Positioning

The patient is in prone position. A tourniquet is placed around the thigh of the affected leg, and a bolster is placed under the foot. Because the surgeon needs to be able to obtain full plantar and dorsiflexion, the foot is placed right over the end of the table.

Instrumentation

We mostly use a 2.7 mm arthroscope for endoscopy of a combined tendinopathy and paratendinopathy. This small- diameter short arthroscope yields an excellent picture comparable to the standard 4 mm arthroscope; however, it cannot deliver the same amount of irrigation fluid per time as the 4 mm sheath. This is important in procedures in which a large diameter shaver is used (e.g. in endoscopic calcaneoplasty). When a 4 mm arthroscope is used, gravity inflow of irrigation fluid is usually sufficient. A pressurized bag or pump device sometimes is used with the 2.7 mm arthroscope.

Portals

Overview of the posterior ankle. Achilles tendon and calcaneus are marked.

The distal portal is located on the lateral border of the Achilles tendon, 2-3 cm distal to the pathologic nodule. The proximal portal is located medial to the border of the Achilles tendon, 2-4 cm above the nodule. When the portals are placed this way, it is usually possible to visualize and work around the complete surface of the tendon, over a length of approximately 10 cm.

The distal portal is made first with a vertical stab incision just lateral to the Achilles tendon.

With a mosquito clamp the subcutaneous layers are spread.

A 4.5 mm blunt trocar is introduced in this instructional session. However, we normally use a 2.7 mm scope (3.2 mm trocar) for this procedure.

With the trocar kept onto the tendon, the layer between the Achilles tendon and peritendineum is locatized.

With the blunt trocar the area around the Achilles tendon is released: Especially the area anterior to the tendon!

The 4.0 mm scope is introduced (normally the 2.7 mm scope) and the tendon and its surroundings can be inspected.

The proximal portal is made with a spinal needle under direct vision, 2-4 cm above the nodule, on the medial border of the Achilles tendon.

With a mosquito clamp the subcutaneous layers are spread.

Through the proximal portal the desired instruments (probe) can be introduced to debride the area and to identify and release the plantaris tendon.

The scope can be moved all around the tendon.

Through the proximal portal the desired instruments (2.7 mm shaver) can be introduced to debride the area and to identify and release the plantaris tendon.