Soft Tissue Pictures

Open Fasciotomy for Acute Compartment Syndrome

Pictured below is an opening of the facial muscle compartments of the left leg. This procedure is performed to release pressure that has built up in the muscle from activity in which the pressure does not go down after a certain amount of time. This increased, sustained pressure within the compartments is very painful and puts at risk loss of blood supply to the muscles, and in severe cases can cause the death of the muscle tissue.

Below is a picture of retention sutures placed over the fasciitomy site in order to allow the muscle compartment to decompress but also does not allow the skin to retract and make closure of the large inscision difficult to perform at a later date.

This is primary closure of the incision site once the compartment has been adequately decompressed, 

Compartment Syndrome

The following is the fascial covering over a muscle compartment. The condition occurs when the pressure within this compartment builds up after an injury or can also occur after exercise from the inability of the muscle to decompress naturally. This leads to pain that is unrelenting and could lead to decrease blood flow and oxygen to muscle tissue causing the death of that tissue.

The picture below demonstrates the fascia overlying the tissue being lifted by the forces at the top of the picture.

Below is demonstrates incision into the compartment exposing the muscle tissue that is a deeper red color where the retractor is to the left of the picture. The opening of this facial tissue is vital in releasing pressure in the compartment after injury or from exercise. It also important that this release is extensive as so the fascial tissue does not heal closed allowing build of pressure again.

Achilles Tendon Rupture

Most Achilles tendon tears occur from chronic degeneration of the tendon in conjunction with the improper conditioning of the tendon to perform certain activities such as jumping and sudden changes in direction. This is why this type of injury occurs in what is considered the "Weekend Warrior". This person usually does not train and condition the tendon to handle intense physical activity then goes and plays a sport over the weekend and the tendon gives out. In the picture below one can see the frayed ends of the torn Achilles tendon.

The image below is the tendon after repair with a complex suture technique called the Krakow stitch. This is a very strong repair and prognosis after repair with physical therapy is very good.

Series of Pics During Achilles Tendon Rupture Repair with Posterior Fasciotomy and FHL Muscle Transposition to Increase Vascularity to the Repair Site (Below)

The Rupture ends are at the top and bottom of the Pic. This is the fascia between the Achilles and the Deep Posterior Compartment.

Below is a pic of the window we make in the fascia to get to the FHL muscle

We weave absorbable suture through the muscle so after the repair, we attach the muscle to the front side of the Achilles to increase vascularity to the repair.

Below are the pics of the Krakow suture technique we use to repair the proximal and distal repair stumps together. We interweave a non-absorbable suture through each rupture end and then tie them together to reapproximate the tendon.

We have repaired the Achilles and are preparing to transpose the FHL muscle to the repair site to increase vascularity. The four sets of the white suture can be seen on the sides of the Achilles.

Pic after complete repair with muscle transposition

The instrument is identifying the FHL muscle as it is transposed to the repair site to increase vascularity.

Intraoperative Pic of Inclusion cyst in a child

Intraoperative picture of an avulsion of the Achilles of the calcaneus

Below the Achilles is pulled through a trough in the heel bone to re-anchor it down)

Pic below of an avulsion of the Achilles off the heel bone prior to repair and re-anchor through the heel

Achilles rupture intraoperatively before and after repair

 

Intraoperative pics of anterior and lateral compartment release for Chronic Exertional Compartment Syndrome

  

These are intraoperative pics of a woman who traumatically dislocated her peroneal tendons in a fall. 

These are pics of the peroneus longus dislocated over the fibula. The instrument on the bottom is pointing towards the tendon. The instrument on th top left is showing where the tendon should be.

 

This is a pic of us relocating the tendons.

The following pic is of us debriding the side of the fibula to allow the ligament and tissue to connect to the fibula during healing so the tendons do not dislocate.

This is a pic of the suture passing through the fibula to attach the retinaculum and tissue so the peroneal tendons do not dislocate or sublux.

This is a final pic of the repair

Intraop pic of Achilles ruptures prior to repair.  There is a 1 cm gap between the tendon ends. The white tendon on the left is called the Plantaris.  Due to this tendon being intact, the Achilles didn't retract much after the rupture.

This is a pic with the sutures on both ends of the rupture prior to being tied.

These are final pics of the repair with the tendon edges tightened before after the suture ends are cut.

 

Series of Intraop Pics of an Achilles rupture with part of posterior calcaneus still attached. This was a 17-year-old competitive cheerleader who jumped and injured her heel.

The Achilles tore off of the back of the calcaneus and a portion of the heel is still attached to the Achilles. The back of the heel bone is the rounded yellowish bone at the bottom of the incision site.

The nonabsorbable suture has been weaved through the Achilles to repair it back to the back of the calcaneus

A trough is made in the calcaneus due allow the tendon to have ingrowth at its reattachment site in the posterior heel.

The suture from the Achilles is placed through two small drill holes in the trough and out the bottom of the heel bone.

The Achilles is tensioned down into the trough and reattached to the calcaneus

Intraop Pic of removal of neuroma. The bifurcation going to the adjacent toes is easily visualized.

Pic of Removal of Retro-Achilles calcified Bursa

Split Tear of the Peroneus Brevis.

The torn damaged portion is removed and the tendon is repaired onto itself

Intrasubstance tear with bulbous thickening before and after repair

Bulbous thickening of peroneus brevis with split thickness tear

The bulbous portion is removed and the remainder of the tendon is repaired back onto itself.

Split-thickness tear before and after excision of a portion of the tear

Flattening of Peroneus Brevis before and after repair

Intraop Pics of the Sural nerve that was entrapped.  We released the nerve and attached the stump of the nerve into the peroneal muscle with suture

Intraop picture of Achilles tendon rupture.  We have made a posterior fasciotomy to visualize the FDL muscle.  We have 4 sutures in the center of the pic that is in the muscle belly.  We tie these sutures on the pic of the tendon after the repair. This gives a better blood supply to the repair site.

This is  a close-up view of the repair and the muscle adhered to the front of the tendon

View of the repair from the top

Pic of Split tear of the Peroneus Brevis and section that was removed. This is caused by the Peroneus longus constantly pushing the Brevis into the back of the fibula.  It can be due to repeated microtrauma or one isolated traumatic event, i.e. ankle sprain or fracture).

Pic of Split tear of the Peroneus Brevis and section that was removed. This is caused by the Peroneus longus constantly pushing the Brevis into the back of the fibula. There was also a low lying muscle belly of the Brevis that was removed with the damaged tendon. This can be seen at the left side of the removed tendon. The tear can be due to repeated microtrauma or one isolated traumatic event, i.e. ankle sprain or fracture).

Series of Pics Biopsy for Subungal Melanoma

Repair of Traumatic Achilles tendon rupture with Krakow Suture Technique and FHL Muscle Transposition

View of the Rupture

View of the Posterior Fasciotomy and Exposed FHL Muscle to increase vascularity to the repair

We have placed absorbable suture through the muscle belly to later transpose to the front of the repair

Achilles Rupture has been repaired with a Krakow technique and the absorbable suture can be visualized from each side of the Achilles prior to suturing

Repair with Transposition of the FHL muscle to increase vascularity to the repair site

(The instrument to the left of the Achilles is identifying the FHL muscle)