Systematic Review
Foot and Ankle Tendoscopy: Evidence-Based Recommendations Chris C. Cychosz, B.S., Phinit Phisitkul, M.D., Alexej Barg, M.D., Florian Nickisch, M.D., C. Niek van Dijk, M.D., Ph.D., and Mark A. Glazebrook, M.Sc., Ph.D., M.D., F.R.C.S.C.
Purpose: The purpose of this study was to provide a comprehensive review of the current literature on tendoscopy of the foot and ankle and assign an evidence-based grade of recommendation for or against intervention. Methods: A comprehensive review of the literature was performed on May 26, 2013, using the PubMed, Cochrane, and Scopus databases. Studies focusing on the use of foot and ankle tendoscopy were isolated, and these articles were then reviewed and assigned a Level of Evidence (I through V). The literature was then analyzed, and a grade of recommendation was assigned for tendoscopy of the tendons of the foot and ankle on which the procedure is generally performed. Results: There is weak evidence (grade Cf) to support the use of tendoscopy on the Achilles, flexor hallucis longus, and peroneal tendons. Insufficient evidence (grade I) exists to assign a grade of recommendation for tendoscopy of the tibialis posterior, tibialis anterior, flexor digitorum longus, extensor hallucis longus, and extensor digitorum longus. Conclusions: A comprehensive review of the literature on foot and ankle tendoscopy has shown predominantly Level IV and V studies, with just 1 Level II study. On the basis of the current literature available, there is poor evidence (grade Cf) in support of Achilles, flexor hallucis longus, and peroneal tendoscopy for the common indications. There is insufficient evidence to make a recommendation (grade I) for or against tendoscopy of the tibialis posterior, tibialis anterior, flexor digitorum longus, extensor hallucis longus, and extensor digitorum longus. Although current literature suggests that tendoscopy is a safe and effective procedure, original scientific articles of higher levels of evidence are needed before a stronger recommendation can be assigned. Level of Evidence: Level IV, systematic review of Level II, IV, and V studies.
n endoscopic tendon procedure was first described in the literature by Wertheimer et al.1 in 1995 for the treatment of posterior tibial stenosing tenosynovitis. In 1997 Niek van Dijk et al.2 published a report on tendon sheath endoscopy of the peroneal tendon, anterior tibial tendon, and Achilles tendon in 40 patients
A
From Carver College of Medicine, The University of Iowa (C.C.C.), and Department of Orthopaedics and Rehabilitation, The University of Iowa Hospitals and Clinics (P.P.), Iowa City, Iowa; and Department of Orthopaedics, University of Utah School of Medicine (F.N.), Salt Lake City, Utah, U.S.A.; the Orthopaedic Department, University Hospital of Basel, University of Basel (A.B.), Basel, Switzerland; the Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam (C.N.v.D.), Amsterdam, The Netherlands; and Division of Orthopaedic Surgery, Dalhousie University (M.A.G.), Halifax, Nova Scotia, Canada. The authors report the following potential conflict of interest or source of funding: P.P. receives support from Arthrex, OREF Young Investigator Grant, MTP Solutions. C.N.v.D. receives support from Smith & Nephew. Received December 16, 2013; accepted February 13, 2014. Address correspondence to Phinit Phisitkul, M.D., The University of Iowa Hospitals and Clinics, 0102X JPP, 200 Hawkins Dr, Iowa City, IA 522421088, U.S.A. E-mail: [email protected] Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America 0749-8063/13880/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.02.022
and named the procedure “tendoscopy.” In the years since, refinements in equipment and techniques have aided the expansion of tendoscopy as both a diagnostic and therapeutic procedure to other tendons of the foot and ankle. However, because it is a relatively new technique, there may not yet be a suitable body of evidence in the form of scientific literature to support the use of foot and ankle tendoscopy. The purpose of this study was to review the literature on the outcomes and complications of tendoscopy of the foot and ankle for the generally accepted indications of each tendon, summarize the quality and quantity of evidence available, and lastly, assign a grade of recommendation for or against the use of tendoscopy.
Methods The methodology of this study was modeled after that described by Glazebrook et al.3 A comprehensive review of the literature was performed (May 26, 2013) by use of the PubMed, Scopus, and Cochrane databases using the search terms “(tendoscopy OR tendoscopic)” and “((endoscopy OR endoscopic) AND tendon AND (foot or ankle)).” The “search within” function available on Scopus was used for the latter term to yield more
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Table 1. Levels of Evidence for Therapeutic Studies4,70 Level of Evidence Level I
Level II
Level III
Level IV Level V
Description High-quality randomized trial with no statistically significant difference but narrow confidence intervals Systematic reviews of Level I RCTs (and study results were homogeneous) Lesser-quality RCTs (e.g., 80% follow-up, no blinding, or improper randomization) Prospective comparative studies Systematic reviews of Level II studies or Level I studies with inconsistent results Case-control studies Retrospective comparative studies Systematic reviews of Level III studies Case series Expert opinion
RCT, randomized controlled trial. Reprinted with permission from the Journal of Bone & Joint Surgery and the Centre for Evidence Based Medicine.
results. Searches were limited to articles in the English language. All dates and all types of publications including prospective and retrospective studies, case reports, and review articles were allowed by the initial search criteria. The decision to eliminate articles was made by a minimum of 2 reviewers. These searches together returned 328 articles. Of these articles, 134 were eliminated based on the title alone and 71 were eliminated by reading the abstract. The remaining articles were examined for content, and an additional 66 were eliminated. Finally, the references of the remaining 57 articles were reviewed, and 8 additional publications included in this study were retrieved. Cadaveric studies and technique tips without any patients were excluded. For the Achilles tendon, only non-insertional interventions were included in this study. Studies reporting the arthroscopic or endoscopic release of the flexor hallucis longus (FHL) tendon for the treatment of stenosing tenosynovitis were included as long as adequate data separation was provided to distinguish patients undergoing these procedures from patients undergoing various hindfoot endoscopic procedures. In the event that the same series Table 2. Grades of Recommendation for Summaries or Reviews of Orthopaedic Surgical Studies5 Grade of Recommendation A
B
C
I
Description Good evidence (Level I studies with consistent findings) for or against recommending intervention Fair evidence (Level II or III studies with consistent findings) for or against recommending intervention Poor-quality evidence (Level IV or V studies with consistent findings) for or against recommending intervention Insufficient or conflicting evidence not allowing a recommendation for or against intervention
Reprinted with permission from the Journal of Bone & Joint Surgery.
of patients was reported on in more than 1 publication, only the publication with the most comprehensive series was included. All articles were reviewed and assigned a Level of Evidence classification (I through V) by use of the Journal of Bone and Joint Surgery “Levels of Evidence for Primary Research Question” (Table 1).4 Series with fewer than 5 patients or those that had poor data correction were classified as Level V Evidence, and studies in which the retrospective or prospective nature was not apparent were classified as retrospective. An analysis of the literature reviewed was used to assign a grade of recommendation (A, B, C, or I)5 for each current generally accepted indication for foot and ankle tendoscopy (Table 2). A subscale proposed by Stevens et al.6 was used for further differentiation of the evidence for indications receiving a grade C recommendation. Three subscripts were applied: “c” for conflicting literature, “f” for literature for the use of tendoscopy, and “a” for literature against the use of tendoscopy.
Results On the basis of the literature, weak evidence (grade Cf) exists in support of tendoscopy on the Achilles, FHL, and peroneal tendons for the generally accepted indications. Insufficient evidence (grade I) exists to make a recommendation for or against the use of tendoscopy on the tibialis posterior, tibialis anterior, flexor digitorum longus (FDL), extensor hallucis longus (EHL), and extensor digitorum longus (EDL). A summary of the grades of recommendation based on the current literature is presented in Table 3. Achilles Tendoscopy Level of Evidence II. The first case series on Achilles tendoscopy was published by Niek van Dijk et al.2 in 1997. Since then, there has been one Level II study on Achilles tendoscopy.7 Halasi et al.7 prospectively compared a group of 57 patients undergoing percutaneous Achilles tendon repair with the use of endoscopy (E group) with a group of 87 patients undergoing the same procedure without endoscopic assistance (P group). The primary purpose of tendoscopy during the procedure was to control the adaptation of the tendon ends. In a subjective evaluation, 51 of 57 patients (89%) in the E group and 76 of 87 patients (88%) in the P group had good to excellent results. The rerupture rate was lower in the E group (1 of 57, 1.75%) than in the P group (5 of 87, 5.74%) during a follow-up period that ranged from 12 to 60 months. This difference was not statistically significant, however. The authors noted that Achilles tendoscopy was able to give them a more precise repair. Levels of Evidence IV and V. There were 10 Level IV studies8-17 and 2 Level V studies18,19 on Achilles tendoscopy (Table 4). The average number of patients
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FOOT AND ANKLE TENDOSCOPY Table 3. Summary of Recommendations for or Against Tendoscopy of Foot and Ankle Tendon Achilles Peroneal FHL Tibialis anterior Tibialis posterior FDL EHL/EDL
No. of Studies 13 20 20 2 7 2 4
Level I 0 0 0 0 0 0 0
Level II 1 0 0 0 0 0 0
per study was 16.7, and the majority of case series reported patient satisfaction rates or good to excellent outcome rates approaching 100%. Complications encountered include sural nerve injury, tendon rerupture, deep vein thrombosis, fusiform thickening, hematoma, and delayed keloid lesions; however, no studies reported rates above 11%. In a retrospective study by Pearce et al.,9 11 patients with non-insertional tendinopathy underwent Achilles tendoscopy with division of the plantaris tendon. The mean American Orthopaedic Foot & Ankle Society hindfoot scores improved from 68 (range, 51 to 82) preoperatively to 92 (range, 74 to 100) postoperatively; 8 of 11 patients (72.7%) were satisfied, and the other 3 were somewhat satisfied. None of the patients in this study had complications. Maquirriain12 evaluated the long-term results of Achilles tendoscopy for the treatment of chronic midportion Achilles tendinopathy. Twenty-four patients underwent 27 procedures (3 bilateral) consisting of paratenon debridement and longitudinal tenotomies, with a mean follow-up period of 7.7 years (range, 5 to 14 years). Fifteen patients were evaluated with the Victorian Institute Sport AssessmenteAchilles questionnaire and had an improvement from a mean score of 37 points before the procedure to 97.5 after the procedure. The mean score with the Achilles Tendon Scoring System improved as well, increasing from 32.6 before the procedure to 97.6 at follow-up. At the latest-follow-up, 96% of patients were completely free of symptoms. There were 2 postoperative complications, comprising a delayed keloid lesion and a seroma with chronic fistula. No infections or systemic complications occurred in this series. Grade of Recommendation. Generally accepted indications for non-insertional Achilles tendoscopy include peritendinopathy13,19 and tendinopathy.8,9,12-14,19 Studies have also found tendoscopy to be helpful in assisting with the repair of tendon ruptures.7,10,11,15,16 Although highlevel evidenceebased literature for Achilles tendoscopy is still somewhat sparse, the literature mentioned earlier reported consistently good outcomes with few complications; therefore tendoscopy of the Achilles tendon was assigned a grade Cf recommendation (for intervention).
