Foot and Ankle Tendoscopy: Evidence-Based Recommendations

Systematic Review

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Foot and Ankle Tendoscopy: Evidence-BasedRecommendations

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 thefoot and ankle and assign an evidence-based grade of recommendation for or against intervention. Methods: Acomprehensive review of the literature was performed on May 26, 2013, using the PubMed, Cochrane, and Scopusdatabases. Studies focusing on the use of foot and ankle tendoscopy were isolated, and these articles were then reviewedand assigned a Level of Evidence (I through V). The literature was then analyzed, and a grade of recommendation wasassigned 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 thetibialis 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 IVand V studies, with just 1 Level II study. On the basis of the current literature available, there is poor evidence (grade Cf) insupport of Achilles, flexor hallucis longus, and peroneal tendoscopy for the common indications. There is insufficientevidence to make a recommendation (grade I) for or against tendoscopy of the tibialis posterior, tibialis anterior, flexordigitorum longus, extensor hallucis longus, and extensor digitorum longus. Although current literature suggests thattendoscopy is a safe and effective procedure, original scientific articles of higher levels of evidence are needed before astronger recommendation can be assigned. Level of Evidence: Level IV, systematic review of Level II, IV, and V studies.

n endoscopic tendon procedure was first described1
Ain the literature by Wertheimer et al. in 1995
for the treatment of posterior tibial stenosing tenosyno-vitis. In 1997 Niek van Dijk et al.2 published a report ontendon sheath endoscopy of the peroneal tendon,anterior tibial tendon, and Achilles tendon in 40 patients

From Carver College of Medicine, The University of Iowa (C.C.C.), andepartment of Orthopaedics and Rehabilitation, The University of Iowaospitals and Clinics (P.P.), Iowa City, Iowa; and Department of Orthopae-ics, University of Utah School of Medicine (F.N.), Salt Lake City, Utah,.S.A.; the Orthopaedic Department, University Hospital of Basel, UniversityBasel (A.B.), Basel, Switzerland; the Department of Orthopaedic Surgery,cademic Medical Center, University of Amsterdam (C.N.v.D.), Amsterdam,he Netherlands; and Division of Orthopaedic Surgery, Dalhousie University.A.G.), Halifax, Nova Scotia, Canada.The authors report the following potential conflict of interest or source ofnding: P.P. receives support from Arthrex, OREF Young Investigator Grant,TP 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 Iowaospitals and Clinics, 0102X JPP, 200 Hawkins Dr, Iowa City, IA 52242-088, U.S.A. E-mail: [email protected] by Elsevier Inc. on behalf of the Arthroscopy Association of Northmerica0749-8063/13880/$36.00http://dx.doi.org/10.1016/j.arthro.2014.02.022

Arthroscopy: The Journal of Arthroscopic and Related

and named the procedure “tendoscopy.” In the yearssince, refinements in equipment and techniques haveaided the expansion of tendoscopy as both a diagnosticand therapeutic procedure to other tendons of the footand ankle. However, because it is a relatively newtechnique, there may not yet be a suitable body of evi-dence in the form of scientific literature to support theuse of foot and ankle tendoscopy.The purpose of this study was to review the literature

on the outcomes and complications of tendoscopy of thefoot and ankle for the generally accepted indications ofeach tendon, summarize the quality and quantity ofevidence available, and lastly, assign a grade of recom-mendation for or against the use of tendoscopy.

MethodsThe methodology of this study was modeled after that

described by Glazebrook et al.3 A comprehensive re-view of the literature was performed (May 26, 2013) byuse of the PubMed, Scopus, and Cochrane databasesusing the search terms “(tendoscopy OR tendoscopic)”and “((endoscopy OR endoscopic) AND tendon AND(foot or ankle)).” The “search within” function availableon Scopus was used for the latter term to yield more

Surgery, Vol 30, No 6 (June), 2014: pp 755-765 755

mailto:[email protected]

http://dx.doi.org/10.1016/j.arthro.2014.02.022

Table 1. Levels of Evidence for Therapeutic Studies4,70

Level ofEvidence Description

Level I � High-quality randomized trial with no statisticallysignificant difference but narrow confidence intervals

� Systematic reviews of Level I RCTs (and study resultswere homogeneous)

Level II � 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 resultsLevel III � Case-control studies

� Retrospective comparative studies� Systematic reviews of Level III studies

Level IV � Case seriesLevel V � Expert opinion

RCT, randomized controlled trial.Reprinted with permission from the Journal of Bone & Joint Surgery

and the Centre for Evidence Based Medicine.

