Endoscopic Procedures for Retrocalcaneal Bursitis, Achilles Tendon, Posterior Tibial Tendon, Peroneal Tendons, and Flexor Hallucis Longus Tendon
C. NIEK van DIJK
JOHANNES I. WIEGERINCK
MAAYKE N. van STERKENBURG
PETER A. J. de LEEUW
GENERAL INTRODUCTION
Arthroscopic surgery is regarded as one of the three greatest improvements in the diagnosis and treatment of musculoskeletal disorders.1 Ankle arthroscopy experienced major technological advancements in the 20th century. In 1930, the American physician, Michael S. Burman, MD, a resident at the Hospital for Joint Disease in New York, went to Germany for a fellowship in endoscopy.1 Shortly after, he published his results on three endoscopically examined cadaveric ankles.2 Tagaki and later Watanabe made considerable contributions to arthroscopic surgery. Watanabe developed the first fiberoptic scope, the “#22,” in 1967 and later published a series of 28 ankle arthroscopies in 1972 (see Chap. 1).3
Over the last few decades, ankle arthroscopy has become an important procedure with numerous indications. Both anterior and posterior pathology as well as tendon pathology can be addressed. Endoscopic approaches offer multiple advantages over open procedures; among others, it provides a direct visualization of structures without the need of an extensive surgical approach; improved assessment of articular cartilage; less postoperative morbidity; faster and functional rehabilitation; and earlier resumption of sports, and treatment can be offered at an outpatient clinic.1, 4, 5, 6 Posterior ankle problems pose a diagnostic and therapeutic challenge, based on their nature, but also due to the deep location of hindfoot structures.
Historically, the ankle joint was approached by a three-portal technique, the anteromedial, anterolateral, and posterolateral portals. Using this technique, the patient is placed in the supine position.7, 8, 9 The traditional posteromedial portal has been associated with potential damage to the tibial nerve, the posterior tibial artery, and local tendons.10
In 2000, the senior author introduced a two-portal endoscopic approach to the hindfoot with the patient in the prone position.11 This technique has shown to provide an excellent access to the posterior ankle compartment, the subtalar joint, and extra-articular structures.11, 12, 13, 14 Later, he introduced an endoscopic approach to the peroneal tendons, posterior tibial tendon, and the Achilles tendon.15, 16, 17 This chapter provides up-to-date information on posterior ankle arthroscopy and tendoscopy with a wide variety of indications highlighted.
ACHILLES TENDOSCOPY FOR ACHILLES TENDINOPATHY AND PARATENDINOPATHY
Introduction
Achilles tendon pathology can be divided into two separate entities, noninsertional and insertional.18, 19 The first can present as a local degeneration of the tendon, which most often occurs in combination with paratendinopathy. Most patients present with a nodular thickening of the Achilles tendon. The pain is predominantly located at the medial side.20 Insertional pathology is related to abnormalities at the insertion of the Achilles tendon, including the posterior aspect of the calcaneus and the retrocalcaneal bursa. This section describes the noninsertional tendinopathies, which can be divided into three entities: tendinopathy, paratendinopathy, or a combination.