Level III 0 0 0 0 0 0 0
Level IV 11 7 9 0 3 0 0
Level V 2 13 11 2 4 2 4
Grade of Recommendation Cf (for intervention) Cf (for intervention) Cf (for intervention) I I I I
Peroneal Tendoscopy Levels of Evidence IV and V. There were 7 Level IV studies20-26 and 13 Level V studies27-39 on peroneal tendoscopy (Table 5). These studies ranged in size from 1 to 52 patients, with a mean of 7.6 patients. Only minor complications including suture irritation and mild post-static dyskinesia were noted. The majority of patients reported significant or complete relief of symptoms shortly after the procedure. The results were generally stable through the final follow-up, ranging from 2 months to 6 years. In a Level IV retrospective study, Scholten and van Dijk21 performed peroneal tendoscopy on 23 patients with a minimum follow-up period of 2 years. Two patients presented with recurrent peroneal tendon dislocation and underwent tendoscopic fibular groove deepening. Another 10 patients had chronic tenosynovitis and underwent tendoscopic synovectomy. The remaining 11 patients had a longitudinal rupture of the peroneal brevis tendon and underwent tendoscopic synovectomy and suturing if necessary (by way of a mini-open procedure). None of the patients had complications, nor was there a recurrence of any preoperative pathology. Peroneal tendoscopy was used primarily as a diagnostic procedure in a Level V study by Panchbhavi and Trevino.35 A peroneus quartus tendon that did not show up on magnetic resonance imaging (MRI) was found to be causing lateral ankle pain in 1 patient. Another individual underwent peroneal tendoscopy with subtalar arthroscopy, and it was discovered that she had a low-lying muscle belly attached to her peroneus brevis. Tendoscopy in a third patient identified a tendinous structure between the peroneus longus and brevis, which had not been identified on the preoperative MRI scan. These tendon anomalies were excised through an open procedure, and the symptoms resolved in all patients. In a recent Level IV study by Vega et al.,24 52 patients underwent peroneal tendoscopy from 2008 to 2011 with a minimum follow-up period of 1 year. The indications for peroneal tendoscopy were peroneal adhesions (2), tenosynovitis (13), tendon rupture (24), recurrent peroneal tendon subluxation (7), and intrasheath peroneal tendon subluxation (6). The symptoms diminished
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Table 4. Level II-IV Studies in Support of Achilles Tendoscopy Author (Year) Doral et al.10 (2009)
Type of Study Level IV (prospective case series)
Indications Achilles rupture
Measurement Tools AOFAS score
Fortis et al.11 (2008)
Level IV (prospective case series) Level II (prospective comparative study)
Achilles rupture
Merkel scale
Achilles rupture
Subjective
Level IV (retrospective case series) Level IV (prospective case series)
Chronic noninsertional Achilles tendinopathy Peritendinitis, tendinosis, partial tear
ATSS-17 score
Improved from mean ATSS-17 score of 29.4 to 89
ATSS score, MRI
ATSS score improved from 39 to 89
Maquirriain12 (2013)
Level IV (retrospective case series)
Chronic midportion Achilles tendinopathy
ATSS score, VISAA score, PGART score using 5-point Likert scale
Pearce et al.9 (2012)
Level IV (retrospective case series)
Non-insertional chronic Achilles tendinopathy
AOFAS score, AOS score, SF-36 score
Tang et al.16 (2007)
Level IV (retrospective case series)
Acute Achilles rupture
Arner-Lindholm scale
Thermann et al.14 (2009)
Level IV (prospective case series) Level IV (retrospective case series)
Chronic midportion Achilles tendinopathy Acute Achilles rupture
VAS
Level IV (retrospective case series)
Non-insertional chronic Achilles tendinopathy
ATSS score improved from 32.7 to 97.2; VISA-A score improved from 37.1 to 97.6; 24 of 24 patients (100%) had good to excellent PGART scores AOFAS score improved from 68 to 92; AOS score improved from 28% to 8% for pain and from 38% to 10% for disability; SF-36 score improved from 76 to 87 (not statistically significant) Excellent in 15 of 20 (75%) and good in 5 of 20 (25%) according to Arner-Lindholm scale VAS for pain improved from 40 to 97.5; VAS for function increased from 22.5 to 90 11 of 11 (100%) had satisfactory results; 10 of 11 (91%) had no significant change in ROM Excellent Nelen scale score in 8 of 8 (100%); preoperative MRI showed degeneration in 8 of 8 patients (100%); postoperative MRI showed degeneration in 3 of 8 patients (37.5%)
Halasi et al.7 (2003)
Lui17 (2012)
Maquirriain et al.13 (2002)
Turgut et al.15 (2002)
Vega et al.8 (2008)
ROM
Nelen scale, MRI
Outcome Excellent in 94% and good in 6% according to AOFAS score; postoperative mean, 94.6 Mean postoperative Merkel score, 604; good to excellent outcomes in 20 of 20 (100%) Good to excellent in 88% in P (percutaneous) group and 89% in E (endoscopic) group
Comments 2 of 62 patients (3.2%) had hypoesthesia in sural nerve region, which resolved spontaneously after 6 mo 2 of 20 patients (10%) had sural neuralgia; 1 subsided with no further treatment E group: 1 partial rerupture, 4 fusiform thickening, 1 DVT P group: 2 total and 3 partial reruptures, 4 fusiform thickening, 2 DVT FHL transfer also performed 1 of 7 patients (14.3%) had minor subcutaneous hematoma with ankle edema, which resolved after 1 wk of rest 2 of 27 procedures (7.4%), comprising 1 delayed keloid lesion and 1 seroma with chronic fistula
AOFAS, American Orthopaedic Foot & Ankle Society; AOS, Ankle Osteoarthritis Scale; ATSS/ATSS-17, Achilles Tendoninopathy Scoring System; DVT, deep vein thrombosis; PGART, Patient Global Assessment Response to Therapy; ROM, range of motion; SF-36, Short Form 36; VISA-A, Victorian Institute Sport AssessmenteAchilles.
for both patients who underwent tendoscopic lysis of adhesions. Of the 24 patients diagnosed with ruptures of the peroneal tendons, 15 (62.5%) reported complete relief of their symptoms, 6 (25%) reported partial relief, and 3 (12.5%) had no change in symptoms after the procedure. Of the 7 patients treated with tendoscopic
groove deepening for peroneal tendon subluxation, 5 (71.4%) reported excellent results and were able to return to their normal activities without limitations. No recurrent subluxation occurred at follow-up in any of the cases; however, 2 patients had discomfort and a clicking sensation in the lateral retromalleolar area
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FOOT AND ANKLE TENDOSCOPY Table 5. Level IV Studies to Support Tendoscopy of Peroneal Tendons Author (Year) Guillo and Calder23 (2013) Jerosch and Aldawoudy26 (2007)
Lui25 (2012)
Marmotti et al.20 (2012) Scholten and van Dijk21 (2006)
Type of Study Level IV (retrospective case series) Level IV (prospective case series)
Level IV (retrospective case series) Level IV (retrospective case series) Level IV (retrospective case series)
van Dijk and Kort22 (1998)
Level IV (prospective case series)
Vega et al.24 (2013)
Level IV (retrospective case series)
Indications (No.) Recurring peroneal tendon subluxation (7)
Outcome 7 of 7 patients (100%) returned to previous activity level
Comments 1 patient had skin irritation due to suture knot
Tenosynovitis (7), partial lesions of peroneal tendon (5), LLMB (2), peroneal tendon instability (1) Retrofibular pain (7)
15 of 15 patients (100%) were symptom free at 3 mo postoperatively
Peroneal tendon instability required open repair of retinaculum; 1 longitudinal tear required open repair
6 of 7 patients (86%) resumed previous sport or activity within 24 mo 5 of 5 patients (100%) reported subjective improvement of lateral ankle pain No recurrence of preoperative pathology
Mild post-static dyskinesia of operative site occurred in all patients
Thickened vincula lesions (5) Longitudinal rupture of peroneal brevis tendon (11), chronic tenosynovitis (10), recurrent peroneal subluxation (2) Diagnostic (5), snapping sensation (2), exostosis (1), partial tendon tear (1)
Peroneal tendon rupture (24), tenosynovitis (13), recurrent peroneal tendon subluxation (7), intrasheath subluxation (6), adhesions (2)
3 of 4 (75%) had no recurrence after adhesiolysis; 1 of 1 (100%) peroneal tubercle successfully removed; 1 of 1 (100%) longitudinal rupture successfully sutured Intrasheath subluxation: excellent results in 6 of 6 (100%) (mean AOFAS score increased from 79 to 99) Lysis of adhesions: 2 of 2 (100%) had symptoms diminish Ruptures: 15 of 24 (62.5%) symptom free, 6 of 24 (25%) partially symptom free, 3 of 24 (12.5%) no change Recurrent peroneal tendon subluxation: 5 of 7 patients (71.4%) had excellent results (AOFAS score increased from 75 to 93)
Suturing of tendon tears required mini-open procedure
Some tendon ruptures required open repair
AOFAS, American Orthopaedic Foot & Ankle Society; LLMB, low-lying muscle belly.
during active dorsiflexion and eversion of the foot. All 6 patients treated for intrasheath subluxation had excellent results. Grade of Recommendation. Generally accepted indications for peroneal tendoscopy include tenosynovitis,21,24,26,32,34,38 subluxation or dislocation,21,23,24,27,30,37 snapping,22 partial tears requiring debridement,22,24,26 and postoperative adhesions and scarring.24 Peroneal tendoscopy was also found to be valuable as a diagnostic tool in some instances.22,35 The Level IV and V studies on peroneal tendoscopy generally reported good to excellent outcomes in most patients with a relatively low occurrence of complications. On the basis of the literature available, peroneal tendoscopy was assigned a grade Cf recommendation (for intervention).
