This document summarizes a journal club presentation on tendoscopy. It discusses what tendoscopy is and provides details on techniques for Achilles, peroneal, and posterior tibial tendoscopy. Key indications, surgical procedures, results, advantages, disadvantages, and complications are outlined for each type of tendoscopy. The presenter concludes that while tendoscopy is becoming an important tool, there is little high-quality evidence to fully support its use in daily practice at this time.

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