Ankle Arthroscopy – Repairing Ankles with Keyhole Surgery

James Torhorst
Featured Speaker:

James Torhorst, DPM
Dr. James Torhorst is a podiatrist and foot and ankle surgeon with Aspirus Riverview Clinic in Wisconsin Rapids. He is board certified in foot surgery and reconstructive rearfoot/ankle surgery. Dr. Torhorst earned his DPM degree at Des Moines University in Iowa and completed his residency at Jewish Hospital in Louisville, Kentucky.

Ankle arthroscopy – also known as keyhole surgery – can be an excellent option for repairing ankle tissue damaged by a fall, twist or sprain.

Ankle arthroscopy typically requires only two tiny incisions, a few stitches, and bandages for about 10 days.

Many patients don’t even need crutches following surgery, and most return to working out and running in just six to eight weeks.

Dr. Torhorst is here to explain this minimally invasive procedure that is helping his ankle surgery patients enjoy fewer complications, less scarring and faster recoveries.

Transcription

Melanie Cole (Host):  Have you had ongoing ankle pain? Ankle arthroscopy, also known as keyhole surgery, can be an excellent option for repairing ankle tissue that might have been damaged by a fall, a twist or a sprain. My guest today is Dr. James Torhorst. He is a podiatrist and foot and ankle surgeon with Aspirus Riverview Clinic in Wisconsin Rapids. Welcome to the show, Dr. Torhorst. Tell us a little bit about the physiology of the ankle and what goes wrong with it generally? 

Dr. James Torhorst (Guest):  Good morning, Melanie. I’m here today to speak a little bit about ankles and the physiology of the ankle; what goes wrong with the ankle. Very often ankle injury is very often caused by a predisposition for lateral ankle instability. That would be the most common cause or problem of issues associated with the ankle that we are going to discuss today that could be affected or treated with arthroscopy.

Melanie:  People often think that the ankle is, as you say, an unstable joint. Is this a result, also, of the shoes that we wear and women wearing high heels? What makes it so unstable? We don’t think, typically, about doing exercises for our ankle.

Dr. Torhorst:  There are several causes of lateral ankle instability. Most of them are not causes by shoes, necessarily, but perhaps injuries from types of shoes. For example, a woman in a pair of high heels or a clog type shoe. If you were to invert your ankle, the inversion could end up causing an injury to the talar dome or the articular surface of the ankle itself due to the disposition of the foot in the shoe prior to the injury. Most of the lateral ankle instability we are discussing is a genetic predisposition or caused by an injury of that nature.

Melanie:  How do you know if it is an acute or a chronic injury? If it’s something that you did, you know you did it, is this the way that you would tell? Or, if it’s something from overuse or poor biomechanics?

Dr. Torhorst:  Most of my patients come in and they have an idea whether or not they injured their ankle in a severe manner. People who have lateral ankle instability and our recurrent ankle sprainers are the patients I most see and that my Brostrom repair through the scope has been most effective for. These patients are usually rolling their ankles in high school sports, rolling their ankle when they are falling off a curb. I even have patients that come in and say they feel like they are going to roll their ankle when they step on a penny.

Melanie:  Wow. What do you do for them? What is your first line of defense? Do you try anti-inflammatories or wrapping or bracing the ankle? What do you do for them? 

Dr. Torhorst:  A chronic ankle sprainer has usually, by the time they show up in my office, have tried some things to control the situation. I try to get them into a good brace for any sporting activities that they participate in. I try to make sure that they are aware of uneven surfaces, try to have them acutely aware of their surroundings and their environment, the shoes they wear, what they are doing to try to avoid recurrent ankle sprains and damage. The ankle itself, once it becomes unstable, is very difficult to control and I’ve seen ankle instability that is bad enough that these patients come in and even with a brace they still feel as though they are rolling their ankle. Once you lose the integrity and the stabilization on the anterior and anterolateral  and lateral portion of the ankle joint--which is the more common type of instability and the type that we’re talking about today – the patients come to my office, we try conservative care that is bracing, Ace wraps stabilization through possibly a Cam boot or isolation of motion. If they don’t respond well to that, then we start talking pretty seriously about surgery. We usually get an MRI first to get some information and see if there is a legion on the talus. We can talk about legions on the talus as we go forward.

Melanie:  Tell us a little bit about the procedure itself. If they’ve decided and you’ve helped them decide this is something you are really going to have to do, what are you doing for them when you go in there?

