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Microfracture of the Talus

Preoperative Patient Care

A

Outpatient Evaluation and Management

1

Provide patient care in complex sports medicine conditions with supervision
Performs examination of the central nervous system, eye, mouth, throat, skin, genitourinary (GU) system

2

Workup patient by ordering basic imaging and laboratory studies
manage first-line nonoperative treatment

3

Understand surgical indications for common conditions

4

Able to manage patient in early postoperative period, including recognizing and managing early complications

B

Advanced Evaluation and Management

1

Independently provides patient care in all aspects of sports medicine conditions

2

Manage all musculoskeletal aspects and acute sports medicine injuries

3

Refer medical sports medicine conditions to specialists

4

Defines occult injuries of subchondral bone and cartilage that may not be detected with routine radiographs

5

Correlates imaging studies with clinical findings

C

Preoperative H & P

1

Demonstrate basic skills for routine patient care

2

Perform regional physical examination of the musculoskeletal system

  • history
  • Age
  • Gender
  • HPI
  • PMHx
  • identify medical co-morbidities that might impact surgical treatment
  • Social history
  • physical exam
  • ROM
  • joint effusion
  • joint tenderness
  • complete neurovascular exam of extremity.

3

Provides patient care in routine sports medicine conditions without supervision

4

Order appropriate imaging studies

  • order triplanar standing radiographs of the knee
  • review plain films for fractures, cartilage lesions, hindfoot and midfoot malalignment
  • weightbearing radiographs
  • AP of the foot and ankle
  • lateral view of the foot

5

Perform operative consent

  • describe complications of surgery including
  • pain
  • infection

Operative Techniques

E

Preoperative Plan

1

Determine pathology

2

Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical Instrumentation

  • standard arthroscopy pump

2

Room setup and Equipment

  • standard OR table with leg holder

3

Patient Positioning

  • supine
  • leg holders
G

Ankle Distractor Placement

1

Check the instrumentation

  • inspect all instruments
  • confirm that all parts of the noninvasive external distractor are sterile on the operative field

2

Place the patient for placement of the ankle distractor

  • place the patient on the operative table supine
  • the foot should rest within 10 cm of the end of the bed
  • place a bump under the hip to internally rotate the leg so that the toes are pointing straight up
  • place a tourniquet on the calf below the level of the fibular head to prevent peroneal nerve impingement
  • flex the hip 60 degrees
  • place the posterior thigh on a well padded thigh holder
  • secure with straps
  • prep and drape the ankle with standard arthroscopic draping
  • the distal portion of the arthroscopy drape is pulled off the end of the foot to allow distractor placement
  • place the bed clamp as far distal on the bed as possible
  • the external distractor strap is placed with the foam portions over the posterior inferior heel and on the dorsal foot
  • after creating equal lengths on the medial and lateral sides of the foot pull the hook lop distally with manual distraction
  • once this is connected use the threaded rod to provide further distraction to the ankle
H

Anterior Portal Placement

1

Prepare the ankle

  • inject the ankle with 20 cc of sterile saline via the anteromedial ankle
  • this allows identification of the correct orientation and location for the anteromedial arthroscopy portal

2

Make incision

  • make a 5 mm longitudinal skin incision and spread the subcutaneous tissue down to and then through the capsule with a small hemostat
  • A small gush of fluid will confirm the intra-articular location

3

Enter the joint

  • use a blunt tip trocar with the arthroscopic cannula to enter the joint
  • insert the arthroscope and start the water flow

4

Start the water pressure

  • place the water pressure about 5 mmhg above the systolic pressure if possible but no higher than 120 mmhg
  • this will help reduce the bleeding which often obscures the view
  • unless there is severe arthrofibrotric tissue in the anterior ankle the anterolateral ankle should be easily visualized upon introducing the arthroscope

