Evolution in Surgical Management of Ankle Instability in Athletes

Brian C. Lau, MD; Alexej Barg, MD; C. Thomas Haytmanek, MD; Kirk McCullough, MD; Annunziato Amendola, MD


J Am Acad Orthop Surg. 2021;29(1):e5-e13. 

In This Article

Use of Ankle Arthroscopy

An increasing use of ankle arthroscopy is noted during surgical management of ankle instability in athletes to assist with management of concomitant injuries. Concomitant injuries may range from soft or bony impingement, deltoid injury, syndesmosis injury, osteochondral lesions, or loose bodies.[9] Undiagnosed and untreated pathology may lead to persistent symptoms and failure of ankle stabilization.[3,9] Ankle arthroscopy is a minimally invasive procedure with low complication rates (3.3%) and can allow early identification and treatment of concomitant injuries, thereby reducing revision surgery rates.[10] Although an increasing understanding in the benefit of concurrent ankle arthroscopy exists, there remains some reticence among practitioners. Less than half of surgeons (47%) do ankle arthroscopy for chronic lateral ankle instability.[11] One of the concerns over concomitant ankle arthroscopy is fluid extravasation that may render soft tissues less workable, and hence more prone to inadequate ligament tensioning. However, Araoye et al[12] found that concurrent arthroscopy actually lowered complication rates compared with staging the arthroscopy. This may be because at the time of diagnostic arthroscopy, surgeons can visualize articular cartilage defects and use "drive-through" signs along the medial gutter and syndesmosis to diagnose deltoid and syndesmosis injury, respectively[13] (Figure 3). A positive "drive-through" sign indicates that the surgeon is able to insert a 2.9- to 3.5-mm shaver or an arthroscope into the medial gutter (deltoid injury) or tibiofibular syndesmosis (syndesmotic injury) that is normally not possible with intact ligaments.[13]

Figure 3.

Ankle arthroscopy case with ankle instability. A) Demonstrates drive-through sign with 3.5 mm shaver into the syndesmosis. B) Demonstrates the camera being able to be inserted into the syndesmosis.

In our experience, the benefits of an efficient ankle arthroscopy outweigh potential difficulties with soft-tissue handling and tensioning. In experienced hands, a diagnostic arthroscopy adds only about 15 to 20 minutes of the procedure time and can assist decision-making for whether additional procedures should be done with the lateral ligament stabilization such as deltoid, syndesmosis, or cartilage procedures.