndesmosis disruption occurs in up to 11% of all ankle injuries [46]. In rotational ankle fractures, 30% to 39% have a concomitant syndesmotic injury [46].

Osteochondral defects and other chondral injuries may be present in 57 to 90% of patients with ankle fractures [46]. Concomitant intra-articular injuries have been reported in up to 80% of patients with ankle fractures [74]. Osteochondral lesions were present in 26% of Weber B fractures, 24% of Weber C fractures, and 20% of isolated medial malleolar fractures [74]. Chondral lesions were identified in 78% of 116 patients with acute ankle fracture [74]. Talar dome chondral lesions were identified in 43% of patients with acute ankle fracture [74]. All patients with ankle dislocations had a chondral lesion [74]. Patients with complete syndesmosis disruption and instability were more likely to have chondral injury [74]. Patients younger than 30 were less likely to have a chondral injury following acute ankle fracture [74].

In symptomatic chronic ankle instability, a rupture or elongation of the ATFL was noted in 86% of ankles [25]. A rupture or elongation of the CFL was noted in 64% of ankles [25]. A rupture or elongation of the deltoid ligament was noted in 40% of ankles [25]. Cartilage damage was noted in 66% of ankles with lateral ligament injuries [25]. Cartilage damage was noted in 98% of the ankles with deltoid ligament injuries [25]. Medial instability was presumed clinically in 38 patients but was actually detected in 54 patients arthroscopically [25].

Anterolateral soft-tissue impingement is a common cause of chronic ankle pain after one or more lateral ankle sprains [46]. Anterolateral soft-tissue impingement has been noted to occur with or without associated lateral ankle instability [46]. Injury to the ankle syndesmosis can result in persistent pain and dysfunction secondary to syndesmotic impingement [46]. The intra-articular position of an injured ATFL superior fascicle is thought to impair healing, similar to the resynovialization process of a ruptured anterior cruciate ligament remnant in the knee [158]. A degree of microinstability due to a deficiency of the ATFL could explain intra-articular pathological findings and patient complaints in those with chronic anterolateral pain and functional instability after an ankle sprain [162]. The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction in chronic ankle joint instability [129]. Abnormal internal rotation of the talus in patients with mechanical ankle instability was decreased after ankle lateral stabilization surgery [133]. The ATFL–PTFL angle decreases after ankle lateral stabilization surgery [154].

Iatrogenic and Anatomical Risks

The ankle is more susceptible than other joints to iatrogenic cartilage injury during an arthroscopic procedure due to its anatomic characteristics [17]. The incidence of cartilage injury during ankle arthroscopy is high, with severe damage found in only 6.7% of ankle arthroscopies [17]. Of the cartilage injuries found during ankle arthroscopy, 78.2% were superficial and 21.8% were deep [17]. 65% of iatrogenic cartilage injuries during ankle arthroscopy were sustained during the therapeutic portion of the procedure, and 35% occurred during the portal creation portion [17].

The structure at greatest risk of injury during placement of the anterolateral portal is the intermediate dorsal cutaneous branch of the superficial peroneal nerve [46]. The structures at greatest risk of injury during placement of the posterolateral portal are the sural nerve and the lesser saphenous vein [46]. The structures at greatest risk of injury during placement of the posteromedial portal during posterior ankle arthroscopy are the tibial nerve and posterior tibial artery and veins [46]. A synovial cutaneous fistula is a more common complication with ankle arthroscopy than with arthroscopy of other joints [46].

The superficial peroneal nerve penetrates the deep fascia and lies subcutaneously 8 to 10 cm proximal to the tip of the lateral malleolus, anterior to the subcutaneous border of the fibula shaft [92]. The deep peroneal nerve lies between the tendons of the anterior tibial and extensor digitorum longus, just lateral to the extensor hallucis longus, and usually lies just lateral to the anterior tibial artery [92]. The saphenous nerve is located just medial or posterior to the saphenous vein and in a slightly deeper plane, 3 to 5 cm proximal to the tip of the medial malleolus [92]. An accessory incision for arthroscopic repair of the lateral ligament should not surpass a 22 mm distance from the lateral malleolus in the anterior direction due to the risk of damaging the superficial peroneal nerve [96].

Classification

Ligamentous Pathology

Arthroscopy provides superior diagnostic accuracy compared to current imaging studies for the definitive assessment of ligament lesions in patients with chronic ankle instability (CAI) [40]. An established arthroscopic classification of chronic anterior talofibular ligament (ATFL) lesions allows for the assessment of these structures and helps determine the optimal surgical technique for ankle stabilisation [39]. The final diagnosis of chronic instability of the anterior syndesmosis can be made during ankle arthroscopy [21]. In a series of 148 patients with symptomatic chronic ankle instability, arthroscopy revealed a rupture or elongation of the ATFL in 86% of ankles, the calcaneofibular ligament in 64%, and the deltoid ligament in 40% [25]. Preoperative arthroscopy detected medial instability in 54 patients, whereas clinical examination presumed it in only 38 [25]. Conversely, grading the three major ligamentous complexes and individual ankle ligaments according to the Schneck grading system on 3 T MRI resulted in limited diagnostic reliability [161].

Osteochondral and Chondral Pathology

Ankle arthroscopy is an effective method for diagnosing ankle osteochondral lesions (OLTs) and other intraarticular pathologies [190]. In patients with chronic lateral ankle instability accompanied by intra-articular symptoms, cartilage damage was noted in 66% of ankles with lateral ligament injuries and 98% of ankles with deltoid ligament injuries [25]. The Berndt and Harty classification system is primarily a radiographic staging system for osteochondral lesions of the talar dome [180]. Its stages are defined as follows: * Stage I: Small compression fracture [180]. * Stage II: Incomplete avulsion of a fragment [180]. * Stage III: Complete avulsion without displacement [180]. * Stage IV: Avulsed fragment displaced within the joint [180].

An increase in the radiographic stage of a talar osteochondral lesion does not necessarily predict increasing fragmentation or loosening of the lesion [180]. An international consensus has derived appropriate terminology for osteochondral lesions of the ankle [163].

Diagnostic Utility and Trends

Preoperative ankle arthroscopy reveals essential information regarding the causes and mechanisms of ankle instability that would otherwise remain undetected [25]. It serves as a useful adjuvant tool to understand the severity and complexity of acute ankle fracture [29]. In a study of 116 consecutive patients undergoing acute ankle fracture ORIF with concurrent arthroscopy, the presence of a dislocation at the time of injury, unstable syndesmosis injury, or deltoid ligament injury was recorded and confirmed intraoperatively [86]. Anterior ankle arthroscopy was superior to MRI in detecting "web impingement" pathology of the ankle [33]. The number of indications for anterior ankle arthroscopy is rising, with open surgery increasingly replaced by arthroscopic surgery [9]. Ankle arthroscopy was performed more frequently in female patients and most commonly in patients younger than 50 years [3]. The Diagnostic Ankle Arthroscopy Skills Scoring System is a valid measure to objectively assess trainees' ankle arthroscopy clinical knowledge and operative skills [144].

