The afternoon session is around Achilles tendon, and we've got a good set of speakers. The first up is Steve Heppel. Steve is a foot and ankle surgeon and trauma surgeon in Bristol, which is down in the West Country of England. And I first met Steve when we were both in Australia a few years ago, 2001 to 2002. So we were both working out there at the same time, doing fellowships. So I'd like to introduce Steve. I'd like to thank the AOFAS committee for the invite. It's been a great couple of days I've been in Quebec so far, and I hope to enjoy the next couple. So I've been asked to talk about arthroscopic treatment of posterior heel pain, essentially. I've no financial disclosures to make. And as James has said, I come from Bristol, which is approximately 100 miles directly west of London. It's famous for its suspension bridge designed by Brunel and for its balloons, funnily. So we need to get straight what we're talking about, really. There's often confusion in the discussion around the actual pathology and the posterior heel pain, I find. So I'm going to go through some of the terms that we're likely to use. So chronic insertional Achilles tendinopathy that presents like this, with a large emphasite, in my hands is not treatable arthroscopically. There are some reports in the literature of people who do the arthroscopic detachment of the Achilles and then debride the bone spare and then reattach it with a percutaneous speed bridge. In my opinion, life is too short for that type of behavior. But I do treat insertional Achilles tendinopathy if it's mild, if there's just tendinopathic changes and there's no new bone formation. I think the procedures I'm going to talk about in the next five minutes are applicable to the early stages of insertional Achilles tendinopathy, but not this condition. What we are mainly focusing on is the Haglund deformity first described in 1928, which is obviously a prominence of the posterior superior part of the oscalsis and results in a bump just proximal to the insertion of the Achilles. Lots of different ways have been described to define what Haglund's deformity is, and this slide is not a complete list of them, which only goes to prove that it's actually a difficult thing to design because no one's got the perfect system of defining what Haglund's is. In my view, it's a clinical diagnosis. If there's pain and a bump in the right place, then that's a Haglund's deformity for that patient. We can also see retrocalcaneal bursitis, which may mean that it's independent of the bony lump or it occurs at the same time, and that's also amenable to this type of treatment. And then of course everything can happen at the same time, so you can get a bony lump, some retrocalcaneal bursitis, and some tendinopathic changes as seen in these slides, and that's often referred to as the Haglund syndrome. So these are the things we're trying to treat with this surgery. There are other considerations. Sometimes the effects of other deformity will manifest themselves as Achilles tendinopathy, but of course that probably needs different treatments, and that's not the subject of this talk. So it needs to be a localized pathology. So we've heard lots this morning why we would consider endoscopic treatments. It protects the soft tissues, probably a reduced complication rate, and reduced operative time, once you've gone through the learning curve. The one fact that I've noticed from this particular technique is the faster rehabilitation, both in my own practice and as we can see from this paper, in the evidence base. So return to activities was almost 70% better in an arthroscopic approach versus to an open approach, and returned to sport 50% of the time. So that's the main reason I use it. The patients just seem to get over it quicker. So how do I do it? Well, equipment I use, I don't think there's any particular hard evidence about this. I think it is a difficult procedure. It's technically demanding. It's close to the skin. The triangulation is difficult. Small movements create big changes in the image whenever anyone tries to do this, and when I'm teaching the residents or the trainees, then they often find it very difficult to do this procedure in the first couple of cases, and it's often useful, therefore, to start using a small scope. It makes it a little bit easier, less risk of damage, but ultimately once you get familiar, I do use the large scope just because it's quicker, and the same thing goes for the burrs. I avoid radio frequency probes. I just think there's too much risk of damage to the tendon, and we certainly don't need any traction to do this procedure. So this is the position I use for pretty much all of my posterior ankle surgery. It's not prone. It's what we call lateral bad side down. It keeps the anaesthetic department happy because they don't need to be intubated, and it works very well. As you can see, you're operating on the left leg in this case. You get a good posterior approach to the ankle on all structures. So there are two options for performing the surgery. You can either stand at the foot of the bed, which is the sort of more traditional way with the monitor off to the side, but if you find it difficult to coordinate because you're operating back on yourself, the instruments tend to be coming back towards yourself. Some people find it easier to turn it around, and then you're operating away from yourself, which is more traditional when we're using arthroscopy, but I'm a traditionalist, and I use the method on the right there. So the portals, it's not identical to posterior ankle arthroscopy as we heard from Paul in the morning session. The portals are slightly lower and probably slightly closer to the tendon of Achilles, basically at the superior margin of the oscalsis because we're trying to enter the retrocalcaneal space, not the posterior ankle. So the key is to open up the space, and often I will introduce my needle. I'll insufflate the area with saline, and then I'll get the arthroscopic cannula in, and before I even put the camera into the cannula, I'll use the trocar to open up the space and just create a bit of freedom because there's often, if we're doing this for pathological reasons, there's often some adhesions that need to be broken down, but ultimately you should get a reasonable view with perhaps some cyanobitis, and when you start the resection of the bony lump, the key is to start superiorly at the very top of the oscalsis, and then as you go over the edge down into the retrocalcaneal space, you create more space for yourself, and the technique becomes progressively easier rather than trying to start right at the bottom at the attachment to the tender Achilles, because then it's quite difficult. So here we see a clinical example. It's obviously a very abbreviated video, so it's difficult to see the technique exactly, but once you start opening up the space, it becomes relatively easy to do this debridance. The bone is cleared. The important thing is to be certain that you've resected the full width of the calcaneum. It's very easy to leave prominent