5

Make the anterolateral portal

  • introduce the 18 gauge needle from the anterolateral portal location
  • this serves 2 purposes
  • allows for water flow through the needle which allows better visualization
  • identifies the correct location of the portal incision in order to access the joint properly
  • inspect the joint
  • distraction allows for much greater joint inspection than otherwise possible
  • make the anterolateral portal in the same fashion to the anteromedial portal
I

Anteromedial Inferior Portal Placement

1

Place the portal

  • visualize the medial gutter with the arthroscope through the anteromedial portal

2

Place the 18 gauge needle

  • introduce an 18 gauge needle into the inferior medial gutter which is usually 10 mm inferior to the normal anteromedial portal location
  • once the needle is confirmed to be in the proper position a new portal is then made as described earlier
  • this portal in combination with the conventional anteromedial portal can be used to first inspect and then debride the far anteromedial ankle joint and deltoid insertion
J

Posterior Coaxial Portal Placement

1

Make the skin incision

  • with the arthroscope and inflow in the anterolateral portal make the posterolateral portal with a small vertical skin incision immediately posterior to the peroneal tendon sheath and 1.5 cm proximal to the tip of the fibula

2

Position the ankle

  • hold the ankle in neutral dorsiflexion

3

Place the trocar

  • insert the arthroscope sheath and blunt trocar anterior and slightly inferior on a plane parallel to the bimalleolar axis

4

Confirm placement

  • confirm intracapsular placement by briefly inserting the arthroscope

5

Place switching rod

  • insert a long switching rod through the cannula and direct it towards the medial malleolus
  • use the rod to palpate the posterior colliculus and penetrate just anterior to the posterior tibial tendon

6

Place the posteromedial portal

  • tent and incise the skin over the posteromedial ankle
  • pass a second cannula over the switching stick into the posterior ankle recess

7

Maneuver the arthroscope

8

Place the sheath and blunt trocar appropiately

  • insert the arthroscope sheat and blunt trocar anterior and slightly inferior on a plane parallel to the bimalleolar axis

9

Confirm placement

  • confirm intracapsular placement by briefly inserting the arthroscope
  • for synovectomies or posteromedial osteochondral lesions, place the arthroscope in the posterolateral cannula while the posteromedial cannula is used as the working portal
K

Anatomy Visualization and Lesion Preparation

1

Visualize the ligaments

2

Test the lateral and medial ligament stability

  • apply gentle varus, valgus and anterior pull stress
  • evert and pronate the foot to test deltoid ligament stability
  • check lateral instability
  • check for talar tilting by supination stress of the foot

3

Identify the lesion with a probe

  • address all unstable cartilage and fibrous tissue of the OLT along with the cartilage that lies immediately adjacent to the defect with debridement and curettage
  • create sharp perpendicular margins to optimize conditions for the attachment of the marrow clot
  • completely remove the calcified cartilage layer with a burr
L

Microfracture

1

Prepare the awls

  • use arthroscopic awls of different angles to access all areas of the prepared OLT

2

Perform microfracture

  • place microfractures about 3 to 4 mm apart and 2 to 4 mm deep
  • fat droplets indicate that the subchondral bone has adequately been penetrated
  • ensure that the awl is always placed perpendicular to the surface and the penetration of subchondral bone

3

Check that microfracture is adquate

  • release the tourniquet and stop the flow of saline through the ankle to confirm that blood is indeed escaping from the talus into the talar defect
  • in OLTs associated with subchondral cysts, debride the damaged unhealthy cartilage
  • fenestrate the cortex at the opposite side
  • under fluoroscopic visualization translate the cancellous bone with e curved 4 mm AO plunger into the cyst
N

Wound Closure

1

Use 3-0 and 4-0 biosyn for closure

2

Use 3-0 and 4-0 biosyn for closure

3

Apply steristrips

4

Cover with tegaderm and occlusive dressings

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • schedule follow up in 2 weeks
  • outpatient physical therapy
  • Weightbearing as tolerated
  • ROM exercises without limitations are initiated during the day of surgery
R

Complex Patient Care

1

Acts as a referral to manage complex conditions in sports medicine

2

Develops novel imaging techniques for sports medicine

 

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