Anatomy
The Achilles tendon is the distal tendinous extension of the medial and lateral heads of the gastrocnemius and soleus muscle. The tendon inserts distally on the mid-posterior aspect of the calcaneus. The plantaris tendon is the distal part of a biarticular plantaris muscle. It inserts proximally on the lateral femoral condyle and distally on the calcaneus at the medial side of the Achilles tendon. Simultaneous knee and ankle movements result in a different pull of the soleus and plantaris tendons. A combined tendinopathy and paratendinopathy is typically located 5 to 7 cm proximal of the insertion of the Achilles tendon into the calcaneus. In the healthy patient, the plantaris tendon moves separately from the Achilles tendon. In case of a chronic paratendinopathy, the plantaris tendon gets more or less fixed to the Achilles tendon at the level of the nodule. Hence, separate tendon movements are restricted. This might provide an explanation for the medially located pain.16
Clinical and Physical Examination
General symptoms include stiffness after a period of rest, along with a painful swelling, usually located 4 to 6 cm proximal to the calcaneal insertion. Patients with tendinopathy present with three different patterns: diffuse thickening of the tendon, local degeneration of the mechanically intact tendon, or tendon insufficiency with a partial tear. In paratendinopathy, there is local thickening or inflammation of the paratenon at the level of the nodular thickening in the tendon. The Royal London Hospital Test provides a clinical method to differentiate between tendinopathy and paratendinopathy. This test is positive in patients with isolated tendinopathy of the main body of the tendon: the area of the tendon initially found to be tender on palpation gives little or no pain with the ankle in maximum dorsiflexion.21, 22 Differentiation between tendinopathy and paratendinopathy can be made with physical examination: the tendon swelling will move along during ankle plantar flexion-dorsiflexion movement in tendinopathy but does not in Achilles paratendinopathy.16, 22, 23 A paratendinopathy can be acute or chronic. Patients with chronic tendinopathy experience the pain especially on the medial side.20 The specific location may be explained by involvement of the plantaris tendon, degeneration of the soleus tendon, or a hyperpronation abnormality of the foot. This results in additional stress on the medial side of the Achilles tendon.16
Diagnostic Imaging
Magnetic resonance imaging (MRI) and ultrasonography (US) can provide useful information to differentiate between the various forms of tendinopathy.24
Treatment
Conservative Treatment
Nonoperative intervention is the first treatment of choice. This includes modification of activity level and, in case of paratendinopathy, should be combined with avoidance of strenuous activities. Shoe modification can be advised as well as inlays. Physical therapy includes an extensive eccentric exercise program, combined by icing and nonsteroidal anti-inflammatory drugs (NSAIDs).25, 26, 27, 28, 29 Other alternatives are a night splint, cast immobilization, and shockwave treatment. Sclerosing injections of neovascularization and accompanying nerves around the Achilles tendon have initially shown promising results. This is based upon the observation that neovascularization is seen in the vast majority of patients with Achilles tendinopathy but not in pain-free healthy tendons.30, 31, 32, 33, 34, 35, 36 Surgery must be considered if conservative treatment fails. Around 25% of previous conservative treated patients require surgery.37, 38
Surgical Intervention
Recently minimal invasive techniques were developed.39, 40, 41 When compared to these procedures, the open techniques show higher complication rates and an extensive rehabilitation period (4 to 12 months).39, 40, 41, 42, 43, 44 The extent of the tendinopathy is decisive for the chosen surgical technique. Extensive degeneration resulting in an insufficient Achilles tendon can be reconstructed by an FHL transfer. Combined tendinopathy and paratendinopathy can be treated by endoscopic surgery. The described approach is an endoscopic release of the peritendineum and plantaris tendon at the level of the nodule. Local, epidural, spinal, and general anesthesia can be used for this procedure, which can be performed in an ambulatory setting. The patient is placed in the prone position (Fig. 20-1). To avoid wrong-side surgery, the
involved leg is marked by the patient. A bolster is placed under the affected foot. The foot is placed at the end of the table as the surgeon needs to obtain full plantar and dorsiflexion. After exsanguination, a 300-mm Hg pressured tourniquet is inflated around the affected upper leg. The senior author prefers to use a 2.7-mm arthroscope. This small-diameter arthroscope cannot deliver the same amount of irrigation fluid per time, when compared to the 4-mm arthroscope. It is possible to use the 4-mm arthroscope for these procedures; if it is used, irrigation through gravity is usually sufficient. To compensate for the amount of irrigation fluid provided by the 2.7-mm arthroscope, a pressurized bag or pump device can be used when indicated. The distal portal is located on the lateral border of the Achilles tendon, 2 to 3 cm distal to the nodular thickening (Fig. 20-2). This portal is made first by making a skin incision. A mosquito clamp is introduced, followed by a 2.7-mm blunt trocar, pointing in craniomedial direction. The paratenon is bluntly released from the tendon by moving the trocar around the tendon. Subsequently, the 2.7-mm 30° arthroscope is introduced. The arthroscope should be placed in between on the tendon and the released paratenon. At this moment, it