I'd like to thank John Kelly for the invitation and the Association for the invitation. A bit about myself, for 10 years I was the only foot and ankle surgeon on the Western Seaboard of Ireland, so I've looked after most things. We had a catchment area of about 450,000 people, or approximately 889,000 feet if you look at it that way, including diabetes. This is the view from where I live on my way to work in the morning, so you're more than welcome. Part of this I suppose is to promote Ireland, so you're more than welcome to visit any time. I was asked to talk about all of hindfoot arthroscopy in nine minutes, so that's a little bit of a challenge, but I'm going to focus on the things I think that we all need to know how to do if we have any interest in foot and ankle surgery. Some Jim has covered in elegant detail, but ankle arthroscopy in particular, which is my workhorse, would be my anterior ankle arthroscopy and how I do it safely, opposed to your ankle arthroscopy, which I would do a lot less, but I still think it's very important if you're going to treat pathology in the ankle joint, particularly in sports. Sub-tailor arthroscopy I've done a few, I'm not going to touch on that, or tail and vicular, because I think really they're quite challenging and perhaps really specialised arthroscopy and perhaps more useful in fusion. And then a little bit about tendon and how you can scope tendons in your practice. So the title was how, when, where, why, and to look at when, when do I do arthroscopy, and some of this has been covered, soft tissue pathology like this, this is a meniscioid lesion in one of the physios in our hospital, synovitis in an inter-county hurler, arthrofibrosis. These are all common conditions you will see if you scope the ankle. And here you can see peroneal tendon tenosynovitis, so all of these are amenable to arthroscopic treatment. In terms of cartilage pathology, you will see pure cartilaginous pathology in all these joints, but more typically you see a combination of bone and cartilaginous pathology, so either bony impingement with soft tissue impingement, as we've mentioned, osteochondral lesions of the talus, the distal tibia. And I think increasingly there is an increased awareness of subtle or occult syndesmotic injury, so that we're seeing when you scope a lot of patients you're finding syndesmotic instability. And then there's the interpretation of that in terms of the patient's symptoms and their other pathology. How do I do it? Well, I think you need one good equipment set. That set should have shavers and burrs of different dimensions in it. I use a small joint scope for all my hindfoot arthroscopy. I use traction, as Jim does. I think very important out of the ICCRA meeting was to use small picks. So when you ask for chondral picks, typically you get handed the knee set. It's important you don't use those in the talus. They're just too big. And the microfracture damage caused to the bone is too significant. And I typically use rapivacaine to inflate the joint, because we've shown that's as good as giving the patient a block in terms of pain relief afterwards. So they get 20 mils of rapivacaine, 10 before and 10 after. I do a similar setup. I use a stirrup, and I put on traction on the table, and paint and drape, and then insufflate the joint. Again, use the same anterior portals. I'll put a posterior portal if something, pathology is more posterior, and I need to get at it. I always start anteromedial. That's your safe, consistent portal. It's how, as a trainee, you should inject the ankle. You feel the medial malleolus, feel tip ant, feel the soft spot, put the needle in. And it's important to remember, particularly if you're doing impingement cases, the concavity of the ankle joint. So if your needle is going down, your portal's going to go down. You're not going to be able to do anything. So it's very important that that needle is going up, and that your portal is below any callus so that you can gain access to the joint. The main nerve injury, and Dr. Ferkel and others have published extensively on nerve injury, because it's the main complication of all hindfoot arthroscopy is nerve injury, and the main nerve that gets injured is the superficial perineal. And unfortunately, that nerve is quite variable anatomy. So it is important to look for it. And typically, this is known as the fourth toe flexion sign. So you can see quite clearly here, here's certainly a significant branch of the superficial perineal. And that enables you to put portals either side. And you can transilluminate it once you've got your medial portal in. So that's a very important technique when you're starting out, because neuromas of that nerve can be very painful. And then you do a systematic joint assessment. And here in the video, you can see assessment of the syndesmosis. So this is another intercounty footballer who has profound syndesmotic instability, so that you can easily put the shaver straight up into the syndesmosis, which is always abnormal. But it's important to be systematic and check all these things and document you've checked them. In terms of posterior, I typically use this for distal tibial osteochondral lesions, because they tend to be post remedial impingement at the back, as we've covered, osteogonal postulatal process. And as we've said, FHL pathology, I use a very similar setup. So I think it's important that you have the foot clear, so you can dorsi and plantar flex and invert-evert, so you can identify the subtalar joint and the ankle joint. I typically also would tilt the patient so the foot is straight up and down, so you don't have that issue of the foot being at an angle if they're externally rotated to compute in your head, as well as everything else you're trying to do in terms of anatomy. I do spend a lot of time marking it. I think that's really important. So I mark the malleoli, mark the achilles, mark where I think the subtalar joint is, mark the pulse, so I know where that is, and then I mark where I'm going to put my portals. And I think when you're starting out, this is quite an intimidating scope. It's not like an anterior scope at all. When you put the scope in, there's no joint. You don't go into the joint. You sit outside the joint. So it's much more like a subacromial decompression, perhaps, as Jim has said. Your first view is just this view on the right here. That's all you see. So don't panic. You're not going to see the back of the ankle joint straight off. You're just going to see fat. And what you're trying to do is identify the critical landmarks back here. So the intramalleolar ligament and the FHL really are your friends. They're the two things you want to find and stay lateral to FHL. For the whole procedure, you must stay lateral to FHL. That's where you're safe. And unfortunately, there are documented posterior tibial nerve injuries during this procedure. Then once you've cleared your working space, and I'll show you how we do that in a minute, you have your four