Endoscopic access to the extremities: the principle of fascial clefts

Technology for endoscopic surgery has developed rapidly during the last decade. Applications of endoscopic techniques to orthopaedic surgery have been made possible by the use of balloon dissectors. Balloon dissectors create an optical cavity by separating fascial layers of a constant anatomic plane called the fascial cleft. The optical cavity can be maintained with either carbon dioxide (CO2) insufflation or manual retractors. The authors of the present study have developed a safe, reliable technique using a balloon dissector to create such optical cavities in the extremities, pelvis, and acetabulum to facilitate minimally invasive surgery in these areas. The authors' clinical work and fresh cadaver dissection confirms that the fascial cleft is a universal anatomic constant. It can be accessed quickly to facilitate endoscopic procedures, such as bone grafting for delayed unions, tissue expansion for reconstructive surgery, sural nerve harvesting for nerve cable grafting, and microvascular tissue transfer harvesting and flap prefabrication for extremity reconstruction. Twenty-five cases, each with an average follow-up of 34 months, are presented. Indications, results, and complications of balloon-assisted endoscopic surgery are described.