Positioning

The patient is positioned as in the standard 2-portal hindfoot approach.

Instruments

For irrigation normal saline is used, however ringers solution is also possible. Gravity inflow is adequate for irrigation. When needed a pressure bag is inflated up to 100 mmHg.
A 4.0 mm arthroscope with an inclination angle of 30 degrees is routinely used. Furthermore, a blade, probes, graspers, and basket forceps are used.
We use a non-invasive soft-tissue distraction device when manual distraction is not sufficient. 

Portals

For endoscopic groove deepening, we use the portals for the standard approach for posterior ankle arthroscopy plus a third portal located 4 cm proximal to the posterolateral portal.

First the safe posterior working area must be defined, which is lateral to the flexor hallucis longus FHL tendon. The peroneal tendon sheath can now be opened. The arthroscope is removed from the posterolateral portal and can subsequently be introduced through the posteromedial portal. One or two probes are introduced through the posterolateral portal to dislocate the peroneal tendons lateral and anterior over the lateral edge of the lateral malleolus, thus leaving the fibular groove empty.  Subsequently, 4 cm proximal to the posterolateral ankle portal the third portal is made with a vertical stab incision. 

The subcutaneous tissue is split, with a mosquito clamp, until it is positioned into the fibular groove. Then a 5.5 mm full radius bonecutter shaver is introduced, pointing inferiorly down to the level of the most distal part of the fibular bony groove. Subsequently, under direct arthroscopic view, the fibular groove can be deepened.