The Centerline™ System offers a minimally invasive endoscopic plantar fascia release technique for patients diagnosed with plantar fasciitis. The Centerline System raises the bar for endoscopic soft tissue procedures by increasing safety, visualization, ergonomics and reducing the possibility of mechanical failures.

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Arthrex® has developed a comprehensive, completely disposable system for endoscopic plantar fascia release. This minimally invasive technique allows surgeons to safely and effectively release the plantar fascia from the calcaneus in one simple, controlled cut under direct endoscopic visualization.
The EndoBlade™ system is a dual portal technique that is compatible with all 4 mm arthroscopes. Highlights of the all-in-one EndoBlade System include ergonomic single-use blades, a transparent slotted cannula which allows for real-time visual feedback of the soft tissue environment and a Plane Finder that acts as both an obturator and switching stick to make initial cannula insertion a cinch.

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EndoBlade™ Soft Tissue Release System

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Endoscopic Plantar Fascia Release

A small medial portal incision is created on the plantar medial heel. The plane finder instrument is inserted inferior to the plantar fascia and guided laterally until the lateral skin is tented. A lateral portal incision is created, and the plane finder instrument is inserted until the thickest diameter of the instrument is exposed laterally. The clear cannula is inserted in the lateral port over the plane finder, with the open slot of the cannula pointed planter. The plane finder is removed, and the cannula is rotated to position the slot in a superior direction, allowing visualization of the fascia. Cotton swabs are inserted from lateral to medial through the cannula, clearing soft tissue debris. A 4.0mm, 30 degree arthroscope is inserted laterally, and inspection of the fascia is performed to identify the separation between the central and lateral band of the fascia. At this point, the toes are manually extended, creating fascial tension if any fatty tissue remains obstructing the view of the fascia. A rasp may be inserted to improve visualization. Finally, a triangle or hooked knife is inserted medially and a release of the central band is performed in a slow, controlled manner from a lateral to medial direction. Following confirmation of an adequate release, the instruments are removed and the incisions are closed with suture.

An endoscopic gastrocnemius recession is performed utilizing the EndoBlade™ system, which allows for a dual-portal technique and is compatible with all 4-mm arthroscopes. Highlights of the all-in-one EndoBlade system include ergonomic single-use blades, a transparent slotted cannula with optimized length and diameter to allow for visual feedback, and a unique plane finder to reduce the likelihood of sural nerve damage.

Endoscopic Gastrocnemius Recession

With the ankle held in dorsiflexion against the surgeon's chest. The medial portal is created two centimeters distal to the musculotendinous junction. Puncture the deep coral fascia using a hemostat into the plain just posterior to the gastrocnemius tendon. Insert the clear cannula and trocar into the plain between the gastrocnemius tendon and the deep coral fascia. A lateral portal is then created inside out. The trocar is removed. Insert the sponge tipped applicators to clear the inside of the cannula from any fluid or debris. A four millimeter arthroscope is then inserted with the camera turned towards the gastrocnemius tendon. In some instances, the camera can be aimed posteriorly to view the Stephanus vein and sural nerve on the lateral half of the leg. If there is soft tissue overlying the gastrocnemius tendon, use a plane finder to dissect into the correct plane. The cannula is then removed, turned 180 degrees, and reinserted. Rotate the cannula to where the open slot is facing the tendon and remove the plain finder. The gastrocnemius tendon is then released from midline to lateral. Using the hook blade under endoscopic visualization, the camera is then switched to the lateral portal, and the rest of the gastrocnemius tendon is released from midline to medial. At this point, the instruments can be removed passively. Dorsiflex the ankle joint to demonstrate improvement in ankle motion. The portals are then closed using sutures or steri-strips. When performed in isolation, the patient is generally allowed to weight bear as tolerated in a boot.

Ryan B. Rigby, DPM (Logan, UT), discusses his clinical experiences along with the features and benefits of the EndoBlade™ system to treat gastrocnemius contracture and plantar fasciitis.

