Saudi Journal of Sports Medicine

: 2021  |  Volume : 21  |  Issue : 1  |  Page : 22--29

Ankle arthroscopy: Indications, patterns of admissions, surgical outcomes, and associated complications among Saudi Patients at King Abdul-Aziz Medical City in Riyadh

Mohammed A Alaqil1, Mohammad A Almalki2, Khalid M Alwusaidi3, Lama A Almutairi4, Nader S Alkenani5,  
1 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
2 Reconstructive Orthopedic Department, King Fahad Medical City, Riyadh, Saudi Arabia
3 College of Medicine, Imam Mohamed Ibn Saud Islamic University, Riyadh, Saudi Arabia
4 Pharmacist, King Fahad Medical City, Riyadh, Saudi Arabia
5 Department of Surgery, Division of Orthopedics, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia

Correspondence Address:
Mohammad A Almalki
Reconstructive Orthopedic Department, King Fahad Medical City, Riyadh
Saudi Arabia


Background: Despite the frequent usage of ankle arthroscopy, there is limited medical literature regarding its indications, patterns of admissions, surgical outcomes, and associated complicated at Saudi Arabia. Hence, this study would highlight the surgical outcomes of such surgical approach that will assist orthopedic surgeons to detect which surgical procedure needs to be done as well as to help them regarding their diagnostic workups. Methods: At the Orthopedic Division of King Abdul-Aziz Medical City in Riyadh and through a cross-sectional design and convenient sampling techniques, the present study had recruited 20 subjects who fulfill the inclusion and exclusion criteria between 2016 and 2018. Data collection was carried out by a questionnaire designed and revised by an expert panel of health professionals. Results: Twenty patients were reviewed (11M and 9F) with an average age of 40.1 ± 12.2. Only 30% of the patients (5M, 1F) have no comorbidity, but 70% of patients (7M, 8F) were having at least one comorbidity. The most common indications were osteochondritis dissecans (n = 7, 35%), ankle fracture without dislocation (n = 4, 20%), and tibiotalar impingement (n = 3, 15%). Patients recorded pain in all cases (100%). The top four symptoms after pain were instability (30%, n = 6), muscle weakness (15%, n = 3) swelling (15%, n = 3), and stiffness (5%, n = 1). Two-third of cases reached to their full healthy status and toe-touch weight-bearing was seen in two patients (10%). Conclusion: Ankle arthroscopy improved the rehabilitation rates in our tertiary care center. In addition, the surgical outcomes are favorable in our hospital since it has a very short length of stay, unexpended surgery, and fewest physiotherapy sessions.

How to cite this article:
Alaqil MA, Almalki MA, Alwusaidi KM, Almutairi LA, Alkenani NS. Ankle arthroscopy: Indications, patterns of admissions, surgical outcomes, and associated complications among Saudi Patients at King Abdul-Aziz Medical City in Riyadh.Saudi J Sports Med 2021;21:22-29

How to cite this URL:
Alaqil MA, Almalki MA, Alwusaidi KM, Almutairi LA, Alkenani NS. Ankle arthroscopy: Indications, patterns of admissions, surgical outcomes, and associated complications among Saudi Patients at King Abdul-Aziz Medical City in Riyadh. Saudi J Sports Med [serial online] 2021 [cited 2021 Jun 25 ];21:22-29
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Full Text



Ankle arthroscopy is a well-known surgical operation that deals with a vast array of foot and ankle conditions for diagnosis and therapy purposes. It is considered as an alternative to the open exploratory arthrotomy that is becoming infrequently performed.[1] Ankle arthroscopy reduce morbidity, mortality and has a favorable improvement in rehabilitation compared to open exploratory arthrotomy and malleolar osteotomy.[2] Although the anatomy and biomechanics of foot and ankle are complicated,[3] the advancement of technological fiber optics and video monitors has greatly assisted orthopedic surgeons in directly visualizing the area thoroughly.[4] In addition, arthroscopic surgery is considered as a minimally-invasive operation for which small incisions of 0.5 mm are inserted, which eventually reflects its simplicity and miniature scars and blood loss.[4]

