Up to this point we have discussed clinical and radiographic evaluation of foot and ankle pathology. While many if not most conditions can be treated based on these exams, actually seeing something dynamically through a camera can fundamentally change the way we diagnose and treat foot and ankle problems. Arthroscopy is a commonly utilized tool for evaluation of intraarticular disorders that may either be too small to image or involve actual evaluation of tissue condition. As an imaging tool this is an excellent way to appreciate dynamic conditions (pain with movement.) This tool is also excellent for retrieval of loose bodies and inflamed tissue from small joints. In this episode we explore the conditions amenable to arthroscopy and patient expectations when a surgeon decides on this modality for treatment.
Arthroscopy involves using small scopes placed into a joint to evaluate or treat intraarticular conditions. The ankle, subtalar, and first metatarsophalangeal joints are commonly explored using this technique. Needle arthroscopy has presented a newer modality for even smaller joints in the foot.
Classically, exploration of a joint in this manner was for evaluating tissues that we can't normally seen any other way. Cartilage condition is not able to be determined externally by any method, until severe degeneration occurs and the underlying bone shows changes. Small loose bodies (sometimes called a 'joint mouse') can also be missed in imaging if the slices on MRI are imperfect or the object is hiding in the recesses of the joint.
OLT's or OCD's are a very common indication for arthroscopic evaluation, and if small enough management as well. Probes can be used to test the integrity of the cartilage, curettes and shavers can be used to remove loose cartilage, and abraders can be used to stimulate bleeding from the underlying bone to promote fibrocartilage formation.
Impingement especially anteriorly is also a common condition where arthroscopic treatment can be beneficial. Post sprain impingement (sometimes called 'Bassets impingement') where a part of the synovium or anterior talofibular ligament folds into the joint with certain movement is particularly amenable to treatment using a scope. The corresponding synovitis, inflammation of the inner lining of the joint, can also be removed with this method.
Occasionally arthroscopy is only part of a larger procedure. For example, some ankle fracture patterns would benefit from intraarticular assessment in addition to open reduction and fixation (ORIF.) Any occult damage can be visualized and either documented or repaired as required. These injuries can be missed in "routine" ORIF depending on injury pattern.
Arthroscopic assisted fusion is becoming more common in certain settings. When no deformity exists requiring angular correction, using scope portals to introduce aggressive abraders that can effectively remove all of the cartilage and subchondral bone plate can be very enticing. This minimizes soft tissue disruption and potential vascular embarrassment, and can achieve the goal of adequate joint preparation for fixation. Because this technique is not nearly as common compared to open fusion methods it is unknown if fusion rates exceed or are less than traditional methods.
Patients must understand - using a scope does not necessarily mean this is minor surgery ore recovery will be faster. The surgery is what it is, regardless of how we visualize or the tools we use to fix the pathology. For example, just because a fusion is performed arthroscopically doesn't make the bones unite any faster. Recovery is based on the procedure performed, not the tools used to perform the procedure.