Nonoperative treatment of an os peroneum fracture in a high-level athlete: a case report

Anthropometric Analysis of Cuboid Bones in a South Indian Population

Purpose Cuboid bone and its fibromuscular supports maintain the lateral longitudinal arch in weight transmission during different gait cycle phases. Morphometry of the cuboid bone is essential for designing a cuboid prosthesis for foot reconstruction and establishing an individual's biological profile. The present study aims to assess the morphology and morphometry of the cuboid bone. Materials and methods The study used 103 cuboid bones (right 50, left 53) of unknown sex. Different shapes of cuboid articular facets were observed, and the morphometric parameters such as length, breadth, and height of cuboid, and the dimensions of articular facets in cuboid (calcaneal facet, fourth and fifth metatarsal facets, ecto-cuneiform facet, navicular facet, and facet for os peroneum) were analyzed. Results The mean length, breadth, and height of the cuboid bone were 33.69 ± 2.61 mm, 25.43 ± 2.87 mm, and 23.03 ± 2.43 mm, respectively. The mean transverse and vertical diameters were 23.22 ± 2.4 mm and 15.97 ± 1.85 mm, respectively. Facet for os peroneum was observed in 74.76% and for navicular bone in 26.2%. The mean transverse and vertical diameters were 7.16 ± 2.08 and 6.78 ± 1.78 mm, respectively. The depth of the peroneal groove was 4.30 ± 1.11 mm. Conclusion The morphometric data from the present study could assist in preoperative planning and designing of prostheses for foot reconstruction, and in establishing the biological profile of an individual, which can help the anthropologists in identifying the unknown remains.

Beyond the obvious: Exploring Os Tibiale Externum and Os Peroneum in Foot and Ankle Pain - A Case Series

Introduction

Accessory ossicles are well-corticated bony structures found close to bones or a joint. They may be unilateral or bilateral. The os tibiale externum is also known as accessory navicular bone, os naviculare secundarium, accessory (tarsal) scaphoid, or prehallux. It is found within the tibialis posterior tendon near its insertion on the navicular bone. The os peroneum is a small sesamoid bone located within the peroneus longus tendon, adjacent to the cuboid. We present a case series of five patients with accessory ossicles of the foot to demonstrate pitfalls in the diagnosis of foot and ankle pain.

Case Report

The case series includes four patients with os tibiale externum and one patient with os peroneum. Only one patient had symptoms related to os tibiale externum. The accessory ossicle in the rest of the cases was discovered incidentally after trauma to the ankle or foot. The symptomatic os tibiale externum was managed conservatively with analgesics and shoe inserts for medial arch support.

Conclusion

Accessory ossicles are considered developmental anomalies and they originate from ossification centers that have failed to fuse with the main bone. Clinical suspicion and awareness about the existence of the commonly occurring accessory ossicles of the foot and ankle are necessary. They can be a confounding factor in the diagnosis of foot and ankle pain. Failure to notice their presence might result in a misdiagnosis and unnecessary immobilization or surgery for the patients.

Fracture of an os peroneum

Os peroneum is an accessory ossicle located within the peroneus longus tendon, present in 26% of the population. Fractures of the os peroneum present as pain localized on the lateral aspect of the foot resulting from direct trauma, muscle contraction, inversion injuries or chronic overuse injuries. We document a case of a fractured os peroneum that resulted in the insidious onset of ongoing pain that was managed conservatively.

How to increase the accuracy of the diagnosis of the accessory bone of the foot?

PURPOSE

The study was conducted to search for confident radiological signs in symptomatic cases of accessory bones. A normal accessory bone appearance on X-ray does not exclude that the accessory bone is the source of the discomfort; because of this, MRI examination can later be applied as part of the diagnosis.

METHODS

We retrospectively analysed cases of 64 patients with recognized 70 symptomatic accessory bones of the foot. The average age was 29.2 (range 8-42) years. We included only patients with X-ray and MRI examinations. We investigated the following radiological features of the bone (structural and signal) in relation to soft tissue.

