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Board Review Surgery

Arthroscopy of the Foot and Ankle

Ryan Fitzgerald,

Ryan Fitzgerald, DPM discusses arthroscopic techniques of the foot and ankle. Dr Fitzgerald presents arthroscopy as both a diagnostic and therapeutic option and how to perform such procedures.

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Goals and Objectives
  1. List the indications for arthroscopy of the foot and ankle
  2. Describe the Instrumentation involved in arthroscopic procedures
  3. Describe portal placement for ankle arthroscopy
  4. List foot and ankle surgeries that can be performed arthroscopically
  5. Describe subtalar arthroscopy and pathology usually associated with it
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  • CPME (Credits: 0.75)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

    PRESENT eLearning Systems, LLC has approved this activity for a maximum of 0.75 continuing education contact hours.

    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Ryan Fitzgerald,

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    Ryan Fitzgerald none

  • Lecture Transcript
  • Male Speaker 1: Our next speaker is going to be Dr. Ryan Fitzgerald. He’s a graduate from Barry University in Miami, completed a three-year residency at Washington Hospital in Washington, DC. He is in private practice in Virginia. I see all kinds of things with Ryan, all of which are excellent in the way of his information that he is sharing with us at PRESENT eLearning. He is an academically involved physician that we have grown to appreciate. We are going to be hearing about arthroscopy of the ankle. So please welcome, Ryan Fitzgerald.

    [Applause]

    Ryan Fitzgerald: Okay. They told me I was going to follow Dr. Laporta and I figured, of course, that totally fits. I’m going to be talking about arthroscopy of the foot and ankle. Just to show of hands in here, how many people are doing arthroscopy already? Anybody? Okay, so fair amount. A caveat to this, you cannot learn arthroscopy from a PowerPoint slide. It is a hands-on skill and you have to learn it by doing it. There are many courses that I would recommend ultimately. But, my presentation today is going to be more of an issue with regard to some techniques and some interesting applications of things that I’m doing, things that I’ve seen. A few disclosures, I’m on the Speakers Bureau for Integrity Life Sciences and obviously as Harold [Phonetic] said, I’m one of the consultants for PRESENT eLearning. With regard to ankle arthroscopy, there are no absolute indications, but there are a lot of good uses for it. You have to think about how this can be involved in your practice and how you can help your patients with this technique. Arthroscopy can be both diagnostic as well as therapeutic and you have to consider that option. It should never replace a good clinical examination. You learned day one in school that physical exam is going to be the key. All the diagnostic tests, all the MRIs, everything else is secondary to a good physical exam. Now, there’s often been a question as to whether or not arthroscopy is evidence-based, and the reality is that it is. There’ve been a number of really good lectures and articles recently. Glazebrook et al in 2009 came up with a good indication of the evidence-based medicine with regard to arthroscopy, so it’s there. Relative indications. What are you going to do with your arthroscopy? You’re going to do a survey. A survey is indicated when you think you know what’s going on and your imaging studies are vague and you have an idea but you want to take a look. Nothing beats actually looking in the drawing and taking a look. You can also use that for a washout, if you have a septic joint and things like that, that’s considered survey. Fracture reduction is something that’s becoming increasingly useful with regard to arthroscopy as well as biopsy. Reparative arthroscopy is what you’re most commonly going to do, osteochondral defects, synovitis, things like that. And then ablative procedures, the preparation for joint fusion. This little cartoon was something I found when I was trying to come through the presentation. It was funny to me partially because it’s that the hip bone is connected to the knee bone song. In my practice, it was funny. Apparently, the power is to be decided, we have a good idea to put that song on the radio as one of our ads. That was really embarrassing when I heard it for the first time, so that’s why that’s there. In terms of the instrumentation for arthroscopy, it’s a basic set and there are some varieties among the different companies that provide this information. But ultimately, it’s the same idea. You have a light source and a camera, a cannula that’s used for placement of the scope as well for ingress and egress of fluid. And then there’s power and hand instrumentation. Power instrumentation like burrs and abraders. Hand instrumentation, punches, knives, curettes, things like that. And so we make this work here. Laser, okay. The scope, cannulas, power instruments, things like that and it’s pretty basic, whether it’s Stryker or Arthrex or any of the other companies that work with it. A key point with arthroscopy and something that you’ll learn as you do more arthroscopy is that the point of view in the camera is important. It’s very easy to get lost as a consequence of this. You can change your angle and orientation of your point of view based on rotating out of the light source or the camera itself. You have to pick a stable point and then rotate the other thing. I actually hold the camera setting and rotate the light source because that works for me. But you can ultimately do whatever you want. You just can’t be rotating them both, you’re going to lose where you are. It’s important to know with foot and ankle arthroscopy, the size of the scope is important. Usually, we use 27s or 4-0s in either 30 or 70-degree scopes. That’s important in terms of what you’re trying to do and what you’re trying to look at. A 30-degree scope, you can look straight ahead and then off 30 degrees. A 70-degree scope, you’re starting from an off-center point and you can see more in the field of view, but you can’t see directly in front of you. That’s simply what this picture is showing the limitations in field of view. This again shows the idea of the 30-degree scope gives you in front view, plus a little bit versus the 70, this gives you a wider field of view but not directly in front view.

