Ankle Arthroscopy

Anatomy and Physiology

The ankle joint, or tibiotalar joint, is a synovial hinge joint formed by the articulation of the distal tibia and fibula with the talus. The tibial plafond and medial malleolus, along with the lateral malleolus of the fibula, create a mortise that stabilizes the talus and permits primarily dorsiflexion and plantarflexion, with limited rotation and side-to-side motion. The joint capsule further reinforces stability, with the deltoid ligament medially and the lateral ligament complex, including the anterior talofibular, calcaneofibular, and posterior talofibular ligaments, laterally. The surrounding cartilage and synovium provide smooth motion and distribute load during gait.

Pathophysiology leading to ankle arthroscopy commonly arises from traumatic, degenerative, or inflammatory processes. Acute injuries, eg, ankle sprains and fractures, may result in intra-articular damage, including chondral lesions, synovitis, or loose bodies, which contribute to persistent pain and dysfunction. Recurrent sprains or instability may lead to soft tissue impingement or osteophyte formation, thereby limiting the range of motion. Degenerative changes, often posttraumatic in origin, lead to osteoarthritis with cartilage wear, synovial inflammation, and joint stiffness. Inflammatory conditions (eg, rheumatoid arthritis) cause synovial proliferation and progressive joint destruction. These processes create mechanical symptoms, pain, and functional impairment that often fail conservative management, making ankle arthroscopy an important diagnostic and therapeutic intervention.

Indications

Ankle arthroscopy is a valuable diagnostic and therapeutic technique for managing a range of ankle conditions.

Ankle Joint Septic Arthritis

Through a minimally invasive approach, ankle arthroscopy allows for efficient treatment of the infected joint, enabling orthopedic and podiatric surgeons to address several key issues, including:

• Assessing the extent of the infection and identifying any associated intra-articular pathology
• Obtaining synovial fluid for microbiological analysis, facilitating prompt and accurate diagnosis
• Guiding the selection of appropriate antimicrobial therapy and surgical management strategies
• Performing arthroscopic irrigation and debridement to remove infected synovial tissue, debris, and purulent material from the joint space, thereby reducing bacterial load and promoting joint healing.[7][8]

More than 1 debridement may be required.[9][10] Arthroscopic washout demonstrated equal efficacy to open washout in the treatment of ankle septic arthritis; however, it had a higher rate of readmission within 90 days and a higher rate of surgical site infection compared with open arthrotomy washout.[11] 

Talus Osteochondral Lesions

Ankle arthroscopy provides direct visualization of the talus, enabling a comprehensive assessment of osteochondral lesions. Podiatrists can achieve the following:

• Examining the lesion's size, location, stability, and surrounding cartilage integrity.
• Removing any loose bodies or damaged cartilage using shavers, radio-frequency ablators, hand tools, or graspers, thereby alleviating symptoms, eg, pain and mechanical locking, and facilitating the restoration of normal joint function.
• Addressing bony abnormalities through arthroscopic techniques, including microfracture or osteochondral drilling procedures to promote the formation of reparative fibrocartilage.
• Using chondral fixation devices to stabilize chondral lesions, ensuring optimal healing and long-term joint stability.[12][13][14]
• Utilizing osteochondral autograft transfer (OATS) for the management of more substantial unstable osteochondral lesions. 

Joint Surface Preparation for Ankle Fusion

Ankle arthroscopy is valuable in minimally invasive joint surface reparation for ankle fusion procedures. This preparation involves meticulous debridement and smoothing of the joint surfaces with an arthroscopic burr to enhance fusion outcomes and ensure proper alignment.[15][16]

Posttraumatic Synovitis

Following trauma, ankle arthroscopy can be used to remove inflamed synovial tissue, thereby alleviating pain and improving joint function.[17]

Bony and Soft Tissue Ankle Joint Impingement

Current evidence supports the application of arthroscopic ankle joint debridement primarily for patients experiencing anterior bony impingement, particularly in the context of early-stage arthritis with impinging/overhanging osteophytes. This procedure is effective in addressing localized symptoms and mechanical issues associated with early arthritis. However, treatment is not recommended for patients with moderate to advanced ankle arthritis. The arthroscopic approach enables the precise identification and treatment of these impingements, thereby relieving symptoms and restoring normal joint function.[18]

 Removal of Loose Bodies from the Ankle Joint

Loose bodies within the ankle joint can cause pain, clicking, or locking. Ankle arthroscopy enables the efficient removal of these loose bodies, resolving symptoms and improving joint mobility.[19]

Contraindications

Contraindications to Ankle Arthroscopy

Ankle arthroscopy is contraindicated in patients with the following:

• Active infection: The presence of cellulitis, septic arthritis, or systemic infection increases the risk of contamination and postoperative complications.

