Arthroscopic LDFF surgeries for osteochondral talar defects can be carried out as an outpatient procedure under general or spinal anaesthesia. Patients are placed in a supine position with slight elevation of the ipsilateral buttock. A support is placed at the contralateral side of the pelvis to prevent the patient from moving when the table is turned sideways for straight ankle positioning. The heel of the affected foot rests on the very end of the operating table. This positioning enabled the surgeon to fully dorsiflex the ankle by leaning against the foot sole and to use the table as a lever when maximal plantar flexion is needed. When indicated a noninvasive soft tissue distraction device is used. The ankle joint is assessed by an anteromedial and an anterolateral portal [14]. The anteromedial portal is made first with the ankle in slight dorsiflexion. A 4 mm 30° angled arthroscope will be introduced with the ankle in full dorsiflexion. In this ankle position, the talar cartilage is covered by the distal tibia and is therefore protected for iatrogenic damage on instrument insertion. Under direct arthroscopic vision, the location of the anterolateral portal is determined with a spinal needle and created. With a shaver the distal tibia rim is removed to facilitate better access to the ankle joint. The arthroscopic portals are interchangeable to allow optimal vision. With a probe the location of the OCD is identified, and a beaver knife is used to allow the making of a sharp osteochondral flap (Fig. 8.2a, b). The posterior side of the flap should be left intact and can be used as a lever, allowing lifting from the anterior with the use of a chisel (lift) (Fig. 8.2c). The attached bone of the osteochondral flap and the osteosclerotic area of the bed are debrided and drilled to promote revascularization (drill) (Fig. 8.2d). All subchondral cysts are debrided and punctured. After debridement and drilling the defect is filled with cancellous bone of the distal tibial metaphysis. Cancellous bone is harvested with a chisel by creating longitudinal particles which are transported into the defect with a grasp (fill) (Fig. 8.2e, f). After correct alignment of the osteochondral flap Bio-Compression screw(s) (Arthrex Inc, Naples, USA) or multiple chondral darts (Arthrex Inc, Naples, USA) are used to fix it (fix) (Fig. 8.2g, h). At the end of the procedure, the skin incisions are sutured with 3.0 Ethilon and a short-leg cast is applied at the operation theatre.

In both fixation techniques, a short-leg, non-weight-bearing cast will be applied for 4 weeks postoperatively. After these 4 weeks the foot is placed in a short-leg walking cast in neutral flexion position and neutral hindfoot position, with full weight bearing allowed. At 8 weeks postoperatively the cast will be removed. If a malleolar osteotomy was created during surgery, radiographs of the operated ankle are obtained to confirm consolidation. Physical therapy will be prescribed to assist in functional recovery and extend to full weight bearing in approximately 2 weeks.