Current status and future perspectives of arthroscopic treatment for foot and ankle disorders: a narrative review

Article information

J Korean Med Assoc. 2025;68(8):520-527

Publication date (electronic) : 2025 August 10

doi : https://doi.org/10.5124/jkma.25.0092

Bi O Jeong, MD, PhD, Min Gyu Kyung, MD, PhD

Department of Orthopaedic Surgery, Kyung Hee University College of Medicine, Seoul, Korea

Corresponding author: Min Gyu Kyung E-mail: mgkyung@naver.com

Received 2025 July 3; Accepted 2025 July 28.

Abstract

Introduction

Arthroscopic Treatment of OLTs

OLTs are defined as focal defects of the articular cartilage that are accompanied by subchondral bone damage [2]. Historically, these lesions were described as osteochondritis dissecans or osteochondral fractures; however, “osteochondral lesion of the talus” is now the most widely accepted term [3]. Trauma is the leading cause, with studies indicating that approximately 50% to 73% of acute ankle injuries are associated with concomitant OLTs [3].

Articular cartilage consists of avascular hyaline cartilage, which has a limited blood supply and restricted self-regenerative capacity, resulting in poor healing potential [4]. The natural course of OLTs remains unclear [5], but untreated lesions may progress, causing cartilage softening and loosening, which subsequently increases the risk of early osteoarthritis [6].

OLTs can be classified using plain radiography, computed tomography (CT), magnetic resonance imaging (MRI), and arthroscopic evaluation. Berndt and Harty [7] originally classified these lesions into 4 stages based on plain radiographs. However, this system has become less useful because many lesions are not visible on radiographs, and precise staging is often challenging. Additional classification systems have been developed, such as Ferkel et al. [8]’s CT-based classification, Mintz et al. [9]’s MRI-based system, and Pritsch et al. [10]’s arthroscopic classification, which divides cartilage conditions into 3 stages. MRI, however, may overestimate the severity of lesions [11], and arthroscopy, while allowing direct visualization of cartilage, does not fully assess the status of the subchondral bone [3]. Therefore, treatment planning should integrate information from both imaging modalities and arthroscopic findings.

Treatment options are divided into conservative and surgical approaches, depending on lesion size and cartilage condition. Asymptomatic or small, non-displaced lesions are generally managed conservatively with immobilization, orthoses, and anti-inflammatory medications [3]. Surgical intervention is considered for displaced acute lesions or for chronic lesions that are unresponsive to conservative management. Recent advances in arthroscopy and surgical techniques have expanded the range of options, allowing procedures to be tailored according to lesion size and depth.

Surgical methods are broadly categorized into bone marrow stimulation, osteochondral transplantation, and cartilage regeneration techniques. Bone marrow stimulation, including multiple drilling or microfracture, is most commonly used for small lesions. Larger or deeper lesions may necessitate osteochondral grafting or regenerative procedures. Osteochondral grafting involves transplantation of healthy osteochondral tissue, which can be subdivided into autografts and allografts. Cartilage regeneration techniques include autologous chondrocyte implantation (ACI), in which cultured chondrocytes are implanted after ex vivo expansion, along with emerging biological adjuncts designed to enhance cartilage repair.

Arthroscopic microfracture is the first-line treatment for stimulating bone marrow in patients who do not respond to conservative therapy. The technique involves debridement of damaged cartilage to expose subchondral bone, followed by the creation of small holes with an awl to induce bleeding. This process encourages mesenchymal stem cell infiltration and fibrocartilage formation at the lesion site [3]. Although fibrocartilage is biomechanically inferior to native hyaline cartilage, clinical studies have reported pain relief and functional improvement after microfracture [3]. Choi et al. [12] found that lesion size is a significant determinant of microfracture outcomes, with lesions ≤150 mm² yielding the most favorable prognosis. Lesion size is thus a key prognostic factor. The long-term prognosis remains uncertain; however, a 10-year follow-up by Polat et al. [13] showed no cases of progression to stage 4 arthritis, and only mild progression in approximately 32.9% of patients, suggesting durable efficacy.

The adjunctive use of bone marrow aspirate concentrate (BMAC), a biological agent obtained by centrifuging bone marrow from the iliac crest or tibia to isolate mesenchymal stem cells, has been explored to enhance cartilage regeneration after microfracture. Fortier et al. [14] compared outcomes between microfracture alone and microfracture plus BMAC, reporting superior healing of full-thickness cartilage defects in the BMAC group. Hannon et al. [15] observed no significant differences in clinical improvement but documented MRI evidence of superior structural repair when BMAC was used.

