Name: Posterior Ankle and Subtalar Joint Arthroscopy With FHL Tendoscopy Using the NanoScope™ Visualization System
Uploaded: 2020-06-03T00:00:00Z
Channel: Arthrex
Description: Phinit Phisitkul, MD (Sioux City, IA), demonstrates a posterior arthroscopy including an FHL tendoscopy and diagnostic subtalar joint arthroscopy using the NanoScope™ operative platform.

<p>Phinit Phisitkul, MD (Sioux City, IA), demonstrates a posterior arthroscopy including an FHL tendoscopy and diagnostic subtalar joint arthroscopy using the NanoScope™ operative platform.</p>

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VID1-001060-en-US | A | Posterior Ankle and Subtalar Joint Arthroscopy With FHL Tendoscopy Using the NanoScope™ Visualization System

Phinit Phisitkul

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Posterior Ankle and Subtalar Joint Arthroscopy With FHL Tendoscopy Using the NanoScope™ Visualization System

Is it a permanent physical? I you know, I've been using NanoScope for endoscopy and arthroscopy. This is the perfect indication when we look into the back of the ankle joint and subtalar joint, you have structures that you want to look into in tight corners. For example, endoscopy, the FHL tendon look all the way into the depth of the ankle joint. Look to the side of the subtalar joint. All those can be accomplished using this instrumentation. So we use NanoScope arthroscopy set for this purpose. We start with the portals. The portals are on the medial lateral aspect of the Achilles tendon at the level of the tip of the fibula. So I make portals using an 11 blade, or you can use a blade as appropriate. This is a trocar usually used. Blunt trocar from the NanoScope set, going from the lateral posterolateral portal aiming toward the second toe. Once it's on, I insert the camera. So usually I hold the camera with using my fingers and keeping one finger at the portal so it's more stable. So we are now using a 2.0mm shaver on a small hub shaver handpiece. The critical aspect is that when we put the instrument in, we need to go put put the shaver tip need to be going in to the lateral portal in front of the Achilles tendon, so you're not getting too close to the neurovascular structures. See, the direction of my instrumentation is going to the lateral aspect. Even without looking at the model at all, you just palpate using triangulation to appreciate the tip of the shaver with the tip of the scope. When you look into the screen at the NanoScope, you can see the metal shadow of the shaver. So that's what we expected at the beginning. You not don't expect to see a whole lot, give you a lot of fat tissue, but you start the triangulation process. At this point, I get the ball rolling. So the first few moments, once we get the camera in, is that we're going to start to do some shaving. At this point, we the goal is to create the working space. We don't worry about seeing the ankle joint or anything. Yet we create the working space only using the shaver. See how I use my hand going up and down? And we kind of work through the fiber in the aspect of ankle joint. You can see the fascia and the back of the ankle joint is going to go horizontally, so using a shaver to cut through it as shown here. That this this part takes some time to clean things up a little bit. Now we're seeing the we can see the subtalar joint when we invert it. You see how the motion of the subtalar joint. So this is the back of the subtalar joint. In this case, there's a stout posterior capsule of the subtalar joint. So the very first step of arthroscopy in the posterior approach is to find the FHL tendon. So we're going to go find the FHL tendon which is just above. Here we go. We can see the peekaboo of the FHL tendon a little bit so that when we move the big toe up and down for me again. So this is the FHL tendon. And that's the boundary that we don't want to go any medial to that because neurovascular structure would be in this plane. So we stay away from that. So at this point you can choose to do several things. Some patients with posterior ankle impingement. We then approach to the back of the ankle joint just above this ligamentous tissue here. So we can go above this. And we can then get into the ankle joint. Now I get the ankle in slightly dusty flexed position. So this is again this is a subtalar joint right here. Ankle joint. I need to go to that capsule. So we're going to use travel to go to the capsule and debris that part a little bit more. So. Now you start to see the back of the ankle joint. So we're going to debris some of the tight capsule. So this is called inter-molecular ligament. It's just behind ankle joint that sometimes can cause impingement using a shaver. You can see that the the treatment is going on very well. So this is essentially enough to allow us room to see the back of the ankle joint. You can see bone spurs or soft tissue thickening as needed. Now we're going to look into the ankle joint. This is a maneuver is the is called anterior drawer. Translation with the anterior drawer. You can get the NanoScope, which is only two millimeters in diameter. You actually can see all the way into the ankle joint. This is a notch of hardy way in the front of the joint. You can see the medial gutter. All the way. See the quality of the cartilage. See the side of like this. Sometimes you have loose body in the back. Posterior gutter of the ankle joint. Let's see. In this case there's some synovial hypertrophy in this area. So this is a posterior recess. This is the back of the deltoid ligament. Again we see the dome, the talus all the way to the front. When we look into the lateral side a little bit. Now this is the very positive aspect of the sesamoid is there's some bleeding in this specimen that we can clear up a little bit more. So now we are in the lateral recess. Lateral gutter is at the back of the fibula. This is the posterior talofibular ligament just on the bottom of my camera right here. So this is a fibula. This is the posterior ligament of the ankle. Osmosis. You see everything all the way front to back. Act very clearly. So this is through the back of the ankle joint. You can see all the way to the front using a small approach using a NanoScope. Again we go back and look at the subtalar joint if you prefer to read them thoroughly all around, you can do so, but I can show you if you want to do limited approaches, the way to do it. Now we're going to use a Nanoprobe to allow us to test the structures in the ankle and subtalar joint a little bit more. So the tip is of this instrument is curved, so it has less chance of getting stuck in the plane of soft tissue. I can use the tip to palpate everything. See the tendon. I can use this to lift up the back of the ankle joint. See the synovial hypertrophy. Palpate the Cartilage. And if I need to probe the structures, I can engage the instrument and I can test them out or use that tip of