edges of the calcaneum, which you can palpate during the operation, but it's better to get them, make sure the resection is out to both edges. So I will do the arthroscopy from both sides, switching the portals so you can get a good view of the edge of the calcaneum on both sides, and so ultimately you can get right down to the attachment to tender Achilles and make sure there's a full decompression. So this is a sort of before and after appearance with the Achilles tendon on the left side and the calcaneum obviously on the right side. Good clearance and decompression of the Achilles. So what can go wrong? Well, often it's the wrong diagnosis. As I talked to, as I mentioned at the beginning, treating the wrong condition is obviously going to lead to a bad outcome. The biggest complication in my hands really is the fact that you're in insufficient resection, particularly the lateral wings as I refer to them, prominent wings. Obviously there's risk of damage to the nerves and damage to the tendon itself, but generally it's very well tolerated. The complications are low. So what evidence is there for this procedure? Well, this is a review of 164 patients which concluded that after a short learning curve, the endoscopic exposure is superior to the open technique, less mobility, less operating time, and nearly no complications. Moreover, the pathology can be better differentiated and I would agree with that once you've learned how to do it. And then this very recent paper, it was only published a couple of months ago, an analysis of 20 published papers showing that they're both efficacious, both procedures are efficacious with respect to functional scores and patient satisfaction scores, but the endoscopic surgery appears to have that advantage of shorter operative time and lower complication rates. So in summary, it's an effective procedure in appropriate cases. It minimizes the surgical approach and accelerates the recovery quite substantially. There is, however, a learning curve. Thank you. All right, next up we have Heath Taylor talking about the open treatment of insertional Achilles and Haglons. I shouldn't be able to talk after Steve because they've got to adjust the height of everything. So a lot of what Steve has said, well some of it I'm going to repeat, that's my bit. So we've all done this. So this is where I'm from. I'm from Dorset in the central South Coast. Bournemouth and Poole are our local towns. If you like beaches and sailing, it's the place to come. That's Poole Harbour. As you can see, lots of boats. The second largest natural harbour in the world. So if you want a bit of sailing, come down to Dorset. So this guy's got a lot to answer for and I agree with Steve. And you see patients who say, oh, can you see this patient's got a Haglund? And you think, what's a Haglund? I think we all use words and they often mean different things. When we say chips, you don't know what we mean when we say chips. And as for football, I mean the clue's in the name, isn't it? Why are you picking it up and running around with it? So it's really important that we know what we're talking about. So this patient's got a Haglund. Have they? Who knows? So this is probably what we all think of as a Haglund, the prominent posterior superior border of the calcaneum. And I think we'd all agree that that's quite prominent. And this patient hasn't got Haglund. They've got a calcific insertional tendinitis. When I did a literature search for preparing for this talk, and I'm not going to quote the papers because everybody means different things when they say Haglund. And there are case series published in very good journals talking about my series of managing Haglund. And they're talking about calcific insertional tendinitis and different things. And so I think it's really important that we know what we're talking about. And of course, you can have a bursitis with or without a prominent bony bump. And how do you tell the difference? Well, you're going to take a history and you've got to examine the patient. And that's the proximal Achilles tendinopathy. The insertional tendinitis has pain more at the back and sometimes a prominent post lateral corner. And then if you slightly plantar flex and sort of pinch in just in front, that's more of the sort of true bursitis Haglund syndrome. And I think you can, along with imaging, tell the difference between them. And it really helps you when you're deciding what you're going to do. And we can draw lines. And Steve's shown all the lines that you can do. And you can do ultrasound. I tend to do MRI. And MRI, I think, shows the bursa and it shows any edema in the bone and any erosions. And think about inflammatory arthropathy if you do see erosions. And they should all have had conservative treatment. So bursitis, I think, is pretty easy even if there is a prominent posterior superior process. I think most of us, once we've had all the other treatments, are going to excise it. I do it open through a small scar, I suspect my small scar is open, is probably the same length as both of Steve's incisions, just joined up together. I agree, I think the evidence probably shows that arthroscopic do slightly better and rehabilitate a bit quicker, but if you're not a really slick arthroscopist and you don't do loads of arthroscopy, there's nothing wrong with doing a little mini open and excising it, and I think they do fine. So here's a case, this is somebody who had a Hagelin syndrome, so prominent posterior superior calcaneal process, and the MRI scan looks like this, and you can see the bone edema, and I think these patients will do well with excision. I think the key for the excision is you've got to get right down onto the insertion, so plantar flex, don't leave a little ridge of bone because you're a bit scared to go too distal, go really distal, right onto where the tendon attaches, and you can see on the MRI scan how low down you should be going, and I think these patients will do well. Important to wash all the dust out, we know that all of the bone dust, whether using a saw or a burr, it's really inflammatory, and I think it slows down the recovery, it makes them swell, and so I'll make a real effort to wash everything out. And has this patient's got a Hagelin? Well, they've not got a Hagelin, because what they've got is a calcific insertional tendonitis, and you can see that when you zoom it up, you can see not only have they got the spur at the insertion, but a little bit of calcification in the tendon as well. I do this open, there are some series now talking about doing this procedure arthroscopically, it's not something I can quite see how I could do that, so I do this open, I go straight down the middle, elevate the tendon, and you're excising both the calcification at the insertion and proximally in the tendon, a little bit proximally, and then I take the Hagelin off as well, so that you get this nice, smooth cancellous surface and then reattach it, different companies make different bits of kit, and they all seem to work pretty well, I do that one. And that's what you're