The first tendoscopy procedure occurred in 1995. However, this minimally invasive yet technically challenging approach to addressing various foot and ankle pathologies has not yet become commonplace. Now, orthopedic surgeons at Brigham and Women’s Hospital are embracing the technique for its patient-centered benefits.
One of the Brigham orthopedic surgeons leading the trend is Elizabeth Martin, MD, ScM, of the Foot and Ankle Center. Dr. Martin delivered an instructional course lecture on foot and ankle tendoscopy at the 2022 American Academy of Orthopaedic Surgeons Annual Meeting. She says the procedure is difficult to perform and can take more time than large-open surgery.
“The working space is tight due to the volume of the tendon sheath and the angles at which tendons travel,” she says. “Knowing exactly where to make the minimal incision and being deliberate about instrumentation and the operative setup are crucial. The learning curve can be steep, but it’s really no different than other scope-based procedures.”
Dr. Martin says the Brigham has been an ideal setting in which to hone her tendoscopy technique, allowing her to offer the type of innovative surgical services patients expect when they come to the institution for care.
“As one of the leading academic medical institutions in the country, we benefit from a wealth of smart minds dedicated to innovation,” she says. “Our residents, fellows, partners, and faculty are truly committed to evolving techniques like tendoscopy and teaching the next generation of surgeons.”
Reduction in Soft Tissue Dissection
The biggest benefit of tendoscopy over traditional, open-incision surgery is that it requires less soft tissue dissection. By not disrupting the soft tissue, surgeons can see tendons in their native environment and observe how they move and glide as part of the surgery. The scope’s camera magnification, meanwhile, makes it easier for surgeons to see subtle pathology.
According to Dr. Martin, the reduction in soft tissue disruption also can lead to less scarring, faster wound healing, and quicker mobilization. In addition, because there is no large incision to heal, patients don’t have as much incision-related pain. Moreover, the need for postoperative casting or splinting is eliminated.
“All of these advantages can lead to a quicker recovery and return the range of motion,” she says.
Is Tendoscopy Right for Every Patient?
The decision to pursue tendoscopy is based on several factors. Foremost is the extent of the injury.
“I follow the general rule of thumb that if a tendon is more than 50% torn, tendon debridement or repair may not be successful,” she says. “In those cases, we would pursue other approaches, such as supplementing the injured tendon with another tendon. In addition, it may not be possible to perform suture repair with tendoscopy due to the small working space.”
Dr. Martin says preoperative MRI studies can help determine the extent of tearing involved. However, she added, their ability to do so can be limited in cases of peroneal injury, where tendoscopy is used the most. In some cases, surgeons may have to pivot mid-procedure and convert to a mini-open procedure if needed.
Patients with significant scar tissue from previous surgeries also are not good candidates for the procedure, according to Dr. Martin, because scarring further reduces the amount of space needed to treat the injured tendon. She recommends doing tendoscopy first if concomitant procedures are involved. This will help keep tendon sheaths intact for better fluid management. Moreover, tissue edema can be relieved by subsequent incisions.
For surgeons considering adding tendoscopy to their services, Dr. Martin suggests gaining facility with arthroscopic and endoscopic techniques before attempting it. “If you are an arthroscopist, you can become a tendoscopist,” she says.