ACI is indicated for patients with failed microfracture, large full-thickness defects, or contained lesions surrounded by healthy cartilage [16]. The procedure involves 2 stages: harvesting healthy cartilage from a non-weight-bearing area and culturing chondrocytes for 2 to 6 weeks, followed by arthroscopic implantation beneath a periosteal flap [17]. The regenerated cartilage demonstrates biomechanical properties similar to normal cartilage [18]. Battaglia et al. [19] conducted a 5-year follow-up of 20 patients who underwent arthroscopic ACI, showing an improvement in American Orthopaedic Foot and Ankle Society (AOFAS) scores from 59 to 84, with MRI evidence of hyaline-like cartilage regeneration in 69% of lesions. Kwak et al. [20] reported significant improvements in AOFAS and Tegner activity scores in 32 patients, with a mean follow-up of 70 months, after treating failed bone marrow stimulation with ACI.

Autologous matrix-induced chondrocyte implantation (AMIC), a second-generation form of ACI, employs a collagen scaffold in place of a periosteal flap to support differentiation and new cartilage formation. AMIC can be performed arthroscopically without the need for a second procedure or periosteal harvesting, thus reducing operative time and the risk of cell loss [3]. Giza et al. [21] observed significant functional improvement and cartilage healing 2 years after AMIC in 10 OLT patients. In a 2-year follow-up of 26 patients with previously failed surgeries, Valderrabano et al. [22] reported complete defect filling on MRI in 35% and near-normal cartilage in 84% of cases, accompanied by marked clinical improvement. Kreulen et al. [23] also demonstrated sustained functional gains over 7 years in 10 patients treated with AMIC after surgical failure.

Recently, particulated autologous chondrocyte transplantation (PACT), which uses cartilage chips derived from the OLT, has been investigated. Shim et al. [24] followed 32 patients for 1 year after PACT and reported significant improvements in clinical, radiological, and morphological outcomes.

Despite the growing range of surgical options, the optimal treatment for OLTs has yet to be defined. Standardization of techniques and accumulation of long-term data—including multicenter registries and guidelines—are necessary, especially at the domestic level.

Arthroscopic Treatment of CAI

Lateral ankle ligament injuries are common among athletes and physically active individuals. While most patients recover without complications through conservative management—such as splinting and rehabilitation—some develop CAI. CAI results from incomplete ligament healing and repeated injuries following ankle sprain, leading to both mechanical and functional instability. If left untreated, CAI can result in recurrent sprains, cartilage damage, and soft tissue impingement syndromes, highlighting the importance of early diagnosis and treatment.

Persistent symptoms and signs of lateral instability despite conservative measures indicate the need for surgical intervention. The modified Broström operation (MBO) is the most widely performed procedure for lateral ligament injuries [25], with the open MBO regarded as the gold standard [26]. This procedure involves overlapping and suturing the anterior talofibular and calcaneofibular ligaments, followed by reinforcement using advancement of the inferior extensor retinaculum [27].

Recently, arthroscopic MBO has gained attention and undergone significant development [28]. Arthroscopic techniques enable effective treatment of lateral ankle instability without the need for open incisions. The drive for arthroscopic evolution arises from the widespread recognition that many patients with lateral instability have concomitant intra-articular pathologies requiring assessment and management during ligament repair [29]. Hintermann et al. [30] found cartilage damage in approximately 66% of CAI patients assessed arthroscopically, while Hua et al. [31] reported intra-articular abnormalities in up to 90% of cases. Prolonged instability increases the risk of cartilage lesion progression, and concurrent cartilage damage can negatively affect postoperative outcomes, thereby influencing long-term prognosis [32]. Thus, arthroscopic evaluation and management of intra-articular pathology are essential in CAI, making arthroscopic MBO an appealing alternative to open surgery.

In Korea, Kim et al. [28] first reported favorable clinical and radiological outcomes after arthroscopic MBO in 28 cases of CAI. Nery et al. [33] observed a mean AOFAS score of 90 in 38 patients after arthroscopic repair, with anterior drawer grades 0 and 1 in 25 and 13 patients, respectively. Acevedo and Mangone [34] reported a significant improvement in the Karlsson score from 28.3 preoperatively to 90.2 postoperatively in 93 patients who underwent arthroscopic MBO. Multiple studies have since confirmed excellent outcomes with arthroscopic MBO [35]. In a Level I prospective, randomized study, Yeo et al. [36] compared arthroscopic (n=25) and open (n=23) MBO, finding significant postoperative clinical improvements in both groups, with no significant differences in outcomes or complication rates. Guelfi et al. [37]’s systematic review reported a higher complication rate (15.27%) for arthroscopic versus open MBO, primarily due to superficial peroneal nerve injuries; however, patient satisfaction remained unaffected. Careful portal placement is therefore critical to avoid iatrogenic nerve injury.

