This section is going to be on Tendoscopy and Ostrigonum, and I'm moderating with Jeremy McCormick. Our first speaker is Dr. James Kolder, and he is going to share with us his experience with perineal tendoscopy. Great. First of all, thank you very much indeed for inviting me. It's great to actually be back in person rather than on some little screen again, and great to be back with many friends from North America and elsewhere. So the role of perineal tendoscopy in my practice. My conflicts of interest are, as noted in the AOS website, apologies. I'll try and add some science to this, but you asked for what I do in my practice, and there may not be much science, but I'll try and add some to give some voice of reason as to why I do what I attempt to do. But it is going to be, some of it, level six evidence plus, so apologies to Oxford. I think, basically, if we take it back to my practice for perineal tendons, changed enormously following this meeting where we had a consensus meeting in London. And you'll see, you'll hopefully recognize a few of the reprobates on there, people from Australia, the US, Singapore, and you'll recognize a few of them. The main reason for having the meeting was nothing to do with perineal tendons, it just happened to be there's a FA Cup Final, which is the oldest football cup in the world, and football, soccer, apologies for North Americans. But that's probably the real reason we had it, but it was great fun. But it did change my practice. So what is my practice? What do I find the role for perineal tendoscopy? Now, I tend to do mainly sports injuries, and I'm very lucky with that, and it's mainly the professional sportsman. And if we take it back and look at the predisposing factors, sure, we know the retromalleolar groove morphology is important, and that goes back to the anatomy papers in 1928. So they recognized that then. And the other thing is overcrowding in the sheath, low-lying muscle bellies, say maybe a perineus cortis. And so you've got to address those two points if you're going to treat these. We also know that conservative management is pretty useless. You can stick them in a cast, but they have a 50% success rate at best. So in a professional athlete, that's pretty poor. And conservative management, in my view, is not to be recommended for acute dislocations in athletes. And so if we look at where we're going from here, direct groove deepening is very, very well recognized as a good way forward. So there are various different techniques for addressing that, but a direct groove deepening seems to be a pretty good way of doing it. And so when we looked at the consensus, there was very good evidence to say that we should not be going along with conservative management for these, and operative management is the best way. Well, before the meeting, this was my technique. So I used to do an endoscopic repair. I used to address the groove and deepen the groove, but we used to do a mini incision approach initially, and then use the endoscopy to address those factors. And we wrote up a series of these. Stéphane Guillot, who's in Bordeaux, is a most amazing arthroscopist and convivial character. Anyone who gets a chance to go to Bordeaux, there are obviously more reasons to go to Bordeaux than just visiting Stéphane. But whilst you're there, happen to pop in and look at his surgery as well, because he's the most amazing arthroscopist. But we wrote this up with a few of them. First of all, we addressed the lateral wall of the fibula. And if you roughen that area where the periosteum is being peeled away by the dislocating tendons to encourage it to stick back down again, and then you do the groove deepening into the perineal groove to take away that convex morphology. We then put in a suture anchor, a bone anchor, and used this to come out and cinch back the superior perineal retinaculum, and snug it back down, which then pulls it back down again. And the success rate has been good. This was a very small series back in 2013. However, my opinion on this changed because of the consensus meeting. So the consensus, thank you for the knocking, the consensus suggested monoperative treatment won't work, and it's no place in the athlete. Open techniques certainly appear to work with stripping the periosteum and repair the superior perineal retinaculum. However, one bit that came out of this consensus meeting was that endoscopic treatment, where you can deepen the groove, you roughen the lateral wall of the fibula, but you don't repair the superior perineal retinaculum, and that returns your patient earlier. Now, I argued with John Kennedy, if he's still here, but he had argued with John about it, saying, come on, there's got to be a recurrence rate. But the consensus went that way, and everyone told me I was wrong. Well, most people tell me I'm wrong quite a lot of the time, but there we go. And I took that on board, and I tried it. And I have to say, this is my practice now. So I will now do an endoscopic approach, groove deepening alone, without an acute repair of the superior perineal retinaculum. And hopefully, if we can get this thing to work, it's quite simple. I know that I think John's going to be talking about it later, but lift up the perineals out of the way by putting a white gauge needle across the front of the fibula, and hitch them out the way, so you give enough room to introduce your shaver blade. Personally, I prefer to start at the end, because at the tip of the fibula, and work my way proximally, because otherwise, I end up with a knobbly bit on the end of the fibula. And I've regretted that, and it's just, you can't keep on slipping over the edge. Or I find my technical inability to do it properly, I prefer to start at the distal margin of the fibula, and then groove proximally as I go along. And by and large, that then, you can give a, make the groove in the posterior aspect of the fibula. But you can also then sweep across anteriorly, where that perineal, where that retinaculum has been stripped away from the lateral border of the fibula, and roughen that up so that it sticks back down again during the rehabilitation. This is a 22-year-old professional soccer player, premiership soccer player, with one year follow-up. Just last month. So it's an odd-looking groove, I give you that. He had a perineus cortis, so I think it's important to remove the cortis if it's in there at the same time, as well as do the groove deepening. But he's doing well, he had his MRI scanned because he got an avicular fracture. So that's just unhappy, but there we go, but at least the groove deepening seemed to work. It's a little bit, I give you, it's a little bit odd, but they seem to work. Another indication that I alluded to a minute ago is perineus cortis. If you've got an overstuffing of the perineal tendons, or the perineal tendon sheath, and they're getting pain there, then perineus cortis can be addressed endoscopically very, very easily. And I've got no idea why that isn't playing. It is the easiest operation in the whole world. My anesthetist tells me that it's like a monkey with a machine gun, because all you need to do is just stick the scope in, you stick your shaver blade in, and you have a, it's a bit dark that day in my scope, so apologies, but you'll have a low-lying muscle belly, and you take out the whole of that muscle belly, and can you press the, see if you can press it? It was working earlier. That's it. Oh, it's a bad moment, isn't it? We'll ignore that one. Trust me, you can take it out very, very easily. We'll leave it. You can take that out endoscopically, and it's one of the easiest operations to do with a good success rate. It's not written up very far. The other one is diagnostic. Spelling mistake, sorry about that. What happens if you've got normal radiology, but you've got a patient who's got definite pain in the perineal tendons? Now, I was always taught that a scope is not a diagnostic tool. It's the last resort, and certainly Nick Van Dyke has said, you go into an ankle doing an ankle arthroscopy expecting to deal with the pathology that you nose there. You don't go in blind expecting to find something that you haven't seen beforehand, and I agree with him on most of this, but I think in this situation, if you've got somebody who's got very much perineal tendinopathy, or perineal tendon pain when you look at them, they've got normal pathology on the radiology. An ultrasound-guided injection is a very good way for seeing whether it's actually the symptoms are improved, and in that situation, if it's positive, then I would consider a tendoscopy. There