The role of arthroscopy in ankle fractures
When we think of an ankle fracture, the image that usually springs to mind is that of a broken bone that needs to be properly aligned and fixed in place. And yet, whilst this idea is true, it is often incomplete.
Anatomical and functional complexity of the ankle in the context of a fracture
The ankle is not a simple structure. In fact, it is formed by the interaction of three bones — the tibia, fibula and talus — which together form a joint of great mechanical precision. Surrounding it, a complex network of ligaments, cartilage and stabilising structures allows for fluid yet stable movement.
As Dr Jesús Vilá y Rico, head of the Foot and Ankle Unit at the Publio Cordon Memorial Hospital, explains, “an ankle fracture should not be interpreted as a purely bony injury, but rather as a condition that can compromise the overall function of the joint”.
For this reason, in many fractures, the injury is not limited to the bone: it may also involve damage to the cartilage, ligament damage or minor injuries within the joint that are not always evident on initial assessment.
Understanding this complexity is key. Because, ultimately — as Dr Vilá y Rico emphasises — “it is not just a matter of repairing a bone, but of restoring the balance of the entire joint”.
In this context, arthroscopy has taken on an increasingly important role, as it allows for a more comprehensive and accurate assessment of the injury.
Limitations of the conventional approach to ankle fractures
The standard treatment for unstable ankle fractures continues to be based on open reduction and internal fixation. This approach allows bone alignment to be restored with great precision. However, clinical experience has shown that a correct radiological reduction does not always result in a fully satisfactory recovery.
Some patients continue to experience pain, stiffness or functional limitation. One of the most widely accepted explanations is the presence of associated intra-articular injuries that are not identified in the initial investigation or during conventional surgery.
In this context, Dr Vilá y Rico points out that “an X-ray may show that the bone is correctly aligned, but that does not always mean that the joint has fully recovered from a functional point of view”.
These injuries may include cartilage damage, intra-articular fragments or ligamentous abnormalities which, although not always visible, have a real impact on the ankle’s recovery.
“That is why,” adds the specialist, “the aim is not only for the fracture to heal, but for the ankle to function well in everyday life, without pain and with stability.”
Ankle arthroscopy: fundamentals and contribution to surgical treatment
Arthroscopy is a minimally invasive surgical technique that allows access to the interior of a joint via small incisions. Through these, a high-resolution microcamera – the arthroscope – and specialised instruments are inserted, enabling the exploration and treatment of various structures without the need for extensive open surgery.
As the orthopaedic surgeon explains, “arthroscopy allows us to work inside the joint via very small incisions, directly visualising structures that we would otherwise be unable to assess with the same precision”.
In the case of the ankle, this technique allows us to directly observe the actual condition of the cartilage and the joint surfaces.
“Imaging tests guide us, but they do not always accurately reflect the joint’s actual condition,” he adds, “whereas arthroscopy allows us to see the injury exactly as it is at that moment.”
Thanks to this visualisation, it is possible to:
- Assess the condition of the cartilage
- Detect intra-articular loose bodies
- Identify associated ligament injuries
- Check joint congruence
Furthermore, it allows these injuries to be treated during the same surgical procedure. “It’s not just about looking,” emphasises the specialist, “but about being able to treat, at that very moment, injuries that may affect the patient’s recovery.”
Associated intra-articular injuries: clinical and diagnostic relevance
The identification of associated intra-articular injuries is one of the most important aspects in the treatment of ankle fractures. A prospective study published in the journal *Diagnostic* showed that arthroscopy detects more chondral lesions than magnetic resonance imaging, and that their extent may be underestimated in pre-operative investigations.
As Dr Vilá y Rico explains, “many of these lesions are not visible in the initial tests, but they can subsequently influence pain or the outcome of the ankle if left untreated”.
Therefore, the ability to detect and treat them during surgery represents a significant advance for certain patients.
Functional outcomes and clinical evidence in arthroscopy-assisted surgery
Recent scientific evidence supports the role of arthroscopy as an adjunct in the treatment of certain fractures.
A recent meta-analysis published in an international peer-reviewed scientific journal analysed more than 700 patients and found better functional outcomes and less post-operative pain in those treated with arthroscopy-assisted surgery.
