Positioning

Anterior ankle arthroscopy is carried out as an outpatient procedure under general or spinal anaesthesia. The patient is placed in the supine position with slight elevation of the ipsilateral buttock. The heel of the affected ankle in placed at the very end of the operating table. This way, the surgeon can fully dorsiflex the ankle by leaning against the foot sole. Routine anterior portals used are the anteromedial and anterolateral portal. A soft-tissue distraction device can be used when indicated.

Instruments

A 4.0 mm arthroscope with 30° obliquity is used for removal of osteophytes. Normal saline, glycine or Ringer's lactate can be used for irrigation. When a 4 mm arthroscope is used, gravity inflow is usually adequate if the fluid is introduced through the arthroscope sheath. 
We routinely use a 5.5 mm bonecutter shaver for removal of osteophytes, synovium and excessive soft tissue. The less experienced surgeon might start with a smaller diameter (4.0 mm) shaver. A 4 mm chisel and/or small periosteal elevator can be useful, an arthroscopic punch and small and large graspers.
A non-invasive distraction device can be useful at the end of the procedure to remove the inferior edge of an osteophyte of the anterior tiobial rim without damaging the prosthesis. However, the majority of the procedure is carried out in dorsiflexion because in this position the ankle capsule is not tensed giving the surgeon more space in the anterior compartment. 

Routinely used instruments for ankle arthroscopy

Portals

For removal of osteophytes through anterior arthroscopy, the standard anteromedial and- lateral portals are used. The technique is described in text & figures and in video.