are some level five studies looking at this and suggesting it's a good exploratory procedure to do minimal trauma associated with it, and you can then end up identifying a tear in the perineus brevis in this case, and you can then go on to treat that as you wish, and certainly we do have some patients who are missed on MRI scan. When it comes to surgical management of, say, the perineus brevis, what happens? I've always been worried about what you do with that, because if you identify a big tear in it, you then have to go and open it up, and so you don't have to treat it, you can't treat it necessarily endoscopically. I don't think they should be tubularized. I think the days of tubularization may have gone. I think one of the people who was on that parent consensus was Pim Van Dyck, who did her PhD with Chris DiGiovanni on perineal tendons, and why would we create a round tendon from a flat tendon when we're repairing it? That just seems crazy. From our point of view, I think if you go back to what Jim Brodsky said many, many years ago back in 1998, if you've got 50% of the tendon remaining, just excise the other 50%. Don't bother doing a big repair and stuff. Good results in that have been reported by several authors going back nearly 20 years now. Ultimately, your own tendon is the best tendon, and I have a high threshold for taking other tendons elsewhere and doing a tendon transfer, and certainly if you've got ... Probably I go down to about a third of a tendon. If a third of the tendon's there, I'm happy excising two-thirds of a tendon and leaving the other tendon, and surprisingly enough, a lot of it regenerates. My role for tendoscopy, acute dislocations, excision of a torn perineus brevis and accessory tendon, debridement, if there are adhesions in there, and also possibly diagnostic. I think in summary, perhaps I've adapted my practice from having reflected on the science that's been taught to me by the consensus group. There's one thing I'll put in there, and maybe somebody can discuss it afterwards. Perhaps I've been told that you should be doing it, thinking about it for os perineum. I've got no idea about that. I find that a really difficult one to deal with, but I'm happy to discuss that with somebody. Thank you very much. All right. Thank you, Dr. Calder. Next, we're going to invite Dr. John Kennedy to the stage. He's in New York, and is well-published and well-known in the arena of sports foot and ankle cartilage and biologics work, and I just found out he also is good at telling Dr. Calder he's wrong about things, so tell him he's right about this one. Help us out. Understand perineal groove deepening. All right. Thank you very much, indeed, for that nice introduction. So I'm going to talk to you about endoscopic fibular groove deepening, and it won't be the first time an Irishman has told an English fellow that he's wrong. They don't always believe us, though. All right. These are my disclosures. So perineal dislocation, subluxation, and even stenosis is relatively common. It's not reported very often, but I think we miss a lot of it. This is the mechanism of injury, which you know. It's important, again, to follow on what James was talking about. Almost 100 years ago, most of us believed, most of us, I wasn't arrived 100 years ago, but we were told that most fibulae were concave, and therefore provided mechanical stability and prevented subluxation and so forth. Over the last 100 years, with CT and various other modalities, we now know that that's probably not the case, and in fact, most of these are flat with only about 10% that are truly concave, and the mechanical stability for the fibulae is conferred truly by this fibrocartilaginous rim. Some elegant work by Paugolano and others has shown that the size of the rim determines the volumetric capacity of that retrofibular groove. So it's important, when we think about the treatment for this, to truly look at what the classification, because in many ways the classification can guide the treatment here. Most of these are grade one or two, and that's when the SPR is lax, or the fibrocartilage rim has torn away, and again, it truly creates this laxity within the SPR. Grade three, which is the pathognomonic flexine, is relatively rare, and we really don't see that very often. Of course, at grade four, then is when there's a true tear. By contrast, interstitial subluxation, as defined by Raiken, is more when there's a tight SPR or where there's volumetric reduction in the size or the ability for the tendons to glide over each other. Now, you get subluxation in many patients anyway, and it's not always pathologic, so I agree with what James says, that you should probably inject these with a lidocaine even after you do an ultrasound and see the subluxation, because it's not always pathologic. So again, there's so much agreement between an Irishman and an Englishman here, it's ridiculous. I agree that we shouldn't really be operating on most of these, particularly in the athletic population, and we're left really with a couple of alternatives in terms of surgery. We can do an SPR repair, which was, again, elegantly described over 20, 30 years ago by Desai, known as the Singapore Sling, or we can do direct or indirect groove deepening, a combination of both. I had these in bone blocks and tendon rerouting and so forth, simply for historical perspective. We really don't do those any longer, and they're more for historical reasons. So this is how we can do fibular groove deepening. We can do open, which is useful if there's other pathology in the area, particularly if there's a large tear, sometimes we have to do open. We can do endoscopic, as again described, my great mentor for many years was Nick van Dyck showed us how to do this, and now we're moving on to do nanoscopic, so even smaller. Same procedure, just smaller instruments. So these are the concerns with open groove deepening. You have prolonged postoperative immobilization. Return to play is what all the coaches and all the trainers are telling us. You've got to get their patients back onto the pitch quickly. You can get scar formation. You can even get nerve damage. It's very close to us there. And we can over-tighten the SPR. The SPR is really a diaphanous structure. It's very, very thin. And so, like all orthopedic surgeons, when we over-tighten things, we say it'll loosen up, and we under-tighten them, we say it'll tighten up. But in this case, when we over-tighten the SPR, you create a stenosis, and those patients are the ones who come back. And they're complaining afterwards that they've got some pain and swelling. They can feel almost a squeaking. They can hear the squeaking as the tendons rub against each other in this very tightened, now subfibrillar groove. So I think in endoscopic groove deepening, once you have a new groove, it'll prevent, and it prevents subluxation. You really don't need an SPR repair, and this was what the consensus meeting in London was all about. And we can avoid this post-operative stenosis due to scarring, over-tightening, and we can get a fairly quick recovery and return to play. So when we look at the data out there, and everything we do has to be data-driven, and so we looked at SPR repair alone, and if you look at this, it's pretty good. Eighty to ninety percent of patients are satisfied with their outcomes. But there seemed to be a trend that if you did an SPR with groove deepening, that they got back quicker. So we looked at this, and this was Pim Van Dyck, Pim spent some time with us in New York, and she looked at a systematic review looking at all of these, and she noticed that athletes had a quicker return to play in those patients who had a groove deepening than an SPR alone. Now the first series of this came out from Jordi Vega, and he looked, it was a level 4K series, and he just looked at endoscopic groove deepening. He didn't look at SPR in combination with that, and all of these patients did well. So we looked at our series, and again, Pim Van Dyck and Christy Giovanni were involved in this study, and we looked at 23 patients, and we had over a three-year follow-up, and most of these patients got back to their previous level of sport, and the return to play time was eight weeks for those who did not have a tear. So it was fairly quick for just an endoscopic groove deepening, none of these had recurrence. So we've moved on a little bit now, and we want to look not just at endoscopic, we want to get those players back out a little quicker, and we're very lucky at NYU that we're at the tip of the spear here in terms of looking at newer