Ankle or Subtalar Joint Arthroscopy: A Guide

This leaflet aims to answer your questions about having an ankle arthroscopy under the care of Mr Rajiv Limaye. It explains the benefits, risks and alternatives, as well as what you can expect when you come to hospital.

What is an arthroscopy?

Arthroscopy is an operation on a joint which is done by a ‘keyhole’ technique. An instrument containing a video camera is inserted into the ankle to look inside and small instruments are used to treat the problem. This allows the surgeon to help understand what is wrong with the ankle and treat the problem.

What happens during an ankle arthroscopy?

Ankle arthroscopy can be done as a day surgery procedure unless you have other significant medical problems that mean you may need to stay in hospital overnight. You will usually have a general anesthetic. The ankle is examined whilst you are asleep, and the muscles are relaxed. Traction is applied to the ankle by gently pulling it and fluid injected.

Small cuts are made to allow the camera and any instruments to be inserted into the ankle. The inside of the ankle is viewed through the camera and any necessary treatment carried out. The ankle is then cleaned out and the cuts stitched. The ankle is then bandaged.

Why should I have an ankle arthroscopy?

Ankle arthroscopy is often performed when an injury to the ankle fails to settle. It may help make a diagnosis, but you will often have a scan first. Problems such as arthritis and inflammation can be helped with arthroscopy, and it can be used to remove scar tissue build up, bone spurs and treat certain cartilage defects.

What are the risks?

In general, the risks of any operation relate to the anesthesia and the surgical procedure itself. In most cases you will have a general anesthetic. You will be able to discuss this with the anesthetist before surgery and he/she will identify the best method for your individual case.

The main surgical risks are listed below:

• Numbness: The commonest problem is numbness over the top of the foot or outer toes. This is because the cuts are close to the nerves to these areas. The nerves are pushed aside and may get stretched during surgery. Numbness normally recovers within two months, but a small number of patients have a small patch of permanent numbness.
• Infection: The cuts usually heal within two weeks but may leak a small amount of fluid. In a very small number of cases (less than 3 in 100 patients), the wounds may become infected and need antibiotics.
• Joint damage: Occasionally some damage is done to the surfaces of the ankle joint during arthroscopy. Patients rarely have any symptoms from this.
• Ongoing pain and stiffness: 85 out of 100 patients will find their level of pain has improved. However, 15 out of 100 patients find that some of their pain continues and may get worse over time. The ankle may remain stiff. An ankle that has had a serious injury or surgery is unlikely to ever be as flexible as the normal ankle.
• Deep vein thrombosis: A clot in the leg, which can travel to the lungs, is a very rare but serious risk of ankle surgery. Measures are taken to reduce the chance of this happening.
• Arterial damage: A small artery runs in front of the ankle which can be damaged during surgery. This is rare and unlikely to have long term consequences but may require further surgery.

How can I prepare for an ankle arthroscopy?

You should make arrangements to be collected from the hospital. Someone should stay with you overnight if you have a general anesthetic and your operation is a day case. You will need some time off work after the surgery. This will be at least 1-3 weeks but may be longer if you have a manual job. Mr Limaye will discuss this with you. We advise you speak to your employer before surgery to make plans.

The Day of the Surgery

Mr Limaye will see you before your operation. The anesthetist will also see you before your operation, either on the ward or in theatre. Any queries about the anesthesia are best discussed with him/her directly on the day.

1. Waiting for your operation:

   Please note that you may not be the first patient on the operating list and therefore have a variable amount of time during which you will be waiting to go to theatre; how long will depend in your place on the list. If you are the last patient to be scheduled for surgery, it may be up to three or four hours; you should therefore come prepared for a wait. Some reading material is provided by the day case unit but we appreciate a wait of several hours can be frustrating sometimes; as such you may wish to bring a book, some work or other material to keep yourself occupied.

2. After your operation, prior to discharge:

   Your foot will be heavily bandaged to protect it and reduce the swelling. The bandage which is applied in theatre in a sterile environment will stay on for 2 weeks. There will be no plaster cast unless for example you are also having your ligaments repaired. The physiotherapist will issue you with crutches and a special surgical sandal to wear. If you already have either of these, please bring them with you.

   The hospital may bill for any incidentals such as the crutches, surgical shoe, shower cap and any medications.

   You will be given medications to take home to control the pain. These will be a combination of strong and weak painkillers. A nurse will go through the medications with you, confirming how often and when to take them.