The arthroscopic procedures can be used in four different positioning maneuvers, including supine position, semi-lateral decubitus position of 45°, semi-controlled distraction of Kerlix gauze that loops around the foot, and 90° of knee flexion with the ankle holder placed in the foot.[5] The supine position is highly preferred and has several advantages, for which accessibility to the anterior and posterior portals can be easily visualized and flexibility to the orthopedic surgeon to move, sit, or stand during the surgery would be permitted, but eventually, its preference is completely dependent upon the surgeon and the lesion's area as usual.[6] Arthroscopic portal locations have been well illustrated in the literature studies comprising anteromedial, anterolateral, and posterior-lateral portals.[7] Even though there are many other portals that have been previously defined in the research studies, they are not commonly used for the reason that neurovascular structures could be compromised.[8] In terms of procedural safety, ankle arthroscopy is considered secured, and multiple research studies suggest that the anterior ankle arthroscopy of dorsiflexed approach and posterior ankle arthroscopy of two-portal hind-foot approach are safe and have minimal complication risks varies between 2.3% and 3.5%, respectively.[9],[10] Complications are rare, but they are serious to consider, especially in the portal placement.[11] They include sensory nerve injury to superficial peroneal nerve, sural nerve, saphenous nerve, and deep peroneal nerve, respectively, for which 1.9% is considered the percentage of overall neuronal injuries.[11] The other rare complications associated with ankle endoscopy are superficial and deep infection, delayed wound healing, reflex sympathetic dystrophy (RSD), compartment syndrome, and false aneurysms.[9],[10],[11]

It is estimated that around one in ten thousand people suffer daily from ankle injuries in the United States of America, for which this number can be increased in sportspersons up to 5.23 in 10,000 athletes.[12] This is why it is indispensably useful to diagnose articular and soft-tissue injuries that are etiologically unknown, including undetermined pain, unexplained instability and stiffness, and mechanical symptoms such as ankle lock and click-through using ankle endoscopic procedures.[13] The procedure is usually established by using 1.9–2.7 mm from the anteromedial portal generally at 30°–70°, whereas the posterior portal can be up to 4 mm.[14] In terms of therapeutic indications, ankle arthroscopy should be performed when nonsurgical approaches can be no longer successful.[15] They include tibiotalar impingement both anteriorly and posteriorly, osteochondral defects such as osteochondritis dissecans, artificial ankyloses (arthrodesis), and arthrofibrotic lysis of adhesions. Moreover, the removal of loose bodies and bony spurs as in cheilectomy is evidence of ankle catching or effusion and bony impingement correspondingly, which are considered as indications for ankle arthroscopy.[16] In an excellent systematic review done by Zwiers et al., patients who underwent ankle arthroscopy for anterior ankle impingement showed good outcomes between 64% and 100% with 5% complication rates and up to 74%–100% of satisfaction.[17]

In terms of clinical assessment, it is crucial to have a completely detailed history and physical examination as well as preoperative evaluation, including weight-bearing radiographs of anteroposterior, lateral, and oblique views depending on the clinical context. The projected oblique radiograph is helpful to distinguish between os trigonum's degrees of severity.[2] Cobey and Saltzman's view, on the other hand, is highly recommended for hind-foot malalignment and tibiocalcaneal disorders.[18]

All in all, the research studies concerning ankle arthroscopic procedures need further investigations in the Middle East and North Africa, especially in the Kingdom of Saudi Arabia, despite its frequent use. There has been no single literature regarding ankle arthroscopy around the Kingdom after conducting an extensive search in the databases and up to the authors' knowledge. In this study, the indications, surgical outcomes, and complications associated with ankle arthroscopic procedures would be addressed and investigated starting from our tertiary care center of King Abdul-Aziz Medical City (KAMC) in Riyadh. It would give a clear insight into the current use of ankle endoscopic procedures, taking into account the different demographic measurements, anesthesia, and analytic tests. Our study elucidates the indications, patterns of admission, surgical outcomes, and associated complications among Saudi patients at KAMC in Riyadh. This would highlight the surgical outcomes of such surgical approach that will assist orthopedic surgeons to detect which surgical procedure needs to be done as well as to help the physicians regarding their diagnostic workups and therapeutic options locally based on the clinical assessment and preoperative symptoms.