RESULTS

The most constant symptoms identified in our study were bone marrow oedema (93%) and soft tissue oedema (77%). Changes in structures in which accessory bones were located or in adjacent structures to accessory bone were identified: tendon changes 51%, fluid adjacent to bone 51% and tenosynovitis 46%. MRI revealed changes in bone structure that are not seen on X-ray, including changes in contour (28%), sclerosis (3%) or osteonecrosis (3%).

CONCLUSIONS

MRI plays an important role in determining whether accessory bones cause symptoms because it shows specific and accurate changes in accessory bone and/or in adjacent soft tissue.

Chronic Disorders of the Peroneal Tendons: Current Concepts Review of the Literature

Chronic disorders of the peroneal tendons are a common cause of posterolateral ankle pain, including tendinopathy, tendon instability, and chronic tendon tears. They are often preceded by ligamentous instability or predisposing anatomic abnormalities such as a shallow fibular groove or a cavovarus foot deformity. Given the substantial disability associated with chronic peroneal tendon disorders, it is important for orthopaedic surgeons to optimize the diagnostic and treatment strategies of these entities based on contemporary studies. This article reviews both classic and recent scientific evidence regarding the diagnosis and treatment of patients with chronic peroneal tendon disorders.

Peroneus longus tendon rupture: A case report

BACKGROUND

Peroneal tendinopathies are an under-diagnosed and potentially under-treated pathology. If left untreated it can be a cause of chronic lateral hindfoot pain. Its diagnosis is challenging owing to its low incidence and vague clinical presentation.

CASE SUMMARY

We share a case of a patient who experienced a chronic lateral ankle pain exacerbated after alighting from a bus. This patient came to our attention only after failing conservative management on two separate occasions. Plain radiographs and magnetic resonance imaging revealed rupture of the peroneus longus tendon (PLT). Findings were confirmed intra-operatively and tenodesis of the PLT to the peroneus brevis was performed. Patient was kept non-weight-bear with his foot everted and in plantarflexion before being converted to an off-loading boot at two weeks. Patient was started on a progressive rehabilitation programme at six weeks and was able to return to work shortly after with excellent outcomes.

CONCLUSION

We aim to share our experience in managing this patient and propose some pointers guided by available literature to avoid missing this commonly overlooked pathology.

Os peroneum imaging: normal appearance and pathological findings

The os peroneum (OP) is a small sesamoid bone located inside the peroneus longus tendon (PLT), close to the cuboid. The OP can be the cause of pain and can be associated with lesions of the PLT. OP involvement in PLT disorders is frequently misdiagnosed by radiologists. Painful os peroneum syndrome (POPS) refers to a variety of conditions presenting with pain localized on the lateral aspect of the cuboid area. The syndrome can be observed as a consequence of local acute trauma such as ankle sprains or chronic overuse. Because of its intra-tendinous location, in tears of the peroneus longus tendon, the OP can show changes in its morphology or position, depending on the location of the tendon’s tear. Based on the level of the PLT tears, we propose a classification in three subtypes: tears localized proximal to the os peroneum (type I), at its level (type II) or distal to it (type III). These tears present with different changes on OP morphology or location. The aim of this article is to review the normal anatomy, imaging appearance and differential diagnosis of disorders of the OP as well as post-treatment imaging.

Teaching points

• PLT tears can be classified in three subtypes according to OP location.

• POPS is characterized by pain on the lateral aspect of the cuboid.

• OP involvement in PLT disorders is frequently misdiagnosed by radiologists.

Delayed Surgical Reconstruction of a Peroneal Tendon Rupture in an Accessory Os PeroneumA Rare Differential Diagnosis in Chronic Ankle Pain

A fracture of the os peroneum is a rare cause of ankle and foot pain and is often overlooked and not assumed. Only a few case reports have discussed the different etiologies, options for diagnosis, and therapeutic interventions for acute cases. We present a case of delayed diagnosis of an os peroneum fracture due to a distortion of the ankle that occurred during air sports. Initial diagnostic testing with magnetic resonance imaging demonstrated a rupture of the peroneus longus tendon with no pathologic abnormalities at the peroneus brevis tendon. During surgery, a combination of an os peroneum fracture and a peroneus brevis tendon split was found and was successfully treated with bone and tendon repair using a lasso stich technique.

