The Evolution and Current State-of-the-Art of Anterior Ankle Arthroscopy

Ankle arthroscopy has undergone substantial evolution—from early experimental applications to the era of fixed distraction, and more recently to the dorsiflexion technique. The dorsiflexion approach allows seamless intraoperative transitions between dorsiflexion, neutral, plantarflexion, and distraction, thus accommodating a wide range of pathologies. Although fixed distraction was historically used as a diagnostic modality, modern imaging advancements have rendered routine diagnostic arthroscopy largely obsolete. Fixed distraction is associated with several limitations: increased risk to neurovascular structures, suboptimal ergonomics for the surgeon, and restricted capability to effectively address impingement and instability. In contrast, the dorsiflexion method provides superior safety, improved ergonomics, and dynamic joint positioning to optimize surgical access for treatment of osteochondral defects of the talus, osteophyte resection, syndesmosis evaluation, and ligament repair. Its capacity to reduce nerve injury risk, enhance operative flexibility, and improve therapeutic outcomes makes a compelling case for adopting the dorsiflexion approach as the standard technique. The routine use of fixed distraction in ankle arthroscopy should therefore be reconsidered.