looking for afterwards, so you're looking to have this really nice, smooth contour where the tendon's gonna sit back onto the cancellous bone, and I rehabilitate them really quickly, I think most of mine have done very well, the ones I've seen do badly, this patient was referred to me and had a little bit of calcification at the insertion, and they sort of had a half an operation because they didn't want to take the whole thing off because they thought it was only a little bit and did one bone anchor, and I think these are the ones that don't do as well. For me, the ones that do better is actually where you just do the whole operation. This is one I saw a few years ago, and that's a lot of calcification. I will occasionally do an FHL transfer, people say, you know, if you're gonna debride the tendon, how much do you debride? Well, debride until you get scared, I knew I was gonna be scared in this one because we were gonna debride a lot, and so I did an FHL transfer as well, you can see the amount of almost ossification of the tendon, not just calcification, and so they had an FHL transfer as well, and we got most of the calcification out. Other open options, medial gas rock release if there's a positive silver skull, and it depends on your sort of philosophy, some people just think anybody with a positive silver skull test and insertional Achilles problems just do medial gas rock and they'll get better. I've not tended to go down that route, but there's some papers that show that. Other options, we've seen one slide of this, you can consider this closing wedge osteotomy, the Zarek or the Kelly-Keck osteotomy, and I used to do these, I've gone back to doing more of the insertional detachment and debridement, but I think they have a role. Don't do it like this, this is one, this is not one I did initially, and if you don't use x-ray, this is what happens, and you can sort of see that extra hole where they've been messing around with staples, and so it was revised like that, still not good, and so we had a go and revised it again, and other than the fact he absolutely hated the screws till we took them out, actually did pretty well, and he ended up, his heel pain took a while to settle down, but actually his insertional pain, once the screws came out, did pretty well. There's evidence for everything. There's a case series to support anything that you want to do, whether you want to do open or arthroscopic, whether you want to do an osteotomy or a medial gastroc or an insertional debridement, you can justify everything that you do, and I think the message here is probably the thing that makes the least difference is whether you do it arthroscopically or open. I think the thing that makes the difference is you've got to know what you're talking about. I think you've got to get the diagnosis correct so that you know which of the operations you're going to do. You could do the best operation in the world, but if it's for the wrong condition, it won't work. Do the correct operation and do it properly. Thank you. APPLAUSE Thank you, Heath. Next, we've got Rick. Rick Brown, who is from Oxford. He is one of the Cambridge boys. He trained in, well, he actually, I think he went to university in Cambridge, and he went to the dark side, the dark blue side, and ended up in Oxford, and also trained in London as well. Rick. APPLAUSE Thank you very much, James. Yes, I did train in the dark side, and also I trained in a fellowship in North America as well, so lots of dark side. So thank you very much, and thank you for inviting all of us, both us people, to the conference, and we enjoyed our first day. I would like to spend the next few minutes articulating the argument why there's a need for this operation, and then how, technically, to go about doing the operation. I've got no disclosures particularly relevant to this talk, and the indication of this operation is patients who presented, after Achilles tendon rupture, but presented the delay. In our practice, we see about 10 of these patients per year. That's out of a local population of about half a million, with secondary referrals from elsewhere, and so our patients are often a little bit more complicated, a bit older, more co-morbidities, and quite often they'll have bilateral problems where they've taken quinolones. And all of us will have a strategy for this, and I think there's a consensus that you need a good clinical examination, you need to do correct imaging with an MRI or ultrasound, and then your strategy will depend on really the size of the gap. And there are different ways of dealing with this using open techniques. You can do a lengthening of the gastroc, you can use some FHL tendon turned up or plantaris, and it all depends on the size of the gap, and this is complicated surgery using a big exposure with potential wound problems. And you may also wish to add FHL as an augment, and this is an example of one of mine. So you can see it's a big wound, it's an enjoyable operation, but big wounds can have problems. And even afterwards, patients have a slower post-operative gait speed, they have a limp, and that's those patients that are the good patients. I put to you that there are the high-risk group of patients that we need to find something else. Achilles tendon ruptures are common. The small blue circle are those that present late, and within that blue circle is an even smaller high-risk red circle of patients who are like the chap in the wheelchair with terrible skin, who are at high risk of having a terrible wound problem if you do the operative repair. This is exactly the type of patient that arthroscopic surgery is good for. So using a posterior arthroscopic approach that we saw very well described this morning, I too also learned this in Amsterdam, we pay the patients prone, good fluid management system to be able to expand the cagus triangle to see what's going on, and then go into the same approach as we saw before to the side of the achilles tendon. The first step is to clear away cagus fat pad, and there are two examples here where you can see the FHL tendon, just in the back here or in the back there. It's very much surrounded by scar tissue in these patients, and of course don't go shaving anteriorly where the neurovascular bundle is. Once you've seen it, you want to then clearly define it, you want to pass a hook around it or a ligature, and what I've recently started doing is putting a pin in it to stop it moving. And then when you decide you're going to cut it as distally as possible, then put the foot into plantar flexion so you can cut as far down the tendon as possible, and pull it out through one of your portals. Once it's out of the portal, it's very easy to make a whip stitch, and then back to the arthroscopic component. So you want to look at the superior surface of the calcaneum, there'll be scar tissue, you want to clear that away, make sure you can get a really good view of the superior side, and go as far back as possible, and then you want often a little bit to the medial side of the midline to be able to get a little bit more