    [05:02]

    In terms of hand instrumentation, now, this was the basic. When arthroscopy was first invented, this was all they had. And so a lot of the technology is fairly basic. It’s graspers and punches, and osteochondral picks, probes, rasps, things to work in the joint. They’re still very useful, even with the onset of new things like thermal ablators and power instrumentation. Various sets or different companies have different sizes in things. But it’s essentially a basic stuff. In terms of power instrumentation, shavers and burrs are the most likely that you’re going to be using. There are degrees of shavers both in terms of aggressiveness, whether they’re full cuts or partial. What that simply means is how much of the blade is exposed versus how much is covered to protect the rest of the joint. That’s the difference between sort of an open-ended and side-cutting. And then there are power settings. Based on what you’re trying to do, you modify your power settings appropriately. Joint distraction in the ankle is something that is of some consequence ultimately. They are both invasive and non-invasive distractors. Honestly, I’ve never used a invasive distractor, I don’t see why you would, but it does exist if you needed it. They can be mechanical or soft. You have to be careful when you’re doing ankle distraction, particularly because there is the potential for neurovascular injury. When you’re really torquing on the top of the foot with an ankle distractor, you can easily get a neuropraxia. It’s not something that’s talk about significantly. But if you do a search in the literature, it is one of the more common complications associated with arthroscopy. When you’re thinking of distraction, if you’re going to distract, you have to consider that and pad for it appropriately. This is just a simple mechanical distractor, it’s invasive. It works like a monolateral frame. You put the half pins above in the ankle and just distract it out like you would if you were doing a Pilon fracture. The soft distractor is more wrapped around the foot. You can either tension it directly. There are some that you construct yourself and you can lean back. There are a variety of different types again based on the companies. If you’re going to distract, and there are certainly many physicians who do not ultimately, but if you’re going to distract, be aware of the potential for neurovascular injury. Some basic principles of arthroscopy and this is a pretty busy slide. I ultimately had some videos that didn’t upload well, so I just want it with words. But you have to consider the motions that you are engaging and when you’re using the scope. Pistoning, rotations, sweeping, triangulation, these are all principles of motion that will get you to see what you’re trying to look at. Pistoning is when you can increase the size of something by sliding the scope towards it or vice versa is pulling it away and making it smaller. You can zoom in or zoom out based on how you move the scope forward or backward. Rotation changes the field of view as you rotate your hand. And then sweeping is as you sweep across the joint, you can lift up tissue, you can hold things out of the way, the anterior aspect of the ankle joint, for example. It can give you access to difficult parts to visualize. For example, the gutters, deep down in the gutters. And then triangulation is the concept of, if you’re using both your hands, getting the things that are in your hands to meet without trying to look at them and without being able to see them in front of you, it’s not difficult to do. It’s certainly not difficult to describe but it’s harder to do. It’s something that comes with practice and that goes back to this, the idea that you can’t learn arthroscopy from our PowerPoint presentation. These are the techniques. These are what will help you see the pathology that you’re looking for. So then we start talking about applications of arthroscopy. Now that we have talked about the basics of it, when do you use arthroscopy in the foot and ankle? Certainly the most common would be the ankle joint. Although subtalar joint arthroscopy is something that is gaining some momentum as well. There are some other applications, metatarsophalangeal joint, I have done it. I don’t know why you would do it. It’s something that I did when I was learning to do how to do it, but it’s just as easy to open it up. It’s actually faster to just open it because the setup takes longer than it would be just to open the joint itself. And then there are some that advocate miscellaneous threshold joint arthroscopy. I know recently, Dr. Weinreb [Phonetic] out in California posted on YouTube a arthroscopy video of him doing a medial approach talonavicular arthroscopy for some reason which is interesting. But it’s not necessarily useful, at least not yet. Any of the patients that I’m going to do an arthroscopy on, I do a diagnostic injection. I can’t reiterate this enough. This is valuable to you for a number of reasons. Wherever you practice, everybody has different takes on things. But when I talk to my patients about where they hurt, and they said, “Well, it hurts in my ankle,” and they point to their foot. Or they say, “My ankle hurts,” and they point to their knee. They have a very limited scope of what they believe is their ankle. If somebody tells you they have ankle pain, you need to prove it. You need to prove that it’s in their ankle. What I’ll do is if somebody comes in with ankle pain after we’ve done some other stuff, we’ll do an injection. We’ll inject the ankle to see if, once you remove the ankle out of the equation, does the pain subside or not. Similarly, I did this with subtalar joint pain that is of unknown origin. What I can do is once that pain goes away, I tell the patient to walk on it.