Other Considerations: The incidence of iatrogenic cartilage injury during ankle arthroscopy is high, with severe damage found in only 6.7% of procedures [17]. Of the iatrogenic cartilage injuries found, 78.2% were superficial and 21.8% were deep [17]. Furthermore, 65% of these injuries were sustained during the therapeutic portion of the procedure, while 35% occurred during the portal creation portion [17].

Clinical Presentation

General Clinical Assessment

A history of a twisting injury followed by pain, bruising, and swelling is typical for ankle ligament injuries [53]. Physical examination remains the mainstay for diagnosing acute lateral ankle ligament injuries [125]. In the acute setting (0–2 days post-injury), pain and swelling might negatively affect the reliability of physical examination [125]. Current clinical guidelines recommend delayed physical examination 4–7 days post-injury for acute lateral ankle ligament injuries [125]. In the delayed setting, the sensitivity of common clinical findings increases, resulting in improved diagnostic accuracy for lateral ankle ligament injuries [125].

It is essential to examine the entire leg and foot to avoid missing undisplaced fractures of the ankle, proximal fibula, tarsal bones, or peroneal tendon sheath [53]. Acute low ankle sprains typically manifest by a large amount of lateral ankle swelling, pain with weight bearing, and pain in the lateral ankle [135]. Physical examination for acute low ankle sprains characteristically shows focal tenderness to palpation over the involved lateral ankle ligamentous structures [135]. Patients with acute low ankle sprains may have pain with resisted eversion of the foot, which is a sign of peroneal tendon injury during the inversion episode [135].

In an anterior talofibular ligament (ATFL) sprain, tenderness is maximal just distal and slightly anterior to the lateral malleolus [53]. The slightest attempt at passive inversion of the ankle is extremely painful in the acute phase of an ATFL sprain [53]. Stability assessment in the acute phase of an ankle ligament injury is not possible [53]. Assessment for recurrent instability requires evaluating for hindfoot varus [171]. Patients should be questioned about symptoms of a loose body or osteochondral injury, such as mechanical symptoms like locking or catching [171].

Anterolateral Soft-Tissue Impingement

Anterolateral soft-tissue impingement is a common cause of chronic pain after one or more lateral ankle sprains [156]. Patients with anterolateral soft-tissue impingement typically report a history of persistent anterolateral ankle pain with activity [156]. Diagnosis is based primarily on the history and physical examination [156]. Physical examination notes well-localized tenderness at the anterolateral ankle joint [156]. A specific physical examination test involves reproduction of pain with plantar flexion of the ankle, followed by thumb pressure at the anterolateral ankle joint, and dorsiflexion of the ankle [156]. This specific physical examination test has been reported to be reproducible and accurate [156].

Clinical examination for anterolateral soft-tissue impingement has noted higher sensitivity (94%) and specificity (75%) than conventional MRI [156]. Conventional MRI has a reported sensitivity and specificity of less than 50% for anterolateral soft-tissue impingement of the ankle [156]. A tibiotalar joint injection with anesthetic and/or steroid can aid in differentiating between intra-articular and extra-articular pathology contributing to impingement symptoms [156].

Chronic Ankle Instability

Chronic lateral ankle instability (CLAI) is defined as a minimum 6 months of symptom duration, postinjury duration, or time being unresponsive to nonoperative treatment [72]. Symptoms of CLAI include recurrent ankle sprains, persistent feeling of ankle instability, ankle pain, ankle swelling, or decreased function [72]. Ankle arthroscopy is becoming a mandatory tool for both diagnosis and treatment of chronic ankle instabilities [70]. Arthroscopy plays a crucial role in the definitive assessment of ligament lesions in patients with chronic ankle instability, supplying far more accurate information than any of the current imaging studies [40].

Preoperative ankle arthroscopy revealed an essential amount of information regarding chronic ankle instability that would otherwise have been undetected [25]. In a study of 148 patients with symptomatic chronic ankle instability, a rupture or elongation of the anterior talofibular ligament was noted in 86% of ankles [25]. In the same study, a rupture or elongation of the calcaneofibular ligament was noted in 64% of ankles [25]. A rupture or elongation of the deltoid ligament was noted in 40% of ankles [25]. Cartilage damage was noted in 66% of ankles with lateral ligament injuries [25]. Cartilage damage was noted in 98% of the ankles with deltoid ligament injuries [25]. Although lateral instability could be verified arthroscopically in 127 patients, medial instability was presumed clinically in 38 patients but was actually detected in 54 patients arthroscopically [25].

An arthroscopic classification of chronic anterior talofibular ligament lesions confirms the diagnostic role for arthroscopy in assessing ligaments in patients with chronic ankle instability [39]. Arthroscopy is helpful for determining the best surgical technique for stabilizing the ankle in patients with chronic ankle instability [39]. The endoscopic approach allows assessment of the ankle joint and treatment of associated intra-articular lesions in chronic lateral ankle instability [24]. Anatomical reconstruction of the anterior talofibular ligament is a recommendable choice for treating functional ankle instability in cases with morphologic ligamentous abnormality [42].

Acute Ankle Fractures and Syndesmosis

Ankle arthroscopy has the highest sensitivity and specificity for diagnosing syndesmotic injuries missed on plain and stress view radiographs [46]. Arthroscopic diagnosis of syndesmotic instability includes disruption of the deep portion of the posterior tibiofibular ligament, rupture of the interosseous ligament with a syndesmotic gap > 2 mm, or a fracture of the posterolateral portion of the tibial plafond [46]. Ankle arthroscopy is essential for diagnosis and treatment of syndesmosis instability, allowing for the evaluation of anatomic reduction and residual diastasis [59].

Concurrent ankle arthroscopy at the time of open reduction and internal fixation of ankle fractures provides better visualization and less disruption to surrounding soft tissues to view fracture reduction and intra-articular pathology [46]. Recognition of the ankle fracture component in distal tibial spiral shaft fractures is important as it may alter the surgical plan and postoperative management [71]. Various simultaneous intraarticular pathologies, which are difficult to diagnose by preoperative physical or radiological examination, are responsible for poor outcomes in ankle fractures [128].

Posterior Ankle Pathology

Posterior ankle arthroscopy is effective in patients with residual symptoms after syndesmosis injury [22]. Posterior ankle endoscopy in the supine position is a safe and effective approach for treatment of posterior ankle impingement, particularly when concomitant anterior ankle pathology requires anterior arthroscopy [73]. The first prospective study to evaluate posterior ankle arthroscopy in an exclusively young population demonstrates promising outcomes, supporting its role in the management of posterior ankle pathology [5].

Diagnostic Utility and Imaging Comparison

Ankle arthroscopy appears to give good results when used for the appropriate indications [1]. There exists adequate evidence-based literature to support the surgical technique of ankle arthroscopy for most current generally accepted indications [2]. The number of indications for anterior ankle arthroscopy is rising, and open surgery is increasingly replaced by arthroscopic surgery [9]. Anterior ankle arthroscopy is of great value in the diagnostic work-up and treatment of "web impingement" and was superior to MRI in detecting this type of pathology [33].