Endoscopic Gastrocnemius Recession and Plantar Fascia Release

To be totally honest, I did a lot of open gas trucks and dragged my feet for quite a while. Had some concerns about doing it endoscopically. But the last several years I've been doing them endoscopically and I'll show you the reasons why I switched and why I would highly encourage you to consider it. Reason number one this is a common area. This is a place that people see, especially females. And if you get something like this, this was six months out. This is the actual case that tipped me. She just hated it. It was tenting. I always close the deep fascia with some absorbable suture, but still she ended up with some some adhesion of the subcutaneous tissue to the soleus. And so I thought, okay, I'm going to try this endoscopic. So cosmetics is not the reason that we make a lot of decisions. But it is sometimes it does sometimes play a part in patient satisfaction. So that's reason number one. Reason number two it's easier. A lot of the procedures we do with the gastroc are supine. Not all of them, but a lot triples flat foot reconstruction. Lepidus and I find this is a lot easier unless you're, you know, frog legging the leg, trying to hold it off to the side or hold it in the air, or try to do it from a small incision from the medial side and hope you get everything lateral. So I like this. I can keep the patient directly supine and it simplifies the positioning. Reason number three it's faster less time in the Or for the patient cost savings to the patient. And they get off the table quicker. And oftentimes we're combining it like I said with more complicated longer procedures. So anything we can do to speed it up when you're done simply two little stitches in the skin and you're out. So definitely has has made this a little quicker. And the most important reason, reason number four less complications. So this came out in 20 1840 open versus 40 endoscopic. And the open group had 26% complication rate. Endoscopic had 2%. And so there was a significant difference in the lower complication rate in the endoscopic group. And so that really backs up the the reason to consider doing this endoscopically. So the endoscopic gastric recession. Just to summarize the reason why Cosmesis. Take it for what you want. Simplified positioning. That's been nice. It cuts down my or time. That has been nice. But the big thing for patients is less complications. The EndoBlade is the kit that provides everything you need to do this in the Or so. It's a transparent cannula and I'll show you why. That's been very nice. It's a dual portal system and it's an all inclusive kit. This is what it looks like. The cannula, the obturator, everything comes in the kit along with cotton swabs. Dual portal is nice because you can follow the cut and nothing's obscuring the view as opposed to a camera hooked and pushing it. So I like the dual portal. Okay, this was really my big hold up, and this may be one of your reasons for not doing this. The nerve. So there is variation. We know it lies in different areas just a little over 10%. It's lying actually on the aponeurosis, about 40%. It's lying outside the deep fascia and 45% is lying just underneath. So the variation well, okay, that's that's a problem. I don't want to get in there with a scope. But let me show you a few things. If you put the clear cannula in and you don't, and you inspect along the aponeurosis and you don't see anything, you're fine. Like the image on the left and you don't see the nerve. It's probably that percentage almost half the time where it's outside the fascia. Because it's a clear cannula. You can flip the switch the camera around and look posteriorly, and you can visualize the nerve there and document it, and I'll show you that. And if it's lying on the aponeurosis, you can also see it. You get a nice view. You're not in this metal tunnel that you can't see much. This clear cannula shows you where the nerve is. If it's right behind the cannula, you know you're safe. You can document that the nerve was visualized. It was protected behind the camera. You can do a nice release and feel confident that you have not caused any problems with the nerve. That really was my biggest hold up and I honestly over several years have not had issues with nerve, but I think this cannula makes a big difference for me. The technique is a couple of centimeters below the inferior border of the gastroc, and I actually go about a centimeter in front of that border. I usually try to start on the medial side. I usually take a hemostat across first, just gently, and then I insert the cannula. There's a couple of cotton swabs. This works with a dry fluoroscope. Here's the deep fashion. So if you put it in and you move the foot up and down and you see the aponeurosis moving, and there's still a layer of tissue there, the kit comes with a little dissector tool. And I almost always I never hit it perfect in the right plane. Exactly. I put it in and then I use this little tool which is beveled on one side. You start on one side and it actually works its way through the tissue very nicely underneath the deep fascia. And then you basically use this as a switch stick. So you pull it out and put the