technologies. This is chip-on-tip technology. This has the ability to see just like a regular scope would with just this chip-on-tip technology. It's a 1.9 millimeter scope, so the surgical trauma around the site is very, very low. This is our setup. The patient is awake. We just give intra-articular injection of lidocaine or marcaine, and with some epi in the bag, there's very little bleeding, no need for tourniquet or anything else, and this is our setup. We do dress up like we're real surgeons, but this is not an operating room, and we maintain sterility this way. We've had no complications with infections, and we've done over 300 of these nanoscopes. So the guys in the residence produced this nice paper. It's in arthroscopy, and it's really just showing that you can address all three sub-marker zones with this nanoscope in exactly the same way that Nick Van Dyck told us how to do it with a traditional scope. This is the early results. We just had 12 patients with perineal pathology. Mean follow-up is about 14 months. Ten patients were successful, and the return to play was three weeks. So because the trauma here is so little, they do get some bony pain afterwards. It settles down very, very quickly. Two patients that we brought to this nano room had large tears that weren't diagnosed on MRI, and that's the only drawback in this, because you really can't then convert this into a mini-open. Then you have to bring them to the operating room. So it's not for everybody, but certainly in most of these, you can do an endoscopic groove deepening in office, and they jump off the table and off they run. So these are a couple of quick cases. This is a 24-year-old tennis player, tenderness of perineal tendons, intrasheath subluxation you can see here and in exactly the same way that James describes we come from the distal tip and move proximally and we're removing some of the periosteum here and I do think that the SPR does adhese down to that through secretarization and scarring. You can see that we're protecting the tendon with the backside of the shaver. We can use a burr in here also by using the wire to hold the tendons out of the way. This is a 59-year-old male runner and again the same sort of story that they're getting snapping or they're getting squeaking and we do ultrasounds on these in-office ultrasounds and we try to replicate or provoke the subluxation or the intrasheath subluxation. And again the same thing. So you can see here there was a lot of cyanobitis. We go in and we clean that up and then we're against the periosteum protecting the tendon at all times. The tendon you can see has some fibrillation here because it has been, the volumetric size has been reduced by all this cyanobitis which we remove. This again another one, 29-year-old female, snapping sensation, gets stuck. She had a perineal tendon repaired in an outside facility three years ago. MRI was unremarkable. And again you can see that we just go in the same thing and these are truly very easy operations to do and there's nothing to it. And the real post-op rehab is very quick. They put in a fourth case here, 33-year-old ex-FBI agent. He'd had multiple surgeries, had multiple things going wrong with him. And really this was both diagnostic and therapeutic. So we're able to go and this is the great advantage. We can move and the patient can move for us at the time we can ask them to. And they can see what we're doing. The setup is they're looking at the monitor just as we are. And so we can see that this was subluxing and therefore we were able to reduce that with a groove deepening. So in summary, fibroid groove deepening produces improved return to play time in patients with perineal tendon luxation and stenosis. We believe that SPR repair is not necessary in most cases and that endoscopic groove deepening is preferred than open groove deepening. I think the future is in-office nano-arthroscopy where the patient is under local anesthetic and this can be done in a very quick procedure but has diagnostic and therapeutic benefits with an even faster return to play than traditional endoscopy but is not suitable for all cases. Yeah, but we're working on it. So many thanks indeed. Thank you. Great talk, John. Our next speaker is Tim Clough from Manchester in England. He's gonna teach us about the open approach. Okay. Okay, thank you very much. My name's Tim Clough. I'm one of the guys that's come over from the UK. I'd like to thank AOFAS for inviting me. I'd certainly like to thank the IT team for helping a dinosaur like myself to get through all the IT issues and load the presentation up. So I come from an area called Manchester, which is right in the center of the UK. It's famous really for one thing and that's soccer. We have two clubs. But if you're from Manchester, then there's only one club and that's United. And we're going through a dismal period at the moment. So I usually go around like Johnny Cash dressed in black because I'm a national mourning, not only now for the Queen, but for my soccer team. So, okay. So I don't know how I can follow what you've already been told because I've got to argue against John Kennedy. And so I've already lost because, you know, a great like John is telling you one thing and I'm saying, well, let's take it in moderation. So open groove deepening. How do I go forward? This one, that one. Okay, so those are my disclosures. Okay, so you've already heard perineal tendon dislocations. You should really manage them surgically in some way. They don't do well with conservative management, probably a 6% failure rate of recurrent dislocations. So we're into some form of surgery and you already know what surgical options we have. We can either do just simple repair. We can do repair and groove deepening. And then the other two, we don't really need to discuss because that's a difficult operation which we don't need to do bone blocks or rerouting. That's basically in case you've done your first operation wrong. Okay, so you've already seen this slide. So this is John's own meta-analysis and he's taking you through it. So first of all, do I really need to deepen the groove? Okay, so he looked at 14 studies, 283 patients with SPR repair alone and groove deepening plus SPR repair. And if you read that meta-analysis, the key study is that if you do groove deepening, then your return to sport time is significantly better than if you just do repair alone. So that's the take home message. And if you're doing sport, which we all do, we therefore have to groove deepen. But if you read the paper and you have a little play in real time surgery, then the slightly worrying things, the AOFA score is the same for them both. The percentage re-dislocation rate is roughly the same. There's no statistical difference. So it's about one and a half percent. In that paper, the meta-analysis, the groove deepening was longer, but not significant in terms of return to play time. So there are other things to consider. So then you've got to deepen or not to deepen. And then there was this paper, again, small numbers, looking at SPR repair versus groove deepening. So return to play time is around three months if you're doing it open. AOFA score is about the same. And percentage re-dislocation is probably higher on an SPR repair. But there's only one, and one in a very small number suddenly makes a high percentage. So we can assume, therefore, that you might want to do groove deepening. So therefore it comes to, are we going to do it open or are we going to do it endoscopic? And this is where the dinosaur comes into play because you've got an easy operation with a tiny incision and you want to make that more difficult with higher complication rates for, if all goes well, a much faster return to play time. But if all doesn't go well, then you've got egg on your face. So the open incision, you've all done. It's a small incision at the back and you put a guide wire up through the tip and you create an osteoperiosteal flap. So the aim of this is to preserve your natural fibrocartilage in your fibular groove and you just tampen it down to deepen your groove. It minimizes, that technique minimizes the risk of fibular fracture and allows good repair of the SPR. So what John was saying was, do we need to repair the SPR or can we just groove deepen? Can we flip it the other way? Well, anybody who's done the procedure open knows that these guys have capacious SPR. So suddenly we are producing an operation and not addressing what could be the primary problem. You've got overstretched knicker elastic and you're just going to ignore that and hope your pants