• Severe peripheral vascular disease: Compromised blood flow impairs wound healing and elevates risk of ischemic complications.

• Advanced ankle osteoarthritis: Diffuse cartilage loss and joint space obliteration reduce the utility of arthroscopy, making arthrodesis or arthroplasty more appropriate.

• Severe joint stiffness or ankylosis: Limited joint space prevents safe portal placement and restricts intra-articular visualization.

• Poor soft tissue envelope: Compromised skin integrity, ulcers, or prior radiation increases the risk of wound breakdown and infection.

• Uncorrected coagulopathy or anticoagulation: Bleeding disorders or thrombolytic medications increase the risk of hemarthrosis and perioperative bleeding complications.

• Neuropathic (Charcot) arthropathy: Altered joint mechanics and poor healing potential make outcomes unpredictable, with high complication rates.

Equipment

Performing ankle arthroscopy necessitates a specialized array of equipment tailored to facilitate intricate surgical maneuvers and ensure precise intra-articular visualization, including:

• Sterile drapes and standard surgical instruments: Ensure a sterile field and support portal placement and closure

• Arthroscope: Small-diameter (2.7–4.0 mm) rigid arthroscope, typically with a 30-degree or 70-degree angled lens, for optimal visualization of the ankle joint

• Light source and fiberoptic cable: Provides bright illumination within the joint to allow clear visualization of intra-articular structures

• Video camera system and monitor: A high-resolution imaging system to project and record the arthroscopic view for the surgical team

• Fluid management system: Gravity or pump-assisted irrigation system to distend the joint, maintain visualization, and clear debris or blood

• Cannulas and trocars: Facilitate safe portal creation, maintain joint access, and allow passage of instruments

• Arthroscopic shaver: Motorized cutting and suction device for debridement of synovium, scar tissue, and cartilage fragments

• Arthroscopic burrs and drills: Used for bone debridement, removal of osteophytes, or treatment of osteochondral lesions

• Graspers and forceps: Permit removal of loose bodies, foreign material, or tissue samples for biopsy

• Probes and hooks: Aid in assessing cartilage integrity, ligament stability, and joint surfaces intraoperatively

• Electrocautery or radiofrequency device: Used for coagulation of bleeding vessels or controlled soft tissue ablation

Personnel

Ankle arthroscopy surgery requires a specialized team of healthcare professionals with distinct roles and expertise, including:

• Orthopedic and podiatric surgeons: Lead the surgical team and perform the arthroscopic procedure; require specialized training in ankle arthroscopy techniques and extensive knowledge of ankle joint anatomy and pathology
• Surgical assistants: Assists the orthopaedic or podiatric surgeon during the procedure, handling instruments, maintaining clear visualization, and providing surgical support as needed
• Anesthesiologists: Administer anesthesia tailored to the patient's needs, ensuring safe sedation or anesthesia management throughout the surgery
• Scrub nurses: Prepare and maintain sterile surgical instruments and supplies, assist during the procedure by passing instruments, and ensure aseptic technique is maintained
• Circulating nurses: Manage the overall flow of the surgical procedure, coordinate with the surgical team, maintain patient safety, and manage documentation and equipment throughout the surgery
• Perioperative care nurses: Coordinate preoperative and postoperative care, ensure patient readiness for surgery, and assist with patient education and recovery planning
• Physiotherapists: Collaborate with the surgical team to plan and initiate postoperative rehabilitation protocols, promoting optimal patient recovery and functional outcomes

Each member of the team plays a crucial role in the successful execution of ankle arthroscopy surgery, ensuring patient safety, surgical precision, and comprehensive perioperative care.

Preparation

Preparation for ankle arthroscopy includes the following specialized steps:

• Preoperative planning: A patient's history, clinical examination, and imaging studies should be reviewed to identify specific ankle joint pathologies, eg, cartilage lesions or ligament tears. A detailed surgical plan, outlining the approach, portal placements, and anticipated procedures based on preoperative assessments, should be prepared. Informed consent should be obtained, and the correct side should be marked. 

