Tendoscopy



Tendoscopy


Markus Knupp

V. James Sammarco





PATIENT POSITIONING


Peroneal Tendons

The patient is placed in a lateral decubitus position for isolated endoscopy of the peroneal tendons or supine with a sandbag under the buttock of the affected limb if the tendoscopy is combined with an ankle arthroscopy (Fig. 3-1). After exsanguination of the leg, a pneumatic tourniquet is inflated on the thigh.


Posterior Tibial Tendon

The patient is placed in a supine position. A tourniquet is placed on the thigh of the affected leg. If the endoscopy is combined with an ankle arthroscopy, starting with the ankle will allow removing the leg support prior to the tendoscopy and thereby eases the approach to the tendon.


Flexor Hallucis Longus

The patient is placed in a prone position with a thigh tourniquet. A support is placed under the lower leg with the foot at the edge of the operating table allowing the ankle to move freely (Fig. 3-2).


SURGICAL APPROACHES


Peroneal Tendons

Four portals are described for tendoscopy of the peroneal tendon sheath, although often all are not utilized (Fig. 3-3). The first portal established is between the peroneal tubercle and the tip of the fibula. The tendons are subcutaneous here, and a small nick in the skin with a no. 11 scalpel is all that is needed to allow the tendon sheath to be entered. A blunt trocar is then advanced into
the tendon sheath proximally posterior to the fibula, and a 30-degree 2.7-mm (preferred) or 1.9-mm (for patients with a very tight sheath) arthroscope is introduced to allow visualization. The second portal is then established in a similar manner 3 cm proximal to the tip of the fibula. Visualization of an 18-gauge spinal needle which is passed into the tendon sheath as a trial will help verify position and avoid injury to the tendons as the second portal is established (Fig. 3-4). Most lesions can be treated or diagnosed with these two portals alone. Occasionally, synovitis will extend proximally and further debridement will require a more proximal portal. The inferior peroneal retinaculum can be visualized from proximal to distal. If distal synovectomy or release of the inferior peroneal retinaculum is necessary, a portal distal to the peroneal retinaculum may be established. Neurologic structures at risk in this procedure include the superficial peroneal nerve for the more proximal portals, and the sural nerve which crosses the surgical field distal to the lateral malleolus. The course and branching of these nerves is quite variable but the risk of injury can be minimized by using the “nick and spread” technique, where the skin is nicked with a no. 11 scalpel and the subcutaneous tissue and tendon sheath are spread with a small, pointed hemostat.

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Jan 24, 2021 | Posted by in ORTHOPEDIC | Comments Off on Tendoscopy

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