of the correct pull. And then pass your wire from the superior surface, superior medial surface, down and out through the lateral side, and make a tunnel all the way through the calcaneum. Then with your whip stitch, you can pass the wires through the tunnel, you can pull the graft down into the calcaneum, and with the tension correct, and I tend to set it in a little bit of equinus, then you can put a biotin adhesive screw to secure that fixed firmly into the bone. Postoperatively, they can move, get going quite quickly, so then a below knee cast to allow the portals to heal, and after six weeks, they'll go into, come out of the boot often, and they have early weight bearing at two weeks, and start physiotherapy at six weeks. There's a little bit of literature, not a lot of literature on this. The first small series was produced in Guildford by the team of Matt Solon, and there have been a few more small series throughout the last decade, but if I draw your attention to this particular paper, which I think is the most impressive to me from the Barcelona group, they had 22 patients, mean age of 69, so some of these will have been the high risk patients, significant gaps of 6.3 centimetres, and they all improved afterwards. They improved their AFAS score, they all returned to activities of daily living, they didn't complain of weakness and toe push off, and there were no major complications from this arthroscopic technique. However, the really interesting part of this study was they all MRI'd the patients a year after surgery, and they could see that although nothing had been done, and I'd do nothing to their Achilles tendon, the Achilles tendon had healed itself in some shape or form, and had nearly normal appearances on the MRI scan. And their closing comments were, it's a difficult technique, and it's not one for the less experienced surgeons. Our own experience, we have eight patients, I would describe myself as an early adopter, so not a designer, but someone who's truthfully and honestly trying to take this up. All these patients had a delay of about three months, they'd all lost key mobility, lost power, lost balance, ultrasounds and MRIs showed the gap was significant, and they all had co-morbidities of either obesity, high-use dose steroids, one of them had to have a delay because of a recent hyocardial infarction, so all those patients, those red circle small group of patients. We had no wound healing problems, they all reported good pain relief, improved function, better balance, and those that could perform a single leg raise, it was slow, it took a year. But certainly they're not patients who are likely to complain about big toe weakness. So what can go wrong and what are the technical challenges? Really there are two. Retraction of FHL, so if you cut it a little bit too high and the patient's had a delayed rupture, so it's been tight for a long time, as soon as you release it, it can ping higher approximately. So the trick to that is to pin it and keep it in your visual field, so arthroscopically, then you can grab it. The other difficulty is you might get in there and it's all scar tissue, it's complete white out or blue out in this slide. And then you've just got to take your time, work your way through all the scar tissues, you can see FHL and see the superior border of calcaneum. So I conclude that this arthroscopic technique is a solution to a challenging group of low-demand patients with a high risk of wound problems. I conclude it's safe, beneficial, and reproducible. And really, it's another club to put in your bag, it's another technique to have, and I commend it to you. Thank you. Well, thank you so much. Thanks everyone for sticking around. I know it's afternoon. So, I appreciate it. This is my conflict of interest. We would demonstrate an instrument from Arteryx that I have royalty. So, up to 29% of individuals with Achilles non-insertional tendinopathy would end up needing a surgery. So, almost one in three patients with this problem would end up needing something beyond, you know, rehab, injections, and so on and so forth. The problem is that open surgery is not great. 11% complication rate from Pavola series with half of them related to wound problems. This is an example of a patient with a wound problem. When you start to see Achilles tendon in your patient, when the tendon looks at you, you look at the tendon, you get sick. You don't want to see it. You know it's not going to heal. It's going to be a problem. This is something that we really, really have trouble with. And open surgeries, although I'm talking about open versus endoscopy, open surgery is not perfect. When you look at the literature, most of the literature will show you that they recommend going in, make an incision, cut the tendon, anything looks bad, remove it. But it's tough. You know, you guys might, you guys, any of us work with residents or fellows? Let me see hands. Okay. So, in the past, one of my residents asked me, how much, you know, I let him cut the tendon off and I, you know, when he's done and I kind of go in and look at it and remove a little bit. He asked, what is the data? How much are we supposed to remove the tendon? I asked him, do you really want to know? I told him, fine. Usually, I let you remove some. I come in, remove a little bit more and call it good. So, this is how we do it. There's no science. So, arthroscopy has much more utilization, has much more room to take care of anything. From the proximal aspect, you can do gastrointestinal reservation. In the mid-substance, we can talk about it some more. You can handle rectal calcaneal bursitis, as we talked about today. Insertional problem, we can do that as well. We need to do a little more. We can repair it with endoscopic guidance, too. When a patient has a plantar heel spur, yes, you can also address it with endoscopy. When people have plantar fasciitis, it can also be done with endoscopy. But today, we're going to address mid-substance achilles teninopathy. The reason I highlighted gastrointestinal reservation is that it's related. A big subset of teninopathy is because of gastrointestinal contracture. This is an example of gastrointestinal contracture. How can we address it? Where we can do the release? You can decide to do it more proximally. You can pick the middle head. You can do silver scale technique, Bauman technique that you can actually go in front of the muscle belly and then release the fascia in the entry aspect of the gastrocnemius muscle. Or you can do at the conjoined tendon at the area of stair or valve-based technique, Baker, Hoek, or C-Lenkening. But the most commonly technique that we do is the gastrocnemius recession at number B or C. Bauman or Swearer, this is a technique that we use, endoscopic technique using medial lateral portals. On the left-hand side, the video is playing for the gastrocnemius recession. You can actually under direct visualization decide where you want to cut, where the seronerve is, how far you want to cut, and you can actually feel the foot gaining more dorsiflexion in the