Tendoscopy of the ankle

2-Mm Diameter Operative Tendoscopy of the Tibialis Posterior, Peroneal, and Achilles Tendons: A Cadaveric Study

BACKGROUND

Technical innovation now offers the possibility of 2-mm-diameter operative tendoscopy with disposable arthroscopes and tablet-like control units. The promises of new technology should be critically scrutinized. Therefore, this study assessed whether 2-mm-diameter operative tendoscopy of the tibialis posterior, peroneal, and Achilles tendons was safe and effective in a cadaveric model.

METHODS

A 2-mm-diameter arthroscopic system was used to perform a tendoscopic procedure in 10 nonpaired, fresh-frozen, human ankles. Standard tendoscopic portals were utilized. Visual examination and operative reach with tailored tendoscopic instruments within the tendon sheaths were recorded and documented. Adhesiolysis and vincula resections were performed. After dissection, distances between portal tracts and neurovascular structures were measured and the tendons were inspected for signs of iatrogenic damage.

RESULTS

The entire tendon sheath and tendon of the tibialis posterior, peroneus brevis, and Achilles tendons were visualized and reached with tailored operative instruments. The proximal part of the peroneus longus tendon was visible and reachable from proximally up to the cuboid bone distally. Adhesiolysis and vincula resections were successfully performed in all specimens. The mean distances between portal tracts and local neurovascular structures ranged between 9.4 and 19.2 mm and there were no cases of contact. None of the tendons showed signs of iatrogenic damage.

CONCLUSION

Two-millimeter-diameter operative tendoscopy provided safe and effective visualization and operative reach of the tibialis posterior, peroneal, and Achilles tendons.

CLINICAL RELEVANCE

Compared with current practice, 2-mm-diameter operative tendoscopy has the potential to make tendoscopy around the ankle less invasive and more accessible. Diagnostic, interventional, and second-look procedures might be performed at substantially reduced risk, time, and costs.

Peroneal Tendoscopic Debridement and Endoscopic Groove Deepening in the Prone Position

Tendoscopy of the peroneal tendon is a promising procedure for the treatment of peroneal tendon pathology and its disorders. This procedure is minimally invasive with less physical morbidity and early functional rehabilitation. The present report demonstrates the techniques of peroneal tendoscopic debridement and endoscopic groove deepening in the prone position to treat peroneal tenosynovitis and low-lying muscle belly of peroneus brevis with a shallow and flat surface of the retro-malleolar groove. The prone position provided better ergonomics during this procedure compared with the supine position.

Tendoscopy of Achilles, peroneal and tibialis posterior tendons: An evidence-based update

BACKGROUND

Tendoscopy has been proposed in treating several conditions affecting tendons around the ankle. We reviewed literature to investigate the efficacy of Achilles, peroneal and tibialis posterior tendoscopy.

METHODS

Following the PRISMA checklist, the Medline, Scopus and EMBASE databases were searched, including studies reporting patients affected by disorders of Achilles, peroneal and tibialis posterior tendons and treated by tendoscopy (or tendoscopic-assisted procedures). The tendoscopic technique, rehabilitation protocol, clinical scores, patient satisfaction, success and failure rates and complications were evaluated.

RESULTS

Sixteen studies (319 procedures) dealt with Achilles tendoscopy, nine (108) and six (78) about peroneal and tibialis posterior, respectively. Wound healing, cosmetic results, complication rate, work and sport resumption delay were satisfactory. Clinical scores, classification methods and rehabilitation protocols adopted were heterogeneous.

CONCLUSIONS

The recent scientific evidence suggests that tendoscopy and endoscopic-assisted percutaneous procedures are a safe and effective treatment in chronic and acute disorders of tendons around the ankle.

Ultrasound Guidance in Performing a Tendoscopic Surgery to Treat Posterior Tibial Tendinitis: A Useful Tool?