The peroneocuboid joint: morphogenesis and anatomical study

The peroneocuboid joint, between the peroneus longus tendon and the cuboid bone, has not been anatomically well-defined and no embryological study has been published. Furthermore, the ossification of the os peroneum (a sesamoid inside the peroneus longus tendon) and its associated pathology has been considered to be generated by orthostatic and/or mechanical loads. A light microscopy analysis of serially sectioned human embryonic and fetal feet, the analysis of human adult feet by means of standard macroscopic dissection, X-ray and histological techniques have been carried out. The peroneus longus tendon was fully visible until its insertion in the 1st metatarsal bone already at embryonic stage 23 (56-57 days). The peroneocuboid joint cavity appeared at the transition of the embryonic to the fetal period (8-9th week of gestation) and was independent of the proximal synovial sheath. The joint cavity extended from the level of the calcaneocuboid joint all the way to the insertion of the peroneus longus tendon in the 1st metatarsal bone. The frenular ligaments, fixing the peroneus longus tendon to the 5th metatarsal bone or the long calcaneocuboid ligament, developed in the embryonic period. The peroneus longus tendon presented a thickening in the area surrounding the cuboid bone as early as the fetal period. This thickening may be considered the precursor of the os peroneum and was similar in shape and in size relation to the tendon, to the os peroneum observed in adults. To the best of our knowledge, this is the first study to show that the os peroneum, articular facets of the peroneus longus tendon and cuboid bone, the peroneocuboid joint and the frenular ligaments appear during the embryonic/fetal development period and therefore they can not be generated exclusively by orthostatic and mechanical forces or pathological processes.

Peroneal tendon abnormalities in subjects with an enlarged peroneal tubercle

OBJECTIVE

To examine the association between inframalleolar peroneal tendon abnormalities and an enlarged peroneal tubercle.

MATERIALS AND METHODS

Two independent readers evaluated consecutive ankle MR imaging studies to classify inframalleolar peroneal tendon findings as normal, tenosynovitis, partial tear or complete tear. The size and morphology of the peroneal tubercle was also recorded. We performed statistical analyses for inter-observer agreement and to assess differences in peroneal tubercle size between groups with and without peroneal tendon abnormalities.

RESULTS

The study group comprised 121 subjects (mean age, 45.5 years) of whom 28% (34 out of 121) had lateral ankle symptoms. The peroneal tubercle was absent in 56% of subjects (68 out of 121). In subjects with a peroneal tubercle (>0 mm), the mean size was 3.5 mm (37% triangular and 7% plateau-shaped). Male subjects had significantly larger mean peroneal tubercle size than female subjects (2.1 ± 2.5 vs 1.2 ± 1.9 mm, P = 0.04). Overall, 26% (32 out of 121) of subjects had some peroneal tendon abnormality: 17% (20 out of 121) had tenosynovitis and 17 % (20 out of 121) had partial thickness tears. The peroneal tubercle size was significantly larger in subjects with peroneal tendon partial tears (P = 0.036), tenosynovitis (P < 0.001), and when both abnormalities were present (P = 0.007). ROC statistic showed 73% sensitivity and 74% specificity for detection of partial tears for peroneal tubercle size ≥4.3 mm.

CONCLUSION

Our study shows a significantly larger peroneal tubercle in subjects with inframalleolar peroneal tendon abnormalities. A cut-off of 4.3 mm showed good sensitivity and specificity for the presence of partial tears of the peroneal tendon.

Significance of sesamoid ossification in peroneus longus tendon ruptures

Ruptures of the peroneus longus tendon are uncommon, with a small number of case reports found in published studies. The presence of an os peroneum can predispose the peroneus longus tendon to rupture at the cuboid level with or without concomitant fracture, or fracture through a partite os peroneum. Whether the os peroneum can be represented by various stages of ossification is still a matter of debate. We present 2 cases of acute peroneus longus tendon rupture at the cuboid notch in the presence of an intact os peroneum in the ossified and nonossified form. We treated patients with excision of the os peroneum and tenodesis of the peroneus longus to the peroneus brevis tendon.