    [10:02]

    Do whatever you would do that would normally make it hurt and we’ll see what happens. If the pain goes away, then I can look at them in the eye and say, “You know what, I think arthroscopy is going to be something that we can make you feel better.” And so I would encourage you as you go out in your practice and certainly when you go back to your residency programs, consider the idea of a diagnostic injection. It takes very little time. It has a good billable code on the scheme of things if you’re looking from a practice management standpoint and it does provide good care. It’s going to be apex of good medicine and good business. With regard to ankle arthroscopy, you need to know your anatomy. It’s like everything else. Everybody else who gets up here today and has been up thus far is talked about the various things that they’ve talked about and all of it relates to knowing your anatomy. You have to know your anatomy. You’re going to be the specialist in the field of foot and ankle. You have to know the foot and ankle. With regard to arthroscopy, the next thing that can tank you from the get-go is your portal placement. If your portals are on the wrong spot, you’re not going to be able to see anything and that’s going to be a problem. You’ll fight the entire case. You have to know the anatomy and then where to put the portals. Generally speaking, it is described in the literature that there are both anterior and posterior portals. In the anterior portals, medial, central and lateral portals. I’ve never a done a central portal, I don’t need to. I can get everything I need from the first medial and lateral, or go posterior. It is there though. If you’re going to do it, you have to be wary of the neurovascular structures for the central portal. This slide and picture just shows a drawing of where things should be and then where the portals would go if you were doing a two-portal technique. The medial portal being medial to the tibialis anterior tendon and then the lateral portal being lateral to the peroneus tertius. I can’t reiterate enough, that’s why it’s got two slides. You have to know your portals and you have to be in the right spot or you’re not going to be able to see anything. You want to be medial for that tendon. You don’t want to go through the tibialis anterior because that will be a problem. You’re not going to be appropriately enough clear to see down into the joint. But if you’re too far medial, then you’re going to be on the medial malleolar margins. You’re not going to be able to see in the medial gutter either. Portal placement is key. The anterior medial portal, again, is one of the ones that we start with generally. When I’m doing a scope, that’s where we start. Do the cut down medial to the tibialis anterior tendon. Go into the joint, look around, do the survey that we’ll talk about here shortly. And then transilluminate over to the lateral portal. The central portal, if you’re going to do it, is a cut down incision just over the EDL and then just look for the neurovascular bundle and don’t hit it. And then the anterior lateral portal, normally, what I’ll do is I’ll transilluminate and actually take an 18 gauge needle and come in from where I think I want it to be. And then I’ll look at it in the joint. I’ll see where, decide if I’m too low, too high, or where I want to be. For subtalar joint arthroscopy, you have to know the anatomy. You have to consider what you’re trying to do, what you think is the problem and where you need to be for it. There are multiple approaches for subtalar joint arthroscopy, an anterior approach, a posterior approach and a combined approach ultimately. Generally speaking, I use an anterior approach but you can use a posterior approach if you needed to and if you’re trying to get sort of more on the back of the posterior facet. You need to consider your goals, what are you trying to do, what are you trying to be, and then choose your portals accordingly. If you choose a portal in a bad spot, you’re not going to be able to see what you’re looking for and you’re going to have a problem. With this, the anterior portals for the subtalar joint are up here. You got to watch out for the neurovascular stuff. And again, it’s just a matter of knowing your anatomy. It’s in the area of the sinus tarsi along just posterior to the anterior process of the calcaneus. You can palpate it and feel the dip that’s right there. And then the posterior portal is more back here, just lateral to the Achilles. Techniques of foot and ankle arthroscopy. It depends on your surgeon. Everybody trains differently. Everybody has a different background on what they do or don’t do. In my training, we had people who always did distraction and we had people who never did distraction. Both groups could adequately argue the merits of both. You have to do whatever you’re comfortable doing and consider what you’re trying to accomplish. You need to position the patient as a consequence of that. If you’re doing an ankle scope, it has a very different positioning than a subtalar joint, obviously. You have to think about those situations. Are you supine, are you prone, are you using a leg holder or not? Things like that. Do you use a tourniquet or not? Again, that’s a surgeon preference issue. Generally speaking, just in the joint, I use 20 ccs of Lactated Ringer’s via an 18 gauge, just pops the joint up and opens everything up before I go into the joint, which helps to make it more valuable. And then whether or not you use ankle distraction. That, again, becomes a personal issue. But, there are some cases where ankle distraction is helpful. If you’re trying to get to the back of the talus to get to a osteochondral defect that you’re going into the front, you’re going to need distraction so you can get over the top of that crest. If you’re doing something on the front, or just anterior shoulder, you may not need distraction, in which case, it’s not worth the risk. When you’re performing an ankle arthroscopy particularly, you have to be systematic about how you go about doing it. You want to do a zone survey.