don't fall down. So the technique is simple and you have a low complication rate and a very, very low re-dislocation rate. So why should I do it open? Well, not because I want to, we've heard so much about arthroscopy and it's a modern way, but there are certain things where if you've got great operation, can you make it greater with a new technique? And this open procedure is simple. It's a rapid predictable recovery. It is extremely reproducible and it's a very low failure rate with a high rate of success to sport, high patient satisfaction and excellent pain relief. So to me, the only advantage of doing it arthroscopic is I can get a much faster return to play time or potentially. So if you're doing it open, the three months return to play time is probably long because we're much more aggressive in your rehab. So you can probably get that down to two months. So arthroscopic is three to four weeks. Well, okay, so if you're a soccer player on half a million a year, you're gonna want to do it arthroscopic. But if you're gonna do it arthroscopic on that kind of guy on half a million a week, you're gonna have to know that you're gonna do it well and you're gonna do it very reproducible with a low failure rate. Otherwise you really are in the doo-doo. So why do I do it open? Well, I do it open because I can almost guarantee I'm on a winner. And there are certain things I'd urge caution in terms of technology. You know, you have a simple operation in hand and wrist and it's called carpal tunnel. And then why would I do a carpal tunnel endoscopic when I can have a one and a half centimeter incision and guarantee my success? Okay, thank you very much. Well, thanks for that talk. I can't wait for the discussion section and I hope nobody's pants fall down. We'll be sure of that. Fernando Raduana is gonna be our next speaker. He's gonna talk to us about posterior tibial tendon and the utility of using minimal incision and endoscopic approaches for that. He is starting a new job in Boston coming up soon at Beth Israel. Fernando. Good morning, everybody. So first of all, thanks for Dr. Hunt for the invitation to be here. I'm gonna talk about the posterior tibial tendon endoscopy for the treatment of progressive collapsing foot deformity. Actually, not exactly the collapsing, but thought I'd specifically gonna go through this during my lecture. So the history of this problem, like in 1936, Kulovsky was the first author to describe the tendosynovitis of the posterior tibial tendon. Then later on in 1950, some other authors, they published their case series of larger numbers of patients. And then 1953, Key was the first one to publish the complete rupture of the posterior tibial tendon. Later on, Fowler's and Magnus Kilden, they published their case series with good results after tenosynovectomy. But at this point already, there was a kind of an understanding in the literature that probably the adult acquired flat foot deformity at that time was a consequence of a posterior tibial tendon tenosynovitis leading to a complete rupture and then leading to the deformity itself. So gotta remember the anatomy of that region. Besides the posterior tibial tendon, it helps a lot to maintain the arch of the foot. We also have other structures, like the spring ligament with its both bands. We also have the deltoid ligament that helps a lot in that situation as well. And in this medial view of the ankle, you can see that the deltoid not only helps to maintain the alignment of the ankle, but also inserting on the spring ligament, it tensions the spring ligament. So it also helps in keeping the arch of the foot. Also the anatomy of the posterior tibial tendon is very important for this procedure. So it's inserts approximately in the proximal tibia and also in the interosseous membrane. It's part of the deep compartment of the leg, has a synovial shaft that starts about six centimeters proximal to the medial malleolus, going all the way down to its insertion on the navicular. It has an almost 90 degree deflection right behind the medial malleolus. And it also has a hypovascular region right there. That's where usually the pathology happens. So then in 1989, Dr. Johnson came with his first classification for flat foot deformity actually, showing again that the first stage, which would be a sequence of events, but the first stage would be the tenosynovitis. And then later on, Meyerson came with a newer classification way more detailed, but again, with the same concept that the first stages of this pathology would be the tenosynovitis over the posterior tibial tendon. Dr. DeLand later on also published a very nice paper and gave even more support to this theory that probably the flat foot deformity is caused by posterior tibial tendon degeneration and spring leaving problems leading to the flat foot deformity because 100% of these patients that he operated on, they had posterior tibial tendon problems. But we know that in some cases like this one here, some patients, they can have initial collapse of the foot. Then when you open, then you can see here that the posterior tibial tendon is intact, even though these cases, they can be sometimes traumatic, sometimes they are not, but several times you open the patient's medial border for any surgery over there for flat foot deformity, for progressive collapsing foot deformity, and you several times face an intact and healthy posterior tibial tendon. So that's when this group of smart surgeons, they got together and they came with this new classifications probably after a couple of beers or wine or something. So they have a lot of, again, a lot of detailed classification showing only the deformities, but these guys, they did not address the posterior tibial tendon at all because there is now an understanding that the flat foot deformity or the progressive collapsing foot deformity, which is the new name, does not have per se relation directly with the failure of the posterior tibial tendon. So that's why this talk is mainly about the, I would say the adult acquired flat foot deformity because the progressive collapsing foot deformity does not address problems in the posterior tibial tendon itself. So these patients, they have to have only tenosynovitis and pain around their retromedullary region. They have the length and the function of the tendon is intact. There is a virus of the heel, even during the heel rise. And if you do repetitive heel rises, the patient may have pain, but not a collapse or not being able to have variation of the hind foot. So there's no deformity, maximum of five degrees of valgus and normal x-rays. So these are the patients that can undergo the tenoscopy for the posterior tibial tendon. We know that the first treatment for sure has to be conservative, like resting, orthotics, physical therapy, and sets, sometimes cortisone shots, shoe modification, blah, blah, blah. And a lot of times, this is enough. But for patients, like about 10% of the patients who do not get better after an inoperative treatment, these patients, they really should go to surgery. And this surgery can be either open or an endoscopic tenosynovectomy. So the first author to describe this technique was Werdmeier in 1995. He publishes like one patient with bilateral problems. And then two years later, Dr. Van Dyck came with a modified technique for this. Instead of only one portal, he used two portals. One of them is two to three centimeters distal to the medial malleolus. The other portal is same distance, but proximal to the medial malleolus. And he used a needle to guide himself to be exactly in the shaft, to be in the correct spot, to start working over there. These are pictures from Dr. Janakos. She was my co-fellow last year at MGH. So these are some images of the procedure. So on the top left hand, you can see a normal intact posterior tibial tendon. On the top right hand, we can see a split. On the bottom left hand, you can see that there was stenosis of the tendon. So the tendon had stenotic problems right there. And then on the bottom, after the release of the stenosis. So as I just mentioned, Dr. Werdmeier, he published his first one patient with bilateral problems in 1995 with good results and no symptoms at all after two years. Dr. Van Dyck, 16 patients, overall good results without any complications. So you can see here that the first papers, they're showing that this is a procedure that does not cause a lot of complications. So that it encourages other authors to try the same technique. So Bolstra, in 2005, 33 patients with multiple indications from only stenosis to synovitis, only two