FHL Tendoscopy Levels of Evidence IV and V. There were 9 Level IV studies17,40-47 and 11 Level V studies18,48-57 on FHL tendoscopy (Table 6). Studies often reported the use of FHL tendoscopy in conjunction with other procedures during hindfoot endoscopy. A tendoscopic method of harvesting the FHL tendon was presented in a limited number of studies as well. Most authors reported good to excellent results in greater than 70% of patients, with complication rates ranging from 0% to 25%. Van Dijk et al.54 first described FHL tendoscopy for the treatment of chronic FHL tendinitis in a 22-year-old professional ballet dancer. During operative treatment by means of 2-portal posterior ankle endoscopy, adhesions and thickening of the FHL tendon were found after the os trigonum was removed. Six weeks after
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Table 6. Level IV Studies to Support FHL Tendoscopy Author (Year) Calder et al.40 (2010)*
Type of Study Level IV (prospective case series)
Procedure (No. of Procedures) Debridement with FHL release (5), os trigonum excision (13), bony pull-off excision with FHL release (9)
Corte-Real et al.41 (2012)
Level IV (retrospective case series)
FHL release (27)
Lui et al.42 (2006)
Level IV (retrospective case series)
FHL mobilization, posterior capsulectomy, various
Lui17 (2012)
Level IV (retrospective case series)
Zone 2 FHL harvest for Achilles tendon augmentation (5)
Nickisch et al.43 (2012)*
Level IV (retrospective case series)
Ogut et al.44 (2011)
Level IV (retrospective case series)
FHL tenolysis (38), os trigonum excision (48), partial calcanectomy (5), osteochondral lesion debridement (44), subtalar debridement (38), subtalar fusion (33), ankle debridement (30), partial talectomy (9), fixation of calcaneal fracture (4), revision of subtalar nonunion (1) FHL tenolysis with or without concomitant procedures (59)
Smith and Berlet45 (2009)
Level IV (retrospective case series) Level IV (retrospective case series)
van Dijk46 (2006)*
Willits et al.47 (2008)*
Level IV (retrospective case series)
Posterior ankle debridement, os trigonum excision, FHL release (14) OT resection with FHL release (28), FHL release (7), FHL release with ossicle removal (4), FHL release with OD drilling (5), various others (146 procedures total) Tenolysis of FHL (5), os trigonum excision (11), posterior talar process decompression (5), loose body removal (1), osteochondritis dissecans debridement (1), arthrotomy (1)
Outcome Return to training after softtissue debridement with FHL release was significantly (P ¼ .046) shorter than after “bony surgery” (28 d v 40 d); 26 of 27 (96.3%) resumed training and were symptom free at 23-mo follow-up Mean postoperative AOFAS score was 89; results were excellent in 7 of 27 (26%); good in 12 of 27 (44%); fair in 6 of 27 (23%); poor in 2 of 27 (7%)
AOFAS score improved from 63.8 (range, 55 to 74) to 88.6 (range, 81 to 100); dorsiflexion improved from 1 (range, 0 to 5 ) to 19 (range, 15 to 25 ); plantar flexion improved from 16 (range, 10 to 20 ) to 39 (range, 30 to 45 ) ATSS score improved from 29.4 (range, 28 to 31) to 89 (range, 52 to 100); 2 patients did not achieve full postoperative score Logistic regression analysis did not identify any surgical parameters of hindfoot endoscopy that were significantly associated with occurrence of neurologic complications; 1 of 38 patients (2.6%) with FHL tenolysis had neurologic complications
Mean AOFAS-hindfoot/MFS score improved from 56.7 of 54.8 to 85.9 of 84.9 Good to excellent in 12, fair in 1, poor in 1
Comments 1 patient had persistent portal leakage; 1 patient had recurrent symptoms and was successfully treated by steroid injection
5 of 27 patients (18%) had complications comprising significant swelling and extensive fibrous tissue proliferation (1), transient numbness in medial heel (3), and “triggering of the hallux” (1)
Patient with low postoperative score had severe crushing injury to leg 35 yr earlier Overall complication rate of 16 of 189 (8.5%), comprising plantar numbness (4), sural nerve dysesthesia (3), AT tightness (4), complex regional pain syndrome (2), infection (2), and cyst at posteromedial port (1)
Overall complication rate of 2 of 59 (3.4%), comprising sural nerve injury (1) and sural neuroma (1) 2 of 14 (14.3%) had tibial nerve neuritis
Most patients had good to excellent results
Complications occurred in 2 of 146 procedures (1.4%) (diminished sensation over heel pad)
Mean postoperative AOFAShindfoot score, 91 (range, 77 to 100); mean postoperative SF12 scores, 51.80 (range, 30.77 to 60.53) for mental component and 55.80 (range, 44.26 to 63.33) for physical component
Complications occurred in 6 of 24 procedures (25%), comprising temporary numbness in area of scar (5) and temporary ankle stiffness (1)
AOFAS, American Orthopaedic Foot & Ankle Society; AT, achilles tendon; ATSS, Achilles Tendon Scoring System; MFS, Maryland Foot Score; OD, osteochondral defect; OT, os trigonum; SF-12, Short Form 12 Health Survey. *Mixed hindfoot endoscopy procedure result and/or complication rates.
FOOT AND ANKLE TENDOSCOPY
endoscopic removal of the adhesions, as well as the remnants of the FHL retinaculum, the athlete was able to resume her professional dance activities. At 30 months’ follow-up, the patient had no recurrence of symptoms and no complaints. Between 1994 and 2002, van Dijk46 performed release of the FHL tendon in another 44 patients during hindfoot endoscopy, with the main indication being FHL tendinitis due to posterior ankle impingement syndrome. The author has found the 2-portal posterior endoscopic approach to be a safe and reliable intervention, offering good results, and has reported complication rates as low as 1%.46 Endoscopy has also been used in FHL tendon transfer to treat Achilles tendon pathologies. Lui50 performed tendoscopy to assist with FHL transfer in 3 patients with chronic ruptures of the Achilles tendon in a Level V study. At a mean follow-up of 15 months, all 3 patients were able to walk without a limp. In another study by Lui,17 tendoscopic-assisted transfer of the FHL tendon was performed alongside endoscopic debridement of the Achilles tendon in 5 patients in a Level IV study for the treatment of chronic non-insertional Achilles tendinopathy. The patients were assessed immediately before the operation and at the latest follow-up using the Achilles Tendon Scoring System. The mean score of these patients improved from 29.4 (range, 21 to 38) preoperatively to 89 (range, 52 to 100) after the procedure. The patient with a postoperative score of 52 in this study had a severe crushing injury to her lower leg 35 years ago. No neurologic complications were noted in any patients. Lui48 in a Level V study presented 2 patients who had lateral plantar nerve neurapraxia after FHL tendoscopy for tenosynovitis. Both patients had FHL tendoscopy that included a portal in the arch of the foot to allow more distal access to the tendon (zone 2). The patients had numbness over the lateral sole and plantar surface of the fourth and fifth toes and were unable to actively abduct the little toe. An electromyography-confirmed diagnosis of lateral plantar nerve injury was made for both patients. The symptoms in 1 patient subsided completely within 5 months, whereas the other patient remained symptomatic after 1 year. Grade of Recommendation. Indications for FHL tendoscopy include tenosynovitis41 and stenosing tenosynovitis.52 FHL tendoscopy has also been used to harvest the tendon for use in the augmentation of other tendons such as the Achilles.17,50,51,53 Sufficient evidence-based literature was found to warrant a grade Cf recommendation for tendoscopic FHL release in conjunction with hindfoot endoscopy. Larger case series may be needed yet to verify the safety and efficacy of tendoscopic FHL transfer. Caution must be taken, especially during distal FHL tendoscopy, to avoid lateral plantar nerve injury.48
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Tibialis Posterior Tendoscopy Levels of Evidence IV and V. After the initial description by Wertheimer et al.,1 the first series of 16 patients was published by van Dijk et al.58 in 1997. Since then, only 3 Level IV studies59-61 and 4 Level V studies1,55,62,63 on tibialis posterior tendoscopy were found. Bulstra et al.60 reported the outcomes of 33 patients with diverse pathology of the posterior tibial tendon who underwent tendoscopy in a Level IV study. Eight patients were diagnosed with chronic tenosynovitis due to rheumatoid arthritis and were treated with tenosynovectomy. Of these patients, 4 (50%) had no recurrence of symptoms; 2 (25%) had a recurrence of symptoms at 9 and 18 months and underwent tendoscopy a second time, after which they became symptom free. The final 2 patients were eventually less satisfied. Of the 4 patients who had tendoscopic resection of a pathologic vincula, 3 (75%) became symptom free. Three patients had tendoscopic adhesiolysis, but only 1 of these patients (33.3%) had good results. In another Level IV study, Khazen and Khazen59 found tibialis posterior tendoscopy to be an effective and minimally invasive procedure that offers the advantages of fewer wound problems and less postoperative pain. They used tendoscopic synovectomy in this study to treat 9 patients with stage I posterior tibial tendon dysfunction (PTTD). After the procedure, pain was absent or minor in 8 of 9 patients (89%). One patient was not satisfied with the procedure and required hindfoot reconstruction after progressing to stage II PTTD. It was noted that tendon tears were found during tendoscopy in 3 patients that required open repair. A study by Chow et al.61 reported the outcome of tendoscopic debridement for stage I PTTD in 6 patients. All 6 patients were pain free 2 months after surgery and showed normal strength by means of a heel-rise test. None of the patients progressed to stage II PTTD, and no complications were observed. Grade of Recommendation. Indications for tibialis posterior tendoscopy include dislocation, tenosynovitis,1,60,62 tendinopathy (insertional and non-insertional), and post-traumatic adhesions. Some authors have also reported on its use as a diagnostic procedure.60,62 Because of the low number of Level IV and V studies available on tibialis posterior tendoscopy, it is not possible to make a recommendation for or against this intervention, and therefore this procedure was assigned a grade I recommendation. Tibialis Anterior Tendoscopy Level of Evidence V. Only 2 Level V studies describing tibialis anterior tendoscopy were found.63,64 Maquirriain et al.64 presented a case report of a patient who had
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undergone endoscopic debridement of the tibialis anterior tendon for the treatment of chronic tenosynovitis. The patient had a good outcome and was able to return to golf 8 weeks later. The authors noted that care must be taken to avoid extensor retinaculum damage to prevent the potential bowstring phenomenon during dorsiflexion. Lui63 used tendoscopy to transfer the medial half of the tibialis anterior to the tibialis posterior for stage II posterior tibial tendon insufficiency. This was augmented by transfer of the FDL tendon by FDL tendoscopy and supplemented by subtalar arthroereisis. The patient was pain free at 21 months’ follow-up. Grade of Recommendation. With only 2 Level V studies available describing tendoscopy of the tibialis anterior tendon, there is a paucity of evidence-based literature for this procedure and therefore a grade I recommendation was assigned.
was idiopathic in 2 patients. Tenosynovitis in the last patient was caused by an infected nail penetrating injury. All of the patients had metatarsalgia preoperatively. At latest follow-up ranging from 24 to 31 months, forefoot pain had completely subsided in all patients and no arthroscopy-related complications were observed. Lui63 also used FDL tendoscopy to harvest the FDL tendon during repair of the posterior tibial tendon for stage II posterior tibial tendon insufficiency as previously described. Grade of Recommendation. The main indication for FDL tendoscopy is tenosynovitis.69 Given the lack of evidence-based literature on FDL tendoscopy, it is not possible to make a recommendation for or against this intervention, and therefore we assigned this procedure a grade I recommendation.