756 C. C. CYCHOSZ ET AL.

results. Searches were limited to articles in the Englishlanguage. All dates and all types of publications includingprospective and retrospective studies, case reports, andreview articles were allowed by the initial search criteria.The decision to eliminate articles was made by a mini-mum of 2 reviewers. These searches together returned328 articles. Of these articles, 134 were eliminated basedon the title alone and 71 were eliminated by readingthe abstract. The remaining articles were examinedfor content, and an additional 66 were eliminated.Finally, the references of the remaining 57 articles werereviewed, and 8 additional publications included inthis study were retrieved. Cadaveric studies and tech-nique tips without any patients were excluded. For theAchilles tendon, only non-insertional interventions wereincluded in this study. Studies reporting the arthroscopicor endoscopic release of the flexor hallucis longus (FHL)tendon for the treatment of stenosing tenosynovitis wereincluded as long as adequate data separation was pro-vided to distinguish patients undergoing these pro-cedures from patients undergoing various hindfootendoscopic procedures. In the event that the same series

Table 2. Grades of Recommendation for Summaries orReviews of Orthopaedic Surgical Studies5

Grade ofRecommendation Description

A Good evidence (Level I studies with consistentfindings) for or against recommending

interventionB Fair evidence (Level II or III studies with

consistent findings) for or against recommendingintervention

C Poor-quality evidence (Level IV or V studies withconsistent findings) for or against recommending

interventionI 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 serieswas included.All articles were reviewed and assigned a Level of

Evidence classification (I through V) by use of theJournal of Bone and Joint Surgery “Levels of Evidence forPrimary Research Question” (Table 1).4 Series withfewer than 5 patients or those that had poor datacorrection were classified as Level V Evidence, andstudies in which the retrospective or prospective naturewas not apparent were classified as retrospective. Ananalysis of the literature reviewed was used to assign agrade of recommendation (A, B, C, or I)5 for eachcurrent generally accepted indication for foot and ankletendoscopy (Table 2). A subscale proposed by Stevenset al.6 was used for further differentiation of the evi-dence for indications receiving a grade C recommen-dation. Three subscripts were applied: “c” for conflictingliterature, “f” for literature for the use of tendoscopy,and “a” for literature against the use of tendoscopy.

ResultsOn the basis of the literature, weak evidence (grade Cf)

exists in support of tendoscopy on the Achilles, FHL, andperoneal tendons for the generally accepted indications.Insufficient evidence (grade I) exists to make a recom-mendation for or against the use of tendoscopy on thetibialis posterior, tibialis anterior,flexor digitorum longus(FDL), extensor hallucis longus (EHL), and extensordigitorum longus (EDL). A summary of the grades ofrecommendation based on the current literature ispresented in Table 3.

Achilles TendoscopyLevel of Evidence II. The first case series on Achilles ten-doscopy was published by Niek van Dijk et al.2 in 1997.Since then, there has been one Level II study on Achillestendoscopy.7 Halasi et al.7 prospectively compared agroup of 57 patients undergoing percutaneous Achillestendon repair with the use of endoscopy (E group) witha group of 87 patients undergoing the same procedurewithout endoscopic assistance (P group). The primarypurpose of tendoscopy during the procedure was tocontrol the adaptation of the tendon ends. In asubjective evaluation, 51 of 57 patients (89%) in the Egroup and 76 of 87 patients (88%) in the P group hadgood to excellent results. The rerupture rate was lowerin the E group (1 of 57, 1.75%) than in the P group (5 of87, 5.74%) during a follow-up period that ranged from12 to 60 months. This difference was not statisticallysignificant, however. The authors noted that Achillestendoscopy was able to give them a more precise repair.

Levels of Evidence IV and V. There were 10 Level IVstudies8-17 and 2 Level V studies18,19 on Achillestendoscopy (Table 4). The average number of patients

Table 3. Summary of Recommendations for or Against Tendoscopy of Foot and Ankle

Tendon No. of Studies Level I Level II Level III Level IV Level V Grade of Recommendation

Achilles 13 0 1 0 11 2 Cf (for intervention)Peroneal 20 0 0 0 7 13 Cf (for intervention)FHL 20 0 0 0 9 11 Cf (for intervention)Tibialis anterior 2 0 0 0 0 2 ITibialis posterior 7 0 0 0 3 4 IFDL 2 0 0 0 0 2 IEHL/EDL 4 0 0 0 0 4 I

FOOT AND ANKLE TENDOSCOPY 757

per study was 16.7, and the majority of case seriesreported patient satisfaction rates or good to excellentoutcome rates approaching 100%. Complicationsencountered include sural nerve injury, tendonrerupture, deep vein thrombosis, fusiform thickening,hematoma, and delayed keloid lesions; however, nostudies reported rates above 11%.In a retrospective study by Pearce et al.,9 11 patients

with non-insertional tendinopathy underwent Achillestendoscopy with division of the plantaris tendon. Themean American Orthopaedic Foot & Ankle Societyhindfoot 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 3were somewhat satisfied. None of the patients in thisstudy had complications.Maquirriain12 evaluated the long-term results of

