Positioning

The surgery can be performed under local, regional, epidural or general anesthesia. The patient is placed in the lateral decubitus position. Alternatively, the patient can also be placed in the supine position with the foot in endorotation. To avoid wrong side surgery, the involved leg is marked by the patient. Prior to anesthesia the patient is asked to actively evert the affected foot, enabling a better view and palpation of the peroneal tendon. Its course is drawn on the skin and the portal locations are marked. A support is placed under the affected leg making it possible to move the ankle freely. After exsanguination, a tourniquet is inflated around the affected upper leg.

Instruments

The 2.7 mm arthroscope with an inclination angle of 30° is used. An important advantage of the 2.7-mm arthroscope is the far better flow which is necessary when surgery is undertaken.

Portals

The distal portal is made first, 2-2.5 cm distal to the posterior edge of the lateral malleolus. An incision is made through the skin, and the tendon sheath is penetrated with an arthroscopic shaft with a blunt trocar. Thereafter, the arthroscope is introduced. The inspection starts approximately 6 cm proximal to the posterior tip of the fibula. Here, a thin membrane splits the tendon compartment into two separate tendon chambers. More distally, the tendons lie in one compartment.
Under direct vision a second portal is made. A spinal needle is introduced approximately 2-2.5 cm proximal to the posterior edge of the lateral malleolus. This way the portal is created directly over the tendons. A complete overview of both tendons can be obtained through the distal portal. If a total synovectomy of the tendon sheath has to be performed it is advisable to create a third portal. This should be more distal or proximal than the previously described portals.