Discussion
EHL and EDL Tendoscopy Level of Evidence V. There were 4 Level V studies65-68 on extensor tendoscopy of the foot and ankle. In a 2011 study by Lui,65 1 patient was diagnosed with EHL tenosynovitis by MRI. Extensor tendoscopy was performed, and although no tenosynovitis was found, an EHL ganglion was discovered and drained by arthroscopic resection. Another patient in this study was diagnosed with EDL tenosynovitis after an MRI scan. Tendoscopy confirmed this diagnosis, and arthroscopic synovectomy was performed. Neither patient had recurrence of symptoms at latest follow-up (11 months and 19 months). Chang and Lui66 used tendoscopy to assist in the repair of delayed EHL tendon rupture. The role of tendoscopy in their technique was to help identify the proximal tendon stump and perform tenolysis as well. Three patients underwent this procedure after having an EHL rerupture after primary repair, and in the fourth patient the EHL rupture was missed initially. None of the 4 patients had any neurologic complications, and no reruptures were observed. Grade of Recommendation. Indications for tendoscopy of the extensor tendons include tenosynovitis,65,68 tendinopathy, ganglion,65 and fibrous adhesions.67 Given the lack of evidence-based literature available on extensor tendoscopy, it is not possible to make a recommendation on tendoscopy of the EHL or EDL and therefore both received a grade I recommendation. FDL Tendoscopy Level of Evidence V. We found 2 Level V studies63,69 describing tendoscopy of the FDL. Lui and Chow69 performed tendoscopic synovectomies in 3 patients as a treatment for FDL tenosynovitis. The tenosynovitis
Since the first descriptions of tendoscopy in 1995 by Wertheimer et al.1 and in 1997 by Niek van Dijk et al.,2 orthopaedic surgeons have expanded the use of tendoscopy to other tendons of the foot and ankle including the tibialis anterior, Achilles, EHL, EDL, FHL, and FDL. In general, studies have reported good outcomes, and tendoscopy appears to be an effective diagnostic and therapeutic procedure for a variety of indications. Besides offering a superior cosmetic result compared with open procedures, tendoscopy has the potential to minimize complications and shorten recovery time. In the event that a tendon tear is found, tendoscopy can easily be converted to an open or miniopen repair if needed. The goal of this systematic review is to determine on which tendons of the foot and ankle the use of tendoscopy is supported by the current literature. To date, only weak evidence (grade Cf) exists in support of tendoscopy on the Achilles, FHL, and peroneal tendons whereas insufficient evidence (grade I) exists to assign a grade of recommendation for the other tendons of the foot and ankle. Familiarity with endoscopic procedures may need to be considered in the use of these recommendations because most of the studies were conducted by highly experienced endoscopists. Perhaps one of the most important findings of this review was the limited number of high-level studies currently available to support the use of tendoscopic intervention. Although only limited, low-level evidence exists supporting the use of this procedure, we believe that it is important to clarify that the absence of a “strong recommendation” because of a paucity of evidence-based literature in no way recommends against the use of a procedure. Rather, weak recommendations should be used to call attention to the
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need for original scientific articles of higher levels of evidence. Limitations One limitation of this study is that our search was restricted to articles in the English language, and consequently, it is possible that we may have missed good-quality studies in other languages. Another limitation is that because of the relatively small body of literature currently available on tendoscopy, we were unable to gather enough evidence to assign a grade of recommendation for or against intervention regarding each of the common indications individually for each tendon, and consequently, this may be an area of interest for future studies. Lastly, we must acknowledge that high-level studies are often difficult to conduct in the field of orthopaedics, which imposes limitations on the quality of evidence available to be included in this review and consequently leads to the inability to make a strong recommendation for the use of tendoscopy. However, weak or fair recommendations because of a paucity of evidence in support of a procedure such as this must not be confused in any way as a recommendation against using a procedure.
Conclusions A comprehensive review of the literature on foot and ankle tendoscopy has shown predominantly Level IV and V studies, with just 1 Level II study. On the basis of the current literature available, there is poor evidence (grade Cf) in support of Achilles, FHL, and peroneal tendoscopy for the common indications. There is insufficient evidence to make a recommendation (grade I) for or against tendoscopy on the tibialis posterior, tibialis anterior, FDL, EHL, and EDL. Although current literature suggests that tendoscopy is a safe and effective procedure, original scientific articles of higher levels of evidence are needed before a stronger recommendation can be assigned.
References 1. Wertheimer SJ, Weber CA, Loder BG, Calderone DR, Frascone ST. The role of endoscopy in treatment of stenosing posterior tibial tenosynovitis. J Foot Ankle Surg 1995;34:15-22. 2. Niek van Dijk C, Scholten PE, Kort NP. Tendoscopy (tendon sheath endoscopy) for overuse tendon injuries. Oper Tech Sports Med 1997;5:170-178. 3. Glazebrook M, Glazebrook V, Ganapathy M, Bridge J, Stone J-P. Evidence-based indications for ankle arthroscopy. Arthroscopy 2009;25:1478-1490. 4. Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am 2003;85:1-3. 5. Wright JG, Einhorn TA, Heckman JD. Grades of recommendation. J Bone Joint Surg Am 2005;87:1909-1910.
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6. Stevens M, Stevens D, LeGay M, Glazebrook D. The evidence for hip arthroscopy: Grading the current indications. Arthroscopy 2010;26:1370-1383. 7. Halasi T, Tállay A, Berkes I. Percutaneous Achilles tendon repair with and without endoscopic control. Knee Surg Sports Traumatol Arthrosc 2003;11:409-414. 8. Vega J, Cabestany JM, Golanó P, Pérez-Carro L. Endoscopic treatment for chronic Achilles tendinopathy. Foot Ankle Surg 2008;14:204-210. 9. Pearce CJ, Carmichael J, Calder JD. Achilles tendinoscopy and plantaris tendon release and division in the treatment of non-insertional Achilles tendinopathy. Foot Ankle Surg 2012;18:124-127. 10. Doral MN, Bozkurt M, Turhan E, et al. Percutaneous suturing of the ruptured Achilles tendon with endoscopic control. Arch Orthop Trauma Surg 2009;129: 1093-1101. 11. Fortis AP, Dimas A, Lamprakis AA. Repair of Achilles tendon rupture under endoscopic control. Arthroscopy 2008;24:683-688. 12. Maquirriain J. Surgical treatment of chronic Achilles tendinopathy: Long-term results of the endoscopic technique. J Foot Ankle Surg 2013;52:451-455. 13. Maquirriain J, Ayerza M, Costa-Paz M, Muscolo DL. Endoscopic surgery in chronic Achilles tendinopathies: A preliminary report. Arthroscopy 2002;18:298-303. 14. Thermann H, Benetos IS, Panelli C, Gavriilidis I, Feil S. Endoscopic treatment of chronic mid-portion Achilles tendinopathy: Novel technique with short-term results. Knee Surg Sports Traumatol Arthrosc 2009;17: 1264-1269. 15. Turgut A, Günal I, Maralcan G, Kose N, Göktürk E. Endoscopy, assisted percutaneous repair of the Achilles tendon ruptures: A cadaveric and clinical study. Knee Surg Sports Traumatol Arthrosc 2002;10:130-133. 16. Tang KL, Thermann H, Dai G, Chen GX, Guo L, Yang L. Arthroscopically assisted percutaneous repair of fresh closed Achilles tendon rupture by Kessler’s suture. Am J Sports Med 2007;35:589-596. 17. Lui TH. Treatment of chronic noninsertional Achilles tendinopathy with endoscopic Achilles tendon debridement and flexor hallucis longus transfer. Foot Ankle Spec 2012;5:195-200. 18. Morag G, Maman E, Arbel R. Endoscopic treatment of hindfoot pathology. Arthroscopy 2003;19:E13. 19. Steenstra F, van Dijk CN. Achilles tendoscopy. Foot Ankle Clin 2006;11:429-438. 20. Marmotti A, Cravino M, Germano M, et al. Peroneal tendoscopy. Curr Rev Musculoskelet Med 2012;5:135-144. 21. Scholten PE, van Dijk CN. Tendoscopy of the peroneal tendons. Foot Ankle Clin 2006;11:415-420. 22. van Dijk CN, Kort N. Tendoscopy of the peroneal tendons. Arthroscopy 1998;14:471-478. 23. Guillo S, Calder JDF. Treatment of recurring peroneal tendon subluxation in athletes. Endoscopic repair of the retinaculum. Foot Ankle Clin 2013;18: 293-300. 24. Vega J, Golanó P, Batista JP, Malagelada F, Pellegrino A. Tendoscopic procedure associated with peroneal tendons. Tech Foot Ankle Surg 2013;12:39-48.
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25. Lui TH. Endoscopic management of recalcitrant retrofibular pain without peroneal tendon subluxation or dislocation. Arch Orthop Trauma Surg 2012;132:357-361. 26. Jerosch J, Aldawoudy A. Tendoscopic management of peroneal tendon disorders. Knee Surg Sports Traumatol Arthrosc 2007;15:806-810. 27. Scholten PE, Breugem SJM, van Dijk CN. Tendoscopic treatment of recurrent peroneal tendon dislocation. Knee Surg Sports Traumatol Arthrosc 2013;21:1304-1306. 28. Michels F, Jambou S, Guillo S, Van Der Bauwhede J. Endoscopic treatment of intrasheath peroneal tendon subluxation. Case Rep Med 2013;2013:274685. 29. Lui TH. Endoscopic resection of the peroneal tubercle. J Foot Ankle Surg 2012;51:813-815. 30. Lui TH. Endoscopic peroneal retinaculum reconstruction. Knee Surg Sports Traumatol Arthrosc 2006;14:478-481. 31. Fadel MEM, Jerosch J. Use of endoscopy in peroneal tendons disorders. Fuss Sprunggelenk 2005;3:200-204. 32. Lui TH. Tendoscopy of peroneus longus in the sole. Foot Ankle Int 2013;34:299-302. 33. Kassim MM, Rosenfeld P. Tendoscopic debridement of peroneus quartus muscle for chronic lateral ankle pain: A case report. Foot Ankle Int 2012;33:1024-1026. 34. Lui TH. Tendoscopic resection of low-lying muscle belly of peroneus brevis or quartus. Foot Ankle Int 2012;33:912-914. 35. Panchbhavi VK, Trevino SG. The technique of peroneal tendoscopy and its role in management of peroneal tendon anomalies. Tech Foot Ankle Surg 2003;2:192-198. 36. Yong CK. Peroneus quartus and peroneal tendoscopy. Med J Malaysia 2006;61(suppl B):45-47. 37. De Leeuw PAJ, van Dijk CN, Golanó P. A 3-portal endoscopic groove deepening technique for recurrent peroneal tendon dislocation. Tech Foot Ankle Surg 2008;7:250-256. 38. Lui TH, Chan KB. Arthroscopic management of late complications of calcaneal fractures. Knee Surg Sports Traumatol Arthrosc 2013;21:1293-1299. 39. Ho KK, Chan KB, Lui TH, Chow YY. Tendoscopic-assisted repair of complete rupture of the peroneus longus associated with displaced fracture of the os peroneumdCase report. Foot Ankle Int 2013;34:1600-1604. 40. Calder JD, Sexton SA, Pearce CJ. Return to training and playing after posterior ankle arthroscopy for posterior impingement in elite professional soccer. Am J Sports Med 2010;38:120-124. 41. Corte-Real NM, Moreira RM, Guerra-Pinto F. Arthroscopic treatment of tenosynovitis of the flexor hallucis longus tendon. Foot Ankle Int 2012;33:1108-1112. 42. Lui TH, Chan WK, Chan KB. The arthroscopic management of frozen ankle. Arthroscopy 2006;22:283-286. 43. Nickisch F, Barg A, Saltzman CL, et al. Postoperative complications of posterior ankle and hindfoot arthroscopy. J Bone Joint Surg Am 2012;94:439-446. 44. Ogut T, Ayhan E, Irgit K, Sarikaya AI. Endoscopic treatment of posterior ankle pain. Knee Surg Sports Traumatol Arthrosc 2011;19:1355-1361. 45. Smith WB, Berlet GC. Posterior ankle impingement: The role of posterior ankle arthroscopy. Tech Foot Ankle Surg 2009;8:94-98. 46. van Dijk CN. Hindfoot endoscopy. Foot Ankle Clin 2006;11: 391-414.