can be confirmed whether the scope is positioned in the right layer, between paratenon and the AT. If not, the paratenon still overlying the Achilles tendon can be removed by means of a shaver. The proximal portal is made by introducing a spinal needle, followed by a mosquito clamp and probe. The plantaris tendon can be identified at the anteromedial border of the AT. A classic case of local tendinopathy shows a close connection among the plantaris tendon, the AT, and the paratenon at the location of the tendinopathy. The objectives of this procedure are a release of the plantaris tendon, along with a release or removal of local thickened paratenon on the anteromedial side of the AT at the level of the nodule (Fig. 20-3A, B). A further release of the paratenon is performed if the fibrotic paratenon is firmly attached to the medial, lateral, or anterior border of the
tendon. Neovascularization is a sign of pathology, and we release the involved area by means of a 2.7-mm shaver. Changing portals can be helpful. It should be possible to move the arthroscope over the complete symptomatic area of the Achilles tendon at the end of the procedure. The portal incisions are closed using 3-0 Ethilon sutures. Postoperative care consists of a pressure bandage and partial weight bearing for 2 to 3 days. Full weight bearing is allowed as tolerated, and patients are encouraged to actively perform range of motion exercises.16
involved leg is marked by the patient. A bolster is placed under the affected foot. The foot is placed at the end of the table as the surgeon needs to obtain full plantar and dorsiflexion. After exsanguination, a 300-mm Hg pressured tourniquet is inflated around the affected upper leg. The senior author prefers to use a 2.7-mm arthroscope. This small-diameter arthroscope cannot deliver the same amount of irrigation fluid per time, when compared to the 4-mm arthroscope. It is possible to use the 4-mm arthroscope for these procedures; if it is used, irrigation through gravity is usually sufficient. To compensate for the amount of irrigation fluid provided by the 2.7-mm arthroscope, a pressurized bag or pump device can be used when indicated. The distal portal is located on the lateral border of the Achilles tendon, 2 to 3 cm distal to the nodular thickening (Fig. 20-2). This portal is made first by making a skin incision. A mosquito clamp is introduced, followed by a 2.7-mm blunt trocar, pointing in craniomedial direction. The paratenon is bluntly released from the tendon by moving the trocar around the tendon. Subsequently, the 2.7-mm 30° arthroscope is introduced. The arthroscope should be placed in between on the tendon and the released paratenon. At this moment, it can be confirmed whether the scope is positioned in the right layer, between paratenon and the AT. If not, the paratenon still overlying the Achilles tendon can be removed by means of a shaver. The proximal portal is made by introducing a spinal needle, followed by a mosquito clamp and probe. The plantaris tendon can be identified at the anteromedial border of the AT. A classic case of local tendinopathy shows a close connection among the plantaris tendon, the AT, and the paratenon at the location of the tendinopathy. The objectives of this procedure are a release of the plantaris tendon, along with a release or removal of local thickened paratenon on the anteromedial side of the AT at the level of the nodule (Fig. 20-3A, B). A further release of the paratenon is performed if the fibrotic paratenon is firmly attached to the medial, lateral, or anterior border of the
tendon. Neovascularization is a sign of pathology, and we release the involved area by means of a 2.7-mm shaver. Changing portals can be helpful. It should be possible to move the arthroscope over the complete symptomatic area of the Achilles tendon at the end of the procedure. The portal incisions are closed using 3-0 Ethilon sutures. Postoperative care consists of a pressure bandage and partial weight bearing for 2 to 3 days. Full weight bearing is allowed as tolerated, and patients are encouraged to actively perform range of motion exercises.16
 FIGURE 20-1. Positioning for hindfoot endoscopy. Small leg support (A), tourniquet (B), and leg holder (C). (From Easley ME, ed. Operative techniques in foot and ankle surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2011:754-762, with permission.) |
 FIGURE 20-2. Portal placement in Achilles tendoscopy of the left foot and ankle. The patient is placed in the prone position. The distal portal is made first; thereafter, the proximal portal is made under direct vision. |
 FIGURE 20-3. Tendoscopy of the left Achilles tendon in a 41-year-old male patient with pain during palpation at medial side of the Achilles tendon. The 2.7-mm arthroscope is introduced through the distal portal looking proximally. Adhesions are removed by means of the bonecutter shaver. (A) The plantaris tendon, running medial to the Achilles tendon, is released by means of a punch (B). |
ENDOSCOPIC CALCANEOPLASTY FOR RETROCALCANEAL BURSITIS
Introduction
In 1928, Patrick Haglund described a patient with a painful hindfoot. He interpreted this pain being caused by a prominent posterosuperior aspect of the calcaneus, in conjunction with a sharp rigid heel counter.45 Retrocalcaneal bursitis is caused by repetitive impingement of the retrocalcaneal bursa between the posterior aspect of the calcaneus and the anterior aspect of the Achilles tendon. A swelling is present at the level of the posterosuperior calcaneal prominence along both sides of the Achilles tendon. Although it may occur in both sexes and at any age, females at the end of their second or third decade are most often affected. It frequently presents itself bilaterally.
