Revision surgery is considered if the outcome of the primary operation is suboptimal or for management of complications of the primary operation. Revision surgery of the foot and ankle region by means of arthroscopic or endoscopic technique is mainly applied in 6 areas: Achilles tendon disorders, osteochondral lesions, lateral ligament complex disorders, posttraumatic conditions, complications arising from arthrodesis or arthroplasty procedures, and complications following bunion surgery. In view of the technical demand and the nature of surgery for treatment of failures from a previous operation, revision surgery is often only performed by experienced foot and ankle surgeons. Compared with primary surgical procedures, there is little literature found on revision arthroscopy or endoscopy. Its indications and efficacy are mostly derived from small case series or reports. In nearly every condition, studies or trials comparing revision arthroscopy and other forms of treatment, for example, open revision surgery, are lacking.
Achilles Tendon Disorders
Achilles tendon rupture is a common sports injury. Optimal treatment is controversial, and open surgical repair is still commonly performed in many centers. Complications of Achilles tendon repair include wound dehiscence, nerve injury, rerupture, and adhesions.1 Of these, revision endoscopy has been described in the management of tendon adhesions, secondary impingement, and lengthened Achilles tendon. Lui reported performing endoscopic adhesiolysis and debulking of the Achilles tendon on a 32-year-old man who presented with persistent deep heel cord pain and dyskinesia after repair of Achilles tendon rupture.2 At 2-year follow-up the patient was free from symptoms. Lui reported another case of persistent pain and stiffness after primary repair of combined tibialis posterior and Achilles tendons laceration.3 The patient underwent endoscopic adhesiolysis of both tendons at 10 months after the primary surgery and had a significant improvement in symptoms. The author continues to propose a treatment algorithm for postrepair heel cord pain using revision endoscopy.4 For pain at the mid portion of the Achilles tendon at the site of repair, endoscopic adhesiolysis and debulking of the hypertrophied tendon is recommended. For pain close to the calcaneal insertion caused by impingement by the posterosuperior calcaneal tubercle, endoscopic calcaneoplasty is recommended. For pain close to insertion caused by fibrous adhesion of the posterosuperior calcaneal tubercle to the repaired tendon, endoscopic adhesiolysis with or without calcaneoplasty is recommended. For pain caused by concomitant fibrous adhesion of the adjacent tendons of the posterior compartment, complete adhesiolysis of the whole span of all the symptomatic scarred tendons is recommended.
Operative Technique of Endoscopic Adhesiolysis of the Achilles Tendon
Endoscopic adhesiolysis is indicated for persistent deep mechanical heel cord pain after Achilles tendon repair that is recalcitrant to physiotherapy. There is usually tenderness just anterior to the Achilles tendon, which corresponds to the painful site.
The patient is in prone position and a thigh tourniquet is applied. The procedure is performed with a 4.0-mm 30° arthroscope via the posteromedial and posterolateral portals, which are at the medial and lateral sides of the Achilles tendon’s calcaneal insertion. The portals are interchangeable as the viewing and working portals. A cleavage plane from distal posterior to proximal anterior is developed in the hypertrophied tendon by a hemostat via the portals. This is the initial endoscopic working space. The portion of the thickened tendon and the thick scar tissue anterior to this plane are resected with preservation of the flexor hallucis longus muscle (Figure 28.1). The plantaris tendon is also resected, and the scar tissue at the tendon edges is released. Full weight-bearing walking and vigorous heel cord stretching exercise are started at postoperative day 1. This endoscopic procedure can resect the neovasculature and the concomitant ingrowth of nerve endings, release the peritendinous adhesions, and relieve the tension of paratenon and intratendinous pressure by debulking the hypertrophied tendon.
For cases of lengthened Achilles tendon after tendon rupture with or without previous tendon repair, endoscopic shortening of the tendon is feasible to restore the physiological length and function of the tendon.5 This is indicated for symptomatic limping of the affected leg with reduced power of the triceps surae. The triceps surae muscle bulk may move more proximally compared with the normal side during both legs tiptoeing.
Operative Technique of Endoscopic Shortening of the Achilles Tendon
The patient is in prone position and a thigh tourniquet is applied. The other leg is also draped for comparison of Achilles tendon tension by flexion of the knees and comparing the degree of plantarflexion of both ankles. This procedure is performed with a 4-mm 30° arthroscope via the posteromedial, posterolateral, and proximal posteromedial portals at the medial and lateral sides of the tendon’s calcaneal insertion and at the medial edge of the tendon 4 cm proximal to the posteromedial portal, respectively. The medial edge of the investing fascia is released via the medial portals. The peritendinous scar tissue is released endoscopically. With the posterolateral portal as the viewing portal, the Achilles tendon is cut via the proximal posteromedial portal. Multiple cuts are needed as the tendon is thickened and the previous repairing sutures are difficult to be cut. The arthroscope is put superficial to the tendon to guide the tendon cut and shifted deep to the tendon to avoid accidental cut into the flexor hallucis longus tendon. Locking sutures are applied to the proximal and distal tendon stump with No. 2 ultrabraid sutures via the proximal posteromedial portal under endoscopic guidance via the posterolateral and posteromedial portals. The suture limbs of the proximal tendon stump are passed through the distal tendon stump from superficial to deep and closed to its calcaneal insertion. The suture limbs of the distal tendon stump are passed through the proximal tendon stump from deep to superficial and as proximal as possible. When the pairs of suture limbs are tensioned, the tendon stumps overlap to a point that the tendon tension is slightly more than that of the contralateral Achilles tendon (Figure 28.2). The pairs of suture limbs are then tied individually. Postoperatively, a short leg cast with ankle plantarflexed is applied and the patient is advised on non–weight-bearing for 4 weeks.