47. Willits K, Sonneveld H, Amendola A, Giffin JR, Griffin S, Fowler PJ. Outcome of posterior ankle arthroscopy for hindfoot impingement. Arthroscopy 2008;24:196-202. 48. Lui TH. Lateral plantar nerve neuropraxia after FHL tendoscopy: Case report and anatomic evaluation. Foot Ankle Int 2010;31:828-831. 49. Lui TH, Chow FY. “Intersection syndrome” of the foot: Treated by endoscopic release of master knot of Henry. Knee Surg Sports Traumatol Arthrosc 2011;19:850-852. 50. Lui TH. Endoscopic assisted flexor hallucis tendon transfer in the management of chronic rupture of Achilles tendon. Knee Surg Sports Traumatol Arthrosc 2007;15:1163-1166. 51. Gossage W, Kohls-Gatzoulis J, Solan M. Endoscopic assisted repair of chronic Achilles tendon rupture with flexor hallucis longus augmentation. Foot Ankle Int 2010;31:343-347. 52. Ogut T, Ayhan E. Hindfoot endoscopy for accessory flexor digitorum longus and flexor hallucis longus tenosynovitis. Foot Ankle Surg 2011;17:e7-e9. 53. Lui TH. Whole length flexor hallucis longus transfer with a minimally invasive approach: Technique tip. Foot Ankle Int 2011;32:730-734. 54. van Dijk CN, Scholten PE, Krips R. A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthroscopy 2000;16:871-876. 55. Theodoropoulos JS, Wolin PM, Taylor DW. Arthroscopic release of flexor hallucis longus tendon using modified posteromedial and posterolateral portals in the supine position. Foot 2009;19:218-221. 56. Lombardi CM, Silhanek AD, Connolly FG. Modified arthroscopic excision of the symptomatic os trigonum and release of the flexor hallucis longus tendon: Operative technique and case study. J Foot Ankle Surg 1999;38:347-351. 57. Fadel MEM, Jerosch J. Arthroscopic resection of symptomatic “os trigonum.” Report of 2 cases. Fuss Sprunggelenk 2006;4:112-117. 58. van Dijk CN, Kort N, Scholten PE. Tendoscopy of the posterior tibial tendon. Arthroscopy 1997;13:692-698. 59. Khazen G, Khazen C. Tendoscopy in stage I posterior tibial tendon dysfunction. Foot Ankle Clin 2012;17:399-406. 60. Bulstra GH, Olsthoorn PGM, Niek van Dijk C. Tendoscopy of the posterior tibial tendon. Foot Ankle Clin 2006;11: 421-427. 61. Chow HT, Chan KB, Lui TH. Tendoscopic debridement for stage I posterior tibial tendon dysfunction. Knee Surg Sports Traumatol Arthrosc 2005;13:695-698. 62. van Sterkenburg MN, Haverkamp D, van Dijk CN, Kerkhoffs GMMJ. A posterior tibial tendon skipping rope. Knee Surg Sports Traumatol Arthrosc 2010;18:1664-1666. 63. Lui TH. Endoscopic assisted posterior tibial tendon reconstruction for stage 2 posterior tibial tendon insufficiency. Knee Surg Sports Traumatol Arthrosc 2007;15:1228-1234. 64. Maquirriain J, Sammartino M, Ghisi JP, Mazzuco J. Tibialis anterior tenosynovitis: Avoiding extensor retinaculum damage during endoscopic debridement. Arthroscopy 2003;19:E9. 65. Lui TH. Extensor tendoscopy of the ankle. Foot Ankle Surg 2011;17:e1-e6. 66. Chang JJ, Lui TH. Endoscopic-assisted repair of extensor hallucis longus tendon rerupture. Foot Ankle Int 2013;34: 455-458.
FOOT AND ANKLE TENDOSCOPY 67. Lui TH. Extensor tendons and deep peroneal nerve adhesion: Treated by complete anterior ankle arthroscopic capsulotomy. Foot Ankle Surg 2012;18: e1-e3. 68. Sammarco GJ, Henning C. Peroneus tertius muscle as a cause of snapping and ankle pain: A case report. Am J Sports Med 2007;35:1377-1379.
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69. Lui TH, Chow HT. Role of toe flexor tendoscopy in management of an unusual cause of metatarsalgia. Knee Surg Sports Traumatol Arthrosc 2006;14:654-658. 70. OCEBM Levels of Evidence Working Group. The Oxford Levels of Evidence 2. Oxford Centre for Evidence-Based Medicine. Available at: http://www.cebm.net/index.aspx? o¼5653. Accessed: March 6, 2014.
Foot and Ankle Tendoscopy: Evidence-Based Recommendations Chris C. Cychosz, B.S., Phinit Phisitkul, M.D., Alexej Barg, M.D., Florian Nickisch, M.D., C. Niek van Dijk, M.D., Ph.D., and Mark A. Glazebrook, M.Sc., Ph.D., M.D., F.R.C.S.C.
Purpose: The purpose of this study was to provide a comprehensive review of the current literature on tendoscopy of the foot and ankle and assign an evidence-based grade of recommendation for or against intervention. Methods: A comprehensive review of the literature was performed on May 26, 2013, using the PubMed, Cochrane, and Scopus databases. Studies focusing on the use of foot and ankle tendoscopy were isolated, and these articles were then reviewed and assigned a Level of Evidence (I through V). The literature was then analyzed, and a grade of recommendation was assigned for tendoscopy of the tendons of the foot and ankle on which the procedure is generally performed. Results: There is weak evidence (grade Cf) to support the use of tendoscopy on the Achilles, flexor hallucis longus, and peroneal tendons. Insufficient evidence (grade I) exists to assign a grade of recommendation for tendoscopy of the tibialis posterior, tibialis anterior, flexor digitorum longus, extensor hallucis longus, and extensor digitorum longus. Conclusions: A comprehensive review of the literature on foot and ankle tendoscopy has shown predominantly Level IV and V studies, with just 1 Level II study. On the basis of the current literature available, there is poor evidence (grade Cf) in support of Achilles, flexor hallucis longus, and peroneal tendoscopy for the common indications. There is insufficient evidence to make a recommendation (grade I) for or against tendoscopy of the tibialis posterior, tibialis anterior, flexor digitorum longus, extensor hallucis longus, and extensor digitorum longus. Although current literature suggests that tendoscopy is a safe and effective procedure, original scientific articles of higher levels of evidence are needed before a stronger recommendation can be assigned. Level of Evidence: Level IV, systematic review of Level II, IV, and V studies.
n endoscopic tendon procedure was first described in the literature by Wertheimer et al.1 in 1995 for the treatment of posterior tibial stenosing tenosynovitis. In 1997 Niek van Dijk et al.2 published a report on tendon sheath endoscopy of the peroneal tendon, anterior tibial tendon, and Achilles tendon in 40 patients
A
From Carver College of Medicine, The University of Iowa (C.C.C.), and Department of Orthopaedics and Rehabilitation, The University of Iowa Hospitals and Clinics (P.P.), Iowa City, Iowa; and Department of Orthopaedics, University of Utah School of Medicine (F.N.), Salt Lake City, Utah, U.S.A.; the Orthopaedic Department, University Hospital of Basel, University of Basel (A.B.), Basel, Switzerland; the Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam (C.N.v.D.), Amsterdam, The Netherlands; and Division of Orthopaedic Surgery, Dalhousie University (M.A.G.), Halifax, Nova Scotia, Canada. The authors report the following potential conflict of interest or source of funding: P.P. receives support from Arthrex, OREF Young Investigator Grant, MTP Solutions. C.N.v.D. receives support from Smith & Nephew. Received December 16, 2013; accepted February 13, 2014. Address correspondence to Phinit Phisitkul, M.D., The University of Iowa Hospitals and Clinics, 0102X JPP, 200 Hawkins Dr, Iowa City, IA 522421088, U.S.A. E-mail: [email protected] Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America 0749-8063/13880/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.02.022
and named the procedure “tendoscopy.” In the years since, refinements in equipment and techniques have aided the expansion of tendoscopy as both a diagnostic and therapeutic procedure to other tendons of the foot and ankle. However, because it is a relatively new technique, there may not yet be a suitable body of evidence in the form of scientific literature to support the use of foot and ankle tendoscopy. The purpose of this study was to review the literature on the outcomes and complications of tendoscopy of the foot and ankle for the generally accepted indications of each tendon, summarize the quality and quantity of evidence available, and lastly, assign a grade of recommendation for or against the use of tendoscopy.