the probe to engage the soft tissue better. Now we go back off a little bit and come down to the subtalar joint. So with a small approach here again we use two millimeter instrument and go inside the lateral aspect of the subtalar joint. In this case this is normal. But there are some scar tissue in this area. We want to degrade it more. We can see all the way to the front of the subtalar joint. In many cases there will be a prominent trigeminal process. Trimano process sometimes can cause posterior impingement, or sometimes it's in the form of arthritis. So we're we can demonstrate a debridement of this structure, maybe just a posterior part of the talus in this case. So the normally before we approach to that we usually do a release of the FHL tendon. So now we're going to use a scissors from the nano instrument. So this scissor is used to release the retinaculum on top of the FHL tendon. You can see the tendon is being exposed more. I can use this to also dissect the soft tissue in the plane so that I can push the neurovascular structures away from the tendon. So we are debriding the retinaculum overlying the FHL tendon. So in case of FHL tenosynovitis, this this step is very important. Now we can see the tendon. Tendon sheath clearly indicates with debridement or release require shaving. This area needs to be done carefully because it's close to the neurovascular structures. And if we use a biter from the set allowing us to release the tightening sheath, it release the tight tissue under direct visualization so there's less chance of damage to the tendon, less chance of damage to the neurovascular structures next to it. Wow. Usually I have a harder time doing this step using a different instrument. Now the entire retinaculum is released completely. I can use a probe to see how we can access the FHL endoscopy at this step. Again, the FHL, we can move the toe big toe for me so we can see the FSL tendon moving and gliding. Does he flake out? Completely? Centaflex. Completely. Good. Now you can relax it. Now with the retinal retinaculum release. We can palpate and then use the camera to go inside the tendon sheath further. So these are endoscopy that we can accomplish from the posterolateral portal which is very good already. This is the TigerLoop line completely. If you want to go further I need to switch the camera into a posteromedial portal, which I'm going to do right now. So this is from the Posteromedial portal. The way to get the camera for an endoscopy, the easiest is to push the tendon to the back and use the camera to go in front of it. One advantage of the NanoScope is that it's actually more flexible. So this area is curved underneath the calcaneus. So you need some flexibility of the camera to allow you to reach the far end of the tendon. So we're going to use the probe to retract the tendon anteriorly. So we want aspect to make it easier to plan to flex the toe. That would allow the toe to be the tenant to be less tight. Now I can insert the camera along the tendon sheath. It actually can go very far. Now, I'm actually almost throughout the entire sheath of the. See how I pop out from the sustentaculum talin. Now I'm in the midfoot area. Now I'm all the way just before the tendon sends a branch to the FDL. This is zone two endoscopy. Again, you go from the tight area. Now you have more room. And this is a sign of fall. That means this is the maximum anatomy that we can get to the FHL. You can see the two bundle FHL here that is trying to send another branch to the FDL. So this is you see the camera from the outside. We actually reach in the mid foot for the entire length. Use the NanoScope instrument. We can get to the entire. A lot of times people might have synovitis or loose body that go all the way to this area. This is a technique that we can approach to it in certain cases that we want to harvest the FHL tendon. This is a way to do it so that we can get the maximum length of tendon easily. The way I approach to that is to use a needle to actually localize your tendon. You want to make sure you avoid injury to the tibial nerve. Widebiter from the NanoScope set, we go in and release the tendon at the far end of it. So as digital as we can get, so we can get the longest possible tendon for any reconstruction we can use to reconstruct Achilles tendon you can use to reconstruct peroneal tendons. Again, I put a instrument into the tunnel. Again, you can see how we folded FHL easily. And then we can go to the TigerTail line underneath it. We pop through the part in the midfoot and then starting to go to the zone two all the way to the synovial fold, close to the bifurcation. And that's as far as you can get the harvest of the tendon. You can actually grab a lot of tendon part, A lot of length now, but I want to get it out from this tight skin incision. So with this technique, we can harvest a tendon so long that we can reconstruct the Achilles tendon easily. You can get the tendon from the posterior compartment. You can drive it into the tuberosity. You can actually even route it back to a repair to the Achilles tendon approximately if needed. So this is the utility of this technique. So we can have the tendon now that long all the way before it starts to bifurcate. And send a branch to the FDL tendon. For demonstration purposes, I'm going to cut this thing off. We don't need any more. I'm doing a synovectomy with a Torpedo. However, with the National Trust instrument, we can actually pass the camera all the way to the lateral aspect of the joint of the subtalar joint, and then even pass it to the slightly entry aspect of the subtalar joint. Remove any loose body that we might see in the lateral gutter. All the way toward looking at the posterior facet joint as shown here. So this is all the way to the front. Pathology in the subtalar joint can be seen readily. Again, thanks to the size of the camera and the cannula, that we can actually look in the depth of subtalar joint all the way from medial, from lateral to medial, as shown here. As we discussed, if we have a bone spur, we want to breed. This is the trigone of process that will that may need to need to be debrided. So this is a case with prominent posterior process can be degraded as shown here. At the end of the treatment you aim to eliminate posterior ankle impingement. So when you plant a flexor down there's nothing pinching in the back of the ankle joint. So in this case you want to be a little more we can treat up top in this part. You want to eliminate impingement all together. So you can use burr or chevre to the bread bone in this area some more. So the absence of impingement is what you want to aim for at the end of your debridement for the posterior ankle and subtalar joint arthroscopy.

Posterior Ankle and Subtalar Joint Arthroscopy With FHL Tendoscopy Using the NanoScope™ Visualization System

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