Abstract
The tibialis anterior tendon bursa is located between the tibialis anterior tendon and the medial cuneiform bone and close to the tendon insertion. Bursitis can occur as a result of excessive local friction, infection, arthritides, or direct trauma. Endoscopic resection of the bursa is indicated in case of symptomatic bursitis that is not responding to conservative treatment or infection is suspected. It is contraindicated if there is skin infection at the portal sites. The purpose of this technical note is to describe a minimally invasive approach of endoscopic resection of the tibialis anterior tendon bursa through anterior tibial tendoscopy.
The tibialis anterior tendon (TAT) is the most medially located tendon of the foot and ankle. It begins at the junction between the lower and middle thirds of the tibia and courses towards the medial border of the foot, inserting vertically on the first metatarsal base and the medial cuneiform bone.1 Lesions of the TAT, although not frequently reported in the literature, are similar to those reported in other tendons. Pathology of the TAT can be spontaneous, related to trauma, or associated with arthropathy or more generalized conditions like diabetes.1 It includes distal tendinopathy, tenosynovitis, tendon tear, and bursitis.1, 2, 3, 4, 5 The TAT bursa is the main synovial bursa in association with the insertion of the TAT and is located between the tendon and the medial cuneometatarsal joint and the medial cuneiform.1 It is a subtendinous one deep to the extrasynovial portion of the TAT distally at the level of the medial cuneiform bone.1 Bursitis can occur as a result of excessive local friction, infection, arthritides (fluid extends into the bursa from the adjacent joint), or direct trauma.1 Resection of the inflamed and distended bursa is indicated if it is symptomatic and unresponsive to conservative treatment, for example, local steroid injection. Operation is also indicated if infection is suspected as biopsy can be performed together with resection of the bursa. Tendoscopy of the TAT has been reported to treat tenosynovitis of the tendon. It has the advantage of minimal invasiveness and preservation of the extensor retinacula.2, 3, 6 Anterior tibial tendoscopy has also been reported as part of the technique of endoscopic reconstruction of the tibialis posterior tendon in patients with stage 2 posterior tibial tendon deficiency.7 This technical note reports the minimally invasive approach of endoscopic resection of the TAT bursa through anterior tibial tendoscopy.
Technique
Preoperative Planning and Patient Positioning
Clinically, bursitis mimics several peripheral joint and muscle abnormalities.1 Preoperative magnetic resonance imaging is important for preoperative planning. The location and extent of the ganglion and relationship of the ganglion with the TAT and the adjacent joint can be studied (Fig 1). Any tenosynovitis or tendinosis of the TAT or degeneration or synovitis or the adjacent joint should be noted. The location of the ganglion should correspond to the painful site.
Fig 1.
Endoscopic resection of the tibialis anterior tendon (TAT) bursa of the right foot. Preoperative magnetic resonance imaging shows the distended bursa (arrowhead) between the TAT and the medial cuneiform bone (MC). (A) Coronal view; (B) transverse view. (AbH, abductor hallucis muscle.)
The patient is in supine position with the legs spread. The TAT at the ankle level is outlined. A thigh tourniquet is applied to provide a bloodless operative field. A 2.7 mm 30° arthroscope (Henke Sass Wolf GmbH, Germany) is used for this procedure.
Portal Placement
The proximal portal is located at the lateral side of the TAT and 5 cm above the ankle joint level. The proximal portal should be made more close to the ankle joint line if the ankle cannot be plantarflexed adequately. The distal portal is located at the lateral side of the tendon and just above the medial cuneiform; 3 to 4 mm skin incisions are made at the portal sites, and the subcutaneous tissue is bluntly dissected to the tendon sheath by a hemostat. The synovial tendon sheath of the tibialis anterior extends from above the proximal arm of the inferior extensor retinaculum to the level of the talonavicular joint.1 The tendon sheath is therefore encountered at the proximal portal, which can be either incised open or perforated by the tip of the hemostat. There is no tendon sheath at the distal portal, and the blunt dissection can expose the TAT.
Endoscopic Ganglionectomy
The proximal portal is the viewing portal, and the arthroscope can be advanced distally along the TAT to the cuneiform level. An arthroscopic shaver (Dyonics, Smith and Nephew, Andover, MA) is inserted via the distal portal (Fig 2). The TAT is closely abutted to the medial cuneiform before it inserts to the plantar side of the first metatarsal and medial cuneiform. The shaver can be inserted in the space between the bone and the tendon, but the working space is limited especially when it is filled up by the distended bursa. Bursectomy cannot be done under clear arthroscopic visualization (Fig 3). This will increase the risk of injury to the TAT. On the other hand, the shaver can be placed at the medial side of the TAT and the tendon can be pushed a bit dorsally to expose the ganglion. Resection of the ganglion can be performed with the shaver under arthroscopic guide until the abductor hallucis muscle is exposed (Fig 4).
Fig 2.
Endoscopic resection of the tibialis anterior tendon (TAT) bursa of the right foot. (A) The proximal portal (PP) is located at the lateral side of the TAT and 5 cm above the ankle joint level (An). The distal portal (DP) is located at the lateral side of the tendon and just above the medial cuneiform. (B) Anterior tibial tendoscopy is performed with the proximal portal as the viewing portal and the distal portal as the working portal.