A 25-year-old man with a pronation-external rotation type of fracture was surgically treated using a fibular plate. Five years later, he underwent resection of bone hyperplasia because of the ankle pain and limitation of range of motion. Thereafter, the left ankle became intermittently painful, which persisted for about one year. He presented at the age of 43 with persistent ankle pain. Physical and image analysis findings indicated a diagnosis of posttraumatic posterior tibial tendinitis, which we surgically treated using tendoscopy. Endoscopic findings showed tenosynovitis and fibrillation on the tendon surface. We cleaned and removed the synovium surrounding the tendon and deepened the posterior tibial tendon groove to allow sufficient space for the posterior tibial tendon. Full weight-bearing ambulation was permitted one day after surgery and he returned to his occupation in the construction industry six weeks after surgery. The medial aspect of the ankle was free of pain and symptoms at a review two years after surgery. Although tendoscopic surgery for stage 1 posterior tibial tendon dysfunction has been reported, tendoscopic surgery to treat posttraumatic posterior tibial tendinitis has not. Our experience with this patient showed that tendoscopic surgery is useful not only for stage 1 posterior tibial dysfunction, but also for posttraumatic posterior tibial tendinitis.

Extended indications for foot and ankle arthroscopy

Advances in foot and ankle arthroscopy have allowed surgeons to diagnose and treat a broadening array of disorders that were previously limited to open procedures. Arthroscopy of the posterior ankle, subtalar joint, and first metatarsophalangeal joint and tendoscopy can be used to address common foot and ankle ailments, with the potential benefits of decreased pain, fast recovery, and low complication rates. Posterior ankle and subtalar arthroscopy can be used to manage impingement, arthrofibrosis, synovitis, arthritis, fractures, and osteochondral defects. First metatarsophalangeal joint arthroscopy can address osteophytes, chronic synovitis, osteochondral defects, and degenerative joint disease. Tendoscopy is a minimally invasive alternative for evaluation and débridement of the Achilles, posterior tibial, flexor hallucis longus, and peroneal tendons.

Posterior tibial tendoscopy: Description of an accessory proximal portal and assessment of tendon vascularization lesion according to portal

BACKGROUND

Posterior tibial tendoscopy was codified in 1997 by Van Dijck, who described a portal between 1.5 and 2cm proximally and distally to the tip of the medial malleolus. However, this approach does not allow proximal exploration of the posterior tibial tendon (PTT). We here describe an accessory portal 7cm proximal to the medial malleolus, enabling complete PTT exploration.

METHODS

Posterior tibial tendoscopy was performed on 12 cadaver specimens, mapping PTT exploration and vascularization.

RESULTS

The accessory portal enabled the whole PTT to be explored, from the myotendinous junction to the entry into the retromalleolar groove. PTT observation quality was improved compared to using a submalleolar portal. Dissection confirmed systematic presence of a vincula on the posterior side of the tendon, connected to the flexor digitorum longus (FDL) tendon, containing collateral vessels of the posterior tibial artery. None of these elements were damaged by the tendoscopy as long and the scope and motorized instruments were not rotated on the posterior side of the supramalleolar part of the PTT.

CONCLUSIONS

This accessory entry portal provides complete PTT exploration without the risk of neurovascular bundle lesion.

Peroneal tendoscopy

Peroneal tendoscopy is an innovative technique that allows visualization of the tendons from the myotendinous junction to the peroneal tubercle, together with adjacent anatomic structures such as the recently unveiled vincula. Through a minimally invasive approach, it is possible to diagnose and treat several disorders, such as common tenosynovitis, accessory muscles, hypertrophic bony prominences, and thickened vincula, that can cause pain and tendon catching. Surgical morbidity and postoperative pain are significantly reduced when compared with open procedures. In this paper, the main indications for peroneal tendoscopy are discussed, the available literature is reviewed, and the surgical technique is described. Advantages of this procedure and current limitations are also presented. Anatomic and histological studies were also performed in order to verify: 1) the feasibility of peroneal tendoscopy for evaluation of peroneal tendons, using cadaver specimens; 2) the presence of nervous tissue in cadaver peroneal vincula as well as in tendoscopic vincula biopsies from patients undergoing surgery for chronic lateral ankle pain.