Diagnostic arthroscopy is a useful adjunct for diagnosing consolidation in cases with equivocal imaging findings after tibiotalar arthrodesis [58]. Pre-operative 3.0-T MRI demonstrated excellent accuracy in the diagnosis of syndesmotic ligament tears and allowed for the visualization of individual syndesmotic structures [69]. Pathology diagnosed on pre-operative MRI correlated strongly with arthroscopic findings for syndesmotic ligament disruption [69].

Investigations

General Diagnostic Role: Ankle arthroscopy provides essential insights into the causes and mechanisms of ankle instability and resulting disability [25]. It is crucial for the definitive assessment of ligament lesions in chronic ankle instability, supplying more accurate information than current imaging studies [40]. The procedure allows for the evaluation of anatomic reduction and residual diastasis in syndesmosis instability [59]. Arthroscopy is of great value in the diagnostic work-up and treatment, proving superior to MRI in detecting "web impingement" pathology [33]. An arthroscopic classification of chronic anterior talofibular ligament (ATFL) lesions confirms the diagnostic role for arthroscopy and helps determine the best surgical technique for stabilising the ankle [39]. The endoscopic approach allows assessment of the ankle joint and treatment of associated intra-articular lesions [24].

MRI: Preoperative MRI is a reliable and valid decision-making tool for choosing the surgical stabilization technique in patients with chronic lateral ankle instability [193]. However, MRI does not help determine functional instability, although it confirms the abnormal appearance of affected ligaments, which may be thickened or indistinct [100]. In the setting of syndesmotic injuries, pre-operative 3.0-T MRI demonstrated excellent accuracy for diagnosing ligament tears. For the anterior inferior tibiofibular ligament, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 87.5%, 100%, 100%, 71.4%, and 90.5% respectively [69]. For the posterior inferior tibiofibular ligament, these values were N/A, 95.2%, 0.0%, 100%, and 95.2% respectively [69]. For the interosseous tibiofibular ligament, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 66.7%, 86.7%, 66.7%, 86.7%, and 81.0% respectively [69]. MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time [211]. Regarding soft-tissue impingement, MRI can show osteophytes but is not very sensitive for soft-tissue impingement [105]. MR arthrography or contrast-enhanced, fat-suppressed, three-dimensional (3D), fast-gradient recalled acquisition in the steady state with radiofrequency spoiling (CE 3D-FSPGR) MRI is more sensitive and specific for soft-tissue impingement but is less practical [105].

Plain Radiography: Traditional radiographic measurements should not be relied on solely for determining if the syndesmosis is intact and the ankle mortise is stable [197]. In cases of symptomatic posterior ankle impingement, a PIM view is advised to be used instead of or in addition to the standard lateral view for detection of posterior talar pathologic conditions [209].

Other Considerations: In 148 patients with symptomatic chronic ankle instability, a rupture or elongation of the anterior talofibular ligament was noted in 86% of ankles [25]. A rupture or elongation of the calcaneofibular ligament was noted in 64% of ankles [25]. A rupture or elongation of the deltoid ligament was noted in 40% of ankles [25]. Ninety-eight percent of the ankles with deltoid ligament injuries had cartilage damage [25]. Ankle arthroscopy is useful for the diagnosis of full-thickness talar cartilage lesions in the setting of acute ankle fractures [86]. The presence of an osteochondral lesion had a negative effect on the overall result when compared to that of patients who underwent lateral ankle stabilization as an isolated procedure [215]. Anatomical reconstruction of the ATFL is a recommendable choice for treating functional ankle instability in cases with morphologic ligamentous abnormality [42]. The clinical and radiologic outcomes of patients with chronic ankle instability improved after all-inside arthroscopic ATFL repair [51]. About 20% of athletes referred for MRI after suffering an acute ankle sprain had evidence of a syndesmotic injury regardless of lateral ligament involvement [183]. More than half of athletes referred for MRI after suffering an acute ankle sprain had evidence of any lateral ligament injury without syndesmotic involvement [183]. Simultaneous arthroscopy, independent of pre-operative MRI findings, appears reasonable in highly active patients with acute, isolated and unstable syndesmotic injuries [157]. In one study, 58% of patients with anterior ankle impingement had an associated diagnosis, which changed the surgical plan in 33% [105]. An accessory anteroinferior tibiofibular ligament, although a normal anatomical finding, could lead to anterolateral impingement in cases with coexistent ankle instability [41]. There was a significant increase in the use of ankle arthroscopy for lateral ankle instability management [3]. The frequency of ankle arthroscopy increased from 2814 cases in 2007 to 3314 cases in 2011 [105]. The rate of increase for ankle arthroscopy was greater than that for shoulder, knee, and elbow arthroscopy [105]. A prospective study evaluating posterior ankle arthroscopy in an exclusively young population demonstrates promising outcomes, supporting its role in the management of posterior ankle pathology [5].

Treatment

Non-Operative

Conservative management remains the initial line of defense for acute lateral ankle ligament injuries, where individualized aggressive non-operative measures can achieve successful treatment of grade II and III injuries [149]. However, surgical intervention for chronic inversion instability is indicated in all patients in whom conservative measures have failed [76].

Operative

Indications: Adequate evidence-based literature supports ankle arthroscopy for most generally accepted indications, though further studies are required [2]. The procedure is becoming a mandatory tool for both the diagnosis and treatment of chronic instabilities [70]. Utilization trends show higher frequency in female patients and those younger than 50 years, with a significant increase in its use for lateral ankle instability management [3]. While resident exposure to ankle arthroscopy has remained low and variable despite an overall increase in leg and ankle procedures [66], the technique is now standard for addressing intra-articular pathology.

Surgical Approach / Technique: The no-distraction and dorsiflexion technique is the key for ankle arthroscopy evolution, allowing for more advanced third-generation procedures and reducing morbidity compared to routine distraction [101]. Medial and lateral antero-superior ancillary portals provide strong value in addressing repair procedures to ankle joint compartments that are blind to traditional arthroscopic access [103]. Recent advancements in in-office needle arthroscopy technology enable procedures under local anesthesia in the office setting, revolutionizing the treatment of foot and ankle pathologies [194]. Furthermore, two-millimetre diameter operative arthroscopy is safe and effective, holding the potential to make ankle arthroscopy less invasive and more accessible [20].

Implant Selection: For chronic ankle instability, surgeons may consider novel techniques such as suture anchors, synthetic augmentation, and all-arthroscopic stabilization in the management of lateral ankle instability [169]. The Broström procedure is the gold standard when anatomic reconstruction of the lateral ankle ligaments is attempted [212]. In arthroscopic ligament repair or reconstruction, suture anchor fixation carries a higher complication rate (29%) compared with suture fixation (9%) [44]. Tibiocalcaneal augmentation of deltoid ligament repair has a strong stabilizing effect on the ankle joint, though the surgical technique may be technically challenging [54]. Arthroscopic anterior deltoid plication with bone anchor is an effective procedure to control residual talar anterior translation after lateral ligament repair [210].

Alignment / Balancing Strategy: Surgically, both arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability, although sufficient evidence is still lacking for any particular procedure to be considered a superior construct [68]. A cadaver study showed no difference in the strength of the repair with open or arthroscopic Broström techniques [44]. In a comparison of 48 patients, no significant differences were noted between outcome scores, anterior talar translation, or talar tilt between an open modified Broström procedure and an all-inside arthroscopic modified Broström [44]. An all-inside arthroscopic modified Broström technique can be safely done in patients with lateral ankle instability [44].