Achilles tendoscopy for the treatment of chronic mid-portion Achilles tendinopathy. Twenty-four patientsunderwent 27 procedures (3 bilateral) consisting of par-atenon debridement and longitudinal tenotomies, with amean follow-up period of 7.7 years (range, 5 to 14 years).Fifteen patients were evaluated with the Victorian Insti-tute Sport AssessmenteAchilles questionnaire and hadan improvement from a mean score of 37 points beforethe procedure to 97.5 after the procedure. The meanscore with the Achilles Tendon Scoring System improvedaswell, increasing from 32.6 before the procedure to 97.6at follow-up. At the latest-follow-up, 96% of patientswere completely free of symptoms. There were 2 post-operative complications, comprising a delayed keloidlesion and a seroma with chronic fistula. No infections orsystemic complications occurred in this series.

Grade of Recommendation. Generally accepted indicationsfor non-insertional Achilles tendoscopy includeperitendinopathy13,19 and tendinopathy.8,9,12-14,19 Studieshave also found tendoscopy to be helpful in assisting withthe repair of tendon ruptures.7,10,11,15,16 Although high-level evidenceebased literature for Achilles tendoscopy isstill somewhat sparse, the literature mentioned earlierreported consistently good outcomes with fewcomplications; therefore tendoscopy of the Achillestendon was assigned a grade Cf recommendation (forintervention).

Peroneal TendoscopyLevels of Evidence IV and V. There were 7 Level IVstudies20-26 and 13 Level V studies27-39 on peronealtendoscopy (Table 5). These studies ranged in size from1 to 52 patients, with a mean of 7.6 patients. Onlyminor complications including suture irritation andmild post-static dyskinesia were noted. The majority ofpatients reported significant or complete relief ofsymptoms shortly after the procedure. The results weregenerally stable through the final follow-up, rangingfrom 2 months to 6 years.In a Level IV retrospective study, Scholten and van

Dijk21 performed peroneal tendoscopy on 23 patientswith a minimum follow-up period of 2 years. Two pa-tients presented with recurrent peroneal tendon dislo-cation and underwent tendoscopic fibular groovedeepening. Another 10 patients had chronic tenosyn-ovitis and underwent tendoscopic synovectomy. Theremaining 11 patients had a longitudinal rupture of theperoneal brevis tendon and underwent tendoscopicsynovectomy and suturing if necessary (by way of amini-open procedure). None of the patients had com-plications, nor was there a recurrence of any preoper-ative pathology.Peroneal tendoscopy was used primarily as a diag-

nostic procedure in a Level V study by Panchbhavi andTrevino.35 A peroneus quartus tendon that did notshow up on magnetic resonance imaging (MRI) wasfound to be causing lateral ankle pain in 1 patient.Another individual underwent peroneal tendoscopywith subtalar arthroscopy, and it was discovered thatshe had a low-lying muscle belly attached to her per-oneus brevis. Tendoscopy in a third patient identified atendinous structure between the peroneus longusand brevis, which had not been identified on the pre-operative MRI scan. These tendon anomalies wereexcised through an open procedure, and the symptomsresolved in all patients.In a recent Level IV study by Vega et al.,24 52 patients

underwent peroneal tendoscopy from 2008 to 2011 witha minimum follow-up period of 1 year. The indicationsfor peroneal tendoscopy were peroneal adhesions (2),tenosynovitis (13), tendon rupture (24), recurrentperoneal tendon subluxation (7), and intrasheath pero-neal tendon subluxation (6). The symptoms diminished

Table 4. Level II-IV Studies in Support of Achilles Tendoscopy

Author (Year) Type of Study IndicationsMeasurement

Tools Outcome Comments

Doral et al.10

(2009)Level IV

(prospective caseseries)

Achilles rupture AOFAS score Excellent in 94% and good in6% according to AOFAS score;

postoperative mean, 94.6

2 of 62 patients (3.2%) hadhypoesthesia in sural nerveregion, which resolved

spontaneously after 6 moFortis et al.11

(2008)Level IV


Achilles rupture Merkel scale Mean postoperative Merkelscore, 604; good to excellentoutcomes in 20 of 20 (100%)

2 of 20 patients (10%) hadsural neuralgia; 1 subsidedwith no further treatment

Halasi et al.7

(2003)Level II

(prospectivecomparative

study)

