A 2.7-mm arthroscope with 30° obliquity and a length of 11 cm is routinely used for ankle arthroscopy. It can be applied with a 4.6-mm sheath or with a 2.9-mm sheath (Figs. 4.1 and 4.2). The 4.6-mm sheath has the advantage of a high-volume irrigation. The 2.0-mm sheath cannot deliver the same amount of irrigation fluid per time as the standard sheath. This is an important drawback when motorized instruments are used, as these cases benefit from an adequate amount of irrigation. For routine arthroscopic procedures such as anterior impingement syndrome, loose body removal, treatment of synovitis, and the vast majority of osteochondral defects, it is beneficial to use the 4.6-mm sheath. The 2.9-mm sheath can be used for treatment of osteochondral defects of the posterior talar dome (less than 8 % of all osteochondral defects in the ankle joint); pathology of the articular part of the tibiofibular joint (intrinsic syndesmosis), such as a soft tissue impediment or impregnated ossicles or loose bodies; posterior ankle problems that are treated by an anterior approach; and patients without a preoperative diagnosis.

Routine joint distraction is not necessary to perform ankle arthroscopy. There are situations in which distraction helps to get access to a posterior osteochondral defect. A soft tissue distractor has been developed for better access to posterior lesions. The soft tissue distractor consists of the device which is shown in Fig. 4.3 and 6.​5. This sterile strap is attached to a sterile belt which is placed around the waist of the surgeon. When the surgeon leans backwards, distraction of the ankle joint is obtained.

In the past, standard instruments that are used for knee or shoulder arthroscopy were used to perform ankle arthroscopy. However, the geometry of the ankle joint differs from the knee and shoulder joint. The ankle joint differs also in size. Basic instruments include a blade 11 knife, curved hemostatic forceps (mosquito), spinal needle and straight Kocher forceps (Fig. 4.4). The curved mosquito clamp is used for creating the portals, and a Kocher can be useful for removal of large bony fragments in case an arthroscopic forceps is too small.

Dedicated ankle arthroscopy instrumentation sets have recently been developed. These sets contain instruments specifically designed to accommodate the geometry and size of the ankle joint.

A dedicated arthroscopy set for ankle arthroscopy contains the following instruments: a straight 3.0-mm probe and a probe with a curved tip (Figs. 4.5 and 4.6). The curve accommodates palpating of structures in the posterior ankle joint since the curvature accommodates the curvature of the talus (Fig. 4.6). A calibration on the tip of the probe helps to measure the size of intra-articular structures as, for example, an osteochondral defect. A straight 4-mm osteotome is used for detachment of osteophytes, spurs, and bony ridges (Fig. 4.7).

In some instances, it helps to use a 3- or 4-mm osteotome with a 15° curvature as for removal of a posterior talar process (Fig. 4.8). The most useful instrument for detachment of ossicles is the curved elevator (Fig. 4.9). The curved elevator can also be used for removal of an os trigonum. For treatment of osteochondral defects, a 3-mm closed cup curette with a 15° curvature is most appropriate (Fig. 4.10). A 90° straight curette or curved curette (Fig. 4.11a, b) can also be used for this purpose. For microfracturing, chondro picks with different angles are available. A laser mark on the tip of the pick helps to determine the depth of the holes (Fig. 4.12a, b). Picks with a curved tip ease the access to posterior osteochondral talar defects (Fig. 4.13a, b ). For the 65° pick and 9° pick, a pick assist is available for hammering the device into dense subchondral bone (Fig. 4.14).