Pain Management: Posterior ankle endoscopy in the supine position is a safe and effective approach for treatment of posterior ankle impingement, particularly when concomitant anterior ankle pathology requires anterior arthroscopy, allowing treatment of both pathologies without changing patient position [73]. The review suggests that posterior ankle arthroscopy is a safe and effective surgical procedure in the treatment of posterior ankle impingement [37].

Adjuncts: Since concomitant intraarticular pathologic processes are often associated with chronic ankle instability, arthroscopy is recommended before open lateral ankle ligament surgery [44]. The endoscopic approach for ligament reconstruction allows assessment of the ankle joint and treatment of associated intra-articular lesions [24]. In a study of 16,069 patients, ankle arthroscopy did not decrease the rate of reoperations required after ankle ligament reconstruction; however, there was a lower rate of ankle arthrodesis as a second procedure and lower complications in the patients who had arthroscopy [44].

Setting of Care: Recent advancements in in-office needle arthroscopy technology have made it possible to perform arthroscopic procedures under local anesthesia in the office setting, revolutionizing the treatment of foot and ankle pathologies [194].

Revision: Fourteen years post-procedure, a patient treated with salvage reconstruction for lateral ankle instability using a tendon allograft maintained a stable, painless ankle with no additional instability [50].

Other Considerations: Although only fair-quality evidence exists in support of open operative treatment of chronic ankle instability, this systematic review helps reassure clinicians of their current practices [11]. A survey of practices in chronic ankle instability in France reflected the heterogeneity of surgical practices and provided indications for areas of research in clinical situations with the least consensus [31]. The modified Broström procedure combined with ankle arthroscopy produced satisfactory surgical outcomes in patients with chronic ankle instability accompanied by intra-articular symptoms [56]. All-arthroscopic technique for anatomic reconstruction for chronic lateral ankle instability leads to good clinical results [106]. In a report of 286 patients undergoing arthroscopic ligament repair or reconstruction for chronic ankle instability, significant improvements in AOFAS and Karlsson scores were noted at a mean 10-month follow-up [44]. Neurologic complications occurred in 10% of patients undergoing arthroscopic ligament repair or reconstruction for chronic ankle instability, with cutaneous complications and infection occurring in 4.2% that required surgical revision [44]. The rate of cutaneous complications for arthroscopic ligament repair or reconstruction was at least half that of open surgery [44]. In a comparison of 60 patients, no significant differences were found between arthroscopic repair and open repair of the talofibular ligament in AOFAS score, Karlsson Ankle Functional Score, and the Tegner activity score [44]. Complication rates for arthroscopic ligament repair or reconstruction range between 11.5% and 18% based on systematic reviews and a study of 119 patients [44]. Two-stage arthroscopy was associated with significantly higher complication rates compared with single-stage arthroscopy [44]. Entrapment of the peroneus tertius, extensor tendons, and the superficial peroneal nerve can occur when tying sutures for the anterior talofibular ligament during arthroscopic repair [44]. An arthroscopic modified Broström procedure is successful regardless of whether generalized ligamentous laxity is present [44]. A study of 62 patients noted the added advantage of earlier bearing in arthroscopically treated patients for lateral ankle instability [44]. Anterolateral impingement is a less frequent finding in chronic lateral ankle instability, with 12% of patients having anterior bony impingement [44]. Thermal capsular shrinkage has a grade C recommendation (poor evidence) for the treatment of ankle instability due to sparse evidence in the orthopaedic literature [44]. In a cohort of 241 patients treated with arthroscopic all-inside lateral ligament repair, a positive anterior drawer test indicating residual lateral ankle instability was observed in 8 patients (3.3%) [210]. In a systematic review of level IV studies, all patients had subjective improvement of instability with arthroscopic Broström techniques, but there was a 17% complication rate [44].

Surgical treatment of rotational ankle fractures and their associated injuries can be aided by the use of ankle arthroscopy [46]. Syndesmosis disruption occurs in up to 11% of all ankle injuries and in 30% to 39% of rotational ankle fractures [46]. Concurrent ankle arthroscopy at the time of open reduction and internal fixation of ankle fractures provides both better visualization and less disruption to the surrounding soft tissues to view fracture reduction as well as intra-articular pathology including osteochondral defects and loose bodies [46]. Ankle arthroscopy at the time of open reduction and internal fixation for ankle fractures and injuries can aid in fracture reduction, and diagnosis of syndesmotic instability and allows for identification and treatment of chondral injuries, osteochondral defects, and loose bodies without significant soft-tissue dissection [46]. A meta-analysis revealed that functional outcomes were better after arthroscopically assisted open reduction and internal fixation than conventional open reduction in patients with ankle fractures [74]. Concomitant injuries have been reported in up to 80% of patients with ankle fractures [74]. Chondral lesions were identified in 78% of 116 patients with acute ankle fracture, with talar dome chondral lesions present in 43% [74]. All patients with dislocations had a chondral lesion, and patients with complete syndesmosis disruption and instability were more likely to have chondral injury [74]. Patients younger than 30 were less likely to have a chondral injury in the setting of acute ankle fracture [74]. Arthroscopic evaluation of the joint before fixation of an ankle fracture is more sensitive than MRI and stress radiographs of the syndesmosis in detecting instability [74]. A cadaver study showed that stress radiographs were inadequate in distinguishing between an intact ligament and a single disrupted ligament, whereas arthroscopy better demonstrated an isolated ligament disruption [74]. A systematic review found fair-quality evidence for use of ankle arthroscopy in detecting intraarticular injuries; however, there was insufficient evidence for improvement of functional outcome, reduction in complication rates, or operative time [74]. Patients with unstable ankle fractures who had concomitant ankle arthroscopy showed no statistically significant improvement but also no increased complications [74]. Average operative time was increased by only 15 minutes when ankle arthroscopy was performed with ankle fracture fixation [74]. There is a grade I (incomplete) recommendation for supplementing ankle fracture fixation with arthroscopy [74]. Primary arthroscopic reduction of talar neck fractures was achieved in six of seven patients, with one patient requiring removal of a fracture fragment through a small arthrotomy [74]. Six of seven patients treated with primary arthroscopic reduction of talar neck fractures were pain free, and excellent functional outcomes were achieved in five patients [74]. Two patients treated with primary arthroscopic reduction of talar neck fractures had restricted ankle motion, and a reduction in subtalar motion was noted in all patients [74]. In patients with chronic syndesmosis injuries, arthroscopic debridement of the associated intraarticular pathologic process can be done without screw fixation if there is no lateral displacement of the talus [74]. Patients with chronic widening of the syndesmosis can benefit from arthroscopic debridement and percutaneous placement of screws across the syndesmosis after reduction [74]. Low-flow arthroscopy allows for direct visualized debridement of the tract of a ballistic missile, which can decrease the risk of infection and retained intra-articular foreign bodies compared to open arthrotomy [191]. If no underlying fracture is present in gunshot wounds with retained intra-articular ballistic missiles, patients are allowed early progressive protected weight-bearing, limited by soft-tissue maturation [191].

