Using Arthroscopic Techniques for Achilles Pathology

19 Pages·2017·1.6 MB·English

Using Arthroscopic
Techniques for Achilles
Pathology
Rebecca Cerrato, MDa, Paul Switaj, MDb
KEYWORDS
(cid:1)Arthroscopic (cid:1)Achilles (cid:1)ChronicAchillesrupture (cid:1)Tendinopathy
KEYPOINTS
(cid:1) Endoscopicallyassistedprocedureshavebeenestablishedtoprovidethesurgeonwith
minimallyinvasivetechniquestoaddresscommonAchillesconditions.
(cid:1) Modificationstosomeofthesetechniquesaswellasimprovementsininstrumentation
haveallowedtheseprocedurestoprovidesimilarclinicalresultstothetraditionalopen
surgerieswhilereducingwoundcomplicationsandacceleratingpatient’srecoveries.
(cid:1) Theavailableliteratureonthesetechniquesreportsconsistentlygoodoutcomeswithfew
complications,makingthemappealingforsurgeonstoadopt.
INTRODUCTION
Endoscopicproceduresaroundthefootandankleprovidethesurgeonwiththetech-
niquestotreatavarietyofpathologywithaminimallyinvasiveapproach.Theseless-
invasive approaches can diminish scar tissue and result in less perioperative pain,
fewerwoundcomplications,andquickerrecovery.
SpecialfocushasbeenplacedontheAchillestendoncomplex,wherethesetech-
niqueshavebeenusedtoaddressacuteandchronicruptures,equinuscontractures,
andbothinsertionalandnoninsertionaltendinopathies.Althoughhigh-levelevidence-
basedliteratureforAchillestendoscopyissomewhatlacking,theliteratureavailable
does report consistently good outcomes with few complications, making them
appealingforsurgeonstoadopt.
ANATOMY
Knowledgeofthelocalanatomyismandatoryforreducingcomplicationswhensur-
gicallyaddressingpathologyoftheAchillestendon.TheAchillestendonisthelongest
Dr R. Cerrato Paid consultant for Wright Medical Technology, Depuy Synthes. Dr P. Switaj
Nothingtodisclose.
a MercyMedicalCenter,TheInstituteforFootandAnkleReconstruction,301St.PaulPlace,
Baltimore, MD 21202, USA; b Orthovirginia, 1850 Town Center Parkway, Suite 400, Reston,
VA20190,USA
E-mailaddress:[email protected]
FootAnkleClinNAm22(2017)781–799
http://dx.doi.org/10.1016/j.fcl.2017.07.007 foot.theclinics.com
1083-7515/17/ª2017ElsevierInc.Allrightsreserved.
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782 Cerrato&Switaj
andmostpowerfultendoninthehumanbody,measuring12cmto15cminlength
andupto2.5cmindiameter.1Itistheconfluenceofthesoleusandgastrocnemius
muscleaponeuroses,and,rarely,theplantaris.2Thesemusclesarebothinnervated
bythetibialnerve,andtogetherformthegastrocnemius-soleuscomplex,ortriceps
surae.
Thesoleusliesdeeptothegastrocnemiusandsuperficialtothemusclesofthedeep
posteriorcompartment.Thegastrocnemiusmuscleoriginatesoffthedistalfemurand
crossestheknee,ankle,andsubtalarjointbeforeinsertingbroadlyontothecalcaneus
approximately 13 mm inferior to the most proximal margin of the tuberosity.3 Thus,
when the knee is extended, the gastrocnemius limits dorsiflexion, whereas when
the knee is flexed, the entire triceps surae can limit dorsiflexion. Prior investigators
havedividedthesurgicalanatomyinto5levels.Level5consistsofproximalinsertions
of the gastrocnemius. Level 4 comprises the muscle bellies of the gastrocnemius.
Level3beginswherethemusclebelliesofthegastrocnemiuscoalesceandfinishes
where the aponeuroses of the soleus and gastrocnemius combine. Level 2 starts in
the common aponeurotic tendon of the soleus and gastrocnemius and finishes at
thedistalendofthesoleusmuscle.Level1consistsoftheAchillestendon.2,4
As the tendon courses distally, the fibers rotate, giving it greater mechanical
resistance, but creating a poorly vascularized area 2 to 6 cm proximal to its inser-
tion.5,6 The posterior tibial artery is the major blood supply to the proximal and
distal sections of the tendon, whereas the peroneal artery has fewer vessels and
supplies the midsection.7 This vascular anatomy may predispose the Achilles to
degeneration in this area. In addition, the Achilles tendon does not have a true
tendon sheath, but is surrounded by paratenon. This paratenon is separated into
3layers:theinnervisceral,themesotendon,andouterparietallayers.Theretrocal-
caneal bursa allows for proper gliding of the Achilles tendon and lies between the
tendon and the calcaneus at its insertion point. Both the paratenon and the retro-
calcaneal bursa can be sites of ongoing inflammation that can cause substantial
morbidity to patients.
