Surgical treatment of peroneal tendon tears

Republication of "Peroneus Brevis Tenodesis: Side-to-Side or Weave?"

Background

Inversion ankle injuries are extremely common, sometimes causing injury to the peroneus brevis tendon. If more than 50% of the tendon is injured, it oftentimes requires tenodesis to the adjacent peroneus longus tendon. Both Pulvertaft (PT) and side-to-side (SS) techniques have been used for joining the 2 tendons. The purpose of this study was to compare the strength and stiffness of these 2 techniques.

Methods

Five matched pairs of cadaver ankle specimens were randomized to receive either an SS or PT tenodesis of the peroneus brevis to longus tendons. Following the tenodesis, the specimens were tested for failure load, displacement, energy absorbed at failure, and peak load. Stiffness was also calculated. Paired t tests were performed to detect differences between the 2 conditions.

Results

There were no statistically significant differences between the SS and PT tenodesis for any of the metrics measured. For stiffness, the techniques were very similar (SS = 10.14 [4.35], PT = 12.85 [1.72]).

Conclusion

There is no difference in failure load, displacement, energy absorbed at failure, peak load or stiffness between the PT and SS techniques for peroneal tenodesis.

Level of Evidence

Level V, cadaver study.

Two-Staged Reconstruction of Extensor Tendons After Wide Resection of Clear Cell Sarcoma at the Anterior Ankle: A Case Report

CASE

A 23-year-old woman sustained a skin defect in the anterior ankle involving the extensor retinaculum (ER) and 10 cm of extensor tendons (ETs) after a wide resection of clear cell sarcoma. The skin defect was reconstructed with free latissimus dorsi flap, ER with tensor fascia lata, and ETs with 2-staged tendon reconstruction using silicone rod interposition, followed by semitendinosus and gracilis tendon grafts. Four years postoperatively, she achieved 92% of ankle and 70% of great toe motion of the contralateral side.

CONCLUSION

This reconstruction technique was useful for a large soft-tissue defect at the anterior ankle.

Radiological features accompanying peroneus brevis split rupture revealed on magnetic resonance imaging - a cohort study

BACKGROUND

Peroneal split tears are an underrated cause of ankle pain. While magnetic resonance imaging (MRI) is useful for diagnosis, split tears are challenging to identify. The aim of the study was to investigate the association of peroneus brevis split rupture with abnormalities of the superior peroneal retinaculum (SPR), anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), joint effusion, morphology of the malleolar groove, presence of the bone marrow oedema and prominent peroneal tuberculum.

METHODS

Ankle MRI cases were assessed by independent observers retrospectively in two groups: one with peroneus brevis split tears (n = 80) and one without (control group, n = 115). Two observers evaluated the soft tissue lesions, and three graded the bone lesions. Fisher's exact test and Pearson correlation were used for analysis. The Bonferroni-Holm method (B-H) was used to adjust for multiple comparisons.

RESULTS

Only bone marrow edema in the posterior part of the lateral malleolus was significantly (p < 0.05) more common in the split tear group after applying B-H. SPR total rupture was seen only in the experimental group. No differences in incidence of ATFL and CFL lesions or other SPR lesions were noticed (p < 0.05).

CONCLUSION

Bone marrow edema in the posterior part of the lateral malleolus is associated with peroneus split tears on MRI.

Imaging Tendon Disorders in Athletes

Imaging plays a critical role in evaluating pathology affecting athletes from various fields. Tendon pathology manifests in terms of mechanical, degenerative, enthesitis, neoplastic, and overuse diseases. Tendon pathologies in athletes usually involve injuries to commonly injured tendons such as the tendons involving the ankle, elbow, rotator cuff, hip abductors, patellar tendon, and Achilles tendon. For the purposes of this article, the focus will be on the tendons involving the ankle such as the tibialis posterior and peroneal tendons. The 2 most common imaging modalities used for the evaluation of tendons are ultrasound (US) and magnetic resonance imaging (MRI). There are several emerging imaging techniques such as T2 mapping, ultra-short echo time MRI, and sonoelastography. These novel imaging techniques are all in research phase and have not been adapted to routine clinical practice.

Presurgical Perspective and Postsurgical Evaluation of Non-Achilles Tendons of the Ankle and Retinaculum

The vast majority of non-Achilles ankle tendinopathies are related to overuse. This article discusses the clinical aspect, imaging appearance, and management of tendinopathies of the lateral, medial, and the anterior compartments with a focus on presurgical perspective and postsurgical evaluation.

Tendoscopic-Assisted Repair of Distal Peroneus Longus Rupture: A Novel Approach and 2 Case Reports

LEVELS OF EVIDENCE

Level IV: Case Series.