Methods The methodology of this study was modeled after that described by Glazebrook et al.3 A comprehensive review of the literature was performed (May 26, 2013) by use of the PubMed, Scopus, and Cochrane databases using the search terms “(tendoscopy OR tendoscopic)” and “((endoscopy OR endoscopic) AND tendon AND (foot or ankle)).” The “search within” function available on Scopus was used for the latter term to yield more
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Table 1. Levels of Evidence for Therapeutic Studies4,70 Level of Evidence Level I
Level II
Level III
Level IV Level V
Description High-quality randomized trial with no statistically significant difference but narrow confidence intervals Systematic reviews of Level I RCTs (and study results were homogeneous) Lesser-quality RCTs (e.g., 80% follow-up, no blinding, or improper randomization) Prospective comparative studies Systematic reviews of Level II studies or Level I studies with inconsistent results Case-control studies Retrospective comparative studies Systematic reviews of Level III studies Case series Expert opinion
RCT, randomized controlled trial. Reprinted with permission from the Journal of Bone & Joint Surgery and the Centre for Evidence Based Medicine.
results. Searches were limited to articles in the English language. All dates and all types of publications including prospective and retrospective studies, case reports, and review articles were allowed by the initial search criteria. The decision to eliminate articles was made by a minimum of 2 reviewers. These searches together returned 328 articles. Of these articles, 134 were eliminated based on the title alone and 71 were eliminated by reading the abstract. The remaining articles were examined for content, and an additional 66 were eliminated. Finally, the references of the remaining 57 articles were reviewed, and 8 additional publications included in this study were retrieved. Cadaveric studies and technique tips without any patients were excluded. For the Achilles tendon, only non-insertional interventions were included in this study. Studies reporting the arthroscopic or endoscopic release of the flexor hallucis longus (FHL) tendon for the treatment of stenosing tenosynovitis were included as long as adequate data separation was provided to distinguish patients undergoing these procedures from patients undergoing various hindfoot endoscopic procedures. In the event that the same series Table 2. Grades of Recommendation for Summaries or Reviews of Orthopaedic Surgical Studies5 Grade of Recommendation A
B
C
I
Description Good evidence (Level I studies with consistent findings) for or against recommending intervention Fair evidence (Level II or III studies with consistent findings) for or against recommending intervention Poor-quality evidence (Level IV or V studies with consistent findings) for or against recommending intervention Insufficient or conflicting evidence not allowing a recommendation for or against intervention
Reprinted with permission from the Journal of Bone & Joint Surgery.
of patients was reported on in more than 1 publication, only the publication with the most comprehensive series was included. All articles were reviewed and assigned a Level of Evidence classification (I through V) by use of the Journal of Bone and Joint Surgery “Levels of Evidence for Primary Research Question” (Table 1).4 Series with fewer than 5 patients or those that had poor data correction were classified as Level V Evidence, and studies in which the retrospective or prospective nature was not apparent were classified as retrospective. An analysis of the literature reviewed was used to assign a grade of recommendation (A, B, C, or I)5 for each current generally accepted indication for foot and ankle tendoscopy (Table 2). A subscale proposed by Stevens et al.6 was used for further differentiation of the evidence for indications receiving a grade C recommendation. Three subscripts were applied: “c” for conflicting literature, “f” for literature for the use of tendoscopy, and “a” for literature against the use of tendoscopy.
Results On the basis of the literature, weak evidence (grade Cf) exists in support of tendoscopy on the Achilles, FHL, and peroneal tendons for the generally accepted indications. Insufficient evidence (grade I) exists to make a recommendation for or against the use of tendoscopy on the tibialis posterior, tibialis anterior, flexor digitorum longus (FDL), extensor hallucis longus (EHL), and extensor digitorum longus (EDL). A summary of the grades of recommendation based on the current literature is presented in Table 3. Achilles Tendoscopy Level of Evidence II. The first case series on Achilles tendoscopy was published by Niek van Dijk et al.2 in 1997. Since then, there has been one Level II study on Achilles tendoscopy.7 Halasi et al.7 prospectively compared a group of 57 patients undergoing percutaneous Achilles tendon repair with the use of endoscopy (E group) with a group of 87 patients undergoing the same procedure without endoscopic assistance (P group). The primary purpose of tendoscopy during the procedure was to control the adaptation of the tendon ends. In a subjective evaluation, 51 of 57 patients (89%) in the E group and 76 of 87 patients (88%) in the P group had good to excellent results. The rerupture rate was lower in the E group (1 of 57, 1.75%) than in the P group (5 of 87, 5.74%) during a follow-up period that ranged from 12 to 60 months. This difference was not statistically significant, however. The authors noted that Achilles tendoscopy was able to give them a more precise repair. Levels of Evidence IV and V. There were 10 Level IV studies8-17 and 2 Level V studies18,19 on Achilles tendoscopy (Table 4). The average number of patients
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FOOT AND ANKLE TENDOSCOPY Table 3. Summary of Recommendations for or Against Tendoscopy of Foot and Ankle Tendon Achilles Peroneal FHL Tibialis anterior Tibialis posterior FDL EHL/EDL
No. of Studies 13 20 20 2 7 2 4
Level I 0 0 0 0 0 0 0
Level II 1 0 0 0 0 0 0
per study was 16.7, and the majority of case series reported patient satisfaction rates or good to excellent outcome rates approaching 100%. Complications encountered include sural nerve injury, tendon rerupture, deep vein thrombosis, fusiform thickening, hematoma, and delayed keloid lesions; however, no studies reported rates above 11%. In a retrospective study by Pearce et al.,9 11 patients with non-insertional tendinopathy underwent Achilles tendoscopy with division of the plantaris tendon. The mean American Orthopaedic Foot & Ankle Society hindfoot scores improved from 68 (range, 51 to 82) preoperatively to 92 (range, 74 to 100) postoperatively; 8 of 11 patients (72.7%) were satisfied, and the other 3 were somewhat satisfied. None of the patients in this study had complications. Maquirriain12 evaluated the long-term results of Achilles tendoscopy for the treatment of chronic midportion Achilles tendinopathy. Twenty-four patients underwent 27 procedures (3 bilateral) consisting of paratenon debridement and longitudinal tenotomies, with a mean follow-up period of 7.7 years (range, 5 to 14 years). Fifteen patients were evaluated with the Victorian Institute Sport AssessmenteAchilles questionnaire and had an improvement from a mean score of 37 points before the procedure to 97.5 after the procedure. The mean score with the Achilles Tendon Scoring System improved as well, increasing from 32.6 before the procedure to 97.6 at follow-up. At the latest-follow-up, 96% of patients were completely free of symptoms. There were 2 postoperative complications, comprising a delayed keloid lesion and a seroma with chronic fistula. No infections or systemic complications occurred in this series. Grade of Recommendation. Generally accepted indications for non-insertional Achilles tendoscopy include peritendinopathy13,19 and tendinopathy.8,9,12-14,19 Studies have also found tendoscopy to be helpful in assisting with the repair of tendon ruptures.7,10,11,15,16 Although highlevel evidenceebased literature for Achilles tendoscopy is still somewhat sparse, the literature mentioned earlier reported consistently good outcomes with few complications; therefore tendoscopy of the Achilles tendon was assigned a grade Cf recommendation (for intervention).
Level III 0 0 0 0 0 0 0
Level IV 11 7 9 0 3 0 0
Level V 2 13 11 2 4 2 4
Grade of Recommendation Cf (for intervention) Cf (for intervention) Cf (for intervention) I I I I
Peroneal Tendoscopy Levels of Evidence IV and V. There were 7 Level IV studies20-26 and 13 Level V studies27-39 on peroneal tendoscopy (Table 5). These studies ranged in size from 1 to 52 patients, with a mean of 7.6 patients. Only minor complications including suture irritation and mild post-static dyskinesia were noted. The majority of patients reported significant or complete relief of symptoms shortly after the procedure. The results were generally stable through the final follow-up, ranging from 2 months to 6 years. In a Level IV retrospective study, Scholten and van Dijk21 performed peroneal tendoscopy on 23 patients with a minimum follow-up period of 2 years. Two patients presented with recurrent peroneal tendon dislocation and underwent tendoscopic fibular groove deepening. Another 10 patients had chronic tenosynovitis and underwent tendoscopic synovectomy. The remaining 11 patients had a longitudinal rupture of the peroneal brevis tendon and underwent tendoscopic synovectomy and suturing if necessary (by way of a mini-open procedure). None of the patients had complications, nor was there a recurrence of any preoperative pathology. Peroneal tendoscopy was used primarily as a diagnostic procedure in a Level V study by Panchbhavi and Trevino.35 A peroneus quartus tendon that did not show up on magnetic resonance imaging (MRI) was found to be causing lateral ankle pain in 1 patient. Another individual underwent peroneal tendoscopy with subtalar arthroscopy, and it was discovered that she had a low-lying muscle belly attached to her peroneus brevis. Tendoscopy in a third patient identified a tendinous structure between the peroneus longus and brevis, which had not been identified on the preoperative MRI scan. These tendon anomalies were excised through an open procedure, and the symptoms resolved in all patients. In a recent Level IV study by Vega et al.,24 52 patients underwent peroneal tendoscopy from 2008 to 2011 with a minimum follow-up period of 1 year. The indications for peroneal tendoscopy were peroneal adhesions (2), tenosynovitis (13), tendon rupture (24), recurrent peroneal tendon subluxation (7), and intrasheath peroneal tendon subluxation (6). The symptoms diminished
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Table 4. Level II-IV Studies in Support of Achilles Tendoscopy Author (Year) Doral et al.10 (2009)
Type of Study Level IV (prospective case series)
Indications Achilles rupture
Measurement Tools AOFAS score
Fortis et al.11 (2008)
Level IV (prospective case series) Level II (prospective comparative study)
Achilles rupture
Merkel scale
Achilles rupture
Subjective
Level IV (retrospective case series) Level IV (prospective case series)
Chronic noninsertional Achilles tendinopathy Peritendinitis, tendinosis, partial tear
ATSS-17 score
Improved from mean ATSS-17 score of 29.4 to 89
ATSS score, MRI
ATSS score improved from 39 to 89
Maquirriain12 (2013)
Level IV (retrospective case series)
Chronic midportion Achilles tendinopathy
ATSS score, VISAA score, PGART score using 5-point Likert scale
Pearce et al.9 (2012)
Level IV (retrospective case series)
Non-insertional chronic Achilles tendinopathy
AOFAS score, AOS score, SF-36 score
Tang et al.16 (2007)
Level IV (retrospective case series)
Acute Achilles rupture
Arner-Lindholm scale
Thermann et al.14 (2009)
Level IV (prospective case series) Level IV (retrospective case series)
Chronic midportion Achilles tendinopathy Acute Achilles rupture
VAS
Level IV (retrospective case series)
Non-insertional chronic Achilles tendinopathy
ATSS score improved from 32.7 to 97.2; VISA-A score improved from 37.1 to 97.6; 24 of 24 patients (100%) had good to excellent PGART scores AOFAS score improved from 68 to 92; AOS score improved from 28% to 8% for pain and from 38% to 10% for disability; SF-36 score improved from 76 to 87 (not statistically significant) Excellent in 15 of 20 (75%) and good in 5 of 20 (25%) according to Arner-Lindholm scale VAS for pain improved from 40 to 97.5; VAS for function increased from 22.5 to 90 11 of 11 (100%) had satisfactory results; 10 of 11 (91%) had no significant change in ROM Excellent Nelen scale score in 8 of 8 (100%); preoperative MRI showed degeneration in 8 of 8 patients (100%); postoperative MRI showed degeneration in 3 of 8 patients (37.5%)
Halasi et al.7 (2003)
Lui17 (2012)
Maquirriain et al.13 (2002)
Turgut et al.15 (2002)
Vega et al.8 (2008)
ROM
Nelen scale, MRI
Outcome Excellent in 94% and good in 6% according to AOFAS score; postoperative mean, 94.6 Mean postoperative Merkel score, 604; good to excellent outcomes in 20 of 20 (100%) Good to excellent in 88% in P (percutaneous) group and 89% in E (endoscopic) group
Comments 2 of 62 patients (3.2%) had hypoesthesia in sural nerve region, which resolved spontaneously after 6 mo 2 of 20 patients (10%) had sural neuralgia; 1 subsided with no further treatment E group: 1 partial rerupture, 4 fusiform thickening, 1 DVT P group: 2 total and 3 partial reruptures, 4 fusiform thickening, 2 DVT FHL transfer also performed 1 of 7 patients (14.3%) had minor subcutaneous hematoma with ankle edema, which resolved after 1 wk of rest 2 of 27 procedures (7.4%), comprising 1 delayed keloid lesion and 1 seroma with chronic fistula
AOFAS, American Orthopaedic Foot & Ankle Society; AOS, Ankle Osteoarthritis Scale; ATSS/ATSS-17, Achilles Tendoninopathy Scoring System; DVT, deep vein thrombosis; PGART, Patient Global Assessment Response to Therapy; ROM, range of motion; SF-36, Short Form 36; VISA-A, Victorian Institute Sport AssessmenteAchilles.
