Rejul journal club- tendoscopy
- 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
Editor's Notes
- Neovascularisation and neoinnervation