Keyhole Ankle Surgery

The ankle takes several times body weight with every step, through a joint surface smaller than a knee’s. It tolerates that well and puts up with a great deal of injury, which is the reason ankle problems are often left far longer than knee problems before anyone looks at them properly.

Most of what needs surgery here can be done through keyhole incisions, and a good deal of it does not need surgery at all.

What keyhole surgery means here

A camera a few millimetres across, and fine instruments, passed into the joint through small incisions. The ankle is a tight, closely fitted joint with very little slack, so the equipment is smaller than the knee equivalent and the work is done in a narrow space.

Compared with opening the joint, it means less disturbance to the soft tissue envelope around it, which matters more at the ankle than almost anywhere else: the skin and tissue over the front of the ankle is thin, and it does not forgive being handled roughly.

The problems this covers

An ankle that keeps giving way. Sprains tear the ligaments on the outer side. Most heal. Some heal long, leaving the ankle subtly loose, and it then rolls over on uneven ground, kerbs and stairs. Each episode does a little more damage to the joint surface, which is why recurrent instability is worth treating rather than living with.

Impingement. Something physically blocking the joint at the limit of movement. At the front, usually a bony spur or thickened tissue, pinching when the ankle bends upwards, so it hurts going uphill, squatting, or working a clutch. At the back, felt on pointing the foot down. Keyhole surgery removes the block.

Damage to the cartilage surface. A hard sprain or a twist can knock a fragment off the surface of the talus, the bone that sits inside the ankle joint. It presents as deep pain on weight bearing, sometimes with swelling that comes and goes, and it is a frequent reason an ankle never settles after what was assumed to be a simple sprain.

Loose fragments and an inflamed joint lining. A fragment of bone or cartilage floating in the joint catches and locks. An inflamed, thickened lining gets pinched. Both are dealt with directly at arthroscopy.

Wear in the joint. Ankle arthritis is far less common than knee or hip arthritis, and when it occurs it usually follows an old injury rather than appearing on its own. Keyhole surgery has a limited role here: it can address a spur or a loose fragment, but it does not resurface a worn joint, and it is important to be clear about which of those is being offered.

What tends not to need surgery

• A first sprain, and most repeat sprains. These are treated with early movement, a programme of balance and strengthening work, and time.
• Instability that has not had a real rehabilitation programme. Balance training resolves a good proportion of unstable ankles. Months of the right work, not a leaflet.
• Pain with a normal examination and a normal weight-bearing X-ray, where the story does not fit a mechanical problem.
• Tendon problems around the ankle, most of which are managed without surgery and are a different problem from anything inside the joint.

Being straightforward about this matters. An ankle that hurts is not by itself an ankle that needs arthroscopy, and the honest first question is whether something inside the joint is actually the cause.

What the assessment involves

• History. Whether there was a specific injury and what happened at the time, whether it gives way and on what surfaces, whether it catches or locks, and where exactly the pain sits.
• Examination. Movement, tenderness by location, specific tests of the outer ligaments, and how you stand and walk. An ankle that gives way often examines differently from one that only hurts.
• Weight-bearing X-ray. Often more useful than a scan as a first test, because it shows bone shape, spurs, alignment and the joint space under load.
• MRI or CT. MRI for the cartilage surface, the ligaments and the tendons. CT where the exact shape and size of a bony fragment or spur matters.

Imaging findings have to match the examination. Minor changes turn up on scans of ankles that have never hurt, so a scan finding on its own is not a reason to operate.

Recovery, by operation

• Removing a bony block, a spur or a loose fragment. Weight bearing early, often in ordinary shoes within a week or two, with swelling settling over several weeks. Return to sport commonly within a couple of months.
• Ligament repair or tightening. A period in a boot or brace to protect the repair, then a staged programme of movement, strength and balance work. Return to pivoting and contact sport is considerably later, and it is the balance work rather than the strength that decides whether the ankle holds.
• Work on the cartilage surface. The slowest of the three, because the surface has to be protected while it heals. Expect restricted weight bearing for a period, and a recovery measured in months.

Ankle swelling lasts longer than people expect after any of these, often months, and it is not in itself a sign that something is wrong.

Questions worth asking

1. What exactly do you think is causing my pain, and does my scan agree with my examination?
2. Is my ankle unstable, or is it painful, or both? They are treated differently.
3. What non-surgical treatment should I have had first, and for how long?
4. What will you do inside the joint, and what will you do if you find something else once you are in there?
5. How long in a boot, how long off work, and how long before I can drive?
6. What does the rehabilitation require of me, week by week?
7. What is the itemised estimate, in writing, and what is excluded from it?

Common questions

What is keyhole ankle surgery?

Arthroscopy: a small camera and fine instruments passed into the joint through incisions a few millimetres across, rather than opening it. The ankle is a tight joint with very little spare room, so the camera used is smaller than the one used in a knee and the instruments are finer. It is usually a day case or an overnight stay. What determines the result is what was found and what was done about it, not the size of the incisions.

My ankle still hurts months after a sprain. Is that normal?

Common, but not something to simply wait out. Most sprains settle within six to twelve weeks. Pain that persists well beyond that usually has a reason: the ligament healed loose and the ankle is subtly unstable, a fragment of cartilage or bone was knocked off the joint surface, the lining of the joint is inflamed and getting pinched, or a bony spur has formed at the front. Those are different problems with different treatments, which is why an ongoing ankle needs examining rather than resting further.

My ankle keeps giving way. What can be done?

Repeated giving way after sprains is instability, and the first line is not surgery: a proper programme of balance and strengthening work resolves a good proportion of cases, and it is the cheaper thing to try first. Where that has genuinely been done and the ankle still gives way, the outer ligaments can be tightened or repaired, usually keyhole or through a small incision. It matters because an ankle that keeps rolling over damages the joint surface each time.

What is ankle impingement?

Pain at the limit of movement, from something physically blocking the joint. At the front it is usually a bony spur or thickened tissue that pinches when the ankle bends upwards, which is why it hurts going uphill, squatting or driving. At the back it is felt on pointing the foot down. It is common in footballers and dancers. Keyhole surgery removes the block, and the diagnosis is made on examination and imaging together rather than on a scan alone.

Do I need an MRI before I am seen?

Not necessarily. A weight-bearing X-ray is often the more useful first test, because it shows bone shape, spurs, alignment and the joint space in the position that actually hurts. An MRI is added when the cartilage surface, the ligaments or a tendon is the question. Bring whatever you already have, including the written reports, rather than arranging new imaging first.

How long is the recovery?

It depends on what was done. Removing a bony block or a loose fragment often means walking in ordinary shoes within a week or two and back to sport in a couple of months. A ligament repair means a period in a boot to protect the repair, then a staged rehabilitation programme, with return to pivoting sport considerably later. Work on the cartilage surface is the slowest, because the surface has to be protected while it heals. Pin down the timeline for your operation before you agree to a date.

Related reading

Knee Arthroscopy

Keyhole knee surgery: what it can and cannot fix, why it is no longer recommended for most arthritic knees, and when it remains the right operation.

Keyhole Shoulder Surgery

Rotator cuff tears, frozen shoulder, impingement, a shoulder that keeps dislocating and wear at the collarbone joint: what each is, and what surgery does.

Will Insurance Cover Your Knee Replacement in Malaysia?

How medical cards, guarantee letters, annual limits and pre-existing clauses work for knee surgery in Malaysia, and what to ask before admission.