revisions in 33 cases, and all the patients were satisfied, especially for no post-op pain. So this is a procedure that when it's done endoscopically, the post-op pain is way better than when it's done open. So we know that this has proved to be a safe procedure. So some other authors, six patients, Dr. Chow, 2005, all were pain-free and none of them had collapse after the procedure, but this was only for posterior tibial tendonitis and synovitis, no deformity at all. And all the patients, they resumed work in only 10 weeks. Then Hua, 2012, 16 patients, posterior approach. This is a little bit different because he was going like with the patient in prone position instead of supine, retracting the bundle and the FHL and working on the posterior tibial tendon. Anyways, he had no vascular complications, AOFAS from 49 to 84. Dr. Giannakos again, Food Network International, 12 patients, actually this is a paper with Dr. Kennedy as well. And the posterior tibial tendon dysfunction, grades one and some grades two as well. She had like three revisions, but again, false score from 58 to 81. And then Bernasconi, this is the last paper about this subject, 15 patients with three revisions. Same thing, so if we sum all the patients that are out there in the literature, we have 99 patients that are published in the literature so far. Mainly the indications were adult acquired flat foot deformity stage one, i.e. tenosynovitis, and that's it. Some stenosis or some of them diagnostic. Some authors, they tried to do for the adult acquired flat foot deformity stage two, but the revision rates are a little bit higher. We had only eight revisions so far. It's a very good satisfaction rate. So this conclusion, there's a precise and strict indication for this procedure. It should be avoided if patients already have collapse of the arch or the ankle. It's a quick and technically easy procedure for those who are familiar with arthroscopies overall. It has good and reliable results. Low complication rate and comparative studies that are still lacking the literature. Thank you very much. So these are the references. If you guys wanna scan the QR code, they're gonna have all the references of the talk. Thank you very much. Thank you. Next speaker is Paul Halliwell, and he'll talk about Austrigonum. Thank you very much. My name is Paul Halliwell. I live and work in Guilford in the United Kingdom, about half an hour west of London, and this year it's my privilege to be president of BOFAS. So I just wanted to add my thanks to Chris and AOFAS and the whole team for granting us the honor of being Specialist Society, Overseas Society, this year. We're thoroughly enjoying ourselves. We hope we're contributing. And just thanks again. I just wanted to add that to the thanks that Callum gave earlier on. So I'm talking about arthroscopic Austrigonum removal, and there are no disclosures relevant to this talk. There are several uses, of course, for posterior ankle arthroscopy. Austrigonum removal only being one of them, but you can approach the stator process, deal with problems there, flexor lucis, the subtalar joint can be prepared very easily from the back, and there are lots of other things one can address it as well. But that's what I'm going to concentrate on. It's a nine-minute talk. In many ways, this is an expansion of one of Professor Van Dyck's slides, but I'm going to concentrate on it being more of a to-do talk. But why MIS? I thought I would just sort of throw this thought in. We hear a lot about doing something open, doing something closed, and it's made me think a lot over the years about that. And particularly since in my early days of surgical training, I happened to be doing so in my general surgical training when I was working on a ward as a junior surgeon, where one of the general surgeons had started doing laparoscopic cholecystectomy, and the others were doing it the standard way. And of course, what one would see is this massive difference in the recovery between the two sets of patients, and it was fairly obvious what it was. The patients weren't recovering from the operation of having a gallbladder removed. They were recovering from the surgical approach. And then as I've gone through orthopedics and try to look at whether I should be doing something by minimally invasive surgery, because none of us wants to be old-fashioned. We all want to keep up with things, but when is something a real advance, and when is it a bandwagon or something? You're constantly wanting to get it right. So I always do this thought experiment in my mind of thinking, what is the patient recovering from, and also what generates the complications? Is it the approach to get to the structures you're treating inside, or is the determining factor what you've done inside? And if it's more that if the surgical approach isn't a big deal, and it's all about the inside, then it's often difficult to demonstrate a difference between doing it minimally invasively and open. I think maybe that's one of the reasons it's been so difficult to prove the benefits of minimally invasive Hallux-Valgus surgery, because what you're doing inside is pretty much the same. I just throw that in. I'm not sure how much it applies to this particular talk, because I don't think the incision at the back to get at the ostrigonum openly is a big deal, but I leave you with that thought to play around with. So the ostrigonum, we know all about this, something at the back which causes impingement in dances. I see quite a lot of windsurfers leaning back, getting that pinching effect at the back, and it can cause problems. It shows up fantastically on MRI, because you not only see the anatomy, but you see the physiology of the inflammation, and you can test it, if you like, with test injections, and often you can get the bursitis to settle down with a targeted injection, so not every patient needs surgery. But let's say the case is very solid for doing so. Now, I learned this technique, well, nearly 20 years ago on Professor Van Dyck's course, to take absolutely no credit for any of the technique. I just learned it from him and his team, and I've practiced ever since, and there are multiple papers demonstrating that it's a safe, effective procedure, not just from Professor Van Dyck's team, but lots of other people as well. And I'm not presenting this as this is the way we should all do it. It's just, I can't see a reason to do it any other way, and hopefully I'll make that case. And I ran a UK course with a colleague in Guildford in the UK for several years, before the company pulled funding, and then the two of us got involved in other things. We never picked it up, and lots of the people who helped with that are here today, the faculty on that course. So, now on that course, one of the things we came across, and we taught anterior ankylothrosopy as well, but lots of the more senior, in particular, senior delegates came along wanting to learn posterior arthroscopy, and they were saying they were nervous and reluctant to do it, and we would ask, well, what is it? And it came across pretty, pretty obviously, pretty early on. It's just that it's these neurovascular structures, when we're doing arthroscopy, true arthroscopy, it's intracapsular. We know there are no vessels and nerves running around inside the capsule, inside joints. We feel okay being inside there, but as soon as you're outside, this is more, this is endoscopy. It's just a step away, and it just maybe makes us nervous, and this is where we're working, anterior to the Achilles tendon, and honestly, as long as you stick to those principles, it isn't a problem, and during that course, we successfully got people to get over that slight fear factor. So, yes, there are structures at risk, but there are solutions to each of them. Serial nerve, as long as you get the portals right, the technique right, which I'll run through with you, that's not going to be at risk. The flexor hallucis longus, you see it really clearly, and there's a way of dealing with the shaver to make sure it doesn't get damaged. The neurovascular bundle I just showed you, you just make sure you stay lateral to FHL once you've seen it, and you won't damage that. The perineal tendons, the only way you can really start doing damage there is if you get really disorientated, and the way to not get disorientated is to keep an eye on the second toe, and just aim towards that, and if your portals are right, and you know where the second toe is, you won't go wandering down the lateral side and get completely lost and do some damage. Not much to say about kit and