cannula back in in the right plane. Here you go. This little nerve is sitting in front of the cannula. What do you do. Two options. Pull it out. Go to an open if you want. Or you can actually use this little dissector tool to just gently go in front of it. Work your way across and you can see there's the beveled edge. You can see I'm still in the not not yet in the right plane on this far side. And so just keep working your way underneath that deep fascia layer and you can establish very in a simple, very easy way, a switch stick principle to put the cannula in the right plane. So I like that little tool. Actually when I pull out the cannula I'll take that little switch stick and I'll just kind of gently move it up and down and just create a nice little pocket there and put the cannula back in below the deep fascia and well away from the nerve, and then do a final inspection before we release. Just run that dissector tool just along the fibers, and you can see I'm safe and ready to do the release. It's very sharp, little gentle dorsiflexion. You should see the underlying soleus muscle belly. And you can do a half or a full release and get a nice recession here. And a couple stitches and you're done. At first, I will be honest, it took me a little bit of time in the very beginning to to adjust, but now it's very fast and I'm super happy that I made the switch. So key take home points with the endoscopic gastroc. You can do it supine. That's been nice. You leave the deep fascia intact. There's no herniation or risk of that subcutaneous adhesion or skin tenting. It is cosmetic. That's a great thing. I see less post-op pain, and the clear cannula really has made a difference when being cautious and careful of the nerve. And I see less complications. Just a little side note about the plantar fascia release system. This is very similar. It's a similar kit. The handles are actually leveraged. They're angled to give you a little more leverage as you release this a close up look at the blades. These are very sharp. They spent a lot of time really trying to sharpen these and give us the sharpest blades possible to do it. I'm sure you've all probably done this. You outline the anatomy. I'll just show you a case. Example. This patient had over six months of conservative treatment, and when I got the MRI, which I frequently do, and trying to make sure there's not a neurological component or anything else and make sure it's true plantar fasciitis. She had 8.5cm millimeters of thickening, indicating that this was truly her source of pain. And so we did an endoscopic plantar fascia release. This is the kit ready to go on the back table, make a small incision on the medial side and just establish a plane right under the fascia. The probe exits the lateral side well below the surface nerve and insert the insert the cannula. It slides over that very easily and insert the scope. Sometimes when you get in there, you see some tissue lying on the fascia. The kit comes with a rasp, so you can clear that off and see a little bit better. And then just basically elicit the windlass mechanism. Measure for the release however much you like to do. I usually insert the scope from the lateral side and come in medially. There's a little herniation of tissue that I find right there. That gives me just about the right amount of tissue to release the medial portion and see the underlying intrinsics. Sometimes you have to make a couple passes. You know, this is thick chronic disease fasciosis. And so sometimes you have to come back and make a couple passes. But the blades are very sharp. This thick tissue, it cuts through very nicely. And then just a picture confirming that you went deep enough. A couple stitches and you're done. This is a patient that I obtained an MRI after. Excuse me afterwards for other reasons. And you can see on the medial side the release, but the lateral band is left intact. And that's important for the success of course for this procedure. My post-op protocol is pretty simple. I let them walk in 2 to 3 days in a boot. I think it's important to leave them in a boot, especially at night, to night to maintain, stretch out, keep them at 90 degrees. I like to transfer them out of the boot into regular shoes around 2 to 4 weeks. I just don't want this to tighten up if you leave them non-weight bearing, or in a cast or a boot for quite a while, I think this has a chance of healing in tight, so I like to keep the stretch out and allow them to return to regular activity around 6 to 8 weeks. So in summary reasons I like the endoscopic or the EndoBlade for both these procedures, especially the plantar fascia. The angled handles give you a little more leverage. The clear cannula is very nice. Better visualization. Both of these are a little more cosmetic, which gives you the patient perception that this is, you know, that plays a part, that this is minimally invasive is often perceived well, that they're going to do well. The blades are very sharp. And I like that they're dual portal. I see a little better visualization. I feel I can do the procedure better that way. So great procedures. I would encourage you to try this if you haven't. It's been a nice thing to offer my patients. Thank you.