    [15:00]

    When you first get in, you get your instruments set. First, you want to look around, make sure everything is where it’s supposed to be. It’s easy to get overcome with the pathology. You go and thinking, “Okay, there’s a loose spot in here, I’m going to get it out.” But you have to really take a minute and just look at everything, make sure you know where you are, everything is where it ought to be. It gives you the opportunity to get yourself set. You want to check with your zone survey. You want to check the medial gutter, the medial shoulder, and then cruise along the top of the talus itself. You can then see the lateral gutter, the inside medial aspect to the fibula and that articulation then down into the lateral gutter as well. You don’t want to get caught up in the pathology. You don’t want to get distracted because you can miss things. Often, you will find that there is more stuff in there than you anticipated. You will ultimately have to deal with that, but you don’t want to get overwhelmed when you first get in there. You have to start figure out where everything is, what you need to do, and then be systematic about how you’re going to do it. You want to prioritize the procedures that you’re going to do. We spoke earlier about the types of surgery. The reparative surgery is the most common ultimately. Things like a synovectomy, an impingement syndrome, removal of loose bodies, osteochondral defect repair. And then a newer one that I have been doing is arthroscopic-assisted trauma surgery which is both considered, I guess, survey and then also reparative depending on what you’re having to do. These would be indications that are common in our practice. For a synovectomy, you can see that this is just a picture. Before we did anything, the ankle joint itself had a lot of that sort of feathery looking tissue. It always looked to me like crab meats, it’s feathery and vascular and just out there. You’re going to clean it up to open up the space in the joint. You can see that’s going after here with a burr ultimately, or rather a shaver to just clean up the ankle joint space. And so a synovectomy is going to be indicated in patients who have this sort of anterior pain worse with activity and maybe a previous history of injury. It’s not uncommon. The more you go in scope ankles, the more you’re going to see that this is there and you can address it. Impingement syndrome is something that is very commonly addressed with regard to arthroscopy. Scranton and McDermott in ‘92 came up with a classification system of the types of impingements based on the location of the spur and how much arthrosis was associated with. You can see on the slide here the grades one, two, three and four. Ultimately, it’s interesting, I don’t know that it necessarily matters in the context of what you’re going to do. You’re going to go and you’re going to take this spur down. This is an indication, this was an interesting case. It actually looked like a loose body until we start to try to pull on it and it found that it was attached. I don’t know how well it comes up over there, but you can see that there was a big sort of scouring of the cartilage which was underneath the spot. This patient was an avid water skier and had been active on her ankle for 40 years and started having this persistent anterior ankle pain. We got in MRI, which showed a spur and articular cartilage defect and some other things. But, the spur was just gauging out the cartilage. We went in, you could see here’s with the probe trying to loosen up. We thought it was just a loose body because it has such a strange appearance to it. But it was indeed attached so we ended up taking an osteotome just knock it off. That is another caveat that I would caution you. When you have a spur, you want to take enough to be useful without taking too much and it’s one of those measure twice and cut once situations. You can take too much, you can take too little. You really want to be cognizant of how much bone you’re taking out and be aware of it as you go. Obviously, removal of loose body is something that is common in this post trauma sort of injuries. They can have a lot of loose body formation and it’s pretty easy to go in with the scope and just pull out the pieces. This is actually that same lady. She had a large loose body that was floating around. It had been in the ankle so long. It had a nice cartilage in the surface to it. With regard to osteochondral defects, there’ve been a number of discussions on this topic ultimately, both for the size of the defect. How you go about treating it but then also how big is too big, when do you open it up, things like that. But, Ferkel et al went through and did a CT classification scale. And again, it becomes somewhat esoteric in the context of whether it’s a grade two or stage three. It doesn’t necessarily change your overall treatment options. But for the reality, that obviously if you have a loose body that’s floating out of the joint, or floating around in the space, you’re going to treat that differently than one that’s just sort of sitting there doing nothing in the spot that it’s supposed to be. That’s what I would say with that. With regard to osteochondral defect repair, microfracture technique is one of the agreed upon ways to go about doing this. You can see, you just basically identified the osteochondral defect, debride it out and then microfracture it down to get pinpoint bleeding. Previously, there’ve been discussions of the OATS procedures, autogenous grafts, things like that. There’s some really neat, new technology. There’s a guy in Colorado who’s doing some really interesting work with DeNovo, which is a pediatric cartilage harvest that they can place down into the defect. They’re doing it under a dry scope. It’s actually growing back highly in cartilage which is amazing as compared to the fiber cartilage that you see here with microfracture technique.