Study design, area, and settings

In this retrospectively descriptive cross-sectional study conducted in the Orthopedic Division at KAMC in Riyadh, the charts of Saudi adult patients (18–74 years) who underwent ankle arthroscopy as for diagnosis or therapy between 2016 and 2018 were reviewed after receiving the Institutional Review Board (IRB) approval from King Abdullah International Medical Research Center (KAIMRC). The clinical charts were obtained by using their Medical Record Numbers (MRNs) for the NGHA-BestCare Information Software System Version 2.0A. The patient's data were dealt with full privacy and confidentialityDemographics of the patients including age, gender, weight, height, occupation, and marital status were classified and assorted in parallel with the surgical indications, lesion location, admission date, and any radiographic measurements or follow-up observations that were found in the patients' recordsA comprehensive clinical assessment including history and physical examination was assessed using patients' medical reports. Patterns of admission including outpatients, inpatients, ambulatory, and referred services were also addressedThe type of anesthesia used in ankle arthroscopy was estimated and counted in terms of proportion and percentage. It includes local, intravenous sedation, monitored anesthesia care, regional, and general anesthesiaThe preoperative symptoms were classified according to the most recent version of International Classification of Diseases and Related Health Problems for the World Health Organization-10.[19] It comprised pain, swelling, stiffness, instability, mechanical symptoms as locking and clicking, and ankle sprainThe number of patients along with the diagnosis was estimated in conjunction with the measures of central tendency including mean and median and measures of dispersion as for the standard deviation (SD). The diagnosis was primarily including tibiotalar impingement, osteochondral defect, loose bodies, degenerative joint disorder, septic arthritis, arthrofibrosis, tendon rupture, synovitis, ankle fracture, and any other associated arthropathiesComplications were measured proportionally according to the patients affected postoperatively. The surgical complications primarily included neurovascular damage, infections, wound healing delay, complex regional pain syndrome or RSD, compartment syndrome, false aneurysms, limited range of motions, and any other unclassified complicationsThe short outcomes as certainly written in the charts of the patients were addressed. It is set according to the validated universal evaluation scoring system for the American College of Foot and Ankle Surgeons.

Identification of study participants

Study subjects

All Saudi adult patients (18–74 years) who underwent ankle arthroscopy at KAMC in Riyadh between 2016 and 2018 would be included whether they are considered as inpatients, outpatients, referred, or ambulatory admitted. It would include patients who underwent ankle endoscopic procedure as for diagnosis and therapy whether the cause is apparent or etiologically unknown.

Sample size

It is estimated that 20 patients were the final sample size to our study as expected. It lied within the confidence level of 95%. The overall number of patients who admitted to the foot and ankle ward between 2016 and 2018 was 100 patients to which only 20 patients matched our selected criteria. The margin of error is ±5% as calculated from the Raosoft website.

Data collection process

After receiving KAIMRC IRB-approval, the co-investigators started to access the MRN, under the supervision of the principal investigator, for the patients who underwent ankle arthroscopy and admitted to the Orthopedic Division between 2016 and 2018. The collected data that were collected from the NGHA-BESTCare Information Software System Version 2.0A are the primary data. The demographics of the patients including age, gender, body mass index (BMI), occupation, and marital status were addressed using Excel Data Sheet A, which was interpreted in [Table 1]In addition, the symptoms were classified and measured in conjunction with the demographics as presented in [Table 2]. The indications were reported in [Figure 3]. It included ankle tibiotalar impingement, osteochondral defect, loose bodies, degenerative joint disorder, septic arthritis, arthrofibrosis, tendon rupture, synovitis, ankle fracture, and other arthropathiesThe type of anesthesia used in the procedure was addressed as well. It included general anesthesia and regional spinal anesthetics in parallel with the American Society of Anesthesiologists (ASA) scoring system as illustrated in [Table 3]Finally, the complications of ankle arthroscopic procedures were categorized as sensory nerve injury, vascular damage and aneurysms, bleeding, infections, delayed wound healing, compartment syndrome, reflexive sympathetic dystrophy, and loss of motion. It is presented within [Table 4] in the results.{Table 1}{Table 2}{Table 3}{Table 4}{Figure 3}

Ethical consideration

Confidentiality and privacy were assured for all the patients included in this study. The co-investigators used the MRNs to recruit patients' data privately and after IRB approval. The number was only visible to the research team members. MRNs were omitted and replaced with a serial number created by the team members upon the submission of the datasheet for analysis and manuscript publications.

Data analysis

All the variables were summarized and reported across the transverse study using descriptive statistics including numeric and categorical variables along with measurements of central tendency including mean, median, and measures of dispersion as for the SDThe numeric variables were continuous quantitative variables and categorical variables. The continuous variables were age and weight and height, whereas the categorical variables are the number of patients who underwent arthroscopic procedures, facility type and reason, anesthesia use, preoperative symptoms, and diagnosis for which percentage were usedThe categorical variables were ordinal and nominal variables. The nominal variables were gender and surgical outcomes, for which it was coded as presented in the results. The continuous variable is for the BMI or Quetelet index, giving the unit of kg/m2. The measures of central tendency were the mean and median, as well as measures of dispersion as for the SD were addressed within the presented tables in the results. The surgical outcomes were estimated through using proportionData have been analyzed and modified using IBM-Statistical Package for the Social Sciences® (IBM-SPSS®) Version 23.0. USA.