Biomechanical studies demonstrate similar torque-to-failure, degree of failure, and stiffness between arthroscopic and open MBO [38]. With appropriate patient selection, arthroscopic MBO serves as a viable alternative for managing CAI.

A limitation of MBO is poorer outcomes in patients with compromised soft tissue quality. Viens et al. [39] found that suture tape augmentation improved repair strength. Yoo and Yang [40] further demonstrated that suture tape augmentation combined with arthroscopic MBO allowed for faster return to daily and sports activities.

Given the increasing incidence of ankle ligament injuries, further comparative and long-term studies on arthroscopic ligament surgery are needed to optimize patient outcomes.

Arthroscopic Ankle Arthrodesis

Post-traumatic etiologies account for 70% to 80% of ankle arthritis cases, often affecting younger, more active individuals compared to those with knee or hip arthritis [41]. Advanced ankle arthritis results in chronic pain, restricted range of motion, and gait impairment, leading to significant reductions in quality of life. Surgical intervention is indicated when conservative treatment fails, with arthrodesis or total ankle arthroplasty as the primary options.

Open ankle arthrodesis, the traditional technique, involves thorough removal of damaged cartilage and maximization of cancellous bone contact to achieve rigid fixation and pain relief, making it the definitive procedure for advanced arthritis. Although total ankle arthroplasty preserves joint motion and has grown in popularity, arthrodesis remains preferred in cases of severe deformity or compromised bone stock.

Introduced by Schneider in 1983, arthroscopic ankle arthrodesis has undergone significant evolution [42]. Intraoperatively, traction devices such as external fixators or distractors are used to enhance arthroscopic visualization [43].

Compared to open arthrodesis, arthroscopic approaches offer smaller incisions, reduced blood loss, shorter hospital stays, and more rapid fusion [44]. This method also lowers wound complication rates in patients with diabetes or peripheral vascular disease [43]. Systematic reviews have confirmed these advantages: Mok et al. [45] reported higher fusion rates, less blood loss, and shorter hospitalization with arthroscopic techniques; Bai et al. [46] noted superior fusion rates and fewer complications with arthroscopy; and Xing et al. [47] found arthroscopic arthrodesis superior in tourniquet time, hospital stay, fusion failure rates, and complication rates.

Although initially limited to mild deformities, arthroscopic arthrodesis is now being applied to more severe cases. Yang et al. [48] compared outcomes for coronal deformities <15° (n=26) and ≥15° (n=15), reporting a satisfactory fusion rate of 95.1% and excellent functional outcomes in both groups. Similarly, Issac et al. [49] demonstrated comparable or superior fusion and functional outcomes in severe deformities treated arthroscopically versus open surgery in 122 cases.

Contraindications to arthroscopic arthrodesis include active infection, severe bone loss such as talar avascular necrosis, extreme deformity, and neuropathy [43]. The surgical approach should be individualized, taking into account the stage of arthritis, degree of deformity, and bone quality.

The complication rate for arthroscopic ankle arthrodesis is approximately 26%, higher than the 2.7% to 17% reported for other ankle arthroscopic procedures [44]. Nonunion occurs in 6% to 7% of cases, underscoring the importance of meticulous fusion bed preparation, adequate compression, and stable fixation [44,50]. Neurological complications may involve the saphenous nerve medially and the superficial peroneal nerve laterally, requiring careful portal placement [43]. Other reported complications include fractures, pin-site infections, hardware irritation, adjacent joint arthritis, and, rarely, deep vein thrombosis, pulmonary embolism, and complex regional pain syndrome, all of which necessitate vigilant monitoring [44].

Future large-scale, long-term studies are needed to further clarify survival rates, functional outcomes, and complication profiles associated with arthroscopic ankle arthrodesis.

Conclusion

Ankle arthroscopy has emerged as an essential therapeutic tool over recent decades, propelled by significant advancements in technique and instrumentation. In particular, for OLTs, CAI, and ankle arthritis, arthroscopy enables minimally invasive and highly precise access to lesions compared to open surgery, thereby reducing complications and facilitating recovery.

Clinicians must thoroughly understand the indications and limitations of arthroscopic techniques for each condition and select optimal, individualized treatment strategies. Given the narrow visualization field and complex anatomy of the ankle, a high level of surgical proficiency is required, underscoring the need for standardized training and systematic education.

Advanced technologies, such as high-resolution arthroscopy and augmented reality, are anticipated to further enhance procedural accuracy and safety. The future of ankle arthroscopy is promising, as continued integration of technological advances and regenerative medicine will further maximize personalized treatment and functional restoration.

Article information Continued