Postoperative Ankle Imaging, 2022

Postoperative ankle imaging requires knowledge of the underlying surgical techniques, the usefulness of various imaging modalities, as well as an appreciation for the desired clinical outcomes. Surgical procedures discussed in this article are tibiotalar fracture fixation, tibiotalar, subtalar, and tibiotalocalcaneal arthrodesis, total ankle arthroplasty, talar osteochondral lesion repair and grafting, lateral ligamentous repair and reconstruction, and peroneal and Achilles tendon repair and reconstruction. Imaging can play a vital role in determining if the expected outcome has been achieved and identifying complications, with particular emphasis placed on the use of radiographs, computed tomography (including weight-bearing), magnetic resonance imaging, and ultrasonography.

Enlarged Reactional Periostitis of the Peroneal Tubercle Mimicking Osteochondromatosis of the Calcaneus: A Case Report

Foot and ankle tumors are relatively rare. Nevertheless, the calcaneus is a prevalent location accommodating various lesions. Reactional periostitis of the lateral wall is rarely encountered but can potentially mimic a wide variety of tumors. We present a case of excessive proliferation due to chronic compression of the peroneal tendons against the calcaneus in a female patient with a history of diminished foot control, treated successfully by tumor excision and peroneal restoration via the tubularization technique. This study aimed to underline the mimicking potential of reactional periostitis and its effect on the peroneal tendons and hindfoot motion.

A Biomechanical Analysis of Peroneus Brevis Split Lesions, Repair, and Partial Resection

BACKGROUND

Peroneus brevis tendon tears are associated with chronic ankle pain and instability following sprain injuries. The aim of this study is to elucidate the biomechanical changes induced by a peroneus brevis split and surgical treatment by tubularizing suture or partial resection.

METHODS

Nine human lower leg specimens were biomechanically tested. Preexisting tendon pathology was ruled out by magnetic resonance imaging and histology. Specimens were subjected to sequential testing of 4 conditions of the peroneus brevis tendon: (1) native, (2) longitudinal lesion, (3) tubularizing suture, and (4) 50% resection. The outcome parameters were the tendon stiffness (N/mm) and the length variation of the split portion at 5 N load.

RESULTS

The median specimen age at death was 55.8 years (range 50-64 years). The longitudinal tendon split led to an elongation by 1.21 ± 1.15 mm, which was significantly reduced by tubularizing suture to 0.24 ± 0.97 mm (P = .021). Furthermore, 50% resection of the tendon elongated it by a mean 2.45 ± 1.9 mm (P = .01) and significantly reduced its stiffness compared to the intact condition (4.7 ± 1.17 N/mm, P = .024) and sutured condition (4.76 ± 1.04 N/mm, P = .011).

CONCLUSION

Longitudinal split and 50% resection of the peroneus brevis tendon led to elongation and loss of tendon stiffness. These properties were improved by tubularizing suture. The significance of these changes in the clinical setting needs further investigation.

CLINICAL RELEVANCE

Tubularizing suture of a peroneus brevis split can restore biomechanical properties to almost native condition, potentially aiding ankle stability in symptomatic cases. A split lesion and partial resection of the tendon showed reduced stiffness and increased elongation.

Peronealsehnenverletzungen

Hintergrund

Verletzungen der Peronealsehnen gelten als häufig unterdiagnostizierte Ursache lateraler Rückfußschmerzen. Prädisponierende Ursachen sind u. a. eine chronische laterale Instabilität sowie ein Rückfußvarus, da dies zu einer Überbelastung der Peronealsehnen führt. Klinisch äußern sich Peronealsehnenverletzungen meist unspezifisch mit lateralen Rückfußschmerzen.

Material und Methoden

In der Untersuchung zeigen sich Schmerzen bei Aktivierung der Sehnen gegen Widerstand. Die Sonographie zur Diagnostik bietet die Möglichkeit einer dynamischen Untersuchung, in der Magnetresonanztomographie (MRT) können gleichzeitig weitere Strukturen beurteilt werden. Zu unterscheiden sind eine Tendinopathie der Sehnen, eine Instabilität mit Luxation oder Subluxation verbunden mit Pathologien des superioren Peronealsehnenretinakulums sowie Längssplit und komplette Sehnenruptur. Bei Tendinopathien und Längsrissen erfolgt die Therapie primär konservativ. Ein kompletter Riss und eine Läsion über 50 % sollten operativ versorgt und, falls möglich, direkt genäht werden. Alternativ sind eine Tenodese oder ein Sehnenersatz mit einem Graft zu evaluieren.

