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Severe hindfoot arthritis often requires a multilevel fusion which can be performed with a variety of techniques. The operating surgeon must take several elements into account when choosing a surgical technique as patients requiring a hindfoot fusion has often had multiple surgeries or have compromised soft tissue envelopes. Regardless of the technique used, meticulous joint preparation is paramount and often compliments the means of internal fixation. Beyond joint preparation and internal fixation, the surgeon must also decide if bone grafting is necessary and if so how to obtain the sufficient amount. Given the aforementioned difficulties we propose an arthroscopic ankle and subtalar preparation utilizing a soft tissue noninvasive distraction technique followed by the use of a reamer-irrigator-aspirator system to provide autograft bone grafting followed by intramedullary nailing. This technique maximizes healing potential, minimizing soft tissue injury, and avoids a secondary bone graft harvest site while providing superior biomechanical properties.Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.