• Team briefing: The surgical team should explain the steps and objectives before commencing the operation. Specific or additional equipment that may be required should be outlined. Potential complications, eg, neurovascular injury or infection, and outline preventive measures, including meticulous sterile technique and careful portal placement, should be discussed. Additionally, a WHO Patient Safety Checklist should be completed.

• Surgical instrumentation setup: All necessary equipment should be prepared, including the ankle arthroscope, specialized surgical instruments (eg, graspers, shavers), and a standard arthroscopy pump for joint irrigation and visualization enhancement.

Technique or Treatment

Preoperative Preparation

Preoperative preparation for ankle arthroscopy requires careful attention to patient selection, informed consent, positioning, and intraoperative techniques that optimize visualization and minimize complications. Appropriate candidates must demonstrate clear indications, eg, impingement, osteochondral lesions, loose bodies, synovitis, arthrofibrosis, or early arthritis. Contraindications, including active infection, severe peripheral vascular disease, and advanced arthritis, must be excluded to ensure safe and effective outcomes.

Informed consent

The consent process should include a detailed discussion of potential benefits, risks, and alternatives. Patients need to understand the potential complications (eg, neurovascular injury, infection, or persistent pain) associated with the minimally invasive approach, as well as its therapeutic benefits.

Patient positioning

Proper positioning depends on the surgical approach. For anterior arthroscopy, the patient is placed in a supine position with a thigh tourniquet applied and a bump positioned under the ipsilateral hip to correct external rotation. Posterior arthroscopy requires a prone position with a tourniquet in place, allowing the foot to hang freely over the edge of the table for optimal access.

Joint visualization

Distraction techniques further enhance intra-articular visualization. Either a noninvasive ankle distractor or manual traction can be used to open the joint space, thereby improving exposure and facilitating precise arthroscopic intervention.

Portal Anatomy

Anteromedial portal

The anteromedial portal serves as the principal viewing portal, providing direct access to the anteromedial region of the ankle joint. Positioned medial to the tibialis anterior tendon and lateral to the medial malleolus, this portal is typically created as the first step in ankle arthroscopy. The procedure begins with intra-articular injection of sterile saline into the anteromedial ankle, which distends the joint and establishes accurate orientation for subsequent portal placement.

A 5 mm longitudinal skin incision is then made between the tibialis anterior tendon and the saphenous vein, with precise attention given to avoid injury to the saphenous nerve. This nerve runs along the distal medial tibia and ankle, and careful dissection minimizes the risk of neurovascular complications. Dissection with a hemostat or dissecting scissors continues through the subcutaneous tissue until the joint capsule is reached. The controlled release of saline confirms proper intra-articular positioning.

A blunt-tip trocar with an arthroscopic cannula is then advanced into the joint, enabling insertion of the arthroscope. Once the arthroscope is in place, sterile water flow is initiated to enhance intra-articular visualization. Water inflow pressure should be kept as low as clinically feasible, with typical ranges of 40 to 60 mm Hg sufficient to maintain clear visualization during the procedure.

Anterolateral portal 

The anterolateral portal represents a key anterior access point in ankle arthroscopy and is established under direct visual guidance with a 21-gauge needle. This portal aligns with the joint line in the horizontal plane and lies lateral to both the common extensor tendons and the peroneus tertius tendon in the vertical plane.

Meticulous attention must be directed toward avoiding injury to the superficial peroneal nerve, which courses just beneath the skin surface. Identification of this nerve can often be achieved by placing the foot in forced hyperplantarflexion and supination while plantarflexing the fourth toe, a maneuver that accentuates the nerve and its lateral dorso-cutaneous branches.[20] The intermediate dorsal cutaneous branch of the superficial peroneal nerve traverses the anterior aspect of the ankle joint above the extensor tendons. To reduce the risk of damage to this structure, the portal should be positioned slightly more laterally, thereby protecting both the nerve and its branches during arthroscopic access.

Anterocentral portal

Although this portal is less frequently utilized due to its proximity to the dorsal pedis artery, it serves as an anterior viewing portal. Positioned between the tendons of the extensor digitorum longus (EDL) and extensor hallucis longus (EHL), its placement demands careful attention to avoid potential vascular compromise.