Arthroscopic ankle arthrodesis has been performed with generally favorable union rates [160]. One study reported on 101 ankles in 97 patients who underwent arthroscopic ankle arthrodesis on average 86 months prior, demonstrating that 95% of the ankles achieved fusion with the primary procedure [160]. There are no data to support one approach over another for ankle arthrodesis, and therefore, the approach should be at the discretion of the surgeon based on previous incisions/wounds and any hardware removal needed [160]. Factors that seem to improve results for ankle arthrodesis include arthroscopic or mini-incision technique, the use of more than two screws or an adjunct plate (or fibular strut), and a diagnosis of primary osteoarthritis [175]. With modern techniques, attention to detail, and management of concurrent medical conditions, fusion rates of better than 90% should be expected in standard, uncomplicated ankle arthrodesis [175]. There is fair evidence (grade B) to advocate the use of internal fixation for ankle arthrodesis and evolving grade B evidence suggesting that minimally invasive techniques may be equivalent to open procedures in selected patients [175]. Arthroscopic or open debridement of the arthritic ankle can be effective in the overall management plan, but it must be used judiciously and with realistic expectations of the outcome [137]. Efficacy has been shown in several studies for the removal of anterior impingement osteophytes from the tibia and/or talus [137]. Patients with mechanical locking of the ankle from a demonstrable loose body may benefit from arthroscopic management [137]. Debridement of more advanced arthritic ankles likely provides only short-term relief and is not recommended in most cases [137]. Increased motion following removal of impinging osteophytes in a joint with irregular arthritic surfaces may lead to different or increased pain postoperatively and should be discussed with the patient before surgery [137]. Aggressive removal of osteophytes may lead to anterior extrusion of the talus postoperatively [137]. Arthroscopic or open debridement can be done in combination with other procedures such as osteotomy and distraction arthroplasty [137].

This first prospective study to evaluate posterior ankle arthroscopy in an exclusively young population demonstrates promising outcomes, supporting its role in the management of posterior ankle pathology [5]. There is sparse literature regarding the use of arthroscopy for treatment of septic arthritis of the ankle, with a grade C (poor evidence) recommendation for this indication [44]. In one series of 78 infected joints that included five ankles, there was a 91% cure rate for septic arthritis treated with arthroscopy [44]. In another series of 89 infected joints, three of which were ankles, there were 61% good/excellent, 20% satisfactory, and 19% poor functional outcomes for septic arthritis treated with arthroscopy [44]. There are only small series (level IV studies) on the use of arthroscopy to treat arthrofibrosis of the ankle, most of which report promising results [44]. There is a grade C recommendation (poor evidence) for the use of ankle arthroscopy in the treatment of arthrofibrosis [44].

When performing ankle arthroscopy, it is important to remember the potential complications and try to avoid them [13]. The incidence of cartilage injury during ankle arthroscopy is high, however, severe damage was found in only 6.7% of ankle arthroscopies [17]. In a study of iatrogenic articular cartilage injuries, the lesion was superficial in 78.2% of injuries (24.3% of all patients), and deep in 21.8% of injuries (6.7% of all patients) [17]. Of the 23 cartilage injuries found in a retrospective case series, 65% were sustained during the therapeutic portion of the arthroscopic procedure and the remaining 35% occurred during the portal creation portion [17]. Complications of arthroscopic ankle surgery using small joint instruments and contemporary noninvasive distraction techniques occur [13].

Complications

Overall Safety: Ankle arthroscopy is a safe procedure with a low overall complication rate [14]. Surgeons must remain vigilant regarding potential complications to avoid them [13]. The use of the dorsiflexion method for anterior ankle arthroscopy can prevent a significant number of complications [230].

Iatrogenic Cartilage Injury: The ankle is more susceptible than other joints to iatrogenic cartilage injury due to its anatomic characteristics [17]. The incidence of cartilage injury during the procedure is high [17]. Severe iatrogenic cartilage damage was found in only 6.7% of ankle arthroscopies [17]. Of the identified injuries, 78.2% were superficial and 21.8% were deep [17]. Regarding timing, 65% of injuries were sustained during the therapeutic portion of the procedure, while 35% occurred during portal creation [17].

Nerve Injury: Nerve injury is the most common complication related to ankle arthroscopic procedures [17]. Neurologic complications occurred in 10% of patients undergoing arthroscopic ligament repair or reconstruction for chronic ankle instability, manifesting as transient dysesthesia and neuroma [44]. The intermediate dorsal cutaneous branch of the superficial peroneal nerve crosses the inferior extensor retinaculum and is the primary structure at risk during arthroscopic lateral ankle repair [221]. Entrapment of the peroneus tertius, extensor tendons, and the superficial peroneal nerve can occur when tying sutures for the anterior talofibular ligament [44].

Vascular Complications: In 6.2% of cases, the anterior tibial artery and its branches were located near the anterolateral ankle portal, introducing a risk of vascular damage [226]. A technique for avoiding vein injury using a peripheral vein illumination device during anterior portal placement in ankle arthroscopy could lower the risk of complications [228].

Infection and Steroid Use: The use of intraoperative intra-articular corticosteroid injection at the time of ankle arthroscopy in Medicare patients is associated with significantly increased rates of postoperative infection compared with controls without intraoperative steroid injections [87]. Big data suggest that because of a significant increased risk of postoperative infection, steroid injection is not recommended after ankle arthroscopy [242].

Ligament Repair and Reconstruction Complications: The complication rate for arthroscopic ligament repair or reconstruction is a concern, with rates between 11.5% and 18% reported in systematic reviews and one study of 119 patients [44]. The wide variations in the reported complication rates for arthroscopic lateral ankle repair range from 0% to 29% [221]. Complications of arthroscopic lateral ankle repair include nerve pain, knot irritation, delayed wound-healing, and deep vein thrombosis [221]. Cutaneous complications and infection occurred in 4.2% of patients undergoing arthroscopic ligament repair or reconstruction for chronic ankle instability, requiring surgical revision [44]. The rate of cutaneous complications in arthroscopic ligament repair or reconstruction was at least half that of open surgery [44]. One patient in each group of a study on arthroscopic all-inside anterior talofibular ligament repair presented with neuralgia of the superficial peroneal nerve, which improved over time without any treatment [221]. Two patients in the inferior extensor retinaculum reinforcement group of an arthroscopic all-inside anterior talofibular ligament repair study had knot irritation causing mild discomfort [221]. One patient in the no-inferior extensor retinaculum reinforcement group of an arthroscopic all-inside anterior talofibular ligament repair study presented with an abscess requiring local incision and drainage [221].

Distraction Technique Risks: It was recently suggested that a large number of complications in ankle arthroscopy can be contributed to the continuous distraction itself [62]. If the continuous distraction set-up is responsible for the high complication rate in ankle arthroscopy, one could expect a considerably lower complication rate when using a non-distraction method [62].

Arthrodesis Complications: Arthroscopy significantly reduces the risk of postoperative complications while significantly increasing consolidation rates (nonunion < 10%) in tibiotalar and subtalar joint arthrodesis [243]. Both arthroscopic and mini-open ankle arthrodesis had good clinical outcomes, with high union rates and lower rates of complications [235].