BIOMECHANICS
Contraction of the gastrocnemius-soleus complex produces plantarflexion of the
ankle combined with adduction and internal rotation of the foot.2 The flexion force
of the gastrocnemius is greater when the knee joint is fully extended, because it
crosses the knee joint. The soleus delivers more than twice the plantarflexion force
ofthegastrocnemius,whosemedialheadprovidesmostofitspower,withthelateral
headonlyaccountingfor29%ofthepower.8Overall,theAchillestendonsustainsup
to12.5timesofbodyweightduringcertainrunningactivities.3
ACUTEPATHOLOGY
AchillesRupture
Ruptures of the Achilles tendon represent one of the most common sport injuries.
Although a thorough discussion of the surgical versus nonsurgical treatment is
beyond the scope of this review article, investigators have cited increased wound
complications,9 significant risk of infection, and scar formation at the site of
repair.10 Because of these risks, other minimally invasive approaches have been
developed.MaandGriffith9firstintroducedthisideain1977,whichhasbeenmodi-
fied throughout the years.11,12 Unfortunately, some of the earlier reports on these
techniques had reported a higher complication rate, including increased rate of
rerupture and increased sural nerve injuries.13 These earlier percutaneous
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ArthroscopicTechniquesforAchillesPathology 783
techniquesalsodonotallowforvisualevaluationoftherepairsiteortendonqual-
ity,whichmay resultinpoorapproximationof the tendonends. Newertechnology
allowsthesurgeontoviewtherepairandplaceajigwithintheparatenon,allowing
suture passage without capturing the sural nerve.11 To address earlier concerns
withthepercutaneoustechniques,endoscopic-assistedmethodshavebeenintro-
duced.Thesemethodsallowthesurgeontoevaluatethetendonquality,adequate
mobilize the stumps, ensure accurate needle passage,and confirm approximation
of the tendon ends.
Technique
Thepatientisplacedinaproneposition,andapneumaticthightourniquetisplaced.
Therestingplantarflexionofcontralateralextremityisexaminedwiththekneeflexed.
Intheauthor’sexperience,theytensiontheiracuteAchillesrupturesinmaximumplan-
tarflexion and have not experienced any instances of “overtightening.” The rupture
gapisoutlined.Halasiandcolleagues14describedamodifiedMa-Griffithtechnique,
with6skinincisions,2scopeportals,andadoublesutureconstruct(Fig.1).Thetech-
nique uses no. 2 Vicryl (other investigators have described variations to this repair
using nonabsorbable suture, such as EthiBond). Six incisions are marked, 2 above
therupturebothmedialandlateralattheproximalstump,2attherupturegap,and
2 below the rupture both medial and lateral at the distal stump. The 2 incisions at
thetendongapcanbeusedfortheendoscopicportals.Thesutureispassedusing
Fig.1. Ma-Griffithtechniquewith6incisions.
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784 Cerrato&Switaj
astraightneedle.Toprotectthesuralnerve,theinvestigatorsusedasmalldrillsleeve
asasofttissueprotector.Thesofttissueprotectorisplaceddirectlyontheparatenon
through the skin incisions. The same 6 incisions can be used to place both suture
strands(Fig.2).Theendoscopicportalsarecreatedatthe2centralincisionsdirectly
attherupturegap.A4.0-mm30(cid:3)or2.7-mm30(cid:3)scopeisintroducedfirstlaterally,and
thesecondportalincisioniscreatedatthegap.Thetearisinspected;hematomais
evacuated,andifnecessary,thetendonendsdebrided.Thesurgeryshouldbeper-
formedwithlow-pressuregravityinflowtopreventexcessivefluidextravasationand
compartmentsyndrome.Tendonendreapproximationcanbevisualizedwithsuture
tensioning.Oncethedoublesutureconstructiscompleted,theankleisheldinplan-
tarflexionandthesuturestied.