Ergebnisse

Bei Patienten mit einer Peronealsehneninstabilität führen die Naht oder Rekonstruktion des superioren Peronealsehnenretinakulums zu guten Resultaten. Eine frühe Therapie zeigt eine bessere Heilungschance und kann somit zu einem besseren Outcome führen.

Schlussfolgerung

Zusammenfassend kann gesagt werden, dass bei chronischen lateralen Rückfußschmerzen an eine Peronealsehnenverletzung gedacht und bei Verdacht auf eine Läsion eine MRT oder eine Sonographie zur Bestätigung respektive Ausschluss der Diagnose durchgeführt werden sollte.

Intraosseous Anchorage of a Collagen Matrix Graft to Enhance Repair of Peroneus Brevis Tendon Degeneration

INTRODUCTION

Chronic degeneration of the peroneus brevis tendon (PBT) at its insertion to the base of the fifth metatarsal is uncommon; however, when present it can be a challenge to treat. Repair of the PBT often requires tubularization with or without a peroneus longus tendon transfer. These repairs, however, may not provide resultant full muscle strength, especially if ostectomy of the fifth metatarsal base is required. We report outcomes following a novel technique for anatomic repair of degenerative PBT with intraosseous fifth metatarsal base fixation of a collagen matrix graft.

METHODS

Thirteen consecutive patients (14 procedures) with degeneration of PBT that underwent tendon repair augmented with collagen matrix graft from 2011 to 2019 were reviewed retrospectively. We present outcome data of these 13 patients that were followed for at least 12 months.

RESULTS

Muscle strength, complications, and patient-reported subjective outcomes were reported. There were 10 females and 3 males. Average age was 49.1 years, and average follow-up was 34.9 months. Muscle strength was reported at 5/5 to the PBT by the final follow-up for 92% of patients. There were minimal complications, 84.6% (11/13) of patients had no limitation in activity level, and 92% (12/13) would recommend this procedure to a friend.

CONCLUSION

Outcomes for this novel repair technique for insertional degenerative PBT have never been reported before and show excellent results with long-term follow-up.

Peroneus brevis tendon injuries: Report of two cases and review of literature

The incidence of peroneal tendon disorders in the population is unknown and they are usually overlooked. We report two cases of peroneus brevis injuries and a comprehensive literature review was performed. The first case was a 53-year-old man presented with persistent pain on the lateral aspect on the left ankle during the last four years and difficulty to bear weight during the last year. MRI showed longitudinal tear of peroneus brevis tendon and the patient underwent surgical treatment. The second case was a 46-year-old woman with persistent pain on the lateral aspect of the ankle with a history of a road traffic accident two years ago. Although MRI showed a peroneus brevis tendon tear, this was a false positive finding. Surgical treatment revealed no tear and symphysiolysis managed to relieve patient's symptoms. Even though MRI is the most effective diagnostic tool in depicting peroneal tendon injuries, there are false positive findings. In cases when symptoms persist, surgical exploration is indicated.

The Role of Peroneal Tendinopathy and the Cavovarus Foot and Ankle

Peroneal tendon pathology is often an overlooked and underdiagnosed condition. It is often confused with chronic ankle instability. It is important when surgically managed to assess the condition of the tendons, muscle viability and strength, and associated cavovarus deformity. Complex reconstruction may be needed, including 2-stage procedures with a silicone rod and tendon transfer.

Association of Cavovarus Foot Alignment With Peroneal Tendon Tears

BACKGROUND

Although it is a widely accepted clinical principle that cavovarus deformity predisposes to peroneal tendon problems, there are limited data to support that assumption. This study tested the hypothesis that cavovarus is associated with peroneal tendon tears and evaluated which radiographic measures correlated with that association.

METHODS

A retrospective comparison of radiographic measures of cavovarus in 234 consecutive patients operatively treated for chronically symptomatic peroneal tendon tears was compared to a matched control group. Measures included calcaneal pitch, anteroposterior (AP) talometatarsal and talocalcaneal angles, and talonavicular coverage angle. A novel coordinate system analyzed midfoot and hindfoot components of cavovarus. Analysis of variance was used to compare cohorts, and a Tukey-Kramer test used to analyze 3 subgroups of brevis and longus tears, and concomitant tears.

RESULTS

The distribution of tears was 73% peroneus brevis, 8% longus, and 19% both tendons. Compared with controls, the study group, and subgroups, had multiple measures of increased cavovarus, including greater calcaneal pitch (P = .0001), decreased AP talo-first metatarsal angle (P = .0001), and increased talonavicular coverage angle (P = .0001). Elevated medial longitudinal arch, and rotational changes in the radiographic profiles of the hindfoot were found with the coordinate system described by Yokokura.