instruments, because it's the same as you would use for any other arthroscopy. I use an irrigation system. I feel the pressure, getting the pressure in there is crucial, because the suction is crucial, and you don't want to suck tissues into your shaver that you don't want in there, but then again, you want to suck the tissues in there, you want to get rid of, so the pressure needs to be right. I do use an irrigation system, and there's no need to use any traction. This is the position the patient is prone. There is no traction. You just need the foot dangling over the edge of the table, so that you can do the same leaning against the patient maneuver, which Professor Van Dyck showed you in the anterior arthroscopy. You do the same here, because as long as you've got that foot at 90 degrees, and your scope, everything's coming in horizontal, and your portals are correct, which I'll show you, you will come to exactly the right bits on the back of the ankle joint, and the posterior tailor process. You won't be too high or too low, and if you keep an eye on that second toe, that orientation will be correct as well. You won't get lost. A tibial support there, and the foot be under the bed, under the bed. A tourniquet, so you can see properly, of course. So what is safe technique? Position the portals as follows. Work parallel to the sole of the foot, and working in a way that you can bring the foot to 90 degrees, aim towards the second toe, and the first thing you do is you open up that cogus fat pad space, which is very soft fat, just anterior to the Achilles tendon, and once you've opened that up, it's amazing how the back of the ankle just opens up safely for you to start working on. Okay, so the portals, all worked out by Professor Van Dyck and his team all those years ago. They're geometrically arranged, and your friend is the tip of the lateral malleolus. So one way of doing this is to use a Steimer pin or something against the lateral malleolus, and just roll it around the back of the ankle so that it's over the Achilles, and make two marks either side of the Achilles tendon. That's where your two portals are going to be. That's it, and as long as you follow through, everything will be right. You do the lateral portal first, standard skin incision, opening up with a blunt clip, push through, nothing special about that, and from that lateral side, you aim towards the second toe. Just to show you why this works, as we go through the tissues, the sural nerve is way over to the lateral side, this being a right ankle, and the other structures are deep, and you can see where those two incisions are. That horizontal line is, the white line, is level at the tip of the lateral malleolus. We go deeper. Now you can start seeing why this works, and what Professor Van Dyck's team worked out with the anatomy. You're directly aiming towards the posterior talar process, which is where the arch trigonum is, and then you just, and if you look at that diagram again, look at the second toe, the second metatarsal, that actually takes you right to where the osteotrigonum is. Keep checking the second toe, and work parallel to the sole of the foot, and again, just to show you on a different projection why that trajectory works. And there's the neurovascular bundle. It's the other side of FHL. So the first thing I said to you is that you create a working space. How do you do that? You put your scope into the lateral portal, and you go forward. You're not really seeing very much, but you bump into the back of the ankle, pointing towards the second toe, and actually what you'll be bumping into is pretty much where the osteotrigonum is, and then you put your shaver into the medial portal, pretty much 90 degrees, and you deliberately bump into your scope so you can feel it, almost scratching up against it, and then you draw back your scope, and until you start seeing a glint of metal. So you start seeing this, because the fat is very loose here, and you just start seeing the metal of your shaver, a little bit of suction on there, and you start shaving, you oscillate, you can rotate around, and very quickly that, you can see how loose that fat is, it starts opening up, and then as long as you're pointing in the right direction, you can go forwards towards the back of the ankle, under direct vision, and shave towards the back of the ankle, and then it starts opening up for you, and you start seeing the structure. So there you can see things like, see if I can get the laser pointer to work, so FHL over here, and that there is the posterior tailor process. I tried to give you a complete view here, because you're never going to see everything on one view, so I've got a left ankle here, I've combined two images to see you right across the medial on the right-hand side, and the lateral on the left, and everything shows up for you. So FHL is there, you can see the sub-tailor joint very clearly, and that bottom row there is the calcaneus, and as I say, everything opens up, and particularly loose is the tissue at the back of the ankle, the posterior ankle joint, and then you need to start shaving away, and there's a technique for doing this, which you've seen before with other examples. You just keep the shaver, the shielded area of the shaver against FHL, and sort of scoop and shave towards you, and you won't damage FHL, and the neurovascular bundle is the other side of it, so you're not going to damage that either. There's the ostrigonum, and now I'm just moving things around, and then you can just slot into the back of the ankle if that's what you want to do. I just wanted to show you how much you can see, and there we're seeing the tailors, and you can deal with any pathologies at the back of the ankle if you want to, and then just coming back out of the ankle, and now you'll start seeing the back of the ankle joint, that very loose tissue, and in a second you'll start seeing the posterior tailor process, the FHL up to the top right-hand corner, and down in the lateral side, now you can see why you can deal with lateral pathology as well, because it's so easy to get down there. So on with the sort of business of the matter, here's a ronger coming in. Ronger is really useful to use because you can grab the ostrigonum and move it, and sort of see where the fibrous union is. Obviously, you've got all your information from your MRIs and things, but you really get a good feel for where the stator process is, and you know, where the posterior tailor process is, and you can remove exactly as much as you want, but not too much. I'm just coming in there again to remove that, and you're always going to have some loose bits left to deal with, so you bring your shaver in like this, just to start tidying up, and the FHL, so this is a right ankle, so FHL on the medial side, and you know where it is, so although we're facing towards FHL, we're shaving towards the remnants of the ostrigonum, and just started to sort of tidy up, and you're very safe in this over on that side. Now, we're going on to the other side. This is where you've got a bit more care, so I just wanted to reiterate it because it's important the other way around from the previous one you saw, but I'm just using the shaver in a safe way, scooping towards me. I've just cycled that video to show you the action, and as long as the smooth bits against the FHL, you haven't got too much suction on there, and you're not going to suck any tissue in, you won't damage FHL either, and then it may be that the posterior talar process is still a bit prominent, so you may want to reduce that. You're worried that it's going to cause some friction on FHL, maybe already has been, so there's the burr coming in, and shaving that down. You can do it really precisely. It's the vision, really, doing it this technique. You can see it's magnified for you. You can pick up pathology you might not have seen on other imaging. It's really the access and the imaging which sells it for me, and here I'm just moving the anchor around. You can see the motion of the subtalar joint, how that works in pivot, and that brown surface, of course, is where the os trigonum used to be, and where I've reduced the size of the posterior talar process. It's a very versatile technique, so here's an example where there is an enlarging, sequentially enlarging talar cyst in the back of the talus in association with an os trigonum. It's the only time I've seen this, but I was concerned that that cyst was getting larger. I didn't know how it was going to behave once I've taken the os trigonum out, so I was able to harvest bone from the back of