CHAPTER 1

So I'm going to... I'm going to draw some anatomy so that you guys can see it. So we've got the patient in a full lateral position, held in place with a bean bag. She's got an axillary roll in for protection of the nervous structures to the upper extremity. We've also got the peroneal nerve on the down leg free from any pressure to prevent any common peroneal nerve palsy. And we've got padding between the bony prominences of the leg so that there's no pressure associated complications intraoperatively. There's a stack of blankets underneath her foot to get her leg into a good position, and we also have a well-padded high thigh tourniquet on for hemostasis during the case.

This is the lateral aspect of the ankle and the foot. We've got the fibular prominence right here in the distal fibula and of course the peroneal tendons lie right behind here. We will just draw some rudimentary anatomic surface structures here to help us orient the case and make sure that we’re in the proper position throughout, the during the approach. I'm outlining the anterior portion of the fibula here and posteriorly the back edge of the fibula, and I'll put some hash marks here at indicate that that's bone. The peroneal tendons live right behind here, and the incision will be right in line with this. The peroneal tendons of course extend from the tip of the fibula down, at least the peroneus brevis, goes down directly to the base of the 5th and so if we need to do an extended incision down there to look we can do that. The peroneus longus will reflect underneath the cuboid, lateral portion of the cuboid, right about there.

Yeah we can probably go a little anterior to that and just take it off the anterior portion here. Do you want me to want me to do the approach? So we're going to need some skins hooks, okay? Alright.

So let’s do a pause please. I’ll shape this up a little bit. So you want more to be on bone? Not necessarily I mean…

So we're using an esmarch dressing to exsanguinate the lower extremity, give us a bloodless field. Then we've got a micro sagittal saw, guys? No it will not. Okay can we get the tourniquet up to 250 please?

CHAPTER 2

Good. Starting. Skin hooks please, and forceps please. Bovie. These are some just cutaneous vessels that we're going to electro-cauterize to maintain hemostasis both during this portion of the procedure and postoperatively. We can advance through the tissues here using the electrocautery on cut to help maintain that hemostasis.

Now I'm just going to feel here to make sure that we got the right plane and that we're staying in the right approach to the sheath. Right, right back here we’re on bone.

CHAPTER 3

I'm going to make a full thickness cut in enter the sheath right here. That's pretty much where you cut to the superior... Yeah we’re going right through the superior peroneal retinaculum. You can see here, now the tendons are exposed. Let me have a metzenbaum scissors please. The sural nerve is running, you know, generally in this direction. It's not if you're in the plane that were and it's not too much of a problem. Certainly need to be vigilant for it when you're when you're doing your exposure.

We’re just opening up the retinaculum a little farther and you can see the tendons in here. Now this yellow tissue in here is a little abundant and that's that this is some tenosynovium, which is a nourishing tissue for the tendon. A little bit is normal and desirable but this is this is again pretty abundant here, and although it looks yellow right now if we hadn't exsanguinated the limb this would be much more pink and would show much more clear signs of inflammation.

Let me have a freer elevator. So one of the things that you can notice here as we open this up a little farther is this is this more pinkish red tissue is actually the inferior extent or extension of the peroneus brevis tendon. And you'll see this when I lift the peroneus longus out of the way. You'll see there's a lot of tenosynovitis tenosynovium associated with it and even some adhesions and when I reflect this out of the way and and demonstrate you can see this lowline peroneus brevis a little more clearly and that peroneus brevis is in somewhat of a mass occupying lesion. You've only got so much space in your fibular groove and the in the within the sheath here in as the tendons have excursion back and forth that can get driven down farther and create somewhat of a stenotic lesion and so in these cases we we remove that lowline peroneus brevis muscle belly to give the peroneal tendons a little bit more room to move.

Metzenbaum scissors please. You can see with this this is the peroneus brevis tendon here it is it's effaced and flattened out and there is some curvature to it. This is not to abnormal. It's a bit thin. There's a small tear here within the tendon. I don't know if you guys can make that out. The good news for this patient is that this is less than point that is less than 50% the diameter of the tendon, and it's very superficial and I think that in her case it would be advantageous rather than trying repair this and put suture material in there is just too excise portion. It's not going to weaken the tendon significantly and it's going to get rid of the tear in and help her in pain control. The tear is right here.