   When you feel comfortable and ready you will be allowed to go home. You should have made arrangements to be picked up from the hospital and have someone staying with you at least overnight if you are a day case.

   As a day case patient, you can normally go home about 3-5 hours following surgery. As an overnight, patient you will be discharged around 10 am the next day.

3. Giving my consent (permission):

   We want to involve you in decisions about your care and treatment. If you decide to go ahead, you will be asked to sign a consent form by Mr Limaye. This states that you agree to have the treatment and you understand what it involves.

4. Will I feel any pain?

   There will be some pain after the surgery. During your operation local anesthetic may be injected into your ankle to reduce the pain after the operation. You will be given medicines to take home to control the pain. The nurse will go through the medicines with you, including how often and when to take them. There will be a combination of strong and weak painkillers.

   It is important that you continue to take painkillers as advised after your surgery. However, if you have little or no pain you may not need to take the tablets.

   If your pain does not settle, you can contact the ward or Mr Limaye for advice.

What do I need to do after I go home?

This is a general guide only. Patients will progress and recover from their surgery at different rates. If Mr Limaye gives you different advice, then you should follow that.

Days 1 - 7 after surgery:

The local anesthetic in the joint will start to wear off the day after surgery, so you will need to start taking painkillers. You should keep the ankle elevated when not walking or exercising for the first week after the operation. Whenever the foot is put down, it will swell and become sore. It is normal to see mild bruising. By the end of this week the post- operative pain should be significantly reduced.

Do try and maintain upward and downward bend in the ankle. The physio can show you how to do this on the ward on the day of surgery.

Days 8 - 14 after surgery:

Continue to elevate your foot and ankle as much as possible. You may walk short distances within your home or to a car from this week. In week two you can start working from home and possibly return to work but you must try and keep the ankle elevated. If you have a heavy manual job it may be one month before you can return to work.

If surgery was on your left ankle and you have an automatic car you can start driving within a few days. This time will be longer if surgery was on your right ankle.

The Drivers Vehicle Licensing Agency (DVLA) regards it as your responsibility to judge when you can safely control a car. You should contact your doctor or the DVLA if you are concerned about this. Motor insurance companies vary in their policies, it is best to discuss your circumstances with your insurance company to be sure that you are covered.

You will be seen approximately two weeks after your operation in the outpatient clinic. This appointment will be made for you. At this time the wounds will be checked, and any stitches maybe trimmed. The findings during surgery may be explained and any further treatment plans discussed.

Physiotherapy may be arranged if necessary – Mr Limaye will contact the physiotherapist. Simple ankle exercises will be shown to you at this appointment. Stiffness of the ankle can be prevented by regularly performing the exercises at home, three times a day. Bring a soft shoe with you to this appointment, and you can wear this instead of the sandal.

Days 14 - 21 after surgery:

You should remove all the remaining wound dressings at home. You should apply skin emollient , usually bio oil around the healing wound. Once the wound is completely healed, you should apply the moisturizer over the wound as well.

Continue to perform the exercises. You may go swimming if the wound is dry and healed. Low impact gym work, such as the exercise bike can be started.

At this stage, your foot and ankle may still be swollen.

You will find your mobility will improve over the next few weeks. There is no real merit in walking long distances If it is painful.

When you return to work, travelling outside of the rush hour is a good way of phasing back into work. The first few days are always slightly miserable as you are not able to keep the foot up as easily in the office so expect more swelling and some increased pain.

For short haul flights you will be able to fly after 2 ½ weeks. For long haul it is 6 weeks. We do make exceptions if your home is abroad.

5 - 6 weeks after surgery:

You may have a further appointment to see your consultant in clinic.

3 - 6 months after surgery:

Your foot and ankle may continue to be swollen for up to three months following this surgery.

Return to sporting activities will depend on the damage to your ankle which caused you to need surgery in the first place, and on any other treatment performed during the operation. You will need to gradually increase your activity levels when you begin sport again. It may take several months to return to your normal sporting activity level.

What should I do if I have a problem?

If you experience any of the following symptoms, please contact Mr Limaye, the ward or your GP:

• increasing pain in your foot/ankle
• fever (temperature higher than 38°C)
• if you suspect you have DVT (deep vein thrombosis) – symptoms include pain and/or burning in the back of your lower leg. You may also feel unwell and have a temperature

If, at any time in your post-operative recovery, there is any sign whatsoever of infection, either suspected by you or diagnosed by your GP, please contact Mr Limaye’s secretaries at the hospital.