    [20:04]

    It has been shown in the literature to be effective. Glazebrook et al in that article that we spoke about previously, the evidence-based medicine lecture and then also Schuman and JBJS in 2002 has talked about the efficacy of osteochondral defect repair. It’s definitely something that is useful to you and it’s pretty quick to do. If you have that patient with this persistent pain, plus or minus, something on the MRI, because the reality is the MRI in about 70% cases can pick it up. But there are going to be instances where you don’t see the osteochondral defect and you have to go in and just look at it. And then you could just see what seems soft to you. And then one of the newer topics is arthroscopic-assisted trauma surgery. This is a pediatric triplane fracture that we got a CT scan on. Clearly, it’s intra-articular. You can see that from the plain film X-rays and the CT scan showed even worse sort of articular damage in multitudes of images as you know on a CT scan. If we saw the rest of them, the rotation around, you could see that there was a significant posterior fragment that was displaced. That this fracture actually went back into the joint and then came back down again. There were two areas that it was intra-articular. We decided to go in with the scope in conjunction with closed reduction as part of our surgical repair. What you can see, and I apologize the images are somewhat rotated, so this is tibia, this is talus, this is the ankle joint here. Tibia, talus, ankle joint. Tibia, fibula space where the ankle should be. This is what you see when you go in there. You can actually see the step-off in the fracture fragment. You can look with your scope and you could put King Tongs or something on the outside and close those fracture fragments down. You can watch it close down and you can get a picture of it. You can take that after months. Here we are, this is why we fix this because this was the space we had. Now, it’s narrow. It gives you an idea to really appreciate the step-off deformities that can exist in these kinds of fractures. They have a significant amount of post-traumatic arthritis, at least risk post-traumatic arthritis as a consequence to this fracture. We have found a great success in scoping them in conjunction with the operative repair to really reapproximate that. You can use your arthroscopic tools to pop fragments up or pull them down if you have depression fractures or other step-offs. We’ve had some great results with that. Talking about subtalar joint arthroscopy, again, you have to decide what you’re trying to do and how you’re going to get there with portal selection. Often, this is more of a synovectomy procedure. You go in and you don’t really see anything till you clean it up a little bit and then you can start to see the pathology appropriately. This is an MRI that showed some thickening of the interosseous ligament. You can see there and there was some reactive bone changes in the talus itself. She had pain with eversion and it was recalcitrant to orthotics and therapy and some other stuff. Ultimately, we put the diagnostic injection and her pain went away. We talked to her about going in the scope. We went in and cleaned it up. We’re actually working on an article that we’re doing a research project with regard to subtalar joint arthroscopy because we’re finding that more and more. As we go in, we’re finding pathology that we didn’t expect to be there if somebody has some vague tenders in the subtalar joint. But then we find interosseous ligament tear in conjunction to general synovitis. Well, I think that there’s a conjunction between lateral ankle injuries and subtalar joint injuries and this sort of indolent pathologies that exist. We’re trying to get a large enough case series of people that had negative MRIs, that had positive clinical findings when we actually got in. That’s coming on the pipe a little bit. But, you need to consider what you’re trying to do and how to get there. Often, you can have interosseous ligament pathology. This is actually a loose body, a meniscoid body from a tear. This is the interosseous ligament here. This is talus, calcaneus. This is the beginning portions of the middle and posterior facet, rather posterior facet. I have some more images that will show you where that piece came from. But, this was a guy who just had pain. He had been referred to me for a fusion. They said he needed a subtalar joint fusion, but we went and actually found some stuff to fix. He’s doing really well now. You can have a synovitis with a sort of vague sinus tarsitis which is I think a blanket term to describe us not knowing why they have pain in that area. And then, there are also can be osteochondral defects as well as loose bodies and things like that. This is the interosseous ligament tear and you can actually see in this bottom right hand picture that the area where the ligament tore out. This piece actually came down from there and fit into that spot and was causing it to jam up. This is just a good image that you can actually see the joint further, just so you can actually see anything in the subtalar joint arthroscopy. You actually can particularly if you start everting in the foot while you’re in there. This just shows, again, the top of that that interosseous ligament tear for the subtalar joint. We can debride it and remove that out. Remove the areas that are torn in or causing a problem. This was a patient with a loose body in the subtalar joint. Probably a consequence of some sort of inversion injury and this is the loose body that was vaguely attached on the side.