Anatomy
The retrocalcaneal (subtendinous) bursa is located between the anterior site of the Achilles tendon and the posterosuperior aspect of the calcaneus.
Superior of the calcaneus, we find Kager fat pad or the pre-Achilles fat pad, a lipomatous structure located anterior to the Achilles tendon and superior to the calcaneus. Kager triangle is bordered anteriorly by the flexor hallucis longus, inferiorly by the calcaneus, and posteriorly by the Achilles tendon.46
 FIGURE 20-4. Preoperative lateral radiograph of a right foot and ankle with retrocalcaneal bursitis and prominence of the posterosuperior part of the calcaneus. To compare, the symptomless left foot is also shown. Note the diminished radiolucency at the lower portion of Kager triangle in the right foot. |
Clinical and Physical Examination
One should discern between different pathologies causing pain at the posterior aspect of the heel. The typical pain described by patients appears when starting to walk after a period of rest. Differentiation should be made between retrocalcaneal bursitis, superficial bursitis, and insertional Achilles tendinopathy. In an Achilles tendon insertional tendinopathy, the pain is most frequently located in the midline, at the insertion into the calcaneus. In case of a retrocalcaneal bursitis, a bony prominence can be seen, located at the posterosuperolateral aspect of the calcaneal tuberosity. A patient with retrocalcaneal bursitis typically has pain on the lateral and medial side of the Achilles tendon. Physical examination may show a swelling on both sides of the tendon at the level of the posterosuperior calcaneal prominence. The aforementioned pain may be reproducible by palpating this area.
Diagnostic Imaging
The previously mentioned, Kager triangle is important in diagnosing retrocalcaneal bursitis using conventional radiographs. A hypertrophy of the posterosuperior aspect of the calcaneus can be seen on conventional lateral radiographs. Adjacent to it, a diminished radiolucency of the retrocalcaneal recess and the lower portion of Kager triangle can be found (Fig. 20-4). This is a sign of deep retrocalcaneal bursitis. US is a cost-effective method that can provide useful information on Kager triangle as well as the retrocalcaneal bursa and Achilles tendon.47, 48 MRI is known to be both accurate and precise regarding evaluation of possible pathology and size of the retrocalcaneal bursa.46, 49
Operative Treatment
Endoscopic procedures offer the advantages related to any minimal invasive surgical procedure compared with open surgical approaches. These advantages include low morbidity, better scar healing, short recovery time, and a shorter period until sport resumption.50, 51
Surgery can be performed in an ambulatory setting and is performed under general or regional anesthesia. The patient is asked to mark the involved leg to avoid wrong-side surgery. The patient is placed in the prone position, the feet are positioned over the edge of the operating table, and a bolster is used to slightly elevate the involved leg. Subsequently, important anatomical structures are marked. These include both medial and lateral border of the Achilles tendon and the calcaneus. After exsanguination, a tourniquet is inflated to 300 mm Hg around the affected upper leg (Fig. 20-5A-C).
The lateral portal is made first, located lateral to the Achilles tendon at the level of the superior aspect of the calcaneus. The skin is incised using a small vertical incision. Thereafter, the retrocalcaneal space is penetrated with a blunt trocar. A 4.5-mm arthroscopic shaft with an inclination ankle of 30° is introduced. Irrigation is performed by gravity flow or pressured flow at 100 mm Hg. To locate the medial portal, a spinal needle is introduced under direct vision. This portal is made medial to the Achilles tendon, again at the superior aspect of the calcaneus. After preparing the medial portal by a vertical stab incision, a 5.5-mm bonecutter shaver is introduced and visualized by the arthroscope (Fig. 20-6). To provide a better view, the retrocalcaneal space is freed blindly with a blunt trocar. At this moment, the superior surface of the calcaneus is visualized and resected. The full radius resector is facing the bone throughout the process to prevent iatrogenic damage of Achilles tendon. Preoperatively, impingement between the Achilles tendon and the calcaneus can be assessed by dorsiflexing the foot. Full dorsiflexion of the foot can elicit impingement between the Achilles tendon and the posterosuperior calcaneal edge. Subsequently, the foot is brought in plantar flexion and the posterosuperior calcaneal rim is removed. As this bone is fairly soft, it can be removed using an aggressive full radius resector; the senior author uses the bonecutter shaver (Smith & Nephew). Both portals can be used interchangeably for the arthroscope and the resector. It is important to remove sufficient bone at the posteromedial and lateral corner, hereby changing portals intermittently. The synovial resector is moved beyond the posterior edge onto the lateral and medial wall of the calcaneus to smoothen the edges. Full plantar flexion of the foot is necessary to visualize the Achilles tendon insertion. This part is smoothened by placing the bonecutter against the calcaneus on the insertion site. The resector is reintroduced to remove loose debris and smoothen other possible rough edges (Fig. 20-7A). Although a burr is generally not needed, it can be used at the surgeon’s discretion (Fig. 20-7B). Fluoroscopic control may be useful in the first cases to ascertain whether sufficient bone has been resected. This will no longer be necessary with some experience. 