the calcaneus through the portals, using that tryphine you see in the middle picture there, and actually introduce it into the back of the talus through the same technique. So there on the top left, removing the os trigonum, using the shaver to finish things off, and then you could actually see bottom left that little defect, which I guess is where the cyst was being formed, maybe by tissue pressure. That's a drill going in bottom right to start making holes in the walls of that cyst within the talus from that approach, and then there's a tryphine starting to deliver the bone graft, just coming out of the end, going into the defect, and that's all packed. So really versatile technique. It's safe sticking to those principles. It's very versatile, excellent visualization, aiding diagnosis, and there is a rapid recovery, and I just, in my mind, compare it to meniscal knee surgery. The visualization is so much better. I wouldn't really feel the need to do it any other way. Thank you. Thanks, Dr. Halliwell, and now we'll have our last talk of the session by Dr. Jim Mickelson from Vermont. He's probably sitting back there thinking, man, after all that shaving, I could have been in the lounge waiting for my next case to start. So he'll try to tell us why doing it open is the way to go. Dr. Mickelson. Well thank you very much. I must admit I feel like I'm bringing a Porsche to a Ferrari convention. Everyone wants to drive the Ferrari and no one's interested in the Porsche. Hopefully I'll convince you that sometimes the Porsche is actually a pretty good car. Let's see. Yeah no one pays me to do anything. All right. Just a very brief review about FHL and osteogonal pathology and the reason is context. The issue is that you can have pain not only in the posterior medial corner of the ankle but also all along the FHL and in particular in the midfoot underneath the session tachymetalus and a substantial proportion of patients will also have pain at the first MTP joint. This is important when we're thinking about surgery. If you've already decided figured out it's FHL slash osteogonal pathology and they have first MTP joint pain frequently they will have some element of halic fritidis which means you're going to want to have to deal with that at the same time as you're dealing with the posterior ankle pathology. If you're doing your surgery prone to do the arthroscopy then you have to take down everything, reprep, redrape after you flip the patient. So that's kind of a pain in the butt. Whereas if you're going to do it open you can do everything in the supine position. The other thing that's come up as a result of COVID is there's been a dramatic decrease in the use of general anesthesia. There are a lot of patients who really aren't very comfortable being prone when they're awake and so doing prone surgery with a popliteal block or whatever is sometimes a problematic issue. So what I'm going to talk about is the outgrowth of a study which is being published. The first half was already published on the non-operative treatment but this involves the last segment of patients, about 236 patients who had surgery posterior medial ankle. This is what the approach is. Now I will tell you it will take me longer to describe it than it takes me to do it and I'm not exaggerating. The dots there, the most inferior posterior dot, well actually the most inferior anterior dot is the Sessentachium talus. The superior dot is one centimeter anterior to the Achilles. If you're too close to the Achilles it's a hypovascular region and then that dot in the middle is the right angle. The distance between the bottom dot and the top dot is three finger breadths. This is my resident drawing that line. He made it a little bit bigger than I normally would and this is a dissection. The entire dissection is subcutaneous and you go straight posterior, straight posterior to the compartment but straight lateral until you're at the midpoint. At that juncture what you're seeing is the fascia of the deep posterior compartment and this is a little bit closer up and then all you do is cut it. Now you cut it carefully because a certain percentage of the time the neurovascular bundle is overlying the tendon itself. So the neurovascular bundle is just the interior to where my freer is located. Generally I don't expose the neurovascular bundle. If I don't see it I'm very happy. And so this shows you the FHL and just sticking the freer down you can see where the fibrosis tunnel is located. Then you just cut it with some littler scissors and now it's completely released. And now you can see various kinds of pathology. You can see the impingement on the FHL at the musculotendinous junction. You can see a lot of synovitis. And then if you retract the muscle belly and tendon of the FHL posteriorly you can start seeing the posterior process where the osteogonum is. And at this point you're like where is that? So a little closer and now I've outlined it. So it's right there. You stick your baby home and around it. If it's loose you just resect it. This is the main danger of this approach. It's the medial calcaneal branch. So it exits early from the tibial nerve in about seven to eight percent of patients. So it's something you always have to be careful of. Post-op I get these patients up and around immediately. They're walking immediately, get them out of the boot at two weeks, and tell them they can go back to full athletics at six weeks. Some of my high performance athletes tend to not listen to me and they're usually back in competition at four weeks. The time for me to do this, my tourniquet time routine just to release the FHL is three minutes. If I add the osteogonum we can add another two minutes to that. If my resident does it you can double that. The published data on how long it takes to do endoscopy for this is 40 to 60 minutes. There's another approach which is a straight medial approach which is through the tarsal tunnel and that takes about 40 minutes. And the reason is you have to directly deal with a neurovascular bundle and avoid it. I don't do that approach for that reason and also because the rehab on the tarsal tunnel approach is much longer. The return to sports is equivalent at very least. Complications, the main complications we're worried about is neuritis. With endoscopic techniques it's up to 15 percent both medial and lateral side. In our experience it's been two to three percent, mainly the medial calcaneal branch. If you do a posterolateral approach you can ding the serral nerves, stretch it about 10-15 percent of the time. All of these tend to be temporary issues. The advantages, it's short, it's easy, I don't need any special equipment. I don't need the arthroscopy equipment, I don't need to use a shaver. If I need to do the patient supine I can do it and not re-prep and drape. I can see everything I need to see and it works. So just like my surgery my talk will end early. Thank you. Thank you Dr. Mickelson. So we're going to open it up to questions here. Before we do that there is an audience response question that we would like your input on and it pertains really to the last two talks with regards the use of arthroscopy or endoscopy for osteogonym and posterior ankle impingement. So the question hopefully will come up on the screen shortly. When it does, please respond and we can look at the, there we are, all right. So we'll let those, we'll let that data filter through and look at it here in a minute. If there are questions please come up to the microphone and we'll call on you. Microphone number three there. Hi, Andy Goldberg from London. Thank you to all the speakers for an excellent set of talks. Just on the groove deepening, I always felt very uncomfortable in hundreds of cases of perineal problems. I don't think I've ever had to deepen the groove. So the question I've got really for the faculty is many of these patients are confounded because they've got cavus feet or they've got lateral ligamentus instability. I didn't see many one was talking about that. How do you deal with those other issues rather than just the groove deepening? Was the groove deepening a way of dealing with them? John, maybe you want to try to answer that please? Yeah, I don't see that number of pathologies with these and certainly in an athlete with a cavus foot I wouldn't, or a cavivarous foot, I would never do an osteotomy on an athlete in their professional career. With ATFL insufficiency we can do that endoscopically also and we haven't done a lot of those concomitantly, but we can. So it hasn't been something that we've seen a lot of. Maybe just to