Postoperativecare
Postoperative protocol included 3 weeks of non-weight-bearing in an equinus short
legcast,followedbyweight-bearinginawalkingbracewithaliftedheelforanaddi-
tional5weeksandfunctionalrehabilitationinitiatedaswell.14
CLINICALRESULTS
Turgutandcolleagues15firstreportedendoscopic-assistedtechniquesin2002.Since
then, other studies have demonstrated satisfactory results with differing suture
Fig. 2. Percutaneous Achilles rupture repair. Halasi modification with double suture
constructincludedthe3and4markedincisionsasthelocationfortheendoscopicportals.
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ArthroscopicTechniquesforAchillesPathology 785
techniques.10,12,14–19 There has been one level II study by Halasi and colleagues14
comparingagroupofpatientsundergoingpercutaneousAchillesrepairwiththeuse
of endoscopy to a group undergoing the same procedure without endoscopy. Both
groups yielded similar clinical results, including comparable strength, calf atrophy,
and return to activities. The endoscopy group had lower, but nonsignificant, rate of
rerupture(1.75%vs5.7%),whichthegroupattributedtoimprovedvisualizationand
controlofthetendonsends(Table1).
CHRONICPATHOLOGY
EquinusContracture
Contractureofthegastrocnemius-soleuscomplexhasbeenassociatedwithamulti-
tude of foot and ankle pathologies, both as the root cause and in conjunction with
otherdeformities.20,21Anequinuscontractureisalimitationinankledorsiflexionnot
causedbybonyanklepathology.Itmaybesecondarytoaglobalcontractureofthe
gastrocnemius-soleus complex or isolated to the gastrocnemius muscle alone.
Because the gastrocnemius crosses the knee joint, the contributions of both units
can be differentiated on physical examination with the Silfverskiold test. The test is
considered positive when, with the subtalar joint held in a neutral position, there is
limited dorsiflexion with the knee extended that improves with the knee flexed. The
most commonly used criterion to indicate an isolated gastrocnemius contracture is
less than 10(cid:3) of dorsiflexion with the knee extended, which improves with knee
flexion.20
Isolatedcontracturesofthegastrocnemiushavelongbeentreatedbyopentech-
niques,whereasthetendo-Achilleslengtheningisoftenaddressedinapercutaneous
manner. These techniques sometimes led to delayed wound healing, sural nerve
irritation, undesirable scar formation, and tethering of the skin to the crural fascia.
Thedescribedendoscopictechniquesarefocusedonaddressingthegastrocnemius
contracture.
Technique
Endoscopicgastrocnemiusrecessionwasfirstdescribedinacadavericmodelin2003
byTashjianandcolleagues.22
Thepatientisplacedeitherproneorsupineontheoperatingroomtablewithathigh
tourniquet.Thepositionismostoftendictatedbyotherconcomitantproceduresbeing
performed.
Endoscopy,whichcanbeperformedusing1or2entrypoints,shouldensurethat
thecannulaisplacedbetweenthesuralfasciaandtheaponeurosesoftheinsertion
ofthegastrocnemiustoenablerecessionofthefascia.Analternativetechniquehas
been described in which the intramuscular portion of the aponeuroses is released
instead.23
Medial portal placement has been anatomically detailed in many articles and is
performedattheanatomiclevel3,wherethemusclebelliesofthegastrocnemiuscoa-
lesce.Thisplacementiscrucialtoasuccessful,complication-freeoperationandhas
beendescribedas2cmdistaltotheindentofthemusculotendinousjunction,22,2416
to17cmproximaltothedistaltipofthemedialmalleolus,25justdistaltothejunctionof
themiddleanddistalthirdsoftheleg,26and4fingerbreadthsproximaltotheflareof
themedialmalleolus.27
Themedialportalisestablished,andacurvedhemostatisusedtopuncturethe
curalfasciaoverlyingthesuperficialposteriorcompartment.Theblunttrocarwitha
slotted cannula is introduced and advanced laterally. The lateral portal is estab-
lished in an inside-out technique. The trochar is removed, leaving the slotted
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ArthroscopicTechniquesforAchillesPathology 787
cannula. A 4.0-mm 30(cid:3) arthroscope is inserted medially and the gastrocnemius
aponeurosis is inspected. The lens is rotated 180(cid:3), and the sural nerve and lesser
saphenous veins are visualized. It is important to identify that the sural nerve is
posterior to the cannula; otherwise, it can be inadvertently cut. The ankle is held
in maximum dorsiflexion to tension the Achilles. A retrograde hook blade is intro-
duced into the slotted cannula laterally. The gastrocnemius aponeurosis is
released from medial to lateral. The ankle is passively dorsiflexed to confirm
adequate release.