Achilles rupture Subjective Good to excellent in 88% in P(percutaneous) group and

89% in E (endoscopic) group

E group: 1 partialrerupture, 4 fusiformthickening, 1 DVT

P group: 2 total and 3partial reruptures, 4

fusiform thickening, 2 DVTLui17 (2012) Level IV

(retrospective caseseries)

Chronic non-insertional Achilles

tendinopathy

ATSS-17 score Improved from mean ATSS-17score of 29.4 to 89

FHL transfer alsoperformed

Maquirriainet al.13 (2002)

Level IV(prospective case

series)

Peritendinitis,tendinosis, partial

tear

ATSS score, MRI ATSS score improved from 39to 89

1 of 7 patients (14.3%) hadminor subcutaneoushematoma with ankleedema, which resolved

after 1 wk of restMaquirriain12

(2013)Level IV


Chronic mid-portion Achillestendinopathy

ATSS score, VISA-A score, PGART

score using 5-pointLikert scale

ATSS score improved from32.7 to 97.2; VISA-A scoreimproved from 37.1 to 97.6;24 of 24 patients (100%) had

good to excellent PGARTscores

2 of 27 procedures (7.4%),comprising 1 delayed

keloid lesion and 1 seromawith chronic fistula

Pearce et al.9

(2012)Level IV


Non-insertionalchronic Achillestendinopathy

AOFAS score, AOSscore, SF-36 score

AOFAS score improved from68 to 92; AOS score improvedfrom 28% to 8% for pain and

from 38% to 10% fordisability; SF-36 score

improved from 76 to 87 (notstatistically significant)

Tang et al.16

(2007)Level IV


Acute Achillesrupture

Arner-Lindholmscale

Excellent in 15 of 20 (75%)and good in 5 of 20 (25%)according to Arner-Lindholm

scaleThermann

et al.14 (2009)Level IV


Chronic mid-portion Achillestendinopathy

VAS VAS for pain improved from40 to 97.5; VAS for functionincreased from 22.5 to 90

Turgut et al.15

(2002)Level IV


Acute Achillesrupture

ROM 11 of 11 (100%) hadsatisfactory results; 10 of 11(91%) had no significant

change in ROMVega et al.8

(2008)Level IV


Non-insertionalchronic Achillestendinopathy

Nelen scale, MRI Excellent Nelen scale score in8 of 8 (100%); preoperativeMRI showed degeneration in 8

of 8 patients (100%);postoperative MRI showed

degeneration in 3 of 8 patients(37.5%)

AOFAS, American Orthopaedic Foot & Ankle Society; AOS, Ankle Osteoarthritis Scale; ATSS/ATSS-17, Achilles Tendoninopathy ScoringSystem; 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 ofadhesions. Of the 24 patients diagnosed with ruptures ofthe peroneal tendons, 15 (62.5%) reported completerelief of their symptoms, 6 (25%) reported partial relief,and 3 (12.5%) had no change in symptoms after theprocedure. Of the 7 patients treated with tendoscopic

groove deepening for peroneal tendon subluxation,5 (71.4%) reported excellent results and were able toreturn to their normal activities without limitations. Norecurrent subluxation occurred at follow-up in any ofthe cases; however, 2 patients had discomfort and aclicking sensation in the lateral retromalleolar area

Table 5. Level IV Studies to Support Tendoscopy of Peroneal Tendons

Author (Year) Type of Study Indications (No.) Outcome Comments

Guillo and Calder23

(2013)Level IV


Recurring peronealtendon subluxation (7)

7 of 7 patients (100%) returned toprevious activity level

1 patient had skin irritationdue to suture knot

Jerosch andAldawoudy26

(2007)

Level IV(prospective case

series)

Tenosynovitis (7),partial lesions of

peroneal tendon (5),LLMB (2), peronealtendon instability (1)

15 of 15 patients (100%) weresymptom free at 3 mo

postoperatively

Peroneal tendon instabilityrequired open repair of

retinaculum; 1 longitudinaltear required open repair

Lui25 (2012) Level IV(retrospective case

series)

Retrofibular pain (7) 6 of 7 patients (86%) resumedprevious sport or activity within

24 mo

Mild post-static dyskinesia ofoperative site occurred in all

patientsMarmotti et al.20

(2012)Level IV


Thickened vinculalesions (5)

5 of 5 patients (100%) reportedsubjective improvement of lateral

ankle painScholten and van

Dijk21 (2006)Level IV


Longitudinal rupture ofperoneal brevis tendon

(11), chronictenosynovitis (10),recurrent peronealsubluxation (2)