    [25:00]

    We took it out and then there was some impingement along the fibrous tissue that had formed to stabilize the loose body. And so we had to clean that stuff out as well. You can see. This is calcaneus, this is talus here, this is that cancellous bone. There’s the articular cartilage for that. Talking about post-operative management, it depends on the procedure obviously. What you’re doing is going to have a different sort of post-operative issue than others. But, ankle arthroscopy, if you’re just doing a debridement, then you can get them up and walking pretty quickly. If you’re doing osteochondral defect repair with microfracture and things like that, you might want to keep them non-weightbearing a little longer. What I normally do is keep them off of it fully non-weightbearing for four weeks. But I have to start range of motion too. The idea is you want to get these patients back in their early range of motion both with physical therapy and then also just home range of motion. I give them exercises to do. I’ve also found that aquatic therapy is very helpful. Get them in a pool, get them move around. It’s very low impact on the joints and so that’s good. Complications. You have to consider this a surgery with complications. All too often, people think of arthroscopy as minimally invasive and as a consequence, it’s minimal risk. The reality is it’s just not true. It is minimal incision certainly but that does not mean that it’s minimal risk. There are risks associated with this. Ankle distraction like we talked about, invasive techniques versus not. The potential for neurapraxias which is a significant risk. Also, you can have damage to the extra-articular structures. If you’re torquing the ankle around, you can have damage in the neurovascular bundle. One of the most common complications is the hemarthrosis of the joint, in fact, it’s the most common complication. In 60% of cases, Ross et al demonstrated that. And then just generalized soft-tissue extravasation of the fluid. You’re pumping fluid into the ankle joint or whichever joint you’re scoping. And then that fluid is going to leak out. That always happens, it’s just a matter of whether it’s a problem or not. The way to get around that is to assess your fluid management, how much fluid you’re pumping into the joint itself. And then getting them back, moving again to move that fluid up in a way. The other complications that you can have is instrument failure. This is a picture of the Deepwater Horizon, the oil rig that blew up. It was a series of instrument failures that cause that to occur. But, if your stuff doesn’t work, then obviously that can give you a trouble. And then the other fairly common injury is thermal injury. You can heat the fluid too much in the joint either via the burr or if you’re using a thermal ablator one can make the water temperature in the joint increase enough to the point that you can actually get a burn, which is significant. Some of the newer technologies, the ones actually turned off if it gets too hot. But you have to be aware of that. Just to add onto this, as we have the kind of in conclusion, there’s some other applications for arthroscopy or at least endoscopy in the foot and ankle. The two that are most common is endoscopic plantar fascia release and endoscopic gastrocnemius release. I don’t know if you guys have had any opportunity trying these out. But they’re pretty interesting and the technology is improving. I think more to come moving forward. But, both are minimal incision and that do you allow for early weight bearing. The endoscopic gastrocnemius release, I don’t really do it as an isolated procedure, so those people don’t really weight bear, but they theoretically could. You have to be careful obviously for sural nerve compromise because you’re going in. That’s a reality within an open gastroc release as well, but you have to be aware of it. This is just some imagery, I apologize for the poor quality. But it is endoscopic plantar fascia release. You can see the plantar fascia here. There are multiple systems on the market. I use the one that is a one-portal technique, I Wright makes it. There is another one, you can do, two-portal technique. Basically, you go in and you visualize the plantar fascia and then you use the knife dissection. You can see. Once you’ve done it correctly, there should have been fascia and then now, there was no fascia in the muscle. I dorsiflex the toe, tighten the medial bundle in the plantar fascia and you can see from there. I have those patients walking same day. Two stitches at the arthroscopy side. As soon as the stitches come out, I get them into [indecipherable] [28:47] and back into physical therapy. With an endoscopic gastrocnemius release, it’s similar to, if you were doing an open, you’re essentially doing a strayer. Gastrocnemius release, you’re just doing it through one small incision. Again, there are multiple systems on the market. Some are two portals, some are one portal. I like the single portal technique. Fewer incisions is always better in my book. And so this is just some imagery with a cadaver to show you come in from the medial side. This is an image of what it will look like. The company, when they’re training you how to do this, they have a model. This is the picture of that. I have one on my own to show you here in a second. But, essentially, you’re going to go through, you dissect out and then you look. We talked earlier about measure twice, cut once, particularly in this, particularly in the context of the potential for sural nerve compromise. You want to really make sure that sural nerve is not on that aponeurosis. You have some tools and ways to get around that, but you just want to make sure you can see it. Or rather see that it’s not there. And then once you do, you confirm it, you can see that the muscle bellies is there as well. This is a cure that we did in conjunction with the flatfoot reconstruction. But you can see that the gastrocnemius aponeurosis is there. You can see that the nerve is not there. You can actually go in, you can cruise up now the whole length of the aponeurosis. Look at any sort of plantar defects.