Although we are not able to identify any literature on the management of rerupture by endoscopic means, the technique described by Lui et al6 seems to be a possible option if the rerupture happens in a tendinosis segment that requires excision. In this technique, the proximal end of the tendon is retrieved to a short medial incision away from the calcaneal insertion and is resected. This is followed by minimally invasive gastrosoleus aponeurotic recession and reattachment of Achilles tendon to the calcaneum with suture anchor. Alternatively, an endoscopic-assisted whole-length harvest of the flexor hallucis longus tendon can be performed followed by a double-thickness transfer.7 This endoscopic technique of flexor hallucis longus transfer can also be used to bridge the tendon gap after excision of the infected tendon segment in case of repair of ruptured Achilles tendon complicated by deep infection. This allows second-stage flexor hallucis longus transfer without the need of reopening of the original surgical wound.
Traditionally the primary treatment for talar osteochondral lesions is arthroscopic debridement and microfracture.8,9 The purpose is to stimulate the production of fibrocartilage from bone marrow stem cells. The overall success rate is around 80%, and size of the lesion is often an important factor affecting treatment outcome. Strong associations have been reported between smaller lesion size and a successful clinical result.10 For failed arthroscopic debridement and/or microfracture treatment, revision arthroscopic procedures had been described, including repeat debridement and microfracture, arthroscopic-assisted autologous chondrocyte implantation (ACI), and particulated juvenile allograft cartilage transplantation.
Van Dijk reviewed 38 patients who had been treated for osteochondral lesion of the talus by arthroscopic debridement and drilling.11 The patients were divided into a primary group (22 patients) and revision group (16 patients). In the revision group, patients had failed previous debridement or drilling treatment. The mean follow-up was 4.8 years. There was no information on the size of the lesion. Good or excellent results were found in 86% in the primary group and in 75% in the revision group. Radiological degenerative changes were seen in only 1 ankle in the revision group after 10 years. Saxby reviewed 12 patients who had repeat arthroscopic debridement because of unresolved symptoms after primary arthroscopic debridement.12 No drilling or microfracture was done. The mean area of lesions was 78.6 mm2. The American Orthopaedic Foot and Ankle Society (AOFAS) scores improved from a mean of 34.8 prior to arthroscopy to 80.5 after repeat arthroscopy at a mean follow-up of 5.9 years. Eleven patients were able to return to various levels of sporting activity, and only 1 patient required a salvage procedure.
Giannini reported on 46 patients with talar dome osteochondral lesions who were treated with arthroscopic ACI.13,14 Of these, 16 were revision surgeries. The procedure involves a first operation of an ankle arthroscopy to harvest cartilage from the detached osteochondral fragment from the margins of the lesion. Second, chondrocytes were cultured on a hyalograft C scaffold. Finally, the hyalograft C patch was arthroscopically implanted into the lesion with a specifically designed positioner. No suturing or tissue glue was necessary. The mean size of the lesion was 1.6 cm2. The mean AOFAS score improved from 57.2 preoperative to 86.8 at 1 year and 92 at 7 years. However, patients who received revision surgery performed less well than patients who received primary surgery. There was a significant difference between primary surgery and revision surgery patients in the AOFAS score at 1-year follow-up (91.3 vs 72.6) and at 7-year follow-up (95.2 vs 84.9).
Particulated juvenile allograft cartilage is typically derived from neomorts aged less than 2 years. It is provided as a commercially available sterile package with a preservation medium. The cartilage tissue was provided as particulated pieces approximately 1 mm3 each. The graft could be introduced arthroscopically into the debrided lesion, spread to cover the base, and anchored with fibrin glue. Kruse described the first case of arthroscopic particulated juvenile allograft cartilage implantation in a 30-year-old woman with a satisfactory outcome.15 Subsequently, Coetzee reported its use in revision situations.16 He treated 24 ankles, of which 14 had failed at least 1 prior bone marrow stimulation procedure. The average lesion size was 125 mm2 × 7 mm depth. At an average follow-up of 16.2 months, 78% of ankles demonstrated good to excellent AOFAS-Hindfoot scores. No subgroup analysis was performed to determine whether patients receiving revision surgery would have performed worse or not.
Lateral Ligament Complex Disorders
Patients with chronic lateral ankle instability necessitating operative treatment often received either a ligamentous repair or reconstruction procedure.17 Results are usually good, but complications such as recurrent instability or persistent pain can arise. Using a patient record database, Kennedy studied the reoperation rate following ankle ligament procedures in 16,069 patients.18 It was shown that 1053 patients (6.6%) required a revision procedure. Of these, 44% belonged to revision arthroscopic procedures including debridement, synovectomy, and bone marrow stimulation. Most salvage procedures for recurrent instability are still being performed in an open manner. However, a number of authors would still recommend a concomitant ankle arthroscopy during the revision for proper assessment and treatment of any intra-articular pathology.19,20 Although there is lack of literature support, the arthroscopically assisted ligamentous repair (Figure 28.3) or reconstruction (Figure 28.4) can still be the revision option especially if the primary surgery was not the appropriate choice or it was not properly performed.