No recurrence of preoperativepathology

Suturing of tendon tearsrequired mini-open procedure

van Dijk and Kort22

(1998)Level IV


Diagnostic (5),snapping sensation (2),exostosis (1), partial

tendon tear (1)

3 of 4 (75%) had no recurrenceafter adhesiolysis; 1 of 1 (100%)peroneal tubercle successfully

removed; 1 of 1 (100%)longitudinal rupture successfully

suturedVega et al.24 (2013) Level IV


Peroneal tendonrupture (24),

tenosynovitis (13),recurrent peroneal

tendon subluxation (7),intrasheath subluxation

(6), adhesions (2)

Intrasheath subluxation: excellentresults in 6 of 6 (100%) (meanAOFAS score increased from

79 to 99)Lysis of adhesions: 2 of 2 (100%)

had symptoms diminishRuptures: 15 of 24 (62.5%)symptom free, 6 of 24 (25%)partially symptom free, 3 of 24

(12.5%) no changeRecurrent peroneal tendonsubluxation: 5 of 7 patients(71.4%) had excellent results(AOFAS score increased from

75 to 93)

Some tendon rupturesrequired open repair

AOFAS, American Orthopaedic Foot & Ankle Society; LLMB, low-lying muscle belly.


during active dorsiflexion and eversion of the foot. All 6patients treated for intrasheath subluxation had excel-lent results.

Grade of Recommendation. Generally accepted indicationsfor peroneal tendoscopy include tenosyno-vitis,21,24,26,32,34,38 subluxation or dislocation,21,23,24,27,30,37

snapping,22 partial tears requiring debridement,22,24,26 andpostoperative adhesions and scarring.24 Peronealtendoscopy was also found to be valuable as a diagnostictool in some instances.22,35 The Level IV and V studies onperoneal tendoscopy generally reported good to excellentoutcomes in most patients with a relatively lowoccurrence of complications. On the basis of the literatureavailable, peroneal tendoscopy was assigned a grade Cf

recommendation (for intervention).

FHL TendoscopyLevels of Evidence IV and V. There were 9 Level IVstudies17,40-47 and 11 Level V studies18,48-57 on FHLtendoscopy (Table 6). Studies often reported the use ofFHL tendoscopy in conjunction with other proceduresduring hindfoot endoscopy. A tendoscopic method ofharvesting the FHL tendon was presented in a limitednumber of studies as well. Most authors reported goodto 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-oldprofessional ballet dancer. During operative treatmentby means of 2-portal posterior ankle endoscopy, ad-hesions and thickening of the FHL tendon were foundafter the os trigonum was removed. Six weeks after

Table 6. Level IV Studies to Support FHL Tendoscopy

Author (Year) Type of Study Procedure (No. of Procedures) Outcome Comments

Calder et al.40

(2010)*Level IV


Debridement with FHL release(5), os trigonum excision (13),bony pull-off excision with

FHL release (9)

Return to training after soft-tissue debridement with FHLrelease was significantly (P ¼.046) shorter than after “bonysurgery” (28 d v 40 d); 26 of 27(96.3%) resumed training andwere symptom free at 23-mo

follow-up

1 patient had persistent portalleakage; 1 patient had

recurrent symptoms and wassuccessfully treated by steroid

injection

Corte-Real et al.41

(2012)Level IV


FHL release (27) Mean postoperative AOFASscore was 89; results wereexcellent in 7 of 27 (26%);

good in 12 of 27 (44%); fair in6 of 27 (23%); poor in 2 of 27

(7%)

5 of 27 patients (18%) hadcomplications comprisingsignificant swelling andextensive fibrous tissue

proliferation (1), transientnumbness in medial heel (3),and “triggering of the hallux”

(1)Lui et al.42 (2006) Level IV


FHL mobilization, posteriorcapsulectomy, various

AOFAS score improved from63.8 (range, 55 to 74) to 88.6(range, 81 to 100); dorsiflexionimproved from 1� (range, 0� to5�) to 19� (range, 15� to 25�);plantar flexion improved from16� (range, 10� to 20�) to 39�

(range, 30� to 45�)Lui17 (2012) Level IV


Zone 2 FHL harvest forAchilles tendon augmentation

(5)

ATSS score improved from 29.4(range, 28 to 31) to 89 (range,52 to 100); 2 patients did notachieve full postoperative score

Patient with low postoperativescore had severe crushinginjury to leg 35 yr earlier

Nickisch et al.43

(2012)*Level IV


FHL tenolysis (38), ostrigonum excision (48), partial

calcanectomy (5),osteochondral lesion

debridement (44), subtalardebridement (38), subtalar

fusion (33), ankledebridement (30), partialtalectomy (9), fixation of

calcaneal fracture (4), revisionof subtalar nonunion (1)

