Surgical techniques | Anterior arthroscopy

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Loose bodies may results from minor to major trauma. Loose bodies may arise from defects in the talus, tibia, fibula or osteophytes. They also may be caused by degenerative joint disease, and are either chondral or osteochondral. The loose body can cause major damage and complaints when floating around the joint.


History & Physical Examination

Small loose bodies may cause synovitis and symptoms of catching or locking on moving the ankle, along with pain, swelling and limitation of function. Complaints may resolve over time if a loose body becomes fixed to the synovial lining, ceasing to cause joint irritation. Loose bosies may also grow or shrink over time.

On physical examination sometimes no abnormalities are found. There may be signs of tenderness, limitation of range of motion and cacthing or locking. A loose body is hardly ever palpable. Deep ankle pain may be present because of intra-articular damage caused by the loose body, or may be there because of a  different pathology (osteochondral defect, osteoarthritis). These must be ruled out, together with other extra-articular problems that may cause similar symptoms.


Diagnostic Imaging

Conventional radiography usually reveals an osseous loose body. An important question is whether the detected changes are old or new: is the bony fragment a fresh avulsion or is it an older ossicle? Ossicles or bone spurs may also remain undetected at arthroscopy due to the overlying synovitis and scar tissue that often accompanies these bone lesions. Also, chondral bodies are not visible on routine radiography. When history and physical examination  raise suspicion for a loose body, additional investigation needs to be done. For these reasons, thorough pre-operative planning is important. A CT-scan is advised to make sure that prior to surgery all loose bodies have been located.


Post-operative rehabilitation

The patient can be discharged the same day of surgery and weightbearing is allowed as tolerated. The patient is instructed to perform active dorsiflexion of the ankle to the neutral position (knee slightly bent). This exercise should be performed 2 or 3 days times per hour for the first days after surgery. The patient is instructed to elevate the foot when not walking to prevent edema. The dressing is removed 3 days post-operative. Normal walking without crutches at 4 - 5 days post surgery. Patients with limited range of motion are directed to a physiotherapist. Running can be started when range of motion is normal and in absence of swelling. This can on avarage be expected at 3 weeks post surgery. Sport resumption can on average be expected at 6 weeks post surgery. 


Recommended Literature

Van Dijk CN, Fievez AWFM, Heijboer MP, et al. Arthroscopy of the ankle. Acta Orthop Scand 1993;64(suppl. 253):9.

Van Dijk CN, Scholte D. Arthoscopy of the Ankle Joint. Arthroscopy: The journal of Arthroscopic and Related Surgery, 1997;13(1):90-96.

Van Dijk, Verhagen RAW, Tol JL. Arthroscopy for problems after ankle fracture. J Bone Joint Surg (Br) 1997;79B(2):280-284.