Surgical techniques and instrumentations

In our surgical settings, the supine position maneuver with Guhl's noninvasive distraction was being used for all patients to visualize the anterolateral and anteromedial portals in concurrence with the usage of ipsilateral thigh tourniquet inflated to 300 mmHg for hemostasis (60–80 mmHg intra-articular pressure) within 40°–60° angle along with the pump infusion after following the standard sterile protocol and NS instillation with gravity-assisted position. We eschewed utilizing invasive distraction in our patients to prevent risks during the operation and in the long run. Under general or regional spinal anesthesia, a smaller incision for the 2.7–4.00 mm arthroscopes were obliquely inserted using scalpel blade No. 11 with using curettes and joint shavers for microfracture. Anteromedial portal was initially introduced using 22-Birmingham gauge for Hartmann's solution (10–15 cc) and surgical clamp to bluntly dissect the incision for the cannula's insertion to the long saphenous vein and nerve just medial to the tibialis anticus tendon. Anterolateral portal was followed within the same principle but at the sideline of fibularis tertius tendon in line with talocrural joint. The superficial fibular nerve was secured from damage through marking the area and assessing the nerve functionality including sensory and motor courses within the position of plantar flexion and inversion. Before liberating the tourniquet, the ankle was placed for sterile compression dressing and the wounds were closed with nonabsorbable suture. After the procedure was tolerated, patients were recommended to undergo weight-bearing activities. All the cases were carried out by one single surgeon who is involved in the study.


The advancement in ankle endoscopic procedures is significantly progressing throughout the years of which this minimally-invasive operation can be used both diagnostically and therapeutically for numerous indications with a variety of surgical options and techniques.[1],[2],[13],[14],[15] The most common therapeutic indication for ankle arthroscopy in our study was osteochondral lesion (OCL) of the talus (35%), which relatively corresponds to Best et al.'s study (38%) in his national survey with the difference in terms of the study population.[20] Despite the fact high rate of misdiagnosis or postponement for OCL, which reaches to 81% according to Ferkel et al.,[21] there were no diagnostic errors or incidental delays in our study due to the advanced clinical and imaging techniques. The second most common indication was ankle fracture (20%) followed by anterior tibiotalar impingement (15%), which are proportionally close to Amendola's results, 17.7% on each one, respectively.[22] Only two patients had experienced synovitis (5%) and posttraumatic osteoarthritis (5%), but these sequalae were due arthrofibrosis and degenerative changes after ankle fracture, which was described previously in the literature.[23],[24],[25] In terms of clinical manifestation, all patients in this study were admitted due to pain followed by 30% of patients with chronic ankle instability, which slightly conformed to Komenda and Nicholas's studies in terms of orderings.[22],[26] However, swelling and decrease range of motion came into the third most common cause (15% each) in our study for which this differed from what van Dijk and Scholte proposed previously in their diagnostic findings.[27]

In comparison to Japour et al.,[28] false-negative X-ray readings for osteochondral defects in this descriptive study is immensely low (19%) for which this research article revealed more than 61% of unpredicted error. This was prevented by further clinical examination prior, during, and after the surgery along with previous imaging (serial radiographies, computed tomography [CT], and magnetic resonance imaging [MRI]) used once needed. In support of the fact that any surplus body fat may increase pain intensity or decrease bone ossification and microstructural indices,[29],[30] the average BMI in our patients was 30.81 ± 6.54 kg/m2 of which more than two-third of the patient who came to the hospital with pain were actually overweight. In spite of this information, research studies concluded that obesity has no negative effect on treating anterior impingement syndrome or OCLs with allograft.[31],[32] This is why more than 85% of our patients stated that the pain was reduced and they returned to their daily life activities despite being overweight. Our results were superior to Hall's outcome since more than 50% of their patients had pain after the procedure, with an average of 64% described as subjective postoperative pain in spite of the improvement.[33]

Comorbidities including diabetes, hypertension, dyslipidemia, and other diseases are associated with obesity, resulting in quality-adjusted life-years loss with more than 127% reduction.[34] Our study could not determine whether diabetes or other comorbidities have a clear relationship in outcomes because it requires further research with more specific and related research questions. This corresponds to Steward's difficulties in defining the link between the surgical outcomes and comorbid conditions.[35]

Only one patient in our study developed sensory nerve damage which conformed to the minimal rates of complications described by Suzanger et al.[36]


The study included 20 patients. Males were 11 (55%) and females were 9 (45%), of which their age was ranging from 18 to 74 (mean: 40.10, SD: ±12.20). The demographical baseline characteristics are illustrated further in [Table 1]. The procedure was operated on both the right foot (55%) and left one (45%). The foot side affected was 55% medial (n = 11) and lateral 25% (n = 5), and both sides were affected as 20% (n = 4).