Logistic regression analysis didnot identify any surgicalparameters of hindfootendoscopy that were

significantly associated withoccurrence of neurologic

complications; 1 of 38 patients(2.6%) with FHL tenolysis had

neurologic complications

Overall complication rate of 16of 189 (8.5%), comprisingplantar numbness (4), suralnerve dysesthesia (3), AT

tightness (4), complex regionalpain syndrome (2), infection(2), and cyst at posteromedial

port (1)

Ogut et al.44 (2011) Level IV(retrospective case

series)

FHL tenolysis with or withoutconcomitant procedures (59)

Mean AOFAS-hindfoot/MFSscore improved from 56.7 of

54.8 to 85.9 of 84.9

Overall complication rate of 2of 59 (3.4%), comprising suralnerve injury (1) and sural

neuroma (1)Smith and Berlet45

(2009)Level IV


Posterior ankle debridement,os trigonum excision, FHL

release (14)

Good to excellent in 12, fair in1, poor in 1

2 of 14 (14.3%) had tibialnerve neuritis

van Dijk46 (2006)* Level IV(retrospective case

series)

OT resection with FHL release(28), FHL release (7), FHLrelease with ossicle removal(4), FHL release with ODdrilling (5), various others(146 procedures total)

Most patients had good toexcellent results

Complications occurred in 2 of146 procedures (1.4%)

(diminished sensation overheel pad)

Willits et al.47

(2008)*Level IV


Tenolysis of FHL (5), ostrigonum excision (11),posterior talar process

decompression (5), loose bodyremoval (1), osteochondritisdissecans debridement (1),

arthrotomy (1)

Mean postoperative AOFAS-hindfoot score, 91 (range, 77 to100); mean postoperative SF-12 scores, 51.80 (range, 30.77

to 60.53) for mentalcomponent and 55.80 (range,44.26 to 63.33) for physical

component

Complications occurred in 6 of24 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.



endoscopic removal of the adhesions, as well as theremnants of the FHL retinaculum, the athlete was ableto resume her professional dance activities. At 30months’ follow-up, the patient had no recurrence ofsymptoms and no complaints. Between 1994 and 2002,van Dijk46 performed release of the FHL tendon inanother 44 patients during hindfoot endoscopy, withthe main indication being FHL tendinitis due to poste-rior ankle impingement syndrome. The author hasfound the 2-portal posterior endoscopic approach to bea 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 transferto treat Achilles tendon pathologies. Lui50 performedtendoscopy to assist with FHL transfer in 3 patients withchronic ruptures of the Achilles tendon in a Level Vstudy. At a mean follow-up of 15 months, all 3 patientswere able to walk without a limp. In another study byLui,17 tendoscopic-assisted transfer of the FHL tendonwas performed alongside endoscopic debridement ofthe Achilles tendon in 5 patients in a Level IV study forthe treatment of chronic non-insertional Achilles ten-dinopathy. The patients were assessed immediatelybefore the operation and at the latest follow-up usingthe Achilles Tendon Scoring System. The mean score ofthese patients improved from 29.4 (range, 21 to 38)preoperatively to 89 (range, 52 to 100) after the pro-cedure. The patient with a postoperative score of 52 inthis study had a severe crushing injury to her lower leg35 years ago. No neurologic complications were notedin any patients.Lui48 in a Level V study presented 2 patients who had

lateral plantar nerve neurapraxia after FHL tendoscopyfor tenosynovitis. Both patients had FHL tendoscopythat included a portal in the arch of the foot to allowmore distal access to the tendon (zone 2). The patientshad numbness over the lateral sole and plantar surfaceof the fourth and fifth toes and were unable to activelyabduct the little toe. An electromyography-confirmeddiagnosis of lateral plantar nerve injury was made forboth patients. The symptoms in 1 patient subsidedcompletely within 5 months, whereas the other patientremained symptomatic after 1 year.

Grade of Recommendation. Indications for FHL tendo-scopy include tenosynovitis41 and stenosingtenosynovitis.52 FHL tendoscopy has also been usedto harvest the tendon for use in the augmentation ofother tendons such as the Achilles.17,50,51,53

Sufficient evidence-based literature was found towarrant a grade Cf recommendation for tendoscopicFHL release in conjunction with hindfoot endoscopy.Larger case series may be needed yet to verify thesafety and efficacy of tendoscopic FHL transfer.Caution must be taken, especially during distal FHLtendoscopy, to avoid lateral plantar nerve injury.48