zones to inspect, your superior zones and your inferior zones. They each have a landmark within them. So in the supermedial zone, you have FHL. In the superlateral zone, you have the back of the syndesmosis. In the inferior zone, you may have a lateral process or an osteogonum. And you may see the back of the CFL or indeed the peroneal tendons if you go infralaterally sufficiently. And once those are clear, and once you've identified the boundaries of your working space, you can then get a very good view of the ankle joint and indeed the subtalar joint. Then you can enter both joints if you've done enough release and if the joint's not too tight. So this is what you see when you start out. And this is one of the cases I'm going to show you. So you just see fat. And as Jim said, the most important thing is to either use the trocar or the shaver to actually find yourself. Then you turn the teeth of the shaver towards yourself so that you're definitely not shaving something out of sight. And start working on clearing a working space for yourself until you get to FHL, which you can see here. You can see I've done a bit of extra work in this case to free up that tendon. Then you can debride the posterior capsule and a little bit of the ligaments because they will kind of be in your way until you get a clear view. Here you can see the back of the ankle joint coming into view. And this then gives you a working space with your FHL boundary on one side. And here's a large malunited postural lateral process fracture, actually, which I'm taking down using a curette. And then I'll typically use a small burr and maybe an osteotome and various graspers to take it out. And more often than not, it ends up coming out piecemeal. So don't be frustrated by that. That's okay. You don't have to get it all out in one piece. So just to kind of combine those two talks, this is a patient of mine I treated last year. She's 32. She works in Equestria, which is a big industry back home. She fell off a horse. She went to another hospital south of me. She was treated in a boot for four months. At that, when she came to see me, she was severely swollen ankles. She was unable to weight bear. This was some of her scans. So she has an acute osteochondral fracture of her anterolateral talus. She's high signal in her syndesmosis. She's this unusual pattern of bruising in the anterior distal tibia. She also has some chronic looking cyst formation in the distal tibia and a lot of high signal posteriorly consistent with a syndesmotic injury with avulsion of the posterior syndesmosis. So a very significant injury for her. So my treatment plan was to do an anterior scope. I felt unbalanced. That was where most of the acute pathology was. You could say maybe do two scopes on the day. We can discuss that. I said I would pin that osteochondral lesion in situ. I would debride the distal tibial lesion. I would augment it with biologics as is routine in my practice, and I would assess the syndesmosis. So here is the anterolateral osteochondral lesion. I pinned that using a bioabsorbable pin, and then this is the distal tibia lesion, and this is fairly typical of what you see. It never looks that impressive at arthroscopy, but this is the lesion. You probe it, and the probe will go right up into it, a little bit of curette and microfracture. Probed the syndesmosis. It was grossly unstable. Put in a syndesmotic tightrope. So that was her first procedure. She did very well initially. She was quite sore, but did quite well. Her anterolateral pain went. Her ankle swelling went. She was able to weight bear, but represented with post-remedial pain. So now we have a post-op MRI showing my pin fixation, but I think the big change here is the posterior, or the post-remedial distal tibial lesion has really become a big issue for her after the debridement. It's got bigger. So at this point, we decided to go posterior and retrograde drill this. So here's the posterior scope. You can see the fiber cartilage that is formed in that lesion, and here's the fixed anterolateral osteochondral lesion from the back. So you can see it quite clearly from the back of the ankle joint, and here's the combined fluoroscopic, arthroscopic technique. So a combination of, I always mark the lesion I'm going to drill with the probe, get my assistant to hold that on the scope and make sure nothing bad happens in the joint. Then I do the drilling under live fluoroscopy, and then we use the oil-based calcium phosphate cement because I like that because the water in the joint keeps the oil-based cement out of the joint. So this is a cement made actually in Ireland, in IN3 cement, handy. So that's the arthroscopy part in terms of the joints. When we look at tendonoscopy, the main tendoscopy I've done is of the peroneal tendons, personally. It's an easy thing to do if you're scoping the ankle and you're doing some form of lateral ligament procedure. It is not hard to have a quick look at the peroneals when you're there with a scope, and obviously it's a lot less morbidity than opening them all up. I know John has done a lot of work on posterior tibial tendinitis and tendinopathy using a scope in the post-tendon sheath, and also we've mentioned Achilles. But here you can see the two peroneal tendons very clearly within the sheath using just two small portals. I think the reason here is, and certainly back home, most general practitioners or people who see these patients, emergency physicians, have never even heard of the peroneal tendons as a cause of persistent post-lateral ankle pain following an inversion injury. So they're not generally diagnosed, they often present late. It's also worth noting that one in three patients will have peroneal tendon pathology on MRI and have no symptoms at all. So it can be over-diagnosed and under-diagnosed. And the problem is the surgery, traditional surgery, is quite invasive. So the idea of a tendinoscopy to even confirm your diagnosis certainly has a role, and perhaps allows an easier return to support. So again, it's a simpler setup. The patient's just on their side. You can mark out your anatomy, your ATFL, and your three portals. And then you can directly, your watching portal tends to be proximal, as most of your pathology is perimalleolar or inframalleolar. And that gives you a good view of this kind. So this is normal. This is a peroneal tendon tear. This is tendinosis and tenosynovitis. And you can also deepen the groove in a case of peroneal tendon subluxation. You can do that arthroscopically also. So just to summarize, I think pretty much all trainees should know how to do an anterior scope. That's how you treat septic arthritis of the ankle, et cetera. It's your workhorse in most of what you do. Remember to check the syndesmosis in every patient. And newer techniques allow lesser invasive options for other tendon pathologies. Thank you very much. Thank you, Stephen.

hindfoot arthroscopy

ankle arthroscopy

tendon scoping

soft tissue pathology

cartilage pathology