Articular and peri-articular structures of the hindfoot can be accessed by means of endoscopic techniques. Some recommendations have been produced to guide arthroscopy in the anterior compartment of the ankle joint. The goal of this study is to summarise the quality and quantity of the evidence available regarding hindfoot endoscopy and posterior ankle arthroscopy and to assign a grade of recommendation for the current generally accepted indications to this surgery.

A comprehensive review of the literature was performed by use of the PubMed database. Studies enrolling human subjects of all ages who underwent endoscopic or arthroscopic procedures on the hindfoot in the prone position, using posterior portals as described by Van Dijk et al. or with minimal variations were eligible for inclusion. All articles were assigned a level of evidence classification and categorised depending on the indication for the surgical procedure performed. Information regarding authors, journal and year of publication, study design and level of evidence, patient demographics, indication for treatment, modality for diagnosis, surgical technique, follow-up duration, outcomes and complications were extracted and analysed.

Fifty-two studies, accounting for 985 procedures, were eligible. The most frequent indications of hindfoot endoscopy are posterior ankle impingement (with or without flexor hallucis longus tendonitis), degenerative changes of the subtalar joint and retrocalcanear pain or bursitis; these indications are supported with a grade Cf of recommendation. Achilles tendon pathologies, hindfoot ganglia, talar fractures, posterior tibialis tendon dysfunctions, frozen ankle, chondromatosis or osteoid osteomas have been described as possible indications; for them, only a grade I of recommendation has been defined.

In spite of promising clinical results, only a low grade of recommendation can be derived from the existing literature to support the most frequent indications for hindfoot endoscopy and posterior ankle arthroscopy. Further high-quality studies on this surgical approach are needed.