Tibialis Posterior TendoscopyLevels of Evidence IV and V. After the initial descriptionby Wertheimer et al.,1 the first series of 16 patients waspublished by van Dijk et al.58 in 1997. Since then, only3 Level IV studies59-61 and 4 Level V studies1,55,62,63 ontibialis posterior tendoscopy were found. Bulstra et al.60

reported the outcomes of 33 patients with diversepathology of the posterior tibial tendon whounderwent tendoscopy in a Level IV study. Eightpatients were diagnosed with chronic tenosynovitisdue to rheumatoid arthritis and were treated withtenosynovectomy. Of these patients, 4 (50%) had norecurrence of symptoms; 2 (25%) had a recurrence ofsymptoms at 9 and 18 months and underwenttendoscopy a second time, after which they becamesymptom free. The final 2 patients were eventuallyless satisfied. Of the 4 patients who had tendoscopicresection of a pathologic vincula, 3 (75%) becamesymptom free. Three patients had tendoscopicadhesiolysis, but only 1 of these patients (33.3%) hadgood results.In another Level IV study, Khazen and Khazen59

found tibialis posterior tendoscopy to be an effectiveand minimally invasive procedure that offers the ad-vantages of fewer wound problems and less post-operative pain. They used tendoscopic synovectomy inthis study to treat 9 patients with stage I posterior tibialtendon dysfunction (PTTD). After the procedure, painwas absent or minor in 8 of 9 patients (89%). Onepatient was not satisfied with the procedure andrequired hindfoot reconstruction after progressing tostage II PTTD. It was noted that tendon tears werefound during tendoscopy in 3 patients that requiredopen 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 andshowed normal strength by means of a heel-rise test.None of the patients progressed to stage II PTTD, and nocomplications were observed.

Grade of Recommendation. Indications for tibialis poste-rior tendoscopy include dislocation, tenosynovitis,1,60,62

tendinopathy (insertional and non-insertional), andpost-traumatic adhesions. Some authors have alsoreported on its use as a diagnostic procedure.60,62

Because of the low number of Level IV and V studiesavailable on tibialis posterior tendoscopy, it is notpossible to make a recommendation for or against thisintervention, and therefore this procedure wasassigned a grade I recommendation.

Tibialis Anterior TendoscopyLevel of Evidence V. Only 2 Level V studies describingtibialis anterior tendoscopy were found.63,64 Maquirriainet al.64 presented a case report of a patient who had


undergone endoscopic debridement of the tibialisanterior tendon for the treatment of chronictenosynovitis. The patient had a good outcome andwas able to return to golf 8 weeks later. The authorsnoted that care must be taken to avoid extensorretinaculum damage to prevent the potential bowstringphenomenon during dorsiflexion.Lui63 used tendoscopy to transfer the medial half of the

tibialis anterior to the tibialis posterior for stage II pos-terior tibial tendon insufficiency. This was augmented bytransfer of the FDL tendon by FDL tendoscopy andsupplemented by subtalar arthroereisis. The patient waspain free at 21 months’ follow-up.

Grade of Recommendation. With only 2 Level V studiesavailable describing tendoscopy of the tibialis anteriortendon, there is a paucity of evidence-based literaturefor this procedure and therefore a grade Irecommendation was assigned.

EHL and EDL TendoscopyLevel of Evidence V. There were 4 Level V studies65-68 onextensor tendoscopy of the foot and ankle. In a 2011study by Lui,65 1 patient was diagnosed with EHLtenosynovitis by MRI. Extensor tendoscopy wasperformed, and although no tenosynovitis was found,an EHL ganglion was discovered and drained byarthroscopic resection. Another patient in this study wasdiagnosed with EDL tenosynovitis after an MRI scan.Tendoscopy confirmed this diagnosis, and arthroscopicsynovectomy was performed. Neither patient hadrecurrence of symptoms at latest follow-up (11 monthsand 19 months).Chang and Lui66 used tendoscopy to assist in the

repair of delayed EHL tendon rupture. The role oftendoscopy in their technique was to help identify theproximal tendon stump and perform tenolysis as well.Three patients underwent this procedure after havingan EHL rerupture after primary repair, and in thefourth patient the EHL rupture was missed initially.None of the 4 patients had any neurologic complica-tions, and no reruptures were observed.

Grade of Recommendation. Indications for tendoscopyof the extensor tendons include tenosynovitis,65,68

tendinopathy, ganglion,65 and fibrous adhesions.67 Giventhe lack of evidence-based literature available onextensor tendoscopy, it is not possible to make arecommendation on tendoscopy of the EHL or EDL andtherefore both received a grade I recommendation.