In addition, the type of admission was clustered into four categories: Outpatient, inpatient, ambulatory, and hospital referred [Figure 1]. 50% of the cases were referred (n = 10) 25% of the cases were classified as outpatients (n = 5).{Figure 1}

The comorbidities accompanied with the patients, however, were reported across the charts. Only 30% of the patients (5 males, 1 female) were medically free and have no comorbid conditions. However, 70% of patients (7 males, 8 females) were having at least one comorbidity. Despite this fact, females show more comorbid conditions than males, as illustrated in [Figure 2].{Figure 2}

Moreover, the procedural indications were categorized into three groups. 12 patients underwent ankle arthroscopy as a therapeutic procedure (60%), 2 patients as a diagnostic procedure (10%) and 8 patients underwent the arthroscopic procedure for diagnostic and therapeutic indications at the same time (30%). During the procedure the surgeons followed a protocol of inflating a 300 mmHg thigh tourniquet and the patients were in supine position. The procedure is accompanied with an anthropic three-portal placement along with anesthesia. There were 17 patients who were received general anesthesia (85%) and 3 received regional spinal block (15%). No bone grafting was being used. In addition, the physical status for the patients was assessed [Table 3] before the surgery according to the ASA scoring system.

Almost all patients underwent X-ray as an initial workup (95%). However, there were different imaging modalities that have been used in combination including MRI and CT for certain situations. Neither MRI nor did CT were being used alone.

Furthermore, the indications for ankle arthroscopy were various [Figure 3]. The most common indications were OCL with a total number of 7 cases (35%), ankle fracture without dislocation with a total number of 4 cases (20%), and anterior tibiotalar impingement with a total number of 3 cases (15%). The rest of the categories are 5% each (1 case per each).

All patients have been symptomatic. Patients recorded pain in all cases (100%). There were no mechanical symptoms that the patients were reporting. However, the top four clinical manifestations after pain were instability (30%) which was reported from 6 patients, decrease range of motion (15%) was reported from 3 patients, swelling was reported for 3 patients (15%), and stiffness was reported in one patient (5%).

The joints that were affected the most were dome of the talus, tibiofibular, tibiotalar, and other joints including Lisfranc joint and subtalar with metatarsal joints.

The surgical outcomes were favorable and displayed positive benefits. The average follow-up time was 8.95 ± 4.34 ranging from 2 to 16 months. The number of follow-ups was within the average of 6 ± 3.36 times. However, the average of the physiotherapy session provided after the surgery to reach for the full or partial weight-bearing was 4.9 ± 2.53 (ranging from 1 to 11 physiotherapy activities). In addition, 14 patients (70%) reached their full recovered, healthy status as they started to do full weight-bearing earlier as well as 4 patients (20%) were partially recovered and need few times and activities to reach for the full recovery (partial weight-bearing). Toe-touch weight-bearing was seen in 2 patients (20%). Before the ankle arthroscopic operation, almost 15 patients (75%) cannot tolerate any weight or walk. The average surgery length (in minutes) was estimated to be 80.25 ± 47.53 ranging from 30 to 180 min. However, the average length of stay was not long as almost 11 (55%) persons were immediately released, 8 people for 1 day rest (40%), and 1 patient for 2 days (5%).

Despite the favorable outcomes, there were few complications that patients faced. It was illustrated in [Table 4].


The study concluded that ankle arthroscopy had improved the rehabilitation rates in our tertiary care center. In addition, the surgical outcomes are favorable in our hospital since it has a very short length of stay, unexpended surgery, and fewest physiotherapy sessions. We recommend making our study more inclusive to comprehend the majority of the Kingdom's hospitals and to have Saudi guidelines and protocols to be patient-centered.


The authors would like to acknowledge and appreciate the allocated time and efforts that the Research Unit at the College of Medicine is contributing.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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