Recovery

Light activity (weeks): A driving abstinence of two weeks is necessary after right-sided ankle arthroscopy [63].

Full activity (months): Most patients achieved excellent functional outcomes by 6 weeks, with minimal complications, high satisfaction, and return to sport before 1 year following immediate weightbearing after augmented modified Broström reconstruction [223]. In the context of accelerated rehabilitation with proactive weightbearing exercises from postoperative day 3, as many as 75% of patients were able to make a complete return to sport within 8 weeks [121]. High return to sports and return to work rates were observed after anatomic lateral ankle ligament reconstruction with tendon autograft for isolated chronic lateral ankle instability [165]. All patients were able to return to their preoperative occupational and athletic activities following reconstruction of the lateral ligaments of the ankle using the plantaris tendon [186].

Rehabilitation protocol: The success of lateral ankle instability surgery depends on proper phases of the rehabilitation period [115]. When accelerated rehabilitation with proactive weightbearing exercises was implemented from postoperative day 3 without ankle immobilization after arthroscopic lateral ligament repair, significant improvements were seen in objective assessments of ankle stability and clinical scores [121]. An accelerated rehabilitation program can be practiced and fewer complications arise for fully arthroscopic syndesmotic ligament procedures [167].

Functional milestones: Short-term AOFAS functional outcome scores were significantly improved with arthroscopic lateral ankle repair compared to open repair [231]. The ALR-RSI is a valid, reproducible scale used to identify patients who are ready to resume the same sport after ankle ligament reconstruction [224]. Significant improvements were noted in the 36-items Short Form survey and Foot and Ankle Ability Measure at 36 months following bilateral os trigonum fracture treatment with posterior ankle arthroscopy [67].

Other Considerations: Ankle arthroscopy is associated with decreased morbidity and faster recovery times compared with open arthrotomy [12]. There exists adequate evidence-based literature to support the surgical technique of ankle arthroscopy for most current generally accepted indications, though further studies are needed [2]. The last five years have seen notable advancements in foot and ankle surgery as a result of technical innovations and more consistent reporting of results, with progress made in improving patient-reported outcome measures, basic research, and personalized approaches [82]. Ankle stability resumed with a high clinical success rate following a new arthroscopic Broström procedure for chronic lateral ankle instability [49]. Fourteen years post-procedure, a patient maintained a stable, painless ankle with no additional instability following salvage reconstruction for lateral ankle instability using a tendon allograft [50]. Clinical and radiologic outcomes of patients with chronic ankle instability improved after all-inside arthroscopic anterior talofibular ligament repair [51]. Arthroscopic lateral ankle ligament repair can produce favorable clinical outcomes in the short term [232]. When compared with open lateral ankle repair, arthroscopic repair of lateral ankle ligament produced similarly favorable outcomes at 2 years [233]. One year after the procedure, roentgenograms showed stable ankles with a full range of motion [78]. Residual ankle instability was associated with worse postoperative outcomes in patients with osteochondral lesions of the talus, highlighting the need for adequate stabilization [234]. Only subjects with chronic ankle instability had reductions in self-reported function compared to healthy individuals and copers [195]. Ankle arthroscopy followed by open anatomic ligament repair is a reliable procedure for patients requiring return to high demanding sports after severe acute ankle sprains [164]. The literature identifies a clear deficiency regarding consistent, meaningful postoperative return to sport timelines following lateral ankle ligament repair [166]. Posterior ankle arthroscopy was effective in patients with residual symptoms after syndesmosis injury [22]. In a case of bilateral os trigonum fracture treated with simultaneous posterior ankle arthroscopy, the pain visual analog scale score decreased from 8/10 to 0/10 for both ankles at 36 months [67]. No postoperative complications were recorded in the study of bilateral os trigonum fracture treated with simultaneous posterior ankle arthroscopy [67].