Andrew J. Rosenbaum, MD, (Albany, NY) provides a case presentation detailing his successes with the EndoBlade™ system for endoscopic gastrocnemius recession compared to the challenges seen with the more traditional, open approach.

EndoBlade™ Endoscopic Release System

My name is Andrew Rosenbaum. I'm an orthopedic foot and ankle surgeon from Albany Medical Center in Albany, New York. I'll be talking about the EndoBlade system today. Gastrocnemius contractures are present in anywhere from 65 to 88% of patients with midfoot, forefoot, and other types of symptoms. That's been shown in a jbj's study from 2002. 60% of patients with plantar fasciitis will have a gastrocnemius contracture as well. It's also associated with a lot of other pathology that I'll encounter halleck's, valgus, hammertoes, flatfoot deformity, as well as arthritis within the midfoot and ankle. It's also associated with Achilles, tendinosis diabetes, and non-healing ulcers. The gastrocnemius recession was traditionally performed through an open technique within about three centimeter incision. This technique led to a lot of unattractive and cosmetically unappealing scars. There's tethering of the skin to the underlying fascia, which would lead to persistent pain and deformity at that portion of the leg. Endoscopic techniques have evolved with decreased morbidity and faster recovery times. This is all consistent with other studies looking at endoscopic carpal tunnel and plantar fasciotomy. Release. The gastrocnemius recession with the EndoBlade is an all in one system. There's multiple blade options and a optimized cannula length with a transparent cannula that allows you to visualize the nerve and make sure no other soft tissue is entrapped. It's minimally invasive and compatible with all four millimeter scopes. This is the EndoBlade kit for a gastrocnemius recession. It includes the cannula and trocar again, which is clear, as well as an obturator to remove a synovial layer off of the gastrocnemius aponeurosis. A rasp to do that as well, and several other blade options. In this case, a 48 year old female presented in my practice with recurrent plantar fasciitis. In 2013, she had underwent an open release with a large planar medial incision that was about four centimeters in size. It was hypertrophic and sensitive. She had persistent pain and repeat imaging showing an incomplete release and recurrent plantar fasciitis. She was looking for a quick fix and on physical exam had a gastrocnemius contracture. I had recommended an endoscopic gastrocnemius recession, which is shown here. To the left is the gastrocnemius aponeurosis, as visualized with a 30 degree shoulder scope, and to the right is the release. When I do this surgery, I'll make an approximately five millimeter incision medially, about two fingerbreadths posterior to the posterior medial border of the tibia, just below the gastrocnemius muscle belly. I then make a second lateral incision as the cannula is tenting the tenting the skin again. This is the aponeurosis on the left and the release to the right showing soleus muscle. Consistent with a complete release. She's doing great at six month follow up and is thrilled about her incision size. As you can see, it's a very small incision. She was able to return to running and yoga at ten weeks, and was asymptomatic for the first time in four years. My patients have been very pleased with the endoscopic gastrocnemius recession. It's a smaller incision. They have less muscle cramping, postoperatively. They're able to transition out of a cam boot faster. This is all as compared to my patients with the more traditional open approach. The EndoBlade is an effective tool for soft tissue release, both for the gastrocnemius recession as well as for plantar fasciotomy. In both of those instances, it allows direct visualization of the gastrocnemius aponeurosis or the plantar fascia, and reduces the risk of neurovascular injury with the gastrocnemius in particular the nerve. It's quick with all tools in a single kit and again allows for a small incision. Improved cosmesis, less bleeding, less risk for wound issues, and improved patient satisfaction. Thank you so much.

Phinit Phisitkul, MD, (Sioux City, IA) uses the EndoBlade™ endoscopic soft‐tissue release system to perform an endoscopic Baumann procedure to lengthen the gastrocnemius aponeurosis for patients presenting with equinus contracture.