process. The lower part of the picture are my artwork that are from cadavers, so normally you don't see that big incision. On the right-hand side, you can decide to do a Bauman procedure, which allows you to release the fascia in the entry aspect. Again, you go through the small medial incision and dissect it with your finger, insert the cannula using the retrograde knife to release the gastrocnemius tendon. So we reported a series of 320 patients with gastrocnemius contracture treated endoscopically. Forty-two of them are related to tenopathy of the kidneys tendon and also plantar fasciitis. On average, we have 12 degrees of improvement in ankle dorsiflexion. All of them have significant improvement in FFI, SF36, and BAS. We have only 3% of weakness in ankle dorsiflexion and 3% of seronerve symptoms afterwards. When you look at more studies, now you look at systematic reviews to see the effect of gastrocnemial recession for the treatment of Achilles tendinopathy. But at all, look at nine studies, 145 cases found that there are clinically improvement differences in VSAR, FFI, FAM, and BAS pain control. There is superior outcome actually for non-insertional Achilles tendinopathy versus insertional tendinopathy. So again, they are different animals. We don't know for sure what is the cause of those problems, but for the gastrocnemius contracture problem, non-insertional Achilles is a good treatment. All the patients have increased ankle dorsiflexion with good rate of return to work and sports, overall complication rate of 8.1% with seronerve injury being the most common at 4.1%. When we look at open versus medial invasive treatment, Dr. Velkovic, Dr. Grace Brooke, and the Canadian team actually revealed a study and showed that the level of evidence are about the same. Both open and endoscopic medial invasive are at grade B. If you look at the literature nowadays, in the last 20 years, open surgeries are, you can count on one hand, but most of the study nowadays we are using medial invasive technique. This is biggest series from Argentina. Dr. McQuarrien has 27 cases, 24 patients, 5 to 14 years follow up with debridement of protein and longitudinal tenotomies. So using normal shaver and debrided protein and cut the tendon in the midline using retrograde knife on the lowest picture, patient have improved in pain score and outcome score with 85% excellent result, 1 delay keloid, 1 seroma with chronic fistula. Dr. Calder, our main man here, has to report many studies. This is one of them, 16 patients, 9 of them elite athlete, 14 months follow up. We went in with minimal incision to excise plantar list tendon. Again, like I told you, we don't know for sure why we have non-insertional achilles tenopathy. Plantar list tendon is one of the etiologies. 81% histology are normal, but patient did very well. Pain score come down from 6 to 1, FALS score improved significantly. The way I do it, when I deal with missubstance, I often release the gastrocnemius contracture. I use Van Dyck's technique of proximal medial and distal lateral portals as the picture on the left hand side and also the video. Again, with the pictures on the camera, normal 4mm camera, you can see the tendon and you can see the tunnel around the achilles tendon very well. The goal is to remove all the hypertrophic scar, remove adhesion between achilles tendon and surrounding soft tissue. If I run into plantar list tendon that looks hypertrophic, that looks abnormal, I would excise it. Again, at the end, you should be able to go around the tendon, make sure the tendon is free from all the surrounding tissue. When you are dealing with patient with enlargement of the tendon, a lot of cystic change, and then MRI with positive findings, a lot of times we do long-shot tenotomy using a 15 or 11 blade in the midline. So again, this is why we just keep removing protein that are thickened. When things are getting done, you're going to see a very well-formed tunnel, fibrous tunnel around the tendon. I take my time here a little bit because this is actually almost the entire video. You can go around with a camera, normal camera, go around until you're happy that there's no adhesion on the tendon. This is an example of a 45-year-old female after surgery, three months follow-up, pain-free. You can see the cystic change, you can see the damage and fluid collection at the tendon substance that all of them improved. Of course, there's no sound on this, but she didn't say anything. So this is a three-month follow-up, the patient has no pain. All right, next one, 46-year-old female, 320 pounds, BMI 49, with big, huge enlargement of the calyx tendon, big cystic component with the same surgery. VS score from 7 to 10, go to zero at five months. This is only gastrointestinal recession and debridement and longitudinal apnea without excising the tendon, without big debridement. The patient came with a different story, different problem. At five years, the tendon also returned to normal condition and no symptoms at all. This is the last patient, 70-year-old female, Pilates instructor. She has polio all her life, using AFO, multiple surgery in the past. She has collapsed arch, you can see the plantar catalyst formation. Her heel core is super-duper tight. When you look at her x-rays, you can see the collapse in the arch. And at least tendinopathy has gone so badly, it turned into bone, as big as her fibula. It's painful, it's tight, it's rigid, and it's stiff. The patient wants to have a surgery. She wants to have it done under the regional anesthesia. She wants to be able to be awake and want to see how the surgery is done. That's what she got. So we did it in prone, we make some poke holes, we put a camera inside around the tendon, and use a shaver to remove the bone bit by bit and take it down. We release the gastroc, a tendon for her as well, to improve range of motion. So at the end, we got x-ray without any bone left, and it's very nice and smooth. Unfortunately, the video doesn't work, but just imagine, she's going to move her ankle up and down, and she's going to say, I have no pain. I'm not using AFO anymore, thank you so much. So if things are going out of your hands, and the tendon is so badly damaged, you can go to the next level, which we already talked about, so I'm not going to touch on that. The technique has been described. In summary, open debridement is a conventional method. A lot of process of scarring, devastating wound complications if it happens to you. Endoscopic treatment is a growing, supporting technique with a lot of evidence coming on table. Minimize wound complications with the results, and so has great versatility. Thank you. Thanks very much. The next talk is about endoscopic partial plantar fasciectomy, and that's by a very well-known guy who's a very big supporter from South America of the AOFS, and I think we first met when we were doing a traveling fellowship, the first traveling fellowship back in about 2004, I think, Fernando. Come on stage. Good afternoon. Thanks again for Dr. Hunt and Dr. Maffulli for suggesting my name for this