Key Evidence

• [L5] When used for the appropriate indications, ankle arthroscopy appears to give good results. [1] (10.5435/00124635-199601000-00004)
• [L4] There exists adequate evidence-based literature to support the surgical technique of ankle arthroscopy for most current generally accepted indications; however, further studies in this area are needed. [2] (10.1016/j.arthro.2009.05.001)
• [L4] Ankle arthroscopy was performed more frequently in female patients and most commonly in patients younger than 50 years, with a significant increase in its use for lateral ankle instability management. [3] (10.1016/j.arthro.2015.01.020)
• [L5] Operative procedures that only focus on part of the pathology should be approached with caution until assessment of a patient with ankle instability defines all deficiencies. [4] (10.2106/jbjs.21.00726)
• [L3] This first prospective study to evaluate posterior ankle arthroscopy in an exclusively young population demonstrates promising outcomes, supporting its role in the management of posterior ankle pathology. [5] (10.1177/2325967126s00420)
• [L5] Posterior ankle arthroscopy is a powerful diagnostic and therapeutic modality for orthopaedic foot and ankle surgeons. [7] (10.1016/j.eats.2024.103322)
• [L5] Posterior ankle arthroscopy is a powerful diagnostic and therapeutic modality for orthopaedic foot and ankle surgeons. [8] (10.1016/j.eats.2024.103323)
• [L5] The number of indications for anterior ankle arthroscopy is rising, and open surgery is increasingly replaced by arthroscopic surgery. [9] (10.1136/jisakos-2015-000009)
• [L5] This article outlines the current state of the art for posterior ankle arthroscopy, covering diagnostics, surgical techniques, complications, geographical differences, and future developments. [10] (10.1136/jisakos-2016-000082)
• [L2] Although only fair-quality evidence exists in support of open operative treatment of chronic ankle instability, this systematic review helps reassure clinicians of their current practices. [11] (10.1136/jisakos-2018-000265)
• [L5] Ankle arthroscopy is a relatively new and dynamic tool with decreased morbidity and faster recovery times compared with open arthrotomy. [12] (10.5435/00124635-199601000-00003)
• [L4] When performing ankle arthroscopy, it is important to remember the potential complications and try to avoid them. [13] (10.1530/eor-22-0144)
• [L1] This comprehensive systematic review demonstrates that ankle arthroscopy is a safe procedure with a low overall complication rate. [14] (10.1302/0301-620x.105b3.bjj-2022-0796.r1)
• [L5] With sound knowledge regarding the indications, merits, and potential risks of new techniques, they will be powerful tools in foot and ankle surgery. [15] (10.1016/j.arthro.2007.03.003)
• [L4] [17] (10.1007/s00167-014-3237-5)
• [L5] It may hold the potential to make ankle arthroscopy less invasive and more accessible. [20] (10.1007/s00167-020-05889-7)
• [L4] The final diagnosis of chronic instability of the anterior syndesmosis can be made during arthroscopy of the ankle. [21] (10.1186/1471-2474-12-212)
• [L4] Posterior ankle arthroscopy was effective in patients with residual symptoms after syndesmosis injury. [22] (10.1177/23259671231200934)
• [L2] The endoscopic approach also allows assessment of the ankle joint and treatment of associated intra-articular lesions. [24] (10.1007/s00167-019-05793-9)
• [L4] [25] (10.1177/03635465020300031601)
• [L5] Ankle arthroscopy has become a very handy tool for helping patients to alleviate ankle pain as long as the indication is fulfilled. [26] (10.1177/2325967121s00849)
• [L4] On the basis of these findings, arthroscopic treatment of anterolateral ankle soft-tissue impingement is a very safe procedure when indicated. [27] (10.1016/j.arthro.2013.10.014)
• [L4] Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture. [29] (10.1016/j.arthro.2016.08.016)
• [L3] Arthroscopic ankle stabilisation repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes. [30] (10.1016/j.otsr.2018.09.005)
• [L4] This survey reflected the heterogeneity of surgical practices in ankle instability and provided indications for areas of research in clinical situations with the least consensus. [31] (10.1177/2325967120s00009)
• [Case_report] Anterior ankle arthroscopy is of great value in the diagnostic work-up and treatment, and was superior to MRI in detecting this type of pathology. [33] (10.1007/s00167-012-2077-4)
• [L3] Combining ankle arthroscopy with a modified Brostrom procedure provided significantly improved ankle hindfoot scores at an average of 35 months follow up. [34] (10.1016/j.arthro.2009.04.063)
• [L4] The review suggests that posterior ankle arthroscopy is a safe and effective surgical procedure in the treatment of posterior ankle impingement. [37] (10.1016/j.arthro.2007.08.025)
• [L4] This arthroscopic classification of chronic ATFL lesions confirms the diagnostic role for arthroscopy in assessing the ligaments in patients with CAI and is helpful for determining the best surgical technique for stabilising the ankle. [39] (10.1016/j.otsr.2018.09.004)
• [L2] Arthroscopy plays a crucial role in the definitive assessment of ligament lesions in patients with chronic ankle instability, supplying far more accurate information than any of the current imaging studies. [40] (10.1016/j.otsr.2018.09.008)
• [L5] Although it reflects a normal anatomical finding, it could lead to anterolateral impingement in cases with coexistent ankle instability. [41] (10.1177/0095399703258697)
• [L4] Anatomical reconstruction of the ATFL is a recommendable choice for treating functional ankle instability in cases with morphologic ligamentous abnormality. [42] (10.1177/0363546508315537)
• [L4] Ankle stability resumed with a high clinical success rate. [49] (10.1186/s13018-023-03789-3)
• [L4] Fourteen years post-procedure, the patient maintained a stable, painless ankle with no additional instability. [50] (10.1097/01.blo.0000092976.12414.b0)
• [L3] The clinical and radiologic outcomes of patients with chronic ankle instability improved after all-inside arthroscopic ATFL repair. [51] (10.1177/03635465211008097)
• [L5] While this surgical technique may be technically challenging, it has a strong stabilizing effect on the ankle joint. [54] (10.1177/03635465251352739)
• [L4] The modified Broström procedure combined with ankle arthroscopy produced satisfactory surgical outcomes in patients with chronic ankle instability accompanied by intra-articular symptoms. [56] (10.1016/j.arthro.2010.02.002)
• [Paper] Diagnostic arthroscopy is a useful adjunct for diagnosing consolidation in cases with equivocal imaging findings. [58] (10.1016/j.eats.2019.08.001)
• [L5] Ankle arthroscopy is essential for diagnosis and treatment, allowing for the evaluation of anatomic reduction and residual diastasis. [59] (10.1177/2325967121s00851)
• [L2] [62] (10.1007/s00167-012-2063-x)
• [L2] A driving abstinence of two weeks is necessary after right-sided ankle arthroscopy. [63] (10.1016/j.injury.2015.11.011)
• [L4] [66] (10.1016/j.asmr.2022.06.003)
• [L5] [67] (10.5435/jaaosglobal-d-23-00237)
• [L4] Surgically, both arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability, although sufficient evidence is still lacking for any particular procedure to be considered a superior construct. [68] (10.5435/jaaos-d-20-00145)
• [L2] [69] (10.1007/s00167-014-3399-1)
• [L4] Acute instabilities generally undergo conservative treatment while chronic instabilities are better addressed with surgery, and ankle arthroscopy is becoming a mandatory tool for both diagnosis and treatment. [70] (10.1302/2058-5241.6.210017)
• [L4] Recognition of the ankle fracture component is important as it may alter the surgical plan and postoperative management. [71] (10.1007/s00402-014-2095-4)
• [L4] [72] (10.1177/03635465221084365)
• [Paper] Posterior ankle endoscopy in the supine position is a safe and effective approach for treatment of posterior ankle impingement, particularly when concomitant anterior ankle pathology requires anterior arthroscopy, allowing treatment of both pathologies without changing patient position. [73] (10.1016/j.eats.2016.07.006)
• [L4] The operation is suggested to be considered in all patients with chronic inversion instability of the ankle in whom conservative measures have failed. [76] (10.1016/0020-1383(75)90065-0)
• [L4] The last five years have seen notable advancements in foot and ankle surgery as a result of technical innovations and more consistent reporting of results, with progress made in improving patient-reported outcome measures, basic research, and personalized approaches. [82] (10.1302/0301-620x.107b3.bjj-2024-0873.r2)
• [L4] [86] (10.1016/j.arthro.2017.12.003)
• [L4] The use of intraoperative intra-articular corticosteroid injection at the time of ankle arthroscopy in Medicare patients is associated with significantly increased rates of postoperative infection compared with controls without intraoperative steroid injections. [87] (10.1016/j.arthro.2015.07.029)
• [L3] This supports the interpretation that the dynamic congruency of the joint, which is influenced by ligamentous integrity remains the main anatomical component in mechanical ankle instability. [91] (10.1186/s12891-025-09458-2)