Posterior portals

Posterior visualization during ankle arthroscopy relies heavily on the posterolateral and posteromedial portals, both of which provide essential access to the posterior compartment of the joint. The posterolateral portal is positioned approximately 2 cm proximal to the lateral malleolus tip and offers direct access to the os trigonum region. Placement occurs medial to the peroneal tendons and lateral to the Achilles tendon, requiring careful technique to prevent injury to the sural nerve, which runs nearby. The posteromedial portal, located just medial to the Achilles tendon, serves as a complementary posterior access point, also allowing visualization of the os trigonum. Accurate placement remains critical for this portal as well, since adjacent neurovascular structures lie in close proximity and must be carefully avoided to minimize the risk of complications. 

Portal Establishment

Preoperative preparation begins with careful marking of key anatomical landmarks, including the medial and lateral malleoli, surrounding tendons, and superficial nerves. Accurate identification of these structures establishes safe zones for portal placement and minimizes the risk of iatrogenic injury.

A small longitudinal skin incision is then created at the selected site. Blunt dissection with a hemostat proceeds through the subcutaneous tissue down to the joint capsule, a technique that reduces the likelihood of neurovascular damage. Following dissection, a trocar and cannula are introduced into the joint. Correct intra-articular positioning is confirmed under arthroscopic visualization, ensuring both safety and accuracy before advancing with the procedure. 

Diagnostic Assessment 

A systematic diagnostic survey during ankle arthroscopy begins with evaluation of the anterior compartment. The podiatrist inspects the tibial plafond, talar dome, and both the medial and lateral gutters to establish a comprehensive view of anterior joint structures.

Cartilage integrity requires careful assessment, with attention directed toward identifying fibrillation, softening, or discrete defects that may compromise joint function. The orthopedic or podiatric surgeon also examines the joint for loose bodies, synovitis, or impinging soft tissue, each of which can contribute to pain or restricted motion. Evaluation of the anterior inferior tibiofibular ligament and the capsule provides further insight into potential sources of instability or pathology.

When posterior portals are employed, the assessment extends to the posterior tibial plafond, talar dome, subtalar joint, and os trigonum. This systematic approach ensures a complete diagnostic survey, enabling the accurate identification of intra-articular pathology and guiding appropriate therapeutic interventions.

Anatomy Visualization and Ligament Assessment

Following portal establishment and joint distention, the orthopedic or podiatric surgeon proceeds to visualize the ligamentous structures of the ankle, including assessment of the integrity and stability of both the lateral and medial ligamentous structures. Gentle stress tests are applied to evaluate ligament stability, including varus and valgus stress to assess lateral ligaments and anterior pull stress to evaluate the integrity of the anterior talofibular ligament (ATFL). Eversion and pronation of the foot are performed to determine the stability of the deltoid ligament complex.

Assessment of Instability and Talar Tilt

The orthopedic or podiatric surgeon should continue by evaluating any signs of lateral instability, which is typically tested by manual maneuvers and observation for abnormal movement patterns. Talar tilting is assessed by applying supination stress to the foot and observing for abnormal tilting or instability, which may be indicative of ligamentous injury or chronic instability. 

Interventional Procedures

Interventional procedures during ankle arthroscopy encompass a variety of targeted techniques to address specific intra-articular pathology, including:

• Debridement
  • Arthroscopic shaver: This technique removes inflamed synovium, scar tissue, or loose cartilage.
  • Synovectomy: In cases of inflammatory arthropathy, synovectomy enables the excision of hypertrophic synovial tissue, thereby reducing pain and improving joint function.
• Osteophyte resection: This technique employs a motorized burr to remove anterior or posterior tibial or talar osteophytes that contribute to impingement and restricted motion. Management of osteochondral lesions of the talus includes curettage of unstable cartilage, followed by microfracture or drilling techniques to stimulate the formation of reparative fibrocartilage.
• Adhesiolysis: Arthrofibrosis is addressed through adhesiolysis, which releases capsular scar tissue to restore joint range of motion.
• Graspers: Loose bodies, including cartilage or bone fragments, are extracted using graspers to alleviate mechanical symptoms.
• Adjunct to fusion: In cases requiring arthrodesis, arthroscopy serves as an adjunct for meticulous debridement of tibial and talar cartilage, optimizing joint surface preparation before fusion.