talk. Thanks, James, for the introduction. I'm going to talk about the endoscopic release of plantar fascia, so just remember that the plantar fascia is a complex structure that has multiple insertions just to the foot, so at the plantar aspect of the plantar plates, sometimes also goes to the base of the proximal phalanxes, approximately just inserts in the calcaneus. It gives secondary support to the arch of the foot. It helps a lot with the windless mechanism, helping us to go forward when we are walking, and also protects deeper structures, so it's a very important structure that we have in our foot. So plantar fasciitis is the most common cause of hind foot pain. It can affect not only athletes, but also sedentary patients, obese patients. It can happen in normal feet, in cavus foot, and also on flat feet. It can be debilitating even though it is a self-ended process, but it can be very debilitating. Usually, the diagnosis is made with only history with plantar hind foot pain. The patients, they complain that they have more pain in the first steps early in the morning or after being sitting for a longer period. There is usually no trauma associated to the initial of the symptoms. Physical exam, same thing, pain of our patient with the plantar fascia in the proximal aspect, and it gets worse with hyperextension of the toes. We can x-ray them. We can do ultrasounds. We can MRI the patient, but basically the diagnosis is done clinically. You don't need any fancy exams to diagnose a plantar fasciitis. Of course, the non-operative treatment with like stretch exercises, strengthening, physical therapy, orthotics, night splints, blah, blah, blah, all these methods they should have attempted before we jump to the next steps of the treatment because we have about 90 to 95% of efficacy with non-operative treatment for plantar fasciitis, so we should always start with this. Then for those patients who do not get better after a non-operative treatment, we can offer them one of these options that I remember when I was doing these slides, like gastroc resections is a very good option. We also can do open plantar fascia fasciotomy, open ablation. We can do endoscopic fasciotomy. Then we can also talk about the bone spur removal or not, but we're going to talk today mainly about the endoscopic plantar fascia release. The endoscopic plantar fasciotomy was first described by Barrett and Day in 1991. They described for the first time with only one portal the release, and then two years later they modified their own technique with two portals doing the same release. Two years later again, in 1995, they published their first very, very long case series of 652 patients, and they had 633 good results with a very low complication rate. So this encouraged the other authors to start trying their luck in these procedures. So Tomchak was the first one to come up with a comparative study between patients that underwent endoscopic versus open plantar fasciotomy. In the endoscopic patients, they had 28 days to return to work in comparison to the open procedure that took 83 days, which is 55 days sooner, so that's a big difference. So it's a huge advantage that they found in their paper. Chow later, same thing, endoscopic leads to better clinical outcomes when compared to open fasciotomy, but this was a retrospective study. Then I was addressing the literature regarding the bone spurs, and we have everything actually over there. So we have some papers that support that we don't have to do anything for the bone spur, like that's the paper that I published myself with Dr. Neri and Dr. Mofuli in 2012, and our patients, they had no difference pre or post-operatively whether they had the bone spur or not, and we never addressed the bone spur. Ahmed and Daniel supported our numbers as well, but on the other hand, at Kumeyaay, they showed histologic changes around the bone spur, so that can lead us to think that the bone spur also plays an important role in this pathology and mainly in the pain. But Kwiku and also he addressed the bone spurs specifically, and he felt that the patients were better, but he also acknowledged in his paper that the patients that used to have bone spurs, they were somewhat different from the patients who did not so are more obese patients or more sedentary patients Than patients who did not have bone spurs. So those are the difference There are also we can think about whether we should go from the top and from the bottom so we can do the fisheotomy dorsally to these structures or plantarly The paper that the technique that I use in my paper was going from dorsal to the plantar to the plantar fascia the same thing that was done by Miyato in 2017 but Bezos and Johansson, they did the same technique going from plantar as for the plantar fascia, but apparently there's no difference between those two techniques So this is the technique that we that we published about 10 years ago So this is the medial aspect of foot you kind of palpate exactly the medial border of the plantar fascia You find what it is. You do a small incision over there then with that probe You just you just feel where the plantar fascia is and then you go dorsal to it and then you cross the probe From medial to lateral then you do a lateral portal From there and then after you do the lateral portal you put this slot this canola in it The canola is slotted as you can see so this fenestrate canola and then you rotate So the slot is facing distal since we are proximal to the plantar fascia So the slots facing distant from lateral portal you you we use a hook blade To cut so in our paper, we cut two-thirds of the two the two-thirds for the medial plantar fascia With direct visualization from the medial side. So that's a technique This slot has those small marks that we can see over there has like a double mark in the medial border and then a single Mark, that is supposedly two-thirds of the plantar fascia. So we cut from the first double marked to the second single mark in the slot So these were our numbers like the OFAS score went from 49 to 89 So I'm more about 92% of our patients were good or excellent after this procedure almost half of the patients had bone spur another had another half had no bone spurs and The final results were exactly the same So this is we found some differences so the patient who were sedentary They they tended to have worse results than patients were more active We cannot explain exactly the reason maybe because usually active patients They are more compliant with the physical therapy after the procedure I don't know exactly the reason but they they had better results. And of course, this is not a Not complication procedure at all. So we have some complications open we can have like Infection, dehiscence, post-op pain, nerve damage, lateral column syndrome or chronic pain If you're doing endoscopically, we can also have some of these Complications for example the nerve damage, but Ohushi he published his technique in 2013 where he uses an ultrasound to track the nerve and then he does the release Looking at the nerve with the