In the words of Dr Vilá y Rico, “when we can assess the joint more thoroughly and address associated injuries during the same surgical procedure, we are taking a further step towards a more complete functional recovery”.
Assessment of stability: the role of ligaments and the syndesmosis
Ankle stability depends largely on structures such as the syndesmosis and the deltoid ligament. Arthroscopy allows these structures to be assessed directly, facilitating the detection of instabilities that may go unnoticed with conventional techniques.
As Dr Vilá y Rico explains, “in certain fractures, the main problem is not just the bone, but the stability of the joint”.
“Correctly identifying this instability during surgery is essential for deciding on the most appropriate treatment,” he adds.
Surgical indications and patient selection
Not all ankle fractures require arthroscopy. The decision to perform the procedure must be based on an individualised assessment, taking into account the type of fracture, any suspected associated injuries and the patient’s characteristics.
As the specialist points out, “the key is not to use more technology, but to know in which patients that technology can really make a difference”.
“Every fracture is different, and treatment must be tailored to that reality,” says the specialist.
Specialist training and refresher courses in ankle surgery
The Publio Cordon Memorial Hospital recently hosted the course ‘Current developments, controversies and sequelae in ankle and foot fractures’, led by Dr Vilá y Rico and held at our facilities.
This event brought together specialists to address, from a practical perspective, the management of these injuries and their complications, highlighting the importance of continuous professional development in ankle surgery.
“Events of this kind allow us to share real-world clinical experience and improve decision-making in complex situations,” emphasises the specialist.
Furthermore, collaboration with specialist companies such as JEMED Surgical Devices contributes to the development of more precise surgical techniques.
The impact of arthroscopy on patients’ functional recovery
The introduction of arthroscopy has represented a significant advance in the treatment of certain ankle fractures. It allows for a more comprehensive assessment, improves surgical precision and helps to optimise functional outcomes in selected patients.
As Dr Vilá y Rico concludes, “what really matters is not just that the fracture is repaired, but that the patient regains a stable, functional ankle that allows them to return to their normal life”.
Arthroscopy for ankle fractures: patients’ frequently asked questions
In which cases is arthroscopy recommended for an ankle fracture?
Arthroscopy is not indicated for all ankle fractures. Its use is particularly considered when there is a suspicion of intra-articular injuries that may not be evident in initial tests.
This occurs most frequently in complex, high-energy fractures or when they are associated with ligamentous instability. It may also be considered in patients with high functional demands, for whom optimising recovery is particularly important.
The final decision depends on an individual assessment by the specialist, who will take into account both the type of fracture and the patient’s characteristics.
What advantages does arthroscopy offer over conventional surgery?
The main advantage of arthroscopy is that it allows direct visualisation of the inside of the joint. This facilitates the detection of cartilage lesions, intra-articular fragments or ligamentous abnormalities that may go unnoticed in conventional surgery.
Furthermore, many of these injuries can be treated during the same procedure, contributing to a more comprehensive approach.
In certain cases, this approach can lead to better functional recovery and a lower risk of persistent symptoms, although it is not a substitute for standard treatment in all fractures.
Does arthroscopy always improve recovery following an ankle fracture?
Not necessarily. Arthroscopy can offer significant benefits in certain patients, but its impact depends on the type of fracture and the presence of associated injuries.
Scientific evidence suggests that, where there are intra-articular injuries that can be treated during surgery, arthroscopy can improve functional outcome and pain control. However, in simpler fractures or those without significant joint involvement, its benefit may be limited.
Therefore, rather than being a superior technique in all cases, it should be understood as a precision tool that is used when it can genuinely add value.
What types of additional injuries can arthroscopy detect in the ankle?
Arthroscopy allows for the identification of various types of injuries that are not always visible on initial imaging tests.
Among the most significant are cartilage injuries, which may affect the joint surface; the presence of small loose fragments within the joint; and injuries to ligaments that contribute to ankle stability, such as the syndesmosis or the deltoid ligament.
Detecting these abnormalities during surgery allows them to be treated during the same procedure, which can have a significant impact on the patient’s subsequent recovery.
The information in this article is provided for general awareness and does not replace an individualised medical assessment.