Postoperativecare
Isolated gastrocnemius recessions can be allowed weight-bearing immediately in a
walking boot, although some investigators describe a 2-week period in a non-
weight-bearingsplint.A90(cid:3)nightsplintisprescribed,andankledorsiflexionexercises
areencouraged.Typically,patientsareweanedoutofthebootat4weeks,andphys-
ical therapy is initiated. For patients with concomitant procedures, splinting and
weight-bearingrestrictionsweredirectedbythose.
CLINICALRESULTS
Overall, good outcomes have been described using both 1- and 2-portal tech-
niques. The first clinical series was described in 2004 by Saxena and Widtfeldt28
and demonstrated a mean increase in dorsiflexion of 12.6(cid:3), but with 3 out of 18
patients experiencing sural dysesthesias. All except one of the patients underwent
associated procedures at the time of gastrocnemius recession. Subsequent series
have consistently demonstrated significant increases in dorsiflexion as well as
improved outcome measures.25–27,29–34 The largest series to date from Phisitkul
and colleagues33 demonstrated mean ankle dorsiflexion improvement from
(cid:4)0.8 (cid:5) 5.4(cid:3) preoperatively to 11.0 (cid:5) 6.6(cid:3) at an average of 13 months postopera-
tively. Postoperative weakness in plantarflexion and sural nerve dysesthesias
occurred in 3.1% and 3.4%, respectively, without any wound complications or
Achilles tendon rupture (Table 2).
Onestudyperformedin23diabeticpatientsusingauniportaltechniqueshowed3
conversions to open procedures, 3 delayed wound healing, and 3 undercorrections
(although this was not objectively defined) without any nerve injuries.35 The most
recent study by Thevendran and colleagues34 on 54 feet demonstrated 3 cases of
unsatisfactory scar, 3 cases of sural nerve dysesthesia, and 3 cases of subjective
plantar flexion weakness, while Schroeder32 showed a 1.67% incidence of persis-
tence sural nerve injury and no wound healing or scar problems. Phisitkul and col-
leagues33 reported the largest series to date, noting a 3.1% incidence of weakness
of ankle plantarflexion and 3.4% incidence of sural nerve dysesthesia without any
woundcomplicationsin320patients.
Endoscopy provides a better cosmetic outcome, although it carries a considerable
risk of sural nerve injury. The complication rate can reach 22.2%. The importance of
theassociationbetweenthesuralnerveandtheendoscopicentrypointledtothestudy
byTashjianandcolleagues,22whofoundthedistancebetweenthesuralnerveandthe
lateralborderofthegastrocnemiusandsoleustobe12mm(range,7–17mm).Thisshort
distancejustifiestheuseofamedialentrypointinthistypeofendoscopicprocedure.
NoninsertionalAchillesTendinopathy
NoninsertionalAchillesdisorderstypicallyoccur4cmto6cmproximaltoitsinsertion
andcomprisemidportiontendinosisaswellasacuteandchronicparatendinopathy.It
is important to correctly diagnosis peritendinitis. On physical examination, the pain
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al use only. No othous User (n/a) at N TDrieDvoinmoeenticaol,e26t2a0l,02952005 2381 MMoesiamtabdanplitefiriiseonttdoivcceraObemleal&yescMensoit1gns(8nct8a(cid:3)oifcpritecaeastdnie)tnts 1s1upcoenrfviecirasliownotuonodpiennfection, 2ipsnelcacoocrenrmedceitnnlctoiscniaeotcnieosnssitoatfinpgortal Switaj
er uses withouorthwestern U Saxenaetal,302007 54 (cid:4)8(cid:3)/7(cid:3) 1hotdeevynmesetrailsnetthgone,mgs6taihal,eas1nteinragl,f6oosktin Moresctopnasttireuncttsivweitphroacdeddiutiroensal
t permissionniversity - E GRor2au0dk1yi0s&&KSeclhlyw,3e1in2b01e0rger,35 2430 Meanincrease15(cid:3) 3Noduensludareyaerlcdnoehrrreevaceltiicnoognm,s,3p3lications FPoaptciuaetsnieetdsnot18nallyylhooalnddcaodnmiadbpyeliotceuastnigoenrs;
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017. Elsevier InlinicalKey.com SPchhisriotkeudleer,t32a2l,033122014 63044 (cid:4)(cid:4)20V..98A(cid:3)(cid:3)S-//FA11s21c..o80r(cid:3)(cid:3)e/ssignificant 33.2nre%esrovwelveecaodkm)n,pe1lsiwscaoetfaioknness(s2 NopedrifcfuetraennecoeubseTtAwLeen
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ArthroscopicTechniquesforAchillesPathology 789
remainsinaspecificlocationduringankledorsiflexionandplantarflexionwithperiten-
dinitis,whilethepainmoveswiththetendonintendinosis.