for both patients who underwent tendoscopic lysis of adhesions. Of the 24 patients diagnosed with ruptures of the peroneal tendons, 15 (62.5%) reported complete relief of their symptoms, 6 (25%) reported partial relief, and 3 (12.5%) had no change in symptoms after the procedure. Of the 7 patients treated with tendoscopic
groove deepening for peroneal tendon subluxation, 5 (71.4%) reported excellent results and were able to return to their normal activities without limitations. No recurrent subluxation occurred at follow-up in any of the cases; however, 2 patients had discomfort and a clicking sensation in the lateral retromalleolar area
5
FOOT AND ANKLE TENDOSCOPY Table 5. Level IV Studies to Support Tendoscopy of Peroneal Tendons Author (Year) Guillo and Calder23 (2013) Jerosch and Aldawoudy26 (2007)
Lui25 (2012)
Marmotti et al.20 (2012) Scholten and van Dijk21 (2006)
Type of Study Level IV (retrospective case series) Level IV (prospective case series)
Level IV (retrospective case series) Level IV (retrospective case series) Level IV (retrospective case series)
van Dijk and Kort22 (1998)
Level IV (prospective case series)
Vega et al.24 (2013)
Level IV (retrospective case series)
Indications (No.) Recurring peroneal tendon subluxation (7)
Outcome 7 of 7 patients (100%) returned to previous activity level
Comments 1 patient had skin irritation due to suture knot
Tenosynovitis (7), partial lesions of peroneal tendon (5), LLMB (2), peroneal tendon instability (1) Retrofibular pain (7)
15 of 15 patients (100%) were symptom free at 3 mo postoperatively
Peroneal tendon instability required open repair of retinaculum; 1 longitudinal tear required open repair
6 of 7 patients (86%) resumed previous sport or activity within 24 mo 5 of 5 patients (100%) reported subjective improvement of lateral ankle pain No recurrence of preoperative pathology
Mild post-static dyskinesia of operative site occurred in all patients
Thickened vincula lesions (5) Longitudinal rupture of peroneal brevis tendon (11), chronic tenosynovitis (10), recurrent peroneal subluxation (2) Diagnostic (5), snapping sensation (2), exostosis (1), partial tendon tear (1)
Peroneal tendon rupture (24), tenosynovitis (13), recurrent peroneal tendon subluxation (7), intrasheath subluxation (6), adhesions (2)
3 of 4 (75%) had no recurrence after adhesiolysis; 1 of 1 (100%) peroneal tubercle successfully removed; 1 of 1 (100%) longitudinal rupture successfully sutured Intrasheath subluxation: excellent results in 6 of 6 (100%) (mean AOFAS score increased from 79 to 99) Lysis of adhesions: 2 of 2 (100%) had symptoms diminish Ruptures: 15 of 24 (62.5%) symptom free, 6 of 24 (25%) partially symptom free, 3 of 24 (12.5%) no change Recurrent peroneal tendon subluxation: 5 of 7 patients (71.4%) had excellent results (AOFAS score increased from 75 to 93)
Suturing of tendon tears required mini-open procedure
Some tendon ruptures required open repair
AOFAS, American Orthopaedic Foot & Ankle Society; LLMB, low-lying muscle belly.
during active dorsiflexion and eversion of the foot. All 6 patients treated for intrasheath subluxation had excellent results. Grade of Recommendation. Generally accepted indications for peroneal tendoscopy include tenosynovitis,21,24,26,32,34,38 subluxation or dislocation,21,23,24,27,30,37 snapping,22 partial tears requiring debridement,22,24,26 and postoperative adhesions and scarring.24 Peroneal tendoscopy was also found to be valuable as a diagnostic tool in some instances.22,35 The Level IV and V studies on peroneal tendoscopy generally reported good to excellent outcomes in most patients with a relatively low occurrence of complications. On the basis of the literature available, peroneal tendoscopy was assigned a grade Cf recommendation (for intervention).
FHL Tendoscopy Levels of Evidence IV and V. There were 9 Level IV studies17,40-47 and 11 Level V studies18,48-57 on FHL tendoscopy (Table 6). Studies often reported the use of FHL tendoscopy in conjunction with other procedures during hindfoot endoscopy. A tendoscopic method of harvesting the FHL tendon was presented in a limited number of studies as well. Most authors reported good to excellent results in greater than 70% of patients, with complication rates ranging from 0% to 25%. Van Dijk et al.54 first described FHL tendoscopy for the treatment of chronic FHL tendinitis in a 22-year-old professional ballet dancer. During operative treatment by means of 2-portal posterior ankle endoscopy, adhesions and thickening of the FHL tendon were found after the os trigonum was removed. Six weeks after
6
C. C. CYCHOSZ ET AL.
Table 6. Level IV Studies to Support FHL Tendoscopy Author (Year) Calder et al.40 (2010)*
Type of Study Level IV (prospective case series)
Procedure (No. of Procedures) Debridement with FHL release (5), os trigonum excision (13), bony pull-off excision with FHL release (9)
Corte-Real et al.41 (2012)
Level IV (retrospective case series)
FHL release (27)
Lui et al.42 (2006)
Level IV (retrospective case series)
FHL mobilization, posterior capsulectomy, various
Lui17 (2012)
Level IV (retrospective case series)
Zone 2 FHL harvest for Achilles tendon augmentation (5)
Nickisch et al.43 (2012)*
Level IV (retrospective case series)
Ogut et al.44 (2011)
Level IV (retrospective case series)
FHL tenolysis (38), os trigonum excision (48), partial calcanectomy (5), osteochondral lesion debridement (44), subtalar debridement (38), subtalar fusion (33), ankle debridement (30), partial talectomy (9), fixation of calcaneal fracture (4), revision of subtalar nonunion (1) FHL tenolysis with or without concomitant procedures (59)
Smith and Berlet45 (2009)
Level IV (retrospective case series) Level IV (retrospective case series)
van Dijk46 (2006)*
Willits et al.47 (2008)*
Level IV (retrospective case series)
Posterior ankle debridement, os trigonum excision, FHL release (14) OT resection with FHL release (28), FHL release (7), FHL release with ossicle removal (4), FHL release with OD drilling (5), various others (146 procedures total) Tenolysis of FHL (5), os trigonum excision (11), posterior talar process decompression (5), loose body removal (1), osteochondritis dissecans debridement (1), arthrotomy (1)
Outcome Return to training after softtissue debridement with FHL release was significantly (P ¼ .046) shorter than after “bony surgery” (28 d v 40 d); 26 of 27 (96.3%) resumed training and were symptom free at 23-mo follow-up Mean postoperative AOFAS score was 89; results were excellent in 7 of 27 (26%); good in 12 of 27 (44%); fair in 6 of 27 (23%); poor in 2 of 27 (7%)
AOFAS score improved from 63.8 (range, 55 to 74) to 88.6 (range, 81 to 100); dorsiflexion improved from 1 (range, 0 to 5 ) to 19 (range, 15 to 25 ); plantar flexion improved from 16 (range, 10 to 20 ) to 39 (range, 30 to 45 ) ATSS score improved from 29.4 (range, 28 to 31) to 89 (range, 52 to 100); 2 patients did not achieve full postoperative score Logistic regression analysis did not identify any surgical parameters of hindfoot endoscopy that were significantly associated with occurrence of neurologic complications; 1 of 38 patients (2.6%) with FHL tenolysis had neurologic complications
Mean AOFAS-hindfoot/MFS score improved from 56.7 of 54.8 to 85.9 of 84.9 Good to excellent in 12, fair in 1, poor in 1
Comments 1 patient had persistent portal leakage; 1 patient had recurrent symptoms and was successfully treated by steroid injection
5 of 27 patients (18%) had complications comprising significant swelling and extensive fibrous tissue proliferation (1), transient numbness in medial heel (3), and “triggering of the hallux” (1)
Patient with low postoperative score had severe crushing injury to leg 35 yr earlier Overall complication rate of 16 of 189 (8.5%), comprising plantar numbness (4), sural nerve dysesthesia (3), AT tightness (4), complex regional pain syndrome (2), infection (2), and cyst at posteromedial port (1)
Overall complication rate of 2 of 59 (3.4%), comprising sural nerve injury (1) and sural neuroma (1) 2 of 14 (14.3%) had tibial nerve neuritis
Most patients had good to excellent results
Complications occurred in 2 of 146 procedures (1.4%) (diminished sensation over heel pad)
Mean postoperative AOFAShindfoot score, 91 (range, 77 to 100); mean postoperative SF12 scores, 51.80 (range, 30.77 to 60.53) for mental component and 55.80 (range, 44.26 to 63.33) for physical component
Complications occurred in 6 of 24 procedures (25%), comprising temporary numbness in area of scar (5) and temporary ankle stiffness (1)
AOFAS, American Orthopaedic Foot & Ankle Society; AT, achilles tendon; ATSS, Achilles Tendon Scoring System; MFS, Maryland Foot Score; OD, osteochondral defect; OT, os trigonum; SF-12, Short Form 12 Health Survey. *Mixed hindfoot endoscopy procedure result and/or complication rates.