ultrasound. So he had no cases of Nerve damage in his in this series and the lateral column lengthening and lateral column syndrome Which is a dread problem that we can have after this procedure Brooke showed in his case use that every time that he released only 50% of the plantar fascia He never had a lateral column syndrome in his patients. So that's a good thing to do We did two-thirds and we had two cases among our 26 patients. We had two case of lateral column Syndrome, so what we know about this Pathology, so it's a very frequent pathology despite self-limited the symptoms. They can be Debilitating but they disappear within months sometimes even a year or so the surge is indicating only for cases who are resistant to conservative management and Endoscopic release has the advantage of being of like last complications shorter operative time and shorter recovery time as well But what we don't know yet We don't know if the endoscopic is the best option since this is based mainly in level four studies Even though we have some like one or two comparative studies at this point, but this mainly based on level four studies We don't know we are whether he should we sack the bone or not So our numbers say we don't have to but some some papers support that the bone the bone spur should be addressed as well We don't know if you should go deeper superficial to the plantar fascia and if the obesity age gender or Can play a role in this pathology. So these are the conclusions We've got to exhaust the non-operative treatment before we take patients to you to the OR Endoscopic release is a safe and reliable procedure We've got to be careful with the nerve and don't release more than 50% of of the patient So even though we don't know a lot of things at least we still have good results Thank you very much. So these are the references again So Finally for the counterpoint to endoscopic plantar fasciectomy we have Joshua Metzl talking on open partial plantar fasciectomy Thank You good afternoon everyone, my name is Josh Metzl from the Stedman Hawkins Clinic in Denver And I'm going to speak to you about open plantar fasciotomy indications technique and outcomes My disclosures are listed here with Arthrex and I wanted to speak directly to the residents and fellows first I think this is a nice study out of the UK published in 2012 Looking at 5,000 patients almost 10% of which Described heel pain 60% of those patients sought medical care So if I had to summarize I will say that if you become an orthopedic foot and ankle surgeon Heal pain will find its way into your office and having an appropriate algorithm for diagnosis treatment and surgical indications can not only help grow your practice, but it can help to Maintain it and lead to a very happy patient population. So plantar fasciitis is a very common complaint It will be frequently referred to us in the office. There's variable level of treatment by PCPs These are typically very informed patients and they want to get but they want to get better You can see here the anatomy which has already been reviewed You can see the plantar fascia on the plantar aspect of the foot and what I wanted to Highlight here is the intimate relationship between the plantar fascia and the branches of the posterior tibial nerve in particular the first branch of the lateral plantar nerve and I think this is one of the significant benefits of open decompression is that you can directly directly visualize and Decompress the nerve at the same time as a plantar fasciotomy So in my practice, I'm Very careful to get a detailed history on patients with plantar heel pain and to be a surgical candidate I would want a patient to have greater than one year of pain They should fail a reasonable conservative treatment as well on physical exam I think the most reasonable surgical patient is one with tenderness palpation at the plantar fascial origin I would differentiate this between pain at the mid portion of the plantar fascia, which I do not believe responds as well to surgical intervention It's important to reel out Calcaneal squeeze test for calcaneal stress fractures as well as gastrocnemius Aquinas or gastroc tightness, which could be treated with physical therapy or potential release as we have heard previously And I think this is a nice study published in 2019 showing the association between plantar heel pain and gastrocnemius tightness So you can see on the left over 80% of patients with plantar fasciitis displayed some level of gastrocnemius tightness Compared to the controls on the far right So I think it's very important to look for this on physical exam Direct physical therapy appropriately and consider this as part of the operative treatment when indicated My workup also includes diagnostic imaging including plane radiographs you can see two views of the heel shown here and I do think prior to surgery an MRI is Indicated to evaluate for degeneration of the plantar fascia and again to rule out other causes of plantar heel pain Conservative treatment would consist of anti-inflammatories and therapy orthotics injection either steroid PRP potentially even BMAC Dorsiflexion night splint casting and then also there may be a role for shockwave treatment as well And I think this study looking at respondents from the AOFAS in 2012 showing that Interestingly only 50% of those who responded would indicate surgery after 10 months of conservative care so I think this really highlights that there is at least some heterogeneity in terms of Who needs surgery which surgery is indicated and when that procedure might be done? So clearly this is somewhat of a controversial topic in my practice Patient is indicated for surgery after they've after they have failed conservative care We have ruled out other causes of heel pain importantly tarsal tunnel Which would present with the tunnels and more of a burning sensation extending down into the foot as well as a calcaneal stress fracture And I think as we've already gone through we have options for gastrocnemius recession Endoscopic plantar fasciotomy and then my preference which is open plantar fasciotomy with nerve release So for us this procedure is done as an outpatient is some with general anesthesia and a thigh tourniquet And we begin with a post remedial incision. This is parallel with the posterior aspect of the medium allelis This is a vertical incision because the vertical incision allows us to run parallel with the neurovascular Structures as opposed to a horizontal incision, which would be transverse to those structures So once we come through this skin, I like to place a self-retaining retractor I think this helps put tension on the structures for release and the first structure once we come through the fat that we would Encounter is the abductor hallucis and the abductor hallucis has both deep and superficial fascia So we begin by first releasing these superficial fascia the abductor which you can see nicely here Once the superficial fascia the abductor is released We then dissect deeper and you can see the deep fascia of the abductor hallucis, which is