A short ppt on tendoscopy for Ortho PG residents.

1. JOURNAL CLUB
TENDOSCOPY
Presentor - Dr. Rejul K Raj
Supervisor – Dr. Anupam Mahajan

4. What is Tendoscopy ?
• In 1997 - van Dijk, Sholten and Kort
•
• Published a paper
• Endoscopy of the
– Achilles tendon
– Anterior tibial tendon
– Peroneal tendon sheaths
• Named the technique ‘tendoscopy’

5. 1. Achilles tendoscopy
• Indications
– Non-insertional Achilles tendinopathy
– Peritendinopathy
– Assisting the repair of acute Achilles tendon ruptures.
– Retrocalcaneal bursitis (endoscopic calcaneoplasty)
– Plantaris tendon augmentation
– Flexor hallucis augmentation in chronic neglected ruptures.

6. • Achilles tendoscopy
1. Adhesion release
2. Destruction of neovessels and neonerves
3. Preserving skin integrity.

7. Surgical technique
• Position – prone + tourniquet + foot free
• The distal portal –
– lateral border of the tendon
– 3-4 cm distal to the thickening of the Achilles
• The proximal portal –
– medial border of the tendon
– 3-4 cm proximal to the thickening

9. Procedure
• Scope 2.7 mm or 4.0 mm - release adhesions in the
paratenon space by repeatedly passing it around the Achilles.
•
• Probe - proximal medial portal to release any remaining
fibrotic tissue binding the tendon.
• Shaver system - proximal portal to debride hypertrophic
fibrosis.
• If present, plantaris tendon is released from the Achilles.
• Small tendon nodules may be debrided if present.

12. Results –
Chronic non insertional tendinopathy
Author Follow up No of
patients
Results
Maquirriain et al 7.7 years
(5 to 14)
24 96 %
Pearce et al 11 patients 73%

13. 2. Peroneal tendoscopy
• Indications
– Retrofibular pain
– tenosynovitis
– subluxation or dislocation
– Intrasheath subluxation
– partial tears,
– impingement of peroneus longus at the peroneal
tubercule
– post-operative adhesions and scarring
– resection of a peroneus quartus tendon
– bifid peroneus brevis
– low-lying peroneal muscle belly

14. Surgical technique
• Position - lateral, anterior or prone position + tourniquet
• Distal portal - around 2 cm distal to the malleolar tip.
• Proximal portal -around 3 cm proximal to the lateral
malleolus tip, along the course of the peroneal tendons.

16. Procedure
• 1 cm skin incision is made over the peroneals, following the
longitudinal axis
• The sheath is opened with a 1 cm incision perpendicular
• Blunt trocar is first used to release adhesions.
• 30° 2.7 mm or 4.0 mm scope is first gently introduced
through the distal portal.
• Probe is introduced through the proximal portal to release
any remaining fibrotic tissue around the tendons.

17. • Dry Inspection - ruling out a peroneus quartus tendon,
intrasheath subluxation and longitudinal tears.
• Shaver system - introduced through the proximal portal to
debride hypertrophic synovium and fibrosis.
• Small tendon nodules may be debrided if present.
• Burr may be used through the proximal portal for the
deepening of the malleolar groove in cases of peroneal
dislocation.
• Some peripheral tears may be debrided via a tendoscopic
approach.

19. Results
• Patients with peroneal adhesions and tenosynovitis
seem to benefit most from tendoscopy.

20. Author Indications No : Results
Vega et al Partial ruptures of
the peroneals
24 Complete
relief of pain
in 62.5%
Marmotti et al Lateral ankle pain
Post op adhesion +
scarring.
5 Improvement
Guillo and
Calder
Dislocation of
peroneal tendons
7 Excellent
Michels et al Intrasheath peroneal
subluxation
3 Excellent

21. 3. Posterior tibial tendoscopy
• Indications
– Tenosynovitis
– Degenerative tears
– Dislocation
– Enthesopathies
– Chronic tendinopathy with dysfunction and flat foot
deformity

22. Surgical technique
• Supine + tourniquet.
• Identify the navicular, the PTT, the medial
malleolus.
• Two portals,
– between 2 cm and 2.5 cm proximal and distal
– To the tip of the posteromedial edge of the medial
malleolus

24. Procedure
• A 1 cm skin incision is made over the PTT, halfway between the medial
malleolus and the navicular, following the longitudinal axis of the tendon.
• The sheath is opened with a 1 cm incision perpendicular to the
longitudinal axis of the tendon.
• Dry inspection- The arthroscope with blunt trocar is introduced and the
tendon sheath is inspected without saline to gain information on synovitis.
• The complete tendon sheath may be inspected by rotating the scope
around the tendon.
• Synovitis or partial tears may be debrided with a shaver.

27. Results
• Overall, the best outcome was registered for the
resection of pathological vincula, with more discrete
results for adhesiolysis.

28. Complications
• Achilles tendoscopy
– sural nerve injury
– tendon rupture in cases of aggressive debridement in the insertional
region
– residual equinus in cases of excessive tendon fibrosis post-operatively.
• Pereoneal tendoscopy
– sural nerve damage
– Excessive blurring of the fibula in cases of peroneal instability may
result in fibular stress fracture postoperatively.
• PTT tendoscopy
– posterior tibial nerve injury.

29. Advantages
Tendoscopy vs open procedures
• Fewer wound infections
• Less blood loss
• smaller wounds
• lower morbidity
• Quicker recovery
• Early mobilisation and function
• mild postoperative pain and
• Local anaesthesia on an outpatient basis

30. Disadvantages
• Sufficient endoscopic skills
• To avoid neurovascular and skin complications.

31. Evidence-based recommendations
• Most studies are levels IV and V, with just one level II study.
• No solid body of evidence in the current scientific literature to
support the use of this procedure in our daily surgical
practice.

32. Take Home Message
• Expanding indications for foot and ankle tendoscopy.
• Little quality evidence based data
• Particularly useful in Achilles non-insertional tendinopathy.
• Tendoscopy is becoming an important diagnostic and
therapeutic tool.

33. THANK YOU