FDL TendoscopyLevel of Evidence V. We found 2 Level V studies63,69

describing tendoscopy of the FDL. Lui and Chow69

performed tendoscopic synovectomies in 3 patients asa treatment for FDL tenosynovitis. The tenosynovitis

was idiopathic in 2 patients. Tenosynovitis in the lastpatient was caused by an infected nail penetratinginjury. All of the patients had metatarsalgiapreoperatively. At latest follow-up ranging from 24 to31 months, forefoot pain had completely subsided inall patients and no arthroscopy-related complicationswere observed.Lui63 also used FDL tendoscopy to harvest the FDL

tendon during repair of the posterior tibial tendon forstage II posterior tibial tendon insufficiency as previ-ously described.

Grade of Recommendation. The main indication for FDLtendoscopy is tenosynovitis.69 Given the lack ofevidence-based literature on FDL tendoscopy, it is notpossible to make a recommendation for or against thisintervention, and therefore we assigned this procedurea grade I recommendation.

DiscussionSince 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 ten-doscopy to other tendons of the foot and ankleincluding the tibialis anterior, Achilles, EHL, EDL, FHL,and FDL. In general, studies have reported good out-comes, and tendoscopy appears to be an effectivediagnostic and therapeutic procedure for a variety ofindications. Besides offering a superior cosmetic resultcompared with open procedures, tendoscopy has thepotential to minimize complications and shorten re-covery time. In the event that a tendon tear is found,tendoscopy can easily be converted to an open or mini-open repair if needed.The goal of this systematic review is to determine on

which tendons of the foot and ankle the use of ten-doscopy is supported by the current literature. Todate, only weak evidence (grade Cf) exists in supportof tendoscopy on the Achilles, FHL, and peronealtendons whereas insufficient evidence (grade I) existsto assign a grade of recommendation for the othertendons of the foot and ankle. Familiarity withendoscopic procedures may need to be considered inthe use of these recommendations because most ofthe studies were conducted by highly experiencedendoscopists.Perhaps one of the most important findings of this

review was the limited number of high-level studiescurrently available to support the use of tendoscopicintervention. Although only limited, low-level evidenceexists supporting the use of this procedure, we believethat it is important to clarify that the absence of a“strong recommendation” because of a paucity ofevidence-based literature in no way recommendsagainst the use of a procedure. Rather, weak recom-mendations should be used to call attention to the


need for original scientific articles of higher levels ofevidence.

LimitationsOne limitation of this study is that our search was

restricted to articles in the English language, andconsequently, it is possible that we may have missedgood-quality studies in other languages. Another limi-tation is that because of the relatively small body ofliterature currently available on tendoscopy, we wereunable to gather enough evidence to assign a grade ofrecommendation for or against intervention regardingeach of the common indications individually for eachtendon, and consequently, this may be an area of in-terest for future studies. Lastly, we must acknowledgethat high-level studies are often difficult to conduct inthe field of orthopaedics, which imposes limitations onthe quality of evidence available to be included in thisreview and consequently leads to the inability to makea strong recommendation for the use of tendoscopy.However, weak or fair recommendations because of apaucity of evidence in support of a procedure such asthis must not be confused in any way as a recom-mendation against using a procedure.

ConclusionsA comprehensive review of the literature on foot and

ankle tendoscopy has shown predominantly Level IVand V studies, with just 1 Level II study. On the basis ofthe current literature available, there is poor evidence(grade Cf) in support of Achilles, FHL, and peronealtendoscopy for the common indications. There is insuf-ficient evidence to make a recommendation (grade I)for or against tendoscopy on the tibialis posterior,tibialis anterior, FDL, EHL, and EDL. Although currentliterature suggests that tendoscopy is a safe and effec-tive procedure, original scientific articles of higherlevels of evidence are needed before a strongerrecommendation can be assigned.

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2014 Arthroscopy Journal

Although level of evidence is but one marticle, studies of the highest levels oanswers to clinical questions. The JoBoard, and the Editors are pleasedJournal Prize of $5,000 will again be aLevel I Evidence study. The 2014 prEditors and Associate Editors who will

published duri

69. Lui TH, Chow HT. Role of toe flexor tendoscopy inmanagement of an unusual cause of metatarsalgia. KneeSurg Sports Traumatol Arthrosc 2006;14:654-658.

70. OCEBM Levels of Evidence Working Group. The OxfordLevels of Evidence 2. Oxford Centre for Evidence-BasedMedicine. Available at: http://www.cebm.net/index.aspx?o¼5653. Accessed: March 6, 2014.

Prize for Level I Evidence

easure of the quality of a scientificf evidence are best able to provideurnal Board of Trustees, the AANAto announce that the Arthroscopywarded to the report of the bestize will be judged by the Journal’sconsider those Level I papersng the year.











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Foot and Ankle Tendoscopy: Evidence-Based Recommendations