shown at the tip of the freer elevator Once the deep fascia the abductor hallucis is released. The neurovascular structures are just deep to this So you have to take care you can extend proximally and release the distal aspect of the lisiniate ligament if indicated and The plantar fascia lies just inferior to the abductor hallucis So that's a great landmark, especially for residents and fellows intraoperatively If you can identify the abductor the plantar fascia is just inferior to that again You can decompress the the neurovascular bundle quite easily if needed proximally in a true tarsal tunnel release So that's one of the significant advantages of the open plantar fasciotomy and then extending plantar We release the the plantar fascia. We're careful not to release more than 50% of the plantar fascia as This can cause a lateral column symptoms as I will show shortly and I do like a beaver blade for this portion of the Procedure these patients are placed into a posterior splint. They're non weight-bearing for two weeks They end up follow up in the office and we transition them to a weight-bearing boot typically back to shoes by six weeks and I do recommend orthotics up to three months in shoes, so this is a nice study out of Australia published in 1999 looking at 45 patients with two years of plantar fascial symptoms prior to surgery and two years of follow-up And I think it's important to highlight that the vast majority of these patients were pain-free or had only mild discomfort But interesting the only 48% were totally satisfied with the procedure So I think it's important to stress that these patients will see some improvement But they may have some ongoing symptoms despite surgery. And again this study published in 2019 single surgeon experienced 76 patients high level of patient satisfaction But again 40 approximately 40% of patients have swelling and tenderness despite surgery So I think very important to counsel our patients regarding long-term outcomes at long-term outcomes of these procedures And then the question is how much can we safely release? So this is a nice study where the plantar fascia was measured intraoperatively in terms of how much was released and then the patients were followed clinically and Patients who had greater than 50% of the plantar fascia released had a higher incidence of lateral column symptoms So I think in summary I focus in the office on a thorough history and physical examination considering other diagnoses I do think imaging should consist of plain foams and an MRI I try to push for conservative care for up to one year and it's very important that we set realistic Expectations for our patients after surgery. Thank you Thank you very much indeed there is a chair down there and there is a good excellent this will if we Audience want to ask a question, please come up to the microphone. I'm just gonna make one comment to Fernando I find that frightening. I see one patient with plantar fasciitis in my clinic all week and I find it painful That paper with dr. Bassett operate on 565 patients, that's a whole world of pain. Yeah, I just dr. Bassett's here. I don't know anyway Rick you were gonna just ask the people who operate on plantar fascia The review said that 75% of patients were happy after 34 months The natural history of this condition with conservative measures is for 98% of patients to be happy at One and a half years sure. It's better not to operate Yeah, I think I mean it's I think you need to be very that was the point I was trying to emphasize is that you need To be very selective in which patients you operate on. So and to set expectations that They may have some discomfort. Although the majority of those patients I think would be Improved the VAS because if you look at that study the VAS scores Decrease so I think if you can set an expectation that maybe the majority of those patients So I think if you can set an expectation that they may not be pain-free, but their pain may be decreased I think you can get a reasonable result and also also being very selective in which patients you do operate on Both of you and your talks on the plantar fascia mentioned gastroc recession, which I'm a big fan of Do you prefer these procedures that you mentioned over that procedure? What when when do you indicate patients for which procedure? Well, I like the gastric recession I usually do it the silver skilled way like proximal a poster to the knee here Not only the medial head of the gastrocnemius, but usually the patients they are like doctors I have foot pain. You're gonna open my knee. This is kind of awkward to me so a lot of patients they they're kind of skeptical about that procedure and then instead of you know, do That procedure and maybe having any complication that basically listen What what do you have in your mind like when you're doing my knee use foot pain so but I do both of them, especially when I have to do gastric release for other problems like forefoot pain during for example, or During a flat foot reconstruction. I use I do it proximate but for plantar fasciitis Even though there's a lot of support in literature that that's a good procedure to do I think that the endoscopic release the plantar fascia has also good results on that's that's why I go there We've got time for one question, sorry We're just in the middle there and if you look at the questions as well, if you ask the questions online, that'd be great Great. Thanks, Kevin Martin, Ohio State. So those of you that are doing FHL transfers arthroscopically Can you help me mechanically? I've done two So, how do you actually cut the tendon you have any tips on that? And then when you place your guide wire for your biotinodesis screw Do you have any tips where to place that and how close to the Achilles footprint? Do you put it? So I try and go as far back to the Achilles footprint as possible because you're looking from the medial side It's always a little bit in the medial side, which should help the biomechanics and cutting it you want to have pinned it and then I Get a little bit nervous with the blade down at that neurovascular bundle. So I then use a small set of arthroscopic scissors Yeah, the same so the technique that Dr. Jordi Vega described he used a beaver blade and went right in the Sustentaculum area and cut the FHL. It's very easy to make a complete cut But once you cut the tibial nerve, it's done. Your surgery is not gonna be successful So I agree with I actually use a curved scissors put the suture around the FHL tendon to hold some tension and Then use a curved scissor going to one of the portals and just cut it It takes longer to cut it with with you know with our knife, but I think it's safer that way All right, thank you everyone for these great talks very informative Thank you for the questions, but we're out of time. So I think we have to move on to the next session. Thank you

Achilles tendonitis

plantar fasciitis

arthroscopic detachment

posterior heel pain

Haglund deformity

retrocalcaneal bursitis

Haglund syndrome

arthroscopic treatment

open plantar fasciotomy