Pearls

• For the correct orientation and reproducibility always start with the arthroscope in the posterolateral portal. Initially it is directed towards the first interdigital webspace.

• Instruments introduced through the posteromedial portal are inserted perpendicular to the arthroscopic shaft. The shaft is subsequently used as a guide to direct the instruments anteriorly. The direction of the arthroscopic view (30 degree angulation) is routinely to the lateral side for a good and persistent orientation throughout the procedure.

Pitfalls

• Correct portal placement is important to prevent neurovascular complications. The posteromedial and lateral portal must be positioned 5-7 mm anterior to the Achilles tendon, just above the level of the tip of the lateral malleolus.

• In the hindfoot the crural fascia can be quite thick. This local thickening is called the ligament of Rouvière. This ligament needs to be at least partially excised of sectioned, using arthroscopic punch or scissors, to approach the ankle joint.

• The FHL tendon must always be located first before addressing the pathology. Medial to this tendon the posterior tibial nerve and artery are situated. The working area is therefore lateral to the FHL tendon. The video above is an example of arterial bleeding posteromedial to the FHL. Bleeding is controlled using the Vapor (see video above: Haemostasis with vapor)

• Posterior ankle arthroscopy is an advanced endoscopic procedure, surgeons not familiar with endoscopic surgery are advised to train themselves in a cadaveric setting.