• [L5] The no-distraction and dorsiflexion technique is the key for ankle arthroscopy evolution as it allows for more advanced third-generation procedures and reduces morbidity compared to routine-distraction. [101] (10.1016/j.arthro.2018.02.011)
• [L4] Medial and lateral antero-superior ancillary portals have strong value in addressing repair procedures to ankle joint compartments blind to traditional arthroscopic access. [103] (10.1016/j.arthro.2016.03.079)
• [L4] All-arthroscopic technique for anatomic reconstruction for chronic lateral ankle instability leads to good clinical results. [106] (10.1016/j.arthro.2017.08.159)
• [L4] Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space. [109] (10.2106/jbjs.i.00084)
• [L5] The success of lateral ankle instability surgery also depends on proper phases of the rehabilitation period. [115] (10.1177/2325967124s00376)
• [L5] The greatest increases in laxity after sectioning the ligament occurred in ankle positions and loads corresponding to common modes of injury. [118] (10.2106/00004623-198365010-00011)
• [L4] When accelerated rehabilitation with proactive weightbearing exercises was implemented from postoperative day 3 without ankle immobilization after ALLR, there were significant improvements in objective assessments of ankle stability and clinical scores, and as many as 75% of the patients were able to make a complete return to sport within 8 weeks. [121] (10.1177/23259671221121676)
• [L3] [125] (10.1002/ksa.12079)
• [L3] [128] (10.1016/j.arthro.2020.01.053)
• [L5] The number of mechanoreceptors was negatively correlated with ankle sensorimotor dysfunction. [129] (10.1177/03635465231217490)
• [L2] Most studies found distinct characteristics of the incisura fibularis morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement. [130] (10.1016/j.jisako.2024.100361)
• [L3] Abnormal internal rotation of the talus in patients with mechanical ankle instability was decreased after ankle lateral stabilization surgery. [133] (10.1177/23259671211023447)
• [L4] The Diagnostic Ankle Arthroscopy Skills Scoring System was a valid measure to objectively assess trainees' ankle arthroscopy clinical knowledge and operative skills in a bioskills laboratory. [144] (10.1177/1071100719891418)
• [L5] Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. [147] (10.2106/00004623-199607000-00006)
• [L4] Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, non-operative measures, though acute repair may give better results in professional athletes. [149] (10.1007/s00167-012-2252-7)
• [L3] The ATFL–PTFL angle decreases after ankle lateral stabilization surgery. [154] (10.1007/s00167-020-06174-3)
• [L3] Simultaneous arthroscopy, independent of pre-operative MRI findings, appears reasonable in highly active patients. [157] (10.1007/s00167-020-06141-y)
• [L5] [158] (10.1002/ksa.12538)
• [L4] Grading of the three major ligamentous complexes and of the individual ankle ligaments according the Schneck grading system resulted in limited diagnostic reliability. [161] (10.1136/jisakos-2020-000503)
• [L4] [162] (10.1007/s00167-014-3454-y)
• [L5] This international consensus derived from leaders in the field will assist clinicians with the appropriate terminology for osteochondral lesions of the ankle. [163] (10.1016/j.jisako.2021.12.001)
• [L3] Ankle arthroscopy followed by open anatomic ligament repair is a reliable procedure for patients requiring return to high demanding sports after severe acute ankle sprains. [164] (10.1186/s12891-022-05260-6)
• [L4] These results may be helpful in preoperatively managing patients' expectations regarding sports- and work-related outcomes and provide tangible data on the expectable time frame of the individual return to sports and work trajectory. [165] (10.1007/s00167-022-06937-0)
• [L4] The review identifies a clear deficiency in the literature pertaining to consistent, meaningful postoperative return to sport timeline following lateral ankle ligament repair. [166] (10.1136/jisakos-2016-000064)
• [L4] An accelerated rehabilitation program can be practiced and fewer complications arise, since it is a fully arthroscopic procedure. [167] (10.1016/j.arthro.2008.04.062)
• [L5] Surgeons may consider using novel techniques such as suture anchors, synthetic augmentation, and all-arthroscopic stabilization in the management of lateral ankle instability. [169] (10.5435/jaaos-d-20-00176)
• [L5] Arthroscopic treatment of ankle instability is emerging as the potential gold standard technique, offering the advantage of addressing both instability and associated intra-articular pathology in a single procedure with excellent results. [176] (10.1016/j.arthro.2020.10.043)
• [L5] [180] (10.5435/00124635-199603000-00001)
• [L3] About 20% of athletes referred for MRI after suffering an acute ankle sprain had evidence of a syndesmotic injury regardless of lateral ligament involvement, while more than half had evidence of any lateral ligament injury without syndesmotic involvement. [183] (10.1177/0363546514529643)
• [L4] All patients were able to return to their preoperative occupational and athletic activities. [186] (10.2106/00004623-198567060-00016)
• [L5] [190] (10.1530/eor-22-0024)
• [L4] [191] (10.1016/j.eats.2022.07.018)
• [L3] Preoperative MRI is a reliable and valid decision making tool for the choice of surgical stabilization technique in patients with chronic lateral ankle instability. [193] (10.1016/j.arthro.2017.04.066)
• [L5] Recent advancements in IONA technology have made it possible to perform arthroscopic procedures under local anesthesia in the office setting, revolutionizing the treatment of foot and ankle pathologies. [194] (10.1016/j.arthro.2023.01.005)
• [L3] Only subjects with chronic ankle instability had reductions in self-reported function. [195] (10.2519/jospt.2012.3923)
• [L2] Traditional radiographic measurements should not be relied on solely for determining if the syndesmosis is intact and the ankle mortise is stable. [197] (10.1097/01.blo.0000161090.86162.19)
• [L2] In cases of symptomatic posterior ankle impingement, we advise that a PIM view be used instead of or in addition to the standard lateral view for detection of posterior talar pathologic conditions. [209] (10.1016/j.arthro.2014.05.006)
• [L4] [210] (10.1002/ksa.12328)
• [L3] MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time. [211] (10.1007/s00167-019-05581-5)
• [Paper] [212] (10.1016/j.csm.2015.06.004)
• [L4] The presence of an osteochondral lesion had a negative effect on the overall result when compared to that of patients who underwent lateral ankle stabilization as an isolated procedure. [215] (10.1177/0363546509351556)
• [L1] [221] (10.2106/jbjs.20.01696)
• [L4] Most patients achieved excellent functional outcomes by 6 weeks, with minimal complications, high satisfaction, and return to sport before 1 year. [223] (10.1177/23259671251389196)
• [L4] The ALR-RSI is a valid, reproducible scale with which to identify patients who are ready to resume the same sport after ankle ligament reconstruction. [224] (10.1177/2325967121s00010)
• [L4] In 6.2% of cases, the anterior tibial artery and its branches were located near the anterolateral ankle portal, introducing a risk of vascular damage. [226] (10.1177/0363546511416317)
• [Paper] The technique for avoiding vein injury using a peripheral vein illumination device during anterior portal placement in ankle arthroscopy could lower the risk of complications. [228] (10.1016/j.eats.2017.08.060)
• [L3] They also conclude that the use of the dorsiflexion method for anterior ankle arthroscopy can prevent a significant number of complications. [230] (10.1007/s00167-012-2092-5)
• [L1] Short-term AOFAS functional outcome scores were significantly improved with arthroscopic lateral ankle repair compared to open repair. [231] (10.1007/s00167-018-5100-6)
• [L5] ALALR can produce favorable clinical outcomes in the short term, and it is likely that arthroscopic rather than open lateral ankle ligament repair will become the standard of care in the future. [232] (10.1016/j.arthro.2018.05.001)
• [L3] When compared with open lateral ankle repair, arthroscopic repair of lateral ankle ligament when feasible produced similarly favorable outcomes. [233] (10.1177/0363546517698675)
• [L3] However, residual ankle instability was associated with worse postoperative outcomes, highlighting the need for adequate stabilization of ankle instability in patients with OLT. [234] (10.1177/23259671211007439)
• [L3] Both arthroscopic and mini-open ankle arthrodesis had good clinical outcomes, with high union rates and lower rates of complications. [235] (10.1016/j.arthro.2017.08.160)
• [L5] Big data suggest that because of a significant increased risk of postoperative infection, steroid injection is not recommended after ankle arthroscopy. [242] (10.1016/j.arthro.2015.12.015)
• [L4] Arthroscopy significantly reduces the risk of postoperative complications while significantly increasing consolidation rates (nonunion < 10%). [243] (10.1016/j.otsr.2015.06.033)

See Also

• Ankle impingement
• Syndesmotic injury
• Ankle fracture
• Chronic ankle instability
• Ankle arthrodesis
• Ankle fracture fixation

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