This is a good reason, why this case, you know probably if we had done this tendoscopically, you know with a scope, this is very hard to be easily identifiable, but to go in there and remove this through either biters or arthroscopic instruments is a little more difficult then. It would require a lot of shaving. It’s a pretty tenacious tissue, so it's this worked out for the best that this woman did not have a tendoscopic procedure.

You can see more of this low-lying peroneus brevis here and back here. This is the peroneal groove on the backside of the fibula. Normally there's a nice cradle here, curvature on the backside of the fibula, fibular groove to hold these peroneal tendon. She's very flat, so we're going to reevaluate after we debride all the tendons and and all of the tenosynovitis to see how her tendons move and how they lay within the sheath at the end of the procedure. She may need to have a groove deepening procedure but we're going to re-evaluate that once we clean out this lowline peroneus brevis and some of this tissue here. Okay.

So first thing I'm going to do is to take some forceps and the metzenbaum scissors, and I'm going to come down here I'm going to try and find the most distal extent of this of this tenosynovitis. It seems to be going down a little farther. I'm going to actually extend my incision, so that I can get a good view of that. The other thing that we can do before we go ahead and do that is actually trying move the tendons, actually try and pull on them manually. Let me have a little retractor please. To see if we can find the most distal extent without extending the skin excision. It's going down pretty far, and I think it's probably advantageous for us to just go ahead and extended a little bit.

Okay. Can I have a knife please? Again the sural nerve should be inferior anatomically to where we are and but we do need to be careful of branches here. You can see. Let me have metzenbaum scissors. Luckily we haven't encountered any components of the sural nerve yet. That's looking pretty bad, that's better. You can see how how distal this this stuff extends, and there's the retinaculum again.

Is that also where you would expect the piccolo or that's more than on the surface? To the tendons? You can see them in here. Not such a common finding down here.

Okay. Let me have some skin skin hook retractors. So what Arvin’s doing here is he's going to hold back the retinaculum and what I'm going to do right now is free up some of this tissue. I'm going to keep my tips down so that I'm not staying away from the tendon. I do have to be careful that I do not buttonhole the superior peroneal retinaculum, but I am staying right on it and I'm trying to remove as much of this inflammatory tissue as I can. Again being very careful not to buttonhole. I'm going to turn my scissors over there they don't want a buttonhole that, and I'm in a safe place in terms of the tendon. You can see here there are some is a little bit of blood supply here. We're going to buzz that with the electrocautery, so that she doesn't develop any hematoma within the sheath at the conclusion of the case.

And that's pretty clear that's it, and you can see here it's very much cleared up now. This is pretty much the end of what we are seeing, And we're taking this off of the peroneus longus here. A lot of this may indeed be attached to the peroneus brevis as well, so we're going to try and do this as much in block as possible. You can see they're now the peroneus brevis looks to be pretty clear of it. I'm going to just elevate it. And that's pretty good you can see now there's still some attachments here to the the peroneus brevis muscle belly as well as a peroneus brevis tendon, so we're going to work on that. I’m going to have Arvin reflect this posteriorly, so that we can go ahead and work on the peroneus brevis, and there you get a good view of this is a very effaced tendon. It's very flattened, which is not uncommon. But this is a pretty distal extension of this peroneus brevis muscle belly and again and may in her represent a mass occupying lesion, and so we're just going to we're going to clear it right off the tendon. And take it as a single block with that inflammatory tissue and then again so. Greg can I have you put a hand there?

So again peroneus brevis is now anterior peroneus longus posterior. We've got the muscle belly being resected here from from from the tendon itself. This inflammatory tissue still is a little bit adherent to the superior peroneal retinaculum. I turned my scissors around 2 to prevent any button pulling of the superior peroneal retinaculum.

And got a little bleeder there and will electrical cautery. That is not at all uncommon affect. That's almost always there. Again to prevent any postoperative hematoma within the sheath we will electric cauterize that. And it may bleed again as we advanced up a little bit but we can always go back and obtain hemostasis. Can I get a little Coker please? So what I'll do is apply a little kocher clamp on this, and then because we're not going to continue up much farther… Good.