Closure and Dressing

Closure and dressing after ankle arthroscopy begin with thorough irrigation of the joint to remove residual debris and maintain a clear surgical field. Following irrigation, all instruments and cannulas are carefully withdrawn, and portal skin incisions are closed using nylon sutures or adhesive strips to promote optimal healing.

A sterile dressing is applied over the incision sites, followed by a compressive bandage to support soft tissues and minimize postoperative swelling. After releasing the tourniquet, the limb is inspected for bleeding, hematoma formation, or excessive swelling, ensuring hemostasis and confirming appropriate tissue perfusion before the procedure is completed. 

Postoperative Protocol

Postoperative management following ankle arthroscopy emphasizes recovery, rehabilitation, and careful monitoring to optimize outcomes. For most diagnostic procedures or simple debridement cases, patients may bear weight as tolerated while using crutches for support, facilitating early mobility without compromising healing.

Rehabilitation should begin promptly with range-of-motion exercises to reduce stiffness and maintain joint function. When cartilage repair or microfracture procedures are performed, partial or nonweight-bearing protocols are recommended for 4 to 6 weeks to protect the repaired tissue and promote successful fibrocartilage formation. Follow-up care includes vigilant assessment for signs of infection, neurovascular compromise, or persistent swelling. Regular monitoring ensures timely identification of complications and supports progressive recovery toward full joint function.

Complications

Infection 

Infection after ankle arthroscopy is a known complication necessitating detailed management to reduce risks and promote positive outcomes. Infections range from superficial portal wound infection to septic arthritis.[21] Early detection and appropriate treatment are crucial for preventing complications, eg, joint damage and prolonged recovery times.

Neurovascular Injury

Neurological injuries are the most common complications after ankle arthroscopy, most frequently involving the superficial peroneal nerve injury.[22][23] Most nerve injuries occur through direct injury by portal or distractor pin placement.[24]

Anterolateral portal

The anterolateral portal serves as a commonly used entry point in ankle arthroscopy, providing access to the lateral and anterior regions of the joint. Placement of this portal requires meticulous attention to prevent complications, particularly injury to the superficial peroneal nerve, which supplies sensory innervation to the dorsum of the foot and lateral lower leg.

The dorsal intermediate cutaneous branch of the superficial peroneal nerve runs superficially along the lateral aspect of the leg and crosses the anterior ankle joint, placing it at high risk during portal insertion or tissue manipulation. Injury to this nerve can result in sensory disturbances, including pain, numbness, or tingling, in the areas it innervates. Additionally, damage may cause weakness in foot dorsiflexion and eversion due to impaired function of the peroneal muscles, highlighting the critical importance of careful portal placement and protective technique.

Anteromedial portal

Placement of the anteromedial portal carries multiple risks that require careful management to prevent complications. One primary concern involves injury to the saphenous nerve, a branch of the femoral nerve that runs medially and provides sensory innervation to the medial lower leg and foot.[25] Injury to this nerve can produce postoperative pain, numbness, or tingling in its distribution.

The saphenous vein, which accompanies the saphenous nerve, also faces potential injury during portal placement. Trauma to this vein may result in bleeding or hematoma formation, complicating both the surgical procedure and postoperative recovery. Another structure at risk, the tibialis anterior tendon, lies immediately medial to the portal site. This tendon contributes to dorsiflexion of the foot and stabilization of the ankle joint, and injury can impair foot function, potentially leading to long-term motor deficits. Careful anatomical identification and precise portal placement technique are essential to minimize these risks.

Anterocentral portal

During ankle arthroscopy, the anterocentral portal requires careful attention to avoid injury to the dorsalis pedis artery. Trauma to this artery can result in serious vascular complications, including compromised blood flow to the foot. Accurate portal placement, guided by anatomical landmarks or imaging, helps protect the artery and maintain proper vascular function throughout the procedure.

Posterolateral portal

The posterolateral portal in ankle arthroscopy provides access to the posterior and lateral aspects of the ankle joint but poses risks, including potential injury to the sural nerve and the short saphenous vein. The sural nerve, which is responsible for sensation in the lateral foot and posterior lower leg, can be affected, potentially resulting in sensory issues, eg, pain or numbness. Additionally, damage to the short saphenous vein may lead to vascular complications (eg, bleeding or hematoma). To mitigate these risks, surgeons should use careful anatomical landmarks and imaging techniques to accurately place the portal and avoid these critical structures, thus reducing the risk of complications and improving patient outcomes.

