Dr. Alan Ng utilizing NuShield as a surgical barrier in a Peroneal Tendon Repair procedure.
Dr. Alan Ng is a podiatric surgeon specializing in foot and ankle reconstruction at Orthopedic Centers of Colorado, with more than 23 years of experience. He is the Fellowship Director at Rocky Mountain Reconstructive Foot and Ankle Fellowship. Dr. Ng is the President Elect of the American College of Foot and Ankle Surgeons as well as the past President of the American Board of Foot and Ankle Surgery.
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Good morning everybody. Uh My name is Doctor Allen here in Denver, Colorado. We're gonna do a surgery here. This patient has a small tech condal lesion of his talus as well as a perineal tendon tear. Our plan in this case is to perform arthroscopy to breath and clean up the ankle and then perform a perineal tendon repair. Uh We'll start with the scope first and then we'll proceed to the tendon repair afterwards. So this is a little bruising condom plasty on that area to take off the loose cartilage, roughing up the subchondral bone surface to attempt to get some fibro cartilage regrowth. It's a small and all the grand scheme of things. It's pretty small osteochondral defect that doesn't necessarily need a, a graft at this stage. Um But in some cases, we would cover that with some sort of biologic or cartage substitute or graft. So we just finished up a skill portion. The osteochondral defect was a little bigger than M I showed. So we debrided it as much as we could. Long term of this continued problems with his condal defect, we'll end up grafting him with some sort of uh graft to restore the um cartilage in the area. He's a young guy, he's 38 years old. So we wanna make sure that we can keep him going. Um Post resection of the stage. The hopes is he forms a fibro cartilage, uh cartilage on top of that area and his functional uh poster breed in here. Um A lot of conversations discussing about the sub condal bone plate and in this case here, we used an abrasion. We didn't fenestrate or damage the sub condal bone plate, which is already somewhat damaged from Z osteo condal defect. Um Possibly some future looks at other options for filling or graphing those defects would be an option. So looking at your attendance way different between preus longus preus brevis is if I move the first ray, you'll see Longus move and these are the two tendons here. So if I slide this around the two tendons and I move the big toe, that's pretty its longest. You can see it moving right there. So what we're looking at primarily based on this MRI findings, this train is Brevis. So I isolate the brevis which is the top one and it's very flattened. And we can see this tendon has been flattened out quite a bit, especially you go rectum Molina behind the fibula. This tendon is essentially flattened out and split through here. So what we're gonna do because I'm gonna rein interval this tendon, I'll also extend his decision approximately because it looks like his retro my portion is where the primary split is. Yeah. Yeah. 11 hold up, hold right there. And you can see here when I pull his tendon back here is his low lying muscle belly on the brevis. This causes retro melear impingement and that is the belly right here. That's a muscle belly. And this is a flattening of that tendon. So this lowly muscle belly causes infringement, pushes that tendon against the side of the fibula and can cause the uh some almost like an attrition rupture from the fibula, pushing against the tendon. So almost acts like a little lover. Yeah. Vacuum it. So this is a lowly muscle belly that I debrided. Um When the retromolar space is crowded by the muscle belly, it pushes the brevis tendon against the fibula and acts as almost a deforming force or lever arm against the fibula and can cause an attrition tear. And that's what causes a split or flattening. If you look at the tendon here, it's tubular here, but it becomes very flat here. So what I'm gonna do is in Tate this tendon to make another, make the tendon back what it's supposed to be. So, over time, it's been pushed against the side and essentially split this tendon and cause it to form a um flattening of the tendon. Uh P DS, I tend to use P DS to kind of rebate this and I'll sew this tendon back together and make it back into a tube to prevent it from um flattening and rubbing against that fibula again. And we decompress some of the pines Brevis muscle by taking out that muscle. Um It should in theory, decompress that retro space and give our tenant more room to, to glide and move. So what I got to repair the tendon, I'll put it back, look at it and put it back in the groove. So when I put it back in the groove here, now it sits in the groove and I will sew this retinaculum, which is right here, back to that area in a tighter orientation to repair that and make sure there's no subluxation, post surgery. So you can see here even with our absorbable suture, which is P DS, when it glides, it's, it's right next to the Longus. And we don't want these two to adhere unless and get scar tissue in the sheath. So in this case here, I'll take my Army Navy and I'll separate my Longus and Brevis. So this here is uh our new shield, our notch is to the left that tells me stromal side is up, here's a notch in the middle notching on the left side. So stromal side is facing us. So that's the side I want to articulate with the tendon. So I want the epithelial side out a little more hydration again. OK. Uh Formal monitor. Yeah, I'm tabulating around the tendon. And I'm gonna sew through the new shield with the tendon with this monochrome very gently and very carefully. So it allowed me to cover the majority of the tendon here that was repaired with the new shield and try to hold that in place. Gently, remove some irrigation, please. So this is the tricky part. They gently remove this and gently remove this. So you can see here the new shield is over the tendon which is adjacent to the inferior portion of the fibular malleolus. We're gonna sew the retinaculum back right here in a tight position to keep this tendon in that position so it can heal better. And now it's in Tate, it's not flattened or torn anymore, take OVI. So I'll show how this is incorporated after I sew this back to where it needs to go. And the other issue is that we talked about earlier. Also the seal nerves exposed. Sometimes I'll lay this the new shield over the nerve itself. Um One of the complications or post-operative adverse effects after Peron attendant repair can be CERONE neuritis or CERONE neuropraxia. So, so it's important that you sew this part in very well because you don't want your perineal tendon to sub lx out of the groove. If you don't repair the retinaculum properly, I'll lightly close the sheath back over that area. And the goal would be to prevent this sheath or tissue that was in that area to prevent it from adhesing to the tendon. Right. So we don't want, we want the tendon to glide as much as possible. I gonna lay some of this, the pilar sides out and we can lay this in here over the top. Another pair of pickups. Give me a second pair of pickups. Please. I pull the whole foot over and we're gonna lay this down over the tendon and the soft tissue, the sub cue skin over the top prevent it from he and we're done.