And you don't have to take it up too far just just basically to the terminus of the groove, and once we're there I'm going to have Greg and Arvin hold the muscle the tendon out of the way. I'm going to take the electrocautery and cut and I'm just going to then transect or amputate this muscle belly here. And again in an effort to obtain and maintain hemostasis because there will be a cut surface of muscle within the sheath and so minimizing blood within the sheath in post-operative period is good.

So now you can see there's the transected face of the low-lying peroneus brevis. Peroneus longus peroneus brevis muscle. we still have to deal with the small tear here. We will do that now. Right there.Okay. Do you have any malleable? And I'll take a fresh 15 blade please? At this point you all that inflammatory tissue is been cleared off. You can see there's a lot more room in here, so I'm going to use the backside of this forceps as a malleable. This is good. Alright, you can see here that the tear is located right here. It's about a third of the distance in the tendon so and it's very superficial. I don't think that putting suture in this is going to be… It's going to introduce foreign body and maybe a source of irritant. There's a lot of effacement in this tendon, so I think it's just easier to do a transaction here and cut out the torn section. That's what we're doing right here.

Again this type, this amount of tendon being resected that if this is this would be difficult through a 2.7 mm scope with a rotary shaver. Just because this tissue is so tenacious, so it's a lot easier to do this open.

And then we will complete it here removal added to the diseased portion of the tendon.

CHAPTER 4

So now we'll reevaluate the tendons after their put back into the groove. Let me have another forceps if you will, Greg. So we'll just come over here. That seems pretty stable to me. We're going to move the tendons around a little bit to make sure that dynamically their stable. They stay in that groove even with, you know this is with flexion and eversion. You can see it trying to roll out but I think you know there's no frank dislocation in this is with the sheath completely open, so once we do a repair of the sheath back back up, it's going to be even more stable. I don't think we need to do a groove deepening on her. She did not have any preoperative dislocation, and so I think once we remove that tissue and the mass from within the sheath we're going to be, she's going to feel much better and she's not going to certainly not going to be unstable once we do a repair. So there's no no need to do a groove deepening on this patient.

Alright let's irrigate please. I going to take one more check down here to make sure we've got all of that inflammatory tissue gone and got nice clean tendons down there.

CHAPTER 5

So now we're going to finish the case with a closure. It's going to be a repair of the superior peroneal retinaculum here, and then we're going to do a skin closure after that. I've left a little cuff of tissue here off of the fibula here, so that we're not selling directly to bone or periosteum and that makes the closure a bit easier.

Because she didn't have any frank dislocation preoperative you don’t have to think about retinaculum plasty right? Yeah that would be for cases where at least for my algorithm in terms of peroneal instability if if you do your groove deepening and you still even with the groove deepening then have some indication that you're going to have problems maintaining the tendons in the groove then that's when you think about that. Or if it's a revision case where they've already had a group deepening and some other some other effort to keep the tendons in an anatomic position has failed and you need something stronger to reinforce what was done previously. And that's a fairly unusual occurrence.

I think we are still in the infancy for tendoscopy as a whole. So yeah, I think not only most centers it's just not available and in the places where it is, in case it's like this if you should started out with tendoscopy I think that there would be certainly good indications to open because of the presence of the tear.

If we would have scoped her and saw the tear do you think you would have opened her? I think that in the end probably. If we had gone ahead and done that I think that you obviously make an effort to try and resect that diseased portion of tendon and and you can do that with some end-biters and manual endoscopic instruments and then finish up with a rotary shaver. But whether we would have been able to complete it at endoscopically, that's a good question. I think this was certainly a good move for her having it done open.

When your approximate does it just an atomic or do you embrocate a little bit? Yes you can. You can embrocate. I think it's difficult to create a stenotic condition that’s iatrogenic, but it certainly can be done if you really really embrocate too much you can have it. I've seen it happen, but in some of these tissues will they will shrink postoperatively. Cause she's got a lot less volume within that she's now than she had preoperatively and I think you can you can see that.