Posteromedial portal 

Inserting the posteromedial portal during ankle arthroscopy requires a precise technique to minimize the risk of damaging the posterior tibial artery.

Ankle Joint Stiffness

Patients undergoing ankle arthroscopy may experience postoperative joint stiffness due to incomplete resolution of the pathology or scar tissue formation, necessitating rehabilitative measures, eg, structured physical therapy and additional interventions, to restore a full range of motion and functionality.

Deep Vein Thrombosis

Patients undergoing ankle arthroscopy, particularly those at higher risk, should be assessed and monitored for the development of deep vein thrombosis.[23] Early mobilization and risk assessment for pharmacological thromboprophylaxis are strategies to mitigate this potential complication and promote optimal postoperative recovery.

Iatrogenic Articular Cartilage Injuries

Ankle arthroscopy poses the potential for inadvertent damage to articular cartilage, which can lead to significant complications, secondary degenerative joint disease, and prolonged recovery times.[26] Employing meticulous surgical techniques and maintaining vigilant monitoring are essential strategies to minimize the occurrence of such injuries.

Synovial Cutaneous Fistula 

A rare complication that warrants attention is the development of a synovial cutaneous fistula, characterized by an abnormal connection between the synovial lining and the skin. The risk of this complication can be reduced by surgical closure of portal sites and consideration of ankle immobilization in the early postoperative period.

Clinical Significance

Ankle arthroscopy has become an essential tool in modern podiatric and orthopedic practice due to its dual role as both a diagnostic and therapeutic tool. Clinically, arthroscopy provides minimally invasive access to the ankle joint, allowing for direct visualization of intra-articular structures that are often difficult to assess with imaging alone. This capability is particularly valuable in patients with chronic ankle pain, instability, or posttraumatic sequelae, where plain radiographs and MRI may be inconclusive. Diagnostic arthroscopy facilitates identification of osteochondral lesions, synovitis, ligamentous injuries, loose bodies, and subtle degenerative changes, enabling accurate assessment of pathology and guiding treatment planning.

Therapeutically, ankle arthroscopy offers targeted intervention with reduced morbidity compared to open procedures. The minimally invasive nature of the procedure enables faster recovery, reduced postoperative pain, and a lower risk of soft tissue complications. Additionally, arthroscopy can be combined with other procedures, eg, fracture management or ligament repair, to optimize outcomes. Overall, the clinical significance of ankle arthroscopy lies in its ability to provide a precise diagnosis, guide management, and deliver effective treatment with a favorable safety and recovery profile.

Enhancing Healthcare Team Outcomes

Ankle arthroscopy has become a cornerstone in the diagnosis and management of intra-articular ankle pathology, offering minimally invasive access for conditions such as osteochondral lesions, synovitis, impingement, and posttraumatic arthrofibrosis. The procedure provides direct visualization of joint structures, enabling precise assessment and targeted intervention while minimizing soft tissue trauma and promoting faster recovery. Its applications extend to both diagnostic evaluation when imaging is inconclusive and therapeutic management, including debridement, osteophyte resection, cartilage repair, and adjunctive use in fusion procedures. Successful outcomes rely on careful patient selection, meticulous surgical technique, and structured postoperative rehabilitation to restore function and reduce complications.

Effective ankle arthroscopy requires coordinated skills and strategies across the interprofessional healthcare team. Orthopedic and podiatric physicians and advanced practitioners contribute technical expertise, clinical judgment, and ethical decision-making to ensure surgical indications align with patient goals. Nurses provide perioperative care, monitor for complications, and educate patients on recovery and rehabilitation, while pharmacists optimize medication regimens, manage analgesia and anticoagulation, and prevent drug interactions. Clear interprofessional communication and shared documentation facilitate early recognition of infection, thromboembolism, or neurovascular injury, and coordinated care ensures seamless transitions from preoperative assessment through postoperative rehabilitation. By integrating ethical practice, patient-centered planning, and team collaboration, the healthcare team enhances safety, improves functional outcomes, and fosters high-quality, evidence-based care throughout the ankle arthroscopy continuum.