Overview
Ankle arthroscopy is a useful tool for ankle instability, septic arthritis, arthrofibrosis, loose bodies, impingement, osteochondral lesions of the talus and arthroscopic-assisted fracture management. A purely diagnostic arthroscopy has a low success rate, so a definite diagnosis should be made first. If MRI is not helpful, a diagnostic intraarticular injection can help: significant relief from an intraarticular anesthetic suggests an intraarticular process that may benefit from arthroscopic debridement. (Campbell)
Indications
Soft-tissue impingement
Bony impingement
Intraarticular loose bodies
Osteochondral lesions of the talus
Fractures about the ankle and hindfoot
Ankle instability
Septic arthritis of the ankle
Persistent pain about the ankle after failed conservative management
(Campbell, Box 55.1)
Structures at Risk
Anterior tibial artery lies close to the anterior capsule and to the anterolateral portal; the safe anterior working area decreases with distraction. (Campbell)
Superficial peroneal nerve has widely variable anatomy. It is marked preoperatively with the foot plantarflexed and inverted, and it moves laterally when the foot returns to neutral or dorsiflexion. Transillumination does not show it reliably. In a cadaver study, two or more branches crossed the ankle in most specimens, with a branch near the anterolateral portal in about two thirds. (Campbell)
Saphenous nerve is at risk when penetrating the joint through the anteromedial portal. (Campbell)
Tibial and sural nerve symptoms are reported after posterior debridement. (Campbell)
Setup Recommendations (Campbell's Concepts)
Mark the course of the superficial peroneal nerve at the beginning with the foot in plantarflexion, and stay medial to the marking when establishing the anterolateral portal.
A tourniquet allows better joint visualization.
A 70-degree arthroscope gives better visualization of posterior lesions, the medial and lateral gutters and deltoid lesions.
Needle arthroscopy needs less equipment and can assess intraarticular pathology that often coexists with ankle fractures; some authors use it in the office.
For arthroscopic-assisted fracture treatment, a large rolled blanket bump in the popliteal fossa can replace the leg holder, with a foot strap for gentle noninvasive distraction.
Dynamic arthroscopic evaluation of the syndesmosis can assess stability directly and confirm reduction after fixation.
Posterior arthroscopy improves working space for talar dome lesions. Wire-based distraction improves talar dome access over noninvasive distraction in a posterior approach, but not in an anterior approach.
Preemptive local anesthesia and infiltration of the operative site reduce early postoperative pain and the risk of neuropathic pain.
Technique 55.1: Arthroscopic Examination and Debridement of the Ankle Joint (Campbell)
Place the patient supine with the leg in a leg holder, hip and knee flexed and the foot hanging free for gravity-assisted distraction. This also keeps ankle motion free to reach different parts of the joint.
Mark the course of the superficial peroneal nerve, visible subcutaneously after plantarflexion and inversion.
Palpate the joint line and mark the anteromedial and anterolateral portals away from the nerve. The anteromedial portal lies just lateral to the medial malleolus and medial to the tibialis anterior tendon. The anterolateral portal lies anterior to the fibula, where the peroneal nerve is at risk.
After Esmarch exsanguination and thigh tourniquet inflation, insert an 18-gauge spinal needle at the anteromedial site and insufflate saline. Placement is intraarticular when saline flows with minimal resistance, the foot dorsiflexes as the capsule tightens, and fluid flows back into the syringe at maximal distention. Establish the anteromedial portal first because fewer structures are at risk.
Make a skin incision only large enough for the cannula, since a large incision allows more extravasation.
Penetrate the joint with a blunt straight hemostat (saphenous nerve at risk).
Insert a 2.7-mm 30-degree arthroscope into the anteromedial portal. Localize the anterolateral portal with a spinal needle under direct vision.
Incise the skin, spread gently with a hemostat, penetrate with a blunt instrument and introduce the shaver.
Inspect and debride the lateral joint through the anterolateral portal, then switch portals (scope lateral, instruments medial) for the medial side.
Use noninvasive distraction for deeper areas. Occasionally a posterolateral portal is needed for posterior pathology that distraction cannot reach.
Close the portals with suture to avoid a fistula.
Combined Anterior and Posterior Access (Campbell)
Options: switch from supine to prone; do the anterior arthroscopy, then rotate the leg to place two posteromedial portals; use the lateral position for posterior work with the leg externally rotated for anterior work; or perform posterior arthroscopy prone with the knee flexed 90 degrees to reach the anterior ankle.
Postoperative Care
Patients are placed in a walking boot and may bear weight as tolerated, with caution against excessive activity that inflames the ankle. After arthroscopic fracture management, weight bearing follows the injury pattern and patient factors. Start physical therapy once wounds have healed and pain is minimal. In a small study, emergency braking performance improved by 2 weeks after ankle or subtalar arthroscopy. (Campbell)
Complications (Campbell, Box 55.2)
Reported complication rates were 9% to 17% in older series, with neurologic injury most common, and 3.5% to 6.8% in more recent studies, probably related to noninvasive distraction or dorsiflexion with minimal distraction.
Neurologic injury
Vascular injury, including rare pseudoaneurysm
Joint fistula
Infection (correlated with intraoperative corticosteroid injection)
Complex regional pain syndrome
Instrument breakage
Deep venous thrombosis (rare)
Compartment syndrome
Iatrogenic cartilage damage
References
Rider CM. Arthroscopy of the foot and ankle. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 55.