**2.2.2 Making the portal and the working space**

A line was drawn from the tip of the lateral malleolus to the Achilles tendon, parallel to the sole of the foot. The posterolateral and posteromedial portals were made just above this line and 3 mm medial and lateral of the Achilles tendon using a pneumotourniquet inflated to a pressure of 300 mm Hg (Figure 4).

Fig. 4. Posterolateral portal. 1. Achilles tendon; 2. Lateral malleolus; 3. Posterolateral portal

If the portals are close to the Achilles tendon it may lead to tenosynovitis of the Achilles tendon. On the other hand, if the portals are too far from the Achilles tendon, it is difficult to watch the field fully. The deep layer is split by mosquito clamp via a posterolateral portal that is directed to the first web or second toe through the 1 cm vertical skin incision (Figure 5). When the tip of the clamp touches the bone, it is exchanged for a 4.5 mm arthroscope shaft with the blunt trocar to direct to the first web or second toe (Figure 6).

A line was drawn from the tip of the lateral malleolus to the Achilles tendon, parallel to the sole of the foot. The posterolateral and posteromedial portals were made just above this line and 3 mm medial and lateral of the Achilles tendon using a pneumotourniquet inflated to a

**2.2.2 Making the portal and the working space** 

pressure of 300 mm Hg (Figure 4).

Fig. 4. Posterolateral portal.

1. Achilles tendon; 2. Lateral malleolus; 3. Posterolateral portal

shaft with the blunt trocar to direct to the first web or second toe (Figure 6).

If the portals are close to the Achilles tendon it may lead to tenosynovitis of the Achilles tendon. On the other hand, if the portals are too far from the Achilles tendon, it is difficult to watch the field fully. The deep layer is split by mosquito clamp via a posterolateral portal that is directed to the first web or second toe through the 1 cm vertical skin incision (Figure 5). When the tip of the clamp touches the bone, it is exchanged for a 4.5 mm arthroscope

Fig. 5. Split of the deep layer by mosquito clamp directing to the first web.

Fig. 6. Insert an arthroscope shaft with the blunt trocar directing to the first web.

Posterior Ankle and Hindfoot Arthroscopy 293

Fig. 8. Introducing the shaver into the field of vision of the arthroscopy.

Fig. 9. Flexor hallucis longus tendon (arrow).

The trocar is exchanged to an arthroscope 4.0 mm in diameter with a 30 degree angle. Next, a mosquito clamp is introduced via a posteromedial portal. A mosquito clamp touches the shaft of the arthroscope and the deep layer around the arthroscope is split. A 4.0 to 5.0 mm motorized shaver (full radius shaver) is inserted through the posteromedial portal in order to make the working space (Figure 7).

For bringing the shaver into the field of vision of the arthroscopy, it is helpful that the tip of the shaver touches the shaft of the arthroscope and slide distally (Figure 8).

Adipose tissue and the posterior joint capsule are removed by motorized shaver. First of all, the surgeon must show the FHL tendon (Figure 9). The neurovascular bundle lies medial to the FHL tendon, so the surgeon should perform the arthroscopic surgery laterally to the FHL tendon (Figure 10).

Fig. 7. Hindfoot endoscopy.

The trocar is exchanged to an arthroscope 4.0 mm in diameter with a 30 degree angle. Next, a mosquito clamp is introduced via a posteromedial portal. A mosquito clamp touches the shaft of the arthroscope and the deep layer around the arthroscope is split. A 4.0 to 5.0 mm motorized shaver (full radius shaver) is inserted through the posteromedial portal in order

For bringing the shaver into the field of vision of the arthroscopy, it is helpful that the tip of

Adipose tissue and the posterior joint capsule are removed by motorized shaver. First of all, the surgeon must show the FHL tendon (Figure 9). The neurovascular bundle lies medial to the FHL tendon, so the surgeon should perform the arthroscopic surgery laterally to the

the shaver touches the shaft of the arthroscope and slide distally (Figure 8).

to make the working space (Figure 7).

FHL tendon (Figure 10).

Fig. 7. Hindfoot endoscopy.

Fig. 8. Introducing the shaver into the field of vision of the arthroscopy.

Fig. 9. Flexor hallucis longus tendon (arrow).

Posterior Ankle and Hindfoot Arthroscopy 295

1. Superficial component of the posterior tibiofibular ligament; 2. Deep component of the posterior tibiofibular ligament or transvers ligament; 3. Tibial insertion of the posterior intermalleolar ligament; 4. Tibial malleolar insertion of the posterior intermalleolar ligament; 5. Talar insertion of the posterior intermalleolar ligament; 6. Posterior talofibular ligament; 7. Calcaneofibular ligament; 8. Flexor hallucis longus (FHL) tendon; 9. Entrance of the tarsal tunnel; 10. FHL retinaculum; 11. Lateral malleolus; 12. Tibia; 13. Posterior talar

Posterior ankle impingement syndrome (PAIS) is generally considered to be the clinical disorder characterized by posterior ankle pain in forced plantar flexion6. The etiology of this syndrome is varied and may involve any part of the posterior ankle anatomy, including bony and soft tissue structures. Among them, os trigonum and large posterior talar process

dome; 14. Posterolateral talar process; 15. Subtalar joint; 16. Calcaneus

Fig. 12. Three dimensional computed tomogram of the hindfoot.

An arrow shows a large posterolateral process of the talus and an arrow head shows an os

According to the author's experiences gained in approximately 200 cases, it should be noted that hindfoot endoscopies have shown that large posterolateral talar processes compress a

**2.3 Clinical applications** 

are frequent (Figure 12).

trigonum.

**2.3.1 Posterior ankle impingement syndrome** 

Fig. 10. Anatomic dissection of the posterior ankle around the posteromedial portal (left) and the posterolateral portal (right).

1. Posteromedial portal; 2. Posterolateral portal; 3. Achilles tendon; 4. Flexor hallucis longus tendon; 5. Tibian nerve and posterior tibial artery; 6. Sural nerve; 7. Peroneal tendon