Baumann Procedure Using the EndoBlade™ System

All right. So we are talking about Baumann procedure. Baumann procedure is to release the gastrocnemius fascia. We do this when we want to avoid over lengthening. We want to preserve the length of the soleus complex. More we can do Baumann procedure. We also can do Baumann procedure as an addition to the procedure. So this surgery you can actually palpate the muscle belly. You go just about a centimeter or two posterior to the tibia in the middle of the gastrocnemius muscle belly right here. So we're going to mark the incision. About a centimeter and a half to two centimeters. So you can put your finger across so you make incision. Again we need to look out for the StarFish nerve and vein. In this part we already see the Gastrocnemius muscle belly. Okay, we just go just in front of it. So with your fingers, you go inside with your index fingers. You can have these two come out. So you can then dissect. You can make a plane. You can swivel your finger back and forth in this plane so you can keep coming out toward the lateral aspect. So on the lateral aspect you can make an incision from outside in just a small portal. You can use a hemostat to go in and then create a plane and then touch to your finger. The plane fighter will come from the lateral side. We'll stay right on your finger. You keep coming across and out with you. The next step is to get the cannula to come in from the medial side. We turn the opening of the cannula in the posterior aspect so we can look at the gastric factsheet directly. I keep it in cash on my chest. So we see it nice and tight. Use the cotton. To clean the cannula very well. All right. So we're going to put the camera in here. See the plane of the gastric fascia right away. Okay. So in case they are far away you can put some gentle pressure on the plant from the posterior aspect. Just like that. So there they are right in the plane you want to cut. Again we let the pressure out. You see how the tendons are a little bit wavy. We put some pressure on it. It becomes a straight line. Easier to release. So we can get a knife from lateral to medial in this plane. I keep it engaged on my chest, so I make it nice and tight. And then gradually release it. Okay. I cash on that a little bit and. All right, so it's all done. You can see that you have released the gastroc fascia. When you look up you can see the intact soleus fascia up above. So that's pretty much the end of the procedure. All right. So this is the after the release you can see how the ankle is able to dorsiflex. Furthermore, but we keep it intact in the gastrocnemius muscle belly. And this technique you're not going to expose to the risk of nerve injury. As we worry about gas leaks in general, you have the post-op protocol. Usually, since this technique is so stable, a patient can walk right away using a boot. The boot can be written off at about 3 to 4 weeks if they feel comfortable. So this is not a surgery technique. This is. We want to dissect it out in a specimen to demonstrate the plan that we went through and the risk and benefit of this procedure. And make an incision. So this is the plan that we've gone to. We just go through the fat here and then use the finger to dissect in front of the muscle belly, along the deep fascia of the posterior compartment. With this plan, you can then palpate the gastrocnemius tendon posterior to it. So so we're going to show you again. Typically you might run into the risk of saphenous nerve and vein which is a couple centimeters Anteriorly, so you need to watch out for that. Typically, if you are behind the posterior border of the tibia, you're quite safe. I'm going to extend the caudal fascia opening. And this is the plane that we went through. Okay. So this is the plane of the release. You keep the soleus completely intact, but you keep the gastrocnemius completely released. But the release is remain constant regardless of how much I try to pull it off. It's not going to damage the muscle belly further. In this technique and we look around, you can see the plantar tendon is not a single nerve nerve. In this case it's going to be way, way, way deeper. It should be. We need to cut across the entire muscle belly to run it through the nerve. We want to cut into the nerve. It's going to be way in the back. So in this technique you're not going to be easily running into the sewer runoff. So it's a safer approach in that way. So once we go in we put the finger against soleus. It would be in the plain between the gastroc and soleus. Usually that's a very thin fat shear on top of it. So the solid is tightly adhered to the posterior aspect of the tibia. So when you slide your finger in there, it is not easy for us to actually slide into the soleus. Usually it's much easier after the fascia is open to actually slide the finger, and then you can palpate the soleus in front of you. And then right along turn your finger. You can palpate the tiniest at the same time you select the ankle. So you can interact with the pressure and the tension on the gastroc tendon on the on your finger.

Endoscopic Plantar Fascia

Child (D)

Plantar Fasciitis

Secondary (C)