Fig 3.
Endoscopic resection of the tibialis anterior tendon (TAT) bursa of the right foot. Proximal portal is the viewing portal. The working space between the TAT and the medial cuneiform bone (MC) is limited. (AS, arthroscopic shaver.)
Fig 4.
Endoscopic resection of the tibialis anterior tendon (TAT) bursa of the right foot. Proximal portal is the viewing portal. (A) The bursa can be visualized plantar to the TAT as the tendon is lifted dorsally. (B) The abductor hallucis muscle (AbH) is exposed after bursectomy.
Examination of the TAT
After the ganglionectomy, the arthroscope can be switched to the distal portal and TAT, and its tendon sheath can be examined again for any tendinopathy or tenosynovitis (Fig 5, Video 1). Endoscopic synovectomy can be performed if tenosynovitis is present.
Fig 5.
Endoscopic resection of the tibialis anterior tendon (TAT) bursa of the right foot. (A) Distal portal is the viewing portal, and proximal portal is the working portal. (B) Tendoscopic view shows TAT and its tendon sheath (TS).
Discussion
Endoscopic resection of the TAT bursa is indicated in case of symptomatic bursitis that is not responding to conservative treatment or infection is suspected. It is contraindicated if there is skin infection at the portal sites. There are 2 endoscopic approaches for management of cystic lesions of the foot and ankle: endoscopic resection or internal drainage of the adjacent joint or tendon sheath.8 Internal drainage is not feasible as the bursa is far distal to the synovial tendon sheath, which ends at the level of talonavicular joint.1 Moreover, drainage to the medial cuneometatarsal joint is also not practical as the bursa is not adjacent to the joint in the illustrated case. Endoscopic bursectomy with the shaver between the TAT and medial cuneiform bone can be risky to the distal tendon and its insertion. Passive ankle dorsiflexion and foot inversion may relax the TAT and increase the working space between the TAT and medial cuneiform bone. However, this blocks the instrumentation via the proximal portal. This may be partly solved by placing the proximal portal close to the ankle joint. Resection of the bursa starting distal to the TAT allows better visualization and preservation of the tendon. Sometimes bursitis can associate with distal tendinopathy or tear of the distal part of the TAT. Endoscopic partial detachment of the TAT insertion is needed for adequate debridement through the distal portal. The tendon can be reattached and tenodesed to the cuneiform bone by means of suture anchors. As seen in patients with distal tendinopathy or partial tear of the TAT, the most commonly affected band is the insertion at the medial cuneiform bone (Table 1).1
Table 1.
Pearls and Pitfalls of Endoscopic Resection of the Tibialis Anterior Tendon Bursa
| Pearls | Pitfalls |
|---|---|
| 1. The bursa can be exposed plantar to the tendon after the tendon is lifted dorsally. | 1. The working space between the tibialis anterior tendon and the medial cuneiform bone is limited. |
| 2. Endoscopic resection proves to work more effectively than internal drainage. | 2. The procedure is contraindicated if there is infection at the portal sites. |
| 3. The proximal portal needs to be placed close to the ankle joint if the ankle plantarflexion is limited. | |
| 4. The tendon insertion can be partially detached, debrided, and reattached if there is associated distal tendinopathy. |
The advantages of this endoscopic technique include minimal soft tissue dissection, small incisions, better cosmesis, and examination of the entire TAT and its tendon sheath. The potential risks of this technique include injury to the TAT and its insertion and injury to the branches of long saphenous vein, the saphenous nerve, and the deep peroneal nerve (Table 2).
Table 2.
Advantages and Risks of Endoscopic Resection of the Tibialis Anterior Tendon Bursa
| Advantages | Risks |
|---|---|
| 1. Better cosmesis | 1. Injury to the tibialis anterior tendon |
| 2. Small incisions | 2. Injury to the branches of long saphenous vein |
| 3. Minimal soft tissue dissection | 3. Injury to the saphenous nerve |
| 4. Can examine the tibialis anterior tendon and its tendon sheath for any associated pathologies. | 4. Injury to the deep peroneal nerve |
Footnotes
The author reports that he has no conflicts of interest in the authorship and publication of this article.
Supplementary Data
Endoscopic resection of the tibialis anterior tendon (TAT) bursa of the right foot. Anterior tibial tendoscopy is performed through the proximal and distal portals. The proximal portal is the viewing portal, and the distal portal is the working portal. The working space between the TAT and the medial cuneiform bone is limited. The bursa is exposed plantar to the TAT as the tendon is slightly elevated dorsally. Bursectomy is performed, and the abductor hallucis muscle is exposed. The arthroscope is switched to the distal portal, and the TAT and its tendon sheath are examined.
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Associated Data
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Supplementary Materials
Endoscopic resection of the tibialis anterior tendon (TAT) bursa of the right foot. Anterior tibial tendoscopy is performed through the proximal and distal portals. The proximal portal is the viewing portal, and the distal portal is the working portal. The working space between the TAT and the medial cuneiform bone is limited. The bursa is exposed plantar to the TAT as the tendon is slightly elevated dorsally. Bursectomy is performed, and the abductor hallucis muscle is exposed. The arthroscope is switched to the distal portal, and the TAT and its tendon sheath are examined.