piggyback on that, I think really what's important is indications. You know, is there ever a time, either Jim or John, who were proponing using this endoscopic technique, is there ever a time that you wouldn't use it because of some patient factor? Whether it be presentation, character of rupture, does it matter if they show up 12 weeks out and their tendons are sitting in front of their fibula and have been for a couple of months? Is there a patient you would not use an endoscopic technique for, either of you? Yeah, I mean I think there are. There's, you know, there's many patients you wouldn't use it on. Certainly those that you've identified a tear beforehand. I know James probably does sort of small incision tear repairs. I like to do bigger incision for a tear repair because I want to see how far it goes. But we still use a scope in those cases. We'll do scope above and below because you can get tears above what the one you're directly looking at. So tears are the most common reason why I wouldn't do an endoscopic approach. And, of course, if there is ATFL or rarely CFL concomitant pathology, we'll still do an endoscopic approach, but we'll do an endoscopic repair of those also. So the timing doesn't necessarily affect it, Dr. Calder, any comments? No. Timing does not affect it? No, I don't think so. I think what Andy's talking about there is slightly different, Andy, from what, you know, dislocation is pretty unusual. That's an acute sporting injury. A cavovarous deformity with perineal tendinopathy and splits and things like this, that's a very different pathology which probably can only be addressed through an open approach anyway. If you're going to do a cavovarous deformity correction, certainly if you're going to treat the perineal tendon disorder that's associated with that, I would do it through an open approach and address the bony problem as well, or the malalignment problem. I didn't mean a sort of a chronic cavovarous foot. What I meant was these patients often have a slight sort of tendency to cavus and they go over and they have an acute injury and I guess it's just the question is that they've had a soft tissue injury and you're fixing it with a bony solution. I don't think we'd ever go to the other side, the contralateral side, where they've got the same anatomy and do a bony surgery. So wouldn't we just be treating them like we would with lateral ligamentous injury and just doing a soft tissue repair? Yeah, I mean it's a bit like, you know, you do a, certainly as John said, I would never do bony pathology in a, or an osteotomy in an athlete who's still playing, or they will end up not playing, I guess. But then why do a bony operation, why do a bony operation on the bone when the bone isn't necessarily the pathology? In other words, why do a groove deepening at all and not just do a soft tissue repair? I think everything we do has to be data-driven and in the case, in the patient that you're talking about, a patient who is susceptible to lateral overload or in a caboveris foot, if you just repair that SPR, then the primary driving force is still there for them to recur. So for those cases, we do exactly what we do for the ones who have neutral alignment and that's borne out by the data. They return to play times or quicker and you don't create any of the other problems that you do with inadvertent overtightening of the SPR, creating stenosis and other pathologies. So you're really creating a volumetric problem by increasing the volume. I mean, it's an unusual injury, isn't it? So, you know, to come out in the first place, you've got to think there's a reason for it. So I think you have to address those two issues that both John and I have spoken about, the bony mythology of the back of the fibula and perhaps the overstuffing of the peroneal sheath. Sheldon, number two. Sheldon Lin, a little question to Calder and Dr. Kennedy. Sorry. Very intrigued by your endoscopic peroneal groove deepening and my question is, as you're creating this raw bleeding bony bed, what tricks do you have to avoid the fibrosis or the scarring of the tendon, you know, since you're not maintaining that subperiosteal fibular periosteum? What are the tricks you guys do or maybe you don't see the problem and I'm just dreaming this up. I totally get that and that's why I totally disagree with John in that meeting in Windsor and I said this is crazy, we're gonna end up a nice piece of sandpaper, you know, rough sitting there, you know, my tendons are gonna get and John said, it settles down, don't worry. Trust me, I'm a doctor. It's got this little piece of this gets this fibrous tissue that grows over the top and it goes really silky smooth and I can't quite say in the audience what I said to him at the time but it was something to do with male cows and I'm wrong. He's right. I hate to admit it but he's right. It does, it looks, it looks like it's been recorded. Yeah, for once. No, but it does sit in and I have had to go back and have a look in the back of these and they do form this sort of this tissue and it doesn't seem to and I get them moving early I think is the key thing. So I think the advantage of doing it endoscopically is you get them moving really quickly, you know, a couple of days then they're moving up and down and they glide. I would agree with James. Yeah, I think you're right. I think it they want to go that the pressure is all forcing them into that groove that you've been created and then you've got a bit of Bleeding area where the SPR or the retinaculum has been pulled away stripped away then settles back down I Think it's probably a bit of both. I think I think that you've addressed the two pathologies You haven't got you've got a you've you've done the bone bit and you've dealt with the overstuffing of the retinaculum But I think the key thing Sheldon is to get a moving really quickly, you know within a couple of days They're in the physio. They're getting it moving And Holly, I would just say that the SPR probably does tighten up simply because there's nothing Pushing against it. The tendons are now running in that groove whereas before they were constantly pushing against the SPR and that The SPR itself and the fiber cartilage rim were the only thing keeping it in So, you know the subluxation I'll answer that right here, when I'm doing a perineal tendon repair and I put everything back and I look at it and I go, that could be at risk, and I'll just use a rasp, I won't use anything special, I'll just use a rasp and just create it, and then I circumduct, this is with an open procedure, then I'll circumduct and just see, and you can see the tendons, they come over to the ridge, and I go, I just don't want this coming back, and so I'll do a little bit of a groove deepening until I circumduct and it's really stable and then it's fine. So almost every single tendon repair you're doing it, or is it really... No, it's just, it's an intraoperative, yeah, it's a good start, you just, again, just look at the tendon as you're circumducting, they will always tend to ride up a little bit, but if they look like they're just at that edge and ready to pop over, I'll just create a groove deepening. It really does, the mortality associated with that is so low. Yeah, the mortality's good. Sorry, the morbidity. Hopefully no mortality. Yeah. Eric, last question. Mortality is also quite low in my head. Thank you. I wanted to ask a question of Paul. Paul, that technique that you showed with the pituitary ronger when you had the ostrigonum to twist and find that fibrous seam there is very useful. Can you give us some hints when you're dealing with a steatic process? How do you judge just how deep to resect the bone level so that you don't encroach on any of the articular surface? Are there any hints that you can give us for that? I guess two things, one, the imaging and comparing a sagittal CT to what you regard as normal and then combine that with the MRI to see where the edema is, so that gives you one idea. And the other is that taking the ostrigonum out several times, you then see what's left and when you go in and there's a longer steatic process, you're aiming for the same end result. So I suppose they're the two things, just having taken plenty of ostrigonums out tells you what the anatomy should look like. time to share their experience with us and we'll see everybody over the next couple days.

perineal tendoscopy

endoscopic treatment

open groove deepening

alternative viewpoint

meta-analysis

posterior ankle impingement

osteogonium

proper patient selection

open surgery

Q&A session

different techniques