FOOT AND ANKLE TENDOSCOPY
endoscopic removal of the adhesions, as well as the remnants of the FHL retinaculum, the athlete was able to resume her professional dance activities. At 30 months’ follow-up, the patient had no recurrence of symptoms and no complaints. Between 1994 and 2002, van Dijk46 performed release of the FHL tendon in another 44 patients during hindfoot endoscopy, with the main indication being FHL tendinitis due to posterior ankle impingement syndrome. The author has found the 2-portal posterior endoscopic approach to be a safe and reliable intervention, offering good results, and has reported complication rates as low as 1%.46 Endoscopy has also been used in FHL tendon transfer to treat Achilles tendon pathologies. Lui50 performed tendoscopy to assist with FHL transfer in 3 patients with chronic ruptures of the Achilles tendon in a Level V study. At a mean follow-up of 15 months, all 3 patients were able to walk without a limp. In another study by Lui,17 tendoscopic-assisted transfer of the FHL tendon was performed alongside endoscopic debridement of the Achilles tendon in 5 patients in a Level IV study for the treatment of chronic non-insertional Achilles tendinopathy. The patients were assessed immediately before the operation and at the latest follow-up using the Achilles Tendon Scoring System. The mean score of these patients improved from 29.4 (range, 21 to 38) preoperatively to 89 (range, 52 to 100) after the procedure. The patient with a postoperative score of 52 in this study had a severe crushing injury to her lower leg 35 years ago. No neurologic complications were noted in any patients. Lui48 in a Level V study presented 2 patients who had lateral plantar nerve neurapraxia after FHL tendoscopy for tenosynovitis. Both patients had FHL tendoscopy that included a portal in the arch of the foot to allow more distal access to the tendon (zone 2). The patients had numbness over the lateral sole and plantar surface of the fourth and fifth toes and were unable to actively abduct the little toe. An electromyography-confirmed diagnosis of lateral plantar nerve injury was made for both patients. The symptoms in 1 patient subsided completely within 5 months, whereas the other patient remained symptomatic after 1 year. Grade of Recommendation. Indications for FHL tendoscopy include tenosynovitis41 and stenosing tenosynovitis.52 FHL tendoscopy has also been used to harvest the tendon for use in the augmentation of other tendons such as the Achilles.17,50,51,53 Sufficient evidence-based literature was found to warrant a grade Cf recommendation for tendoscopic FHL release in conjunction with hindfoot endoscopy. Larger case series may be needed yet to verify the safety and efficacy of tendoscopic FHL transfer. Caution must be taken, especially during distal FHL tendoscopy, to avoid lateral plantar nerve injury.48
7
Tibialis Posterior Tendoscopy Levels of Evidence IV and V. After the initial description by Wertheimer et al.,1 the first series of 16 patients was published by van Dijk et al.58 in 1997. Since then, only 3 Level IV studies59-61 and 4 Level V studies1,55,62,63 on tibialis posterior tendoscopy were found. Bulstra et al.60 reported the outcomes of 33 patients with diverse pathology of the posterior tibial tendon who underwent tendoscopy in a Level IV study. Eight patients were diagnosed with chronic tenosynovitis due to rheumatoid arthritis and were treated with tenosynovectomy. Of these patients, 4 (50%) had no recurrence of symptoms; 2 (25%) had a recurrence of symptoms at 9 and 18 months and underwent tendoscopy a second time, after which they became symptom free. The final 2 patients were eventually less satisfied. Of the 4 patients who had tendoscopic resection of a pathologic vincula, 3 (75%) became symptom free. Three patients had tendoscopic adhesiolysis, but only 1 of these patients (33.3%) had good results. In another Level IV study, Khazen and Khazen59 found tibialis posterior tendoscopy to be an effective and minimally invasive procedure that offers the advantages of fewer wound problems and less postoperative pain. They used tendoscopic synovectomy in this study to treat 9 patients with stage I posterior tibial tendon dysfunction (PTTD). After the procedure, pain was absent or minor in 8 of 9 patients (89%). One patient was not satisfied with the procedure and required hindfoot reconstruction after progressing to stage II PTTD. It was noted that tendon tears were found during tendoscopy in 3 patients that required open repair. A study by Chow et al.61 reported the outcome of tendoscopic debridement for stage I PTTD in 6 patients. All 6 patients were pain free 2 months after surgery and showed normal strength by means of a heel-rise test. None of the patients progressed to stage II PTTD, and no complications were observed. Grade of Recommendation. Indications for tibialis posterior tendoscopy include dislocation, tenosynovitis,1,60,62 tendinopathy (insertional and non-insertional), and post-traumatic adhesions. Some authors have also reported on its use as a diagnostic procedure.60,62 Because of the low number of Level IV and V studies available on tibialis posterior tendoscopy, it is not possible to make a recommendation for or against this intervention, and therefore this procedure was assigned a grade I recommendation. Tibialis Anterior Tendoscopy Level of Evidence V. Only 2 Level V studies describing tibialis anterior tendoscopy were found.63,64 Maquirriain et al.64 presented a case report of a patient who had
8
C. C. CYCHOSZ ET AL.
undergone endoscopic debridement of the tibialis anterior tendon for the treatment of chronic tenosynovitis. The patient had a good outcome and was able to return to golf 8 weeks later. The authors noted that care must be taken to avoid extensor retinaculum damage to prevent the potential bowstring phenomenon during dorsiflexion. Lui63 used tendoscopy to transfer the medial half of the tibialis anterior to the tibialis posterior for stage II posterior tibial tendon insufficiency. This was augmented by transfer of the FDL tendon by FDL tendoscopy and supplemented by subtalar arthroereisis. The patient was pain free at 21 months’ follow-up. Grade of Recommendation. With only 2 Level V studies available describing tendoscopy of the tibialis anterior tendon, there is a paucity of evidence-based literature for this procedure and therefore a grade I recommendation was assigned.
was idiopathic in 2 patients. Tenosynovitis in the last patient was caused by an infected nail penetrating injury. All of the patients had metatarsalgia preoperatively. At latest follow-up ranging from 24 to 31 months, forefoot pain had completely subsided in all patients and no arthroscopy-related complications were observed. Lui63 also used FDL tendoscopy to harvest the FDL tendon during repair of the posterior tibial tendon for stage II posterior tibial tendon insufficiency as previously described. Grade of Recommendation. The main indication for FDL tendoscopy is tenosynovitis.69 Given the lack of evidence-based literature on FDL tendoscopy, it is not possible to make a recommendation for or against this intervention, and therefore we assigned this procedure a grade I recommendation.
Discussion
EHL and EDL Tendoscopy Level of Evidence V. There were 4 Level V studies65-68 on extensor tendoscopy of the foot and ankle. In a 2011 study by Lui,65 1 patient was diagnosed with EHL tenosynovitis by MRI. Extensor tendoscopy was performed, and although no tenosynovitis was found, an EHL ganglion was discovered and drained by arthroscopic resection. Another patient in this study was diagnosed with EDL tenosynovitis after an MRI scan. Tendoscopy confirmed this diagnosis, and arthroscopic synovectomy was performed. Neither patient had recurrence of symptoms at latest follow-up (11 months and 19 months). Chang and Lui66 used tendoscopy to assist in the repair of delayed EHL tendon rupture. The role of tendoscopy in their technique was to help identify the proximal tendon stump and perform tenolysis as well. Three patients underwent this procedure after having an EHL rerupture after primary repair, and in the fourth patient the EHL rupture was missed initially. None of the 4 patients had any neurologic complications, and no reruptures were observed. Grade of Recommendation. Indications for tendoscopy of the extensor tendons include tenosynovitis,65,68 tendinopathy, ganglion,65 and fibrous adhesions.67 Given the lack of evidence-based literature available on extensor tendoscopy, it is not possible to make a recommendation on tendoscopy of the EHL or EDL and therefore both received a grade I recommendation. FDL Tendoscopy Level of Evidence V. We found 2 Level V studies63,69 describing tendoscopy of the FDL. Lui and Chow69 performed tendoscopic synovectomies in 3 patients as a treatment for FDL tenosynovitis. The tenosynovitis
Since the first descriptions of tendoscopy in 1995 by Wertheimer et al.1 and in 1997 by Niek van Dijk et al.,2 orthopaedic surgeons have expanded the use of tendoscopy to other tendons of the foot and ankle including the tibialis anterior, Achilles, EHL, EDL, FHL, and FDL. In general, studies have reported good outcomes, and tendoscopy appears to be an effective diagnostic and therapeutic procedure for a variety of indications. Besides offering a superior cosmetic result compared with open procedures, tendoscopy has the potential to minimize complications and shorten recovery time. In the event that a tendon tear is found, tendoscopy can easily be converted to an open or miniopen repair if needed. The goal of this systematic review is to determine on which tendons of the foot and ankle the use of tendoscopy is supported by the current literature. To date, only weak evidence (grade Cf) exists in support of tendoscopy on the Achilles, FHL, and peroneal tendons whereas insufficient evidence (grade I) exists to assign a grade of recommendation for the other tendons of the foot and ankle. Familiarity with endoscopic procedures may need to be considered in the use of these recommendations because most of the studies were conducted by highly experienced endoscopists. Perhaps one of the most important findings of this review was the limited number of high-level studies currently available to support the use of tendoscopic intervention. Although only limited, low-level evidence exists supporting the use of this procedure, we believe that it is important to clarify that the absence of a “strong recommendation” because of a paucity of evidence-based literature in no way recommends against the use of a procedure. Rather, weak recommendations should be used to call attention to the
FOOT AND ANKLE TENDOSCOPY
need for original scientific articles of higher levels of evidence. Limitations One limitation of this study is that our search was restricted to articles in the English language, and consequently, it is possible that we may have missed good-quality studies in other languages. Another limitation is that because of the relatively small body of literature currently available on tendoscopy, we were unable to gather enough evidence to assign a grade of recommendation for or against intervention regarding each of the common indications individually for each tendon, and consequently, this may be an area of interest for future studies. Lastly, we must acknowledge that high-level studies are often difficult to conduct in the field of orthopaedics, which imposes limitations on the quality of evidence available to be included in this review and consequently leads to the inability to make a strong recommendation for the use of tendoscopy. However, weak or fair recommendations because of a paucity of evidence in support of a procedure such as this must not be confused in any way as a recommendation against using a procedure.
Conclusions A comprehensive review of the literature on foot and ankle tendoscopy has shown predominantly Level IV and V studies, with just 1 Level II study. On the basis of the current literature available, there is poor evidence (grade Cf) in support of Achilles, FHL, and peroneal tendoscopy for the common indications. There is insufficient evidence to make a recommendation (grade I) for or against tendoscopy on the tibialis posterior, tibialis anterior, FDL, EHL, and EDL. Although current literature suggests that tendoscopy is a safe and effective procedure, original scientific articles of higher levels of evidence are needed before a stronger recommendation can be assigned.
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