Awesome. I'll get you to talk next, okay? Is that good? I think Brian can do it, I bet. So, well... He can do two talks. He can do it. So, thanks for having me here. I appreciate everyone sticking around. It is tough. It's a long day, but since you guys stick around so much, I will give you everything. I will not keep any secrets to myself. There is a conflict I will talk about, and then DOBLE, which I helped Robert with Arteryx. So, this is the first time I found out during this talk that actually we can use arthroscopy, our beloved tool, to actually address every single thing, from the back of the calf all the way down to the plantar fascia. So, pretty much everything in the Achilles tendon and plantar fascia complex can be addressed using endoscopic technique. So, starting with gastroesophageal, you have multiple techniques you can choose. Usually, the common technique would be a Strayer release and a Bauman procedure, number B and C, respectively. So, you guys done Strayer release before? Let me see, hands, who's done Strayer? Who's done Bauman before? Bauman is actually not as common, but it's more conservative. It's actually keeping the soles more intact and releasing more proximal. So, using this endoscopic technique, you can do, on the left side, a gastroesophageal. On the average, you get about 10 degrees of release. This is a dry scope using this possible candela. Using the same technique, you can also release the gastrocnemius fascia from the front. So, this is a Bauman technique, which you have about maybe 60% of the correction of the equinus contracture using this technique. So, that can be done using the same instrument. You also can take care of more distal problem, acute tendon missubstance. This is Argentinian doctor, Mike Querin, reported 20 cases of endoscopic debridement or tenotomies for missubstance tendinopathy, which great results in 85% excellent result. Only one delayed keloid, one seroma with chronic fistula with a long-term follow-up of 5 to 14 years. The way I take care of this would be endoscopic as well using candela and pretty much a four-millimeter scope from the proximal, medial, and distal lateral portals. This is originally described by Nick Van Dyke. You can actually debride the scar tissue. More scar tissue is actually going to be in the front of the tendon, so you want to focus on how to remove the scar tissue. Sometimes I do some vasulotomy of the deep posterior compartment a little bit to actually create vascular channel from the front. A lot of time you do tenotomies using 11-blade. You can also debride when you are running into cases with big, huge hypertrophy of the tendon. You can actually debride and excise some of it. This is an example of a case of a 70-year-old female Pilates instructor, probably two years old, multiple surgery in the past, using AFO as her baseline, forefoot pain, feeling tight at the heel cord. You can see next why the heel cord is tight. It's tight and hard because she has ossification in the tendon as big as her fibula. It's very tight, stiff, and she's overloading her forefoot substantially. She wants to have her surgery done. She wants to be awake during the surgery. She wants to have full weight bearing, and she did just that. During the surgery, she's been talking to me all along. We did under local, using camera to look into the tendon substance, using a shaver to remove the bone bit by bit and removing it out. At the end, we also did a gastroc recession to remove overloading of her forefoot. At the end, she was very pleased. She said she now would not need any more AFO for her life, and she's happy with a tendon that didn't require open surgery. This is at three months, follow-up. When you go to a little more digital, you take care of the insertion of Achilles tendinopathy. I would recommend for your first few cases, do something close to the right-hand side. Those with retrochemical bursitis respond very well to endoscopic debridement. Those with some more bone spur and bigger the spur, you have more work to do. So just start with something easy first. The way I do it in prone, using a needle to actually be a cutting jig for myself so I can cut right on the needle so I can make it perfect on the camera, perfect on the post-op x-rays as well. You don't really have to do it. I just want to make it as precise as possible. This area is very inflamed, and a lot of times you see the red inflamed sine wave tissue in the bursa. Using the shaver, keep cutting. The bone, and once you are done, you're going to run into the pins, and you can use burr to make sure the bones are removed adequately. Make sure the lateral, medial lateral borders of the calcaneus tuberosus should be polished to make sure they're nice and smooth without any bone spur. This is an example of a case with predominantly retrochemical bursitis that has been treated using the same technique. Again, this is an intra-op picture so that we use a shaver and just debride the soft tissue and remove the bone spur. The patient was pain-free at six weeks. The surgery itself is very satisfactory in terms of having fun doing the surgery. If you guys like doing arthroscopy, this is a surgery that you will enjoy doing. When you are dealing with some more problems with intra-substance disease, tendinopathy, you can also look at the right-hand corner, the lower picture. You can do longitudinal stenotomies on those areas to promote soft tissue and stimulation of bleeding and growth factors. This patient also has pain-free at three months, doing well at two years. When you are running into cases that you need to debride more and more, at some point, you end up taking down some of the kidney tendon insertion. There's a way to repair it, and it's very simple. It looks like a cuff repair, but you actually put anchors into the tuberosity and shuttle the suture across the Achilles tendon insertion and can repair it back down. There's a technique described by Jordi Vega. Again, once you are dealing with something with more damage problem, to the point a tendon is sufficient, you remove so much of the bone, so much of the tendon, you might consider primary tendon transfer to FHL tendon. So this is also you can harvest a tendon using two posterior portals, take the tendon out, put whip stitch around it, and dock into the calcaneus tuberosity or using endoscopic guided method, minimally invasively. When you're dealing with more problem, now going to more distal at the heel, heel spur is something that I was taught that shouldn't touch it. Everyone has it. You don't need a surgery, but end up becoming the happiest patient in my practice nowadays. The technique of how to do a physical exam to detect if the patient has pain on the heel spur is that the patient would have no pain when you do a left-hand side examination for plantar fasciitis. They said they feel fine, but when you push the bone at the bone spur from front to back a little more at the tuberosity, patient will complain about severe pain. This is a technique described by Kumatsu that they use medial lateral portals to identify the plantar calcaneus spur. They report only eight patients. I have done probably more than 15 now with great results, and this is an example of a case that I did. You actually see the bone spur sitting in front of you. The working space is actually not very limited at all. The surgery itself is under control. You remove the bone spur bit by bit using a shaver, at the same time preserving the plantar fascia insertion over the tuberosity. You can debride it, and sometimes there's a tear in that area that you have to debride, but most of the time you just use the shaver, trim it down, use furrow to help monitor that you are adequate in terms of your resection, and at the end you have a good result for your patient. This is a patient of a 47-year-old lady with two bone spurs, so we need to go and chase out the two bone spurs, make it nice and smooth. The patient was happy at the end. When you are dealing with more distal problems, plantar fasciitis, you can do endoscopic plantar fasciotomy. This is a picture of how you put the cannula inside. You see the plantar fascia, and you can release it, exposing the flexor deteriorum bravissimuscle underneath. This technique that I described, and this is from Arteryx, but I think it has the best picture, so I'm going to show it to you. So using the guide pin, find the plantar to the plantar fascia, and you exit on the lateral aspect. Use the cannula, then to go right on top of the trocar. You can go cannula from lateral to medial, or medial to lateral. No difference. And the key for this technique is that the plantar fascia has a lot of fat, a lot of scar tissue. When you clean it up, you're going to run into a lot of rough fat in that area that you need to use a rasp. When you use rasp to clean up the soft tissue, then that would improve the veteratization substantially. See the rasp coming in, and then get rid of the fat, and allowing you to remove the central band of the plantar fascia. Remember, we would not try to release plantar fascia completely, because you are going to take risk of collapsing the arch. The lateral band, highlighted as a blue marking, should be preserved. Just cut the central band using a retrograde blade. You can mark, and then decide how deep you want to go, and just do just that depth without going beyond. So you preserve the lateral band. So this patient usually can start putting weight on right away. Thank you very much. That's awesome.

endoscopic techniques

foot and ankle conditions

arthroscopy

Achilles tendon

plantar fascia complex