    [30:02]

    I encourage you to do that. You can see anything, you can actually rotate the cannula around and look back out into the muscle. If you’ve done it right, you can actually see the nerve on the back side. You know it’s protected and you can go from there. And then we go through. The system that I like has a retractable blade so you can go in. It’s a cannulated knife. You open up the blade and then you can cut back, and then retract the blade and look at again. You can see the before and after. You can really get a good tactile feel when you’re dorsiflexing the foot as a consequence of that. In conclusion, arthroscopy is not a one size fits all situation. It’s one size fits most, obviously. And so you have to consider your goals and objectives. If you have somebody with a really huge loose body that’s down of the distal tip of the medial malleolus, you’re maybe not going to be able to get that. If you tried again within arthroscopy, you have to be ready to open the ankle up. As you have to consider what you’re trying to do and get the best way to go about doing it, you need to take a systematic approach to go through finding the things that you need to do and then doing them stepwise. You don’t want to get overwhelmed. You need to consider the risks and benefits. It is still risky. It is still surgery and you don’t want to under present those risks to your patients because they have the idea that it’s arthroscopy which means that there’s no risk. That’s a trap to fall into. And again, there are no absolute indications but there are a lot of really good uses for it. I would say, look for those opportunities in your practice and you’re going to find that you’re able to provide a good quality service to your patients. Thank you.

    [Applause]

    Male Speaker 1: That was a beautiful presentation. It’s amazing. I’ve always taken a posture, big surgeons make big incisions. Patients probably perceive that as well on the magnitude of the surgery and how much pain they might be having. When you go in through little portals and you put one or two sutures in, they don’t understand how much damage we’ve done inside or potentially could have done. Not that we ever do any damage because we never identified that we’ve done destructive processes. Certainly when you throw that trocar through when you gouge that cartilage, we never tell a patient about that. But these things do happen. I do agree, by the way that probably the most common complication I have seen are nerve injury just from the portal sites. Those things can be as problematic as the original problems we’ve had.