Dr. Torhorst:  We are very often referred these patients by other physicians who have had difficulty treating them conservatively already. As we move forward, we very often talk about a surgical procedure that includes arthroscopy of the ankle joint. We use a small 2.7 arthroscope with a 30 degree or 70 degree bevel which allows me to look and see exactly what’s going on within the ankle joint with a very small incision with less than 1cm each in the front portions or even the back portions of the ankle joint. Upon inspection of the ankle joint, what we’re looking for and what we’re hoping to achieve are several different possible treatments including repairs of OCDs which are osteochondritis dissecans, which is a legion in the articular surface or the cartilage of the talus.  These legions can be repaired with subcondral drilling or microfracture. They can also be repaired with several different modalities, including chondrocytes that have been harvested from other people and placed into the ankle joint to try to recreate a cartilaginous base that prevents the bone on bone pain that these patients get when they have legions in their talus that creates rubbing between the tibia and talus with their unstable ankle. We also stabilize their ankle through a scope by tightening their ligaments and repairing their ligaments to allow the ankle, once it is repaired, not to recreate those injuries and recreate those inversion injuries. Very often, we are able to get these patients out of their braces and back to activities without complications. Doing everything through a scope allows things to happen much faster. In the old days when we had a three month recovery, we’re now able to have patients up and walking within four weeks and it’s really been a game changer much the way knees changed and shoulders changed in the past, arthroscopy of the ankle, I think, is something that is going to become bigger and more important in the future.

Melanie:  What is the recovery like?  How soon is somebody up and around and then, is there limited range of motion after this type of procedure and how do they regain that back?

Dr. Torhorst:  If we are performing a lateral ankle stabilization through a scope, the patient will be in a splint for three to four days and then placed in a cast for two weeks, sutures will be removed, placed in a cast for two more weeks and around the four week post-op period, we remove them from the cast and put them into a boot in which they can walk for two to four weeks before we begin physical therapy.

Melanie:  Then, once they are in physical therapy, the goal, obviously, is getting the range of motion back. Will they still see any swelling because when people, as you say, roll their ankle and it gets swollen and they wait for the swelling to go down, they use ice or whatever. Is that going to then going to go away after this procedure? Is it something that can still come back?

Dr. Torhorst:  One of the most exciting parts of this procedure for me as I’ve begun doing more and more over the past three years is the swelling is so minimal after the surgery because there are no large incisions. Everything is done through scope portal and small incisions less than 2-3 cm. The swelling is minimal and usually by four weeks when they are up and walking--actually usually at their two week recovery – there is almost no swelling whatsoever. That is one of the real advantages to doing this procedure through a scope.

Melanie:  When can they safely return to driving?

Dr. Torhorst:  Depending upon the laws in their state and depending upon whether or not they are wearing a Cam boot, they can return to driving as soon as they are no longer wearing their boot.

Melanie:  That is absolutely fascinating. Dr. Torhorst, in just the last few minutes, give your best advice for people to keep their ankles strong – this fragile joint that is so important for us – to keep their ankles good and strong and why they should come to Aspirus to see you for their care.

Dr. Torhorst:  My advice for people with their ankles, if you’ve got ankle instability, you know it. I would recommend that you see a podiatrist or a foot and ankle surgeon who is specialized in foot and ankle care and done either a fellowship or specialized training in that area. Aspirus has allowed us to move forward with arthroscopic repair of these ligaments. They have allowed us to have the things we need in the operating room even in the small towns in which we live here in Central Wisconsin to perform these procedures. The reason that I would come to Aspirus is the Aspirus group has done such a nice job trying to coordinate and work with the physicians who have come with specialized training. I trained at the University of Louisville and had access to all different types of medicine and medical procedures. We were able to bring that arthroscopy, that technology, that knowledge into central Wisconsin and Aspirus has let us really move forward with some very cutting edge ideas in ankle arthroscopy. My recommendation to any patient is see a specialist. Come in and have your ankle looked at and see what your options are and if we can treat you conservatively, wonderful. If you need surgical procedures, we can certainly perform those right here in central Wisconsin.

Melanie:  Thank you so much. It’s great information, Dr. Torhorst. Thank you so much for being with us today. You’re listening to Aspirus HealthTalk and for more information you can go to Aspirus.org. That’s Aspirus.org. This is Melanie Cole. Thanks so much for listening.

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