Initial conservative treatment incorporating an eccentric therapy program is often
successful, but can still fail to provide adequate symptom relief in almost one-third
of patients.36 A variety of surgical procedures have been described, including open
debridement with or without stripping of the paratenon, percutaneous longitudinal
tenotomy, plantaris release, and isolated gastrocnemius recession. These open
approaches have been associated with wound complications, prolonged recovery,
and scarring.37 Thus, endoscopic techniques have been developed to achieve the
goalsofopensurgery,excisingareasofdegeneration,adhesions,andthickenedpar-
atenon,andstimulatingahealingresponse,whiledecreasingthemorbidity.
Technique
The patient is positioned prone on the operating table with a thigh tourniquet. Their
feetarepositionedoffthetable,allowingankledorsiflexionandplantarflexionduring
theprocedure.
ThebordersoftheAchillestendonandthesuperioraspectofthecalcanealtuberos-
ityaremarkedoutwithasurgicalpen.Severalvariationsinportalplacementhavebeen
described.38,39Typically,2portalsareused.Maquirriain38describedusingaproximal
portal10cmabovetheAchillesinsertionofthecalcaneusatthemidlineoftheAchilles.
Thedistalportalisplacedagainmidline,atthedistallocation,nottodisrupttheconflu-
enceoftheAchillesandtheskinasitnearsattachment.Thermannandcolleagues39
describedplacingportalsatthemedialedgeoftheAchilles.Otherhavedescribeda
similar2-portaltechniqueplacedlateraltotheAchillesborder,placedapproximately
2to4cmproximalanddistaltothepathologicthickeningontheAchilles.
A4.0-or2.7-mm30(cid:3) arthroscopeisintroducedintotheproximalportal,andadry
tendoninspectionisperformed.Gravityinflowisthenusedforinsufflation.Thedistal
portalisestablishedwiththeaidofdirectvisualizationusingthescope.Incasesofperi-
tendinitis,theperitendonisreleased,payingparticularattentiontoreleasingtheante-
rioraspectofthetendon.Incaseswithtendinosis,followingdebridement,longitudinal
incisionsaremadeinthediseasedsegmentofthetendonusingaretrogradeblade.
Postoperativecare
Forpatientswithaperitendonreleaseanddebridementonly,mostinvestigatorsallow
immediateweight-bearinginawalkerboot.Activeankledorsiflexionandplantarflex-
ion are encouraged. Eccentric stretching exercises are initiated after 2 weeks. For
patientsthatunderwenttenotomies,theyareplacedinawalkerbootandkeptnon-
weight-bearingforupto2weeks.
CLINICALRESULTS
Maquirriain38 first described the use of endoscopic treatment of chronic Achilles
tendinopathy in 1998 in a cadaveric model. Maquirriain followed his cadaveric
research with a small clinic series demonstrating satisfactory results.40 Additional
investigators have published small series with satisfactory results and no reported
complications.15,39,41–44 Maquirriain45 more recently reviewed his results on 27 pa-
tients,reportingimprovedoutcomesand2complications(Table3).
InsertionalAchillesTendinopathy
Thesedisordersincludepathologywithinthefirst2cmproximaltotheinsertiontothe
calcaneus.AlthoughthesedisordersincludeinsertionalAchillestendinosisandsuper-
ficialcalcanealbursitis,endoscopictreatmenthasfocusedontreatingretrocalcaneal
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o other use) at Northw Maquirriainetal,402002 7 2pteenridteinnodsiins,it1is,ch4rmonidicppoartritoianltear Imfproromvemmeeannt3in9Atochmileleasnsc8o9re 1msPpoionstnootrpahneereamotuaivtseormeMsaoRlIwuitnitiohtnen.dinosis
s without permissionestern University - E MVeograageteatla,4l2,4210200803 48 2Mpirmduopipsdottpturrotraieroutnimotnaetnticednainddoihnseoisssioiwsnitsh,o2ut A4–llfr46oepmwslaluooktliwtersrne-ewutttupsuitr,rphnn1a0Nittno0oe-%lfdserpaneeoielxsrycctaaieatnllcellgteainsvatitcttieivsi,ty NNoorapecaccttootuiivmmerinntppietelliidswccaatittotiihoopnnirmssio;prarloslpvpoearmttiieennngtts
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