Positioning

The procedure is performed as outpatient surgery under general anesthesia or
epidural anesthesia. The patient is placed in a prone position. A tourniquet is
applied around the upper leg and a small support is placed under the lower leg,
making it possible to move the ankle freely.

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

The landmarks on the ankle are the lateral malleolus, medial and lateral border of the Achilles tendon, and the foot sole.

To mark te lateral portal, the ankle is kept in a 90 degree position. An endoscopic probe can be very useful to determine the exact location of the posterolateral portal. The probe is ‘'hooked'' under the tip of the lateral malleolus, parallel to the foot sole (with the foot still in a 90 degree position). A straight line is drawn from the tip of the lateral malleolus to the Achilles tendon, parallel to the foot sole.

The posterolateral portal is made just above this line, 5-7 mm anterior to the Achilles tendon.

The posteromedial portal is made at the same level, just above the line from the tip of the lateral malleolus, but just anterior to the medial aspect of the Achilles tendon.

  1).  2).  3).

1). To mark the lateral portal, the ankle is brought into a 90 degree position. A ruler or endoscopic probe is placed externally onto the foot sole.

2). The probe is placed under the tip of the lateral malleolus, parallel to the foot sole. With the probe, a straight line is drawn from the tip of the lateral malleolus to the Achilles tendon, parallel to the foot sole. The posterolateral portal is made just above this line, 1 cm anterior to the Achilles tendon.

3). The posteromedial portal is made at the same level, just above the line from the tip of the lateral malleolus, but anterior to the medial aspect of the Achilles tendon.

The technique for portal placement is explained in the video.