And I'm just using some figure-of-eight sutures, interrupted sutures here to close this. I'm using absorbables. Certainly you can, depending on the situation, you can use non-absorbable sutures, but I don't think it's necessary in every case. Another thing to think about this is she's very thin and her skin is, she's got thin skin, she's fair-skinned and so you know you would some of these sutures are green or blue in color and you will right underneath the skin and even if there's even if there's no mechanical irritation from the suture that you can sometimes see the suture through the skin.

And again she's got so much more room now and she doesn't anticipate having any healing problems and I don't think we need to really reinforce the repair with nonabsorbable suture. She's going to do great with just with these mono-cryls. Another thing to just be careful of it’s obvious but you need to make sure that you're not you're not sewing the tendons into the sheath. It goes without saying but always something to keep in mind. One of the things that we've I don't know if there's not much in the literature regarding it. Only a paper or two talking about this low-lying peroneus brevis. It's as you can imagine you know you're you're adding another lane of traffic if you will in the tunnel and that that creates stenosis. So you know in that that will create increased pressure on each of the tendons and you know the peroneus brevis is already got a lot of pressure exerted on it by the longus and so you add a muscle belly down in there and you know you've created you created an additional additional problems. And so again will test her now and this would be the risk risk position high-risk position for dislocation dorsiflexion and inversion and she's she's good.

So really one of the biggest concerns when you do this procedure is not to disrupt the retinaculum when you do the approach or when you repair the part appropriately so you don't cause any subluxation or dislocation? Yeah.

CHAPTER 6

Okay. So this could be pretty mundane, but I really consider this a big important part of each of the surgeries for foot and ankle orthopedics in basically construction of a splint. Some of my trainees will say that this is, this is my my hang up. The splint has to be done well and done uniformly each time.

So I basically take 6 inch webril and make a very healthy posterior padding for it. And then I use a 6-inch and two 4 inches, actually two 6 inches, we will use and they're the same the same length as this. It’s just wrapped end over end. That's going to be the back slab and then there is going to be two side gussets each of the same length and also wrapped end-over-end. And then the second side gusset right here. Again same length. Wrapped end over end.

That's okay I'll be happy to to mop or sweep or whatever. And then in addition to that on the outside with a 6 inch ace bandage and a 4 inch bandage and of course you some 4-inch webril. To hold it in place.

Okay so this is the posterior padding that's going to go on. Arvin’s the most important part of this whole process is the holder. If you don't have a good holder in the splint can't can't go on that well. You can see his his right hand is over the top of the right arm is over the top of the knee and his left is holding the foot in position and ankle in position. I'm just cutting some notches here so that we don't get any dog ears in the in the padding, and then I'm going to form fit the padding with some webril here. That's good. Yep okay. Then another one on the foot just to make sure we've got everything well conforming to her foot and well-padded. Nice. No that's enough.

So next thing we do is use some of that 6 inch and this is called delamination. We don't want any we want to make it all uniform and all the plaster layers to be sticking together, so I'm sort of squeegeeing out the the water, pressing the plaster together. Again Arvin's key here. You're holding it and then I'm going to make sure that adheres to the underlying padding. So that it’s completely custom fit to her leg.

And then the side gussets are going to go on, going to do the same thing make sure that these are there's no lamina present. There's no no layers. Make everything a single layer here, and again just making sure it's perfectly conformed to her anatomy. And then the last side gusset on the lateral side.

Then the next thing we do is put on the ace bandages. Start above the level of the of the splint so you can tuck it in at the end, and work your way down. 4 inch goes first, followed by the 6 inch. Around the heel, slightly over the toes. From of the top again. 3 please. It is taped off right on the bottom. One more up there.

And then and then it's put right on your sternum putting it on your sternum makes it flat there's no rocker bottom to it. If you put it in your abdomen and will press in and become curved and you don't want that. You want to give him a nice flat foot plate.

Yeah please and what I'll do is just tuck this in right here. Then just pop this so that they don't get too tight if there's an post-operative swelling and we will do the same down here after the splint has set completely. Now you just wait until it hardens.

Last step is we just free up the toes here. Pop it right here so she’s got enough room. That’s it.