3-0 Ethilon sutures are used to close the skin incisions and thereby preventing sinus formation. A 10-mL 0.5% bupivacaine/morphine solution is injected at the incision site and surrounding skin. Finally, a sterile compressive dressing is applied.52 Postoperative treatment is functional; weight bearing is allowed as tolerated; the patient is instructed to elevate the foot when not walking. Three days postoperatively, the bandage is removed. Active range of motion exercises are advised from day one for at least three times a day and 10 minutes each. The patient may return to regular shoes as tolerated. After 2 weeks, the sutures are removed. A conventional lateral radiograph can be made to ascertain if sufficient bone has been excised (Fig. 20-8). In case both the patient and the surgeon are satisfied, no further outpatient contact is necessary. Patients are directed to a physiotherapist if a limited range of motion sustains.
The lateral portal is made first, located lateral to the Achilles tendon at the level of the superior aspect of the calcaneus. The skin is incised using a small vertical incision. Thereafter, the retrocalcaneal space is penetrated with a blunt trocar. A 4.5-mm arthroscopic shaft with an inclination ankle of 30° is introduced. Irrigation is performed by gravity flow or pressured flow at 100 mm Hg. To locate the medial portal, a spinal needle is introduced under direct vision. This portal is made medial to the Achilles tendon, again at the superior aspect of the calcaneus. After preparing the medial portal by a vertical stab incision, a 5.5-mm bonecutter shaver is introduced and visualized by the arthroscope (Fig. 20-6). To provide a better view, the retrocalcaneal space is freed blindly with a blunt trocar. At this moment, the superior surface of the calcaneus is visualized and resected. The full radius resector is facing the bone throughout the process to prevent iatrogenic damage of Achilles tendon. Preoperatively, impingement between the Achilles tendon and the calcaneus can be assessed by dorsiflexing the foot. Full dorsiflexion of the foot can elicit impingement between the Achilles tendon and the posterosuperior calcaneal edge. Subsequently, the foot is brought in plantar flexion and the posterosuperior calcaneal rim is removed. As this bone is fairly soft, it can be removed using an aggressive full radius resector; the senior author uses the bonecutter shaver (Smith & Nephew). Both portals can be used interchangeably for the arthroscope and the resector. It is important to remove sufficient bone at the posteromedial and lateral corner, hereby changing portals intermittently. The synovial resector is moved beyond the posterior edge onto the lateral and medial wall of the calcaneus to smoothen the edges. Full plantar flexion of the foot is necessary to visualize the Achilles tendon insertion. This part is smoothened by placing the bonecutter against the calcaneus on the insertion site. The resector is reintroduced to remove loose debris and smoothen other possible rough edges (Fig. 20-7A). Although a burr is generally not needed, it can be used at the surgeon’s discretion (Fig. 20-7B). Fluoroscopic control may be useful in the first cases to ascertain whether sufficient bone has been resected. This will no longer be necessary with some experience. 3-0 Ethilon sutures are used to close the skin incisions and thereby preventing sinus formation. A 10-mL 0.5% bupivacaine/morphine solution is injected at the incision site and surrounding skin. Finally, a sterile compressive dressing is applied.52 Postoperative treatment is functional; weight bearing is allowed as tolerated; the patient is instructed to elevate the foot when not walking. Three days postoperatively, the bandage is removed. Active range of motion exercises are advised from day one for at least three times a day and 10 minutes each. The patient may return to regular shoes as tolerated. After 2 weeks, the sutures are removed. A conventional lateral radiograph can be made to ascertain if sufficient bone has been excised (Fig. 20-8). In case both the patient and the surgeon are satisfied, no further outpatient contact is necessary. Patients are directed to a physiotherapist if a limited range of motion sustains.
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