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ANKLE ARTHROSCOPY
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Beginning of ankle joint arthroscopy- the inflammatory synovitis
is removed via a power synovial resector so that the ankle
joint can be visualized.
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Visualizing the anterior and lateral ankle joint- as the
inflammatory synovitis is removed, we can visualize the articular
cartilage on the talus and the lip of the tibia(shin bone)-
note the synovial tissue that is impinged between the talus
and tibia and the band of tissue extending down from the tibia.
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Moving toward the lateral gutter of the ankle joint- notice
that we are removing the tissue that is impinged between the
tibia and talus Again, notice large fibrous band of tissue
between the tibia and talus.
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As the tissue is debulked, notice that when the ankle joint
is moved, the impingement of tissue between the tibia and
talus is not existent. The articular cartilage on the talus,
due to injury and the amount of synovial impingement is fibrillated.
A Holmium laser is very useful in removing small fragments
of synovial tissue that cannot be removed with the mechanical
resector, as well as any fibrillated/damaged cartilage.
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POSTERIOR TIBIAL TENDOSCOPY
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Initial visualization of the Posterior Tibial(PT) tendon.
This tendon runs down the inside edge of the lower leg, curves
around the medial malleolus(inside ankle bone), and is responsible
for helping maintain the arch. However, this patient had a
severely pronated foot(flat foot type) that was not properly
supported with either proper shoe gear or a custom molded
orthotic. Please note: the last 30 seconds of the video is
just open video- the scope had been removed from the tendon
in order to reposition the patients leg/foot.
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As we scan back and forth, we see areas of the tendon sheath
that have inflammatory changes(dilated red blood vessels are
visualized within the inflamed tissue). At approximately the
1:45 mark, you will see an excellent example of congestive
tenosynovitis.
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As we advance the tendoscope, note that we pass(at 10 o'clock)
a patch of congested inflamed tissue- this prevents the tendon
from sliding smoothly back and forth in the sheath. We then
placed a blunt probe into the operative field and inspected
an area that we had suspected might have been partially torn.
A very small layer of connective tissue is holding the longitudinal
tear intact.
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As we insufflate the operative field with more saline, we
get a good separation between the tendon sheath and the tendon
at the beginning of the video; we can see a good deal of inflammatory
tissue. We then inserted a small resector tool that removes
unwanted debris.
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As we travel down the length of the tendon to it's insertion
on the navicular, we visualize more hypertrophic tenosynovitis.
Due the the amount of tenosynovitis and the partial longitudinal
tear of the PT tendon(which had not been detected on an MRI),
this case was converted to an open repair of the PT tendon.
During the open repair, we removed all of the congestive tenosynovitis.
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ARTHROSCOPIC ASSISTED REDUCTION AND FIXATION OF TIBIAL
PLAFOND FRACTURE
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Note the break in the tibial plafond with the inflammatory
tissue within the fracture. This fracture was only a few days
old and already there was a great deal of inflammatory tissue
within the joint. Actually, this was a Salter-Harris Type
III growth plate fracture. Please see our article on growth
plate fractures for a picture of this pattern of growth
plate fracture.
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Using a blunt instrument to tease the inflammatory tissue
out of the fracture line in order to have bone to bone contact
for proper healing.
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After curettage of tissue from the fracture site, we visualized
the alignment. After visualizing the alignment of the fracture
site, we were able to make a small incision above the ankle
joint, and place a pin across the bone and use a cannulated(hole
in the middle of the screw to slide over the pin) and firmly
fixate the fracture site. This avoided a large incision and
prolonged open procedure, thereby minimizing tissue manipulation
and trauma as well as risk of infection.
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ENDOSCOPIC PLANTAR FASCIOTOMY
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As we visualize the PLANTAR FASCIA, we insert a blunt instrument
to feel the soft tissue boundaries. As we advance the endoscope,
we meet the marking on the inside of the cannula(single black
line) which indicates the end of the medial(inner band) of
plantar fascia, which is what is under so much tension and
causes heel pain. It is important to have a clear field of
view, so removing the camera to wipe the lens and using sterile
cotton swabs to wipe out any excessive fluid in the cannula
is often necessary. Next, a hook blade is utilized to transect
the taut fascia.
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We can sometimes have a patient with an extremely thick plantar
fascia. In this situation, we utilize a delta blade so that
we can span the entire thickness of the plantar fascia. After
the use of the delta blade, note that you no longer see the
upper fibers of the plantar fascia, but a cleft indicating
release of the tight plantar fascia. Also, the pink muscle
belly of the most plantar muscles, which are deep to the plantar
fascia can be seen. After this video was completed, we then
flush the cannula with normal sterile saline, remove the cannula
and put two small stitches in the skin on either side of the
foot.
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