CONCLUSION

This study found a statistically significant association of increased cavovarus deformity with peroneal tendon tears, compared to controls. It documented the relative incidence of tears of peroneus brevis, peroneus longus, and concomitant tears in a large surgical series. It demonstrated which simple radiographic angles and complex coordinate measurements of cavovarus deformity were significantly associated with peroneal tendon tears.

LEVEL OF EVIDENCE

Level III, retrospective comparative cohort study.

Clinical and Functional Outcomes of Peroneus Longus to Brevis Tendon Transfer

BACKGROUND

Peroneal tendon lesions can cause debilitating pain, but operative treatment remains controversial. Some studies recommend peroneal tenodesis or transfer if more than half of the tendon is affected. However, clinical outcomes and inversion/eversion motion after peroneal transfer have not been investigated yet.

METHODS

Patients who underwent distal peroneus longus to brevis transfer for major peroneus brevis tendon tears with a minimum follow-up of 2 years were included. Clinical outcome parameters included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the German Foot Function Index (FFI-D), and Karlsson-Peterson score. Functional outcome was tested with a standardized active range-of-motion (ROM) and isokinetic strength measurement protocol, including concentric and eccentric eversion and inversion tests.

RESULTS

Of total 23 eligible patients, 14 (61%) were available for follow-up. Clinical outcome scores were good with AOFAS 86 ± 16 points, FFI-D pain 26% and FFI-D disability 26%, and Karlsson-Peterson score 78 ± 23 points. There was no difference in strength in comparison to the contralateral foot (all P > .05). Isokinetic strength was 16.3 ± 4.9 Nm (108% of contralateral side) and 18.8 ± 4.5 Nm (101%) at concentric 30 deg/s and eccentric 30 deg/s eversion tests, as well as 15.7 ± 5.2 Nm (102%) and 18.7 ± 3.3 Nm (103%) at concentric 30 deg/s and eccentric 30 deg/s inversion tests, respectively. There was no difference in ROM compared to the contralateral side (eversion/inversion 14.5-0-18.7 vs 14.1-0-16.1 degrees).

CONCLUSION

Peroneus longus to brevis transfer is a viable option for treating severe peroneus brevis tendon tears and does not compromise measurable strength or ROM in inversion or eversion in comparison to the contralateral ankle joint.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Successful reconstruction of distal peroneus longus tendon dislocation associated with a split lesion - a case report

BACKGROUND

Peroneal tendon injuries are one of the differential diagnoses in lateral ankle and rearfoot pain. While partial tears are not uncommon, peroneal tendon dislocation at the peroneal tubercle is very rare. Until now, only three papers have been published, presenting five cases of peroneus longus tendon dislocation over the peroneal tubercle. This report adds a previously undescribed case of a peroneus longus tendon split tear that was partially dislocated and entrapped over the peroneal tubercle. The respective operative approach and the outcome are described.

CASE PRESENTATION

A 25-year-old international top-level speed skater developed a painful mass over the lateral calcaneal wall. There was no specific inducing injury in his medical history. In contrast to previous reports, according to the patient's history, a snapping phenomenon was not present. Conservative treatment was not effective. By inspection and palpation an enlarged peroneal tubercle was assumed. During operative exploration, we found an incomplete longitudinal split tear of the peroneus longus tendon, which was partially dislocated and entrapped over the peroneal tubercle. This mimicked an enlarged peroneal tubercle. A portion of the split tendon was resected. A deepening procedure of the flat groove of the peroneus longus tendon below the peroneal tubercle and a transosseous reconstruction of the avulsed inferior peroneal retinaculum were performed. After six months, the patient had completely reintegrated into his elite sport and has been free of symptoms since then.

CONCLUSIONS

From the presented case it can be speculated that the inferior peroneal retinaculum was overused, worn out, detached, or ruptured due to overpronation and friction the lateral edge of the low-cut speed skating shoe. Then the peroneus longus tendon experienced substantial friction with the peroneal tubercle with possible dislocation during ankle motion. This frictional contact may have finally led to further degeneration and a longitudinal tear of the tendon. Obviously, dislocations can develop insidiously resulting in lesions of the peroneus longus tendon at the peroneal tubercle, ultimately leading to a tendon entrapment. This mimics an enlarged tubercle. The pathology is very rare and can be successfully addressed surgically.

Chronic Peroneal Tendon Dislocation: A Case Report

We present a unique case of chronic peroneal tendon dislocation in a 47-year-old active duty military member with a 2-mo history of acute onset lateral ankle pain due to sports injury. Magnetic resonance imaging revealed superficial peroneal retinaculum (SPR) disruption, a flattened retrofibular groove, dislocation of the peroneus longus tendon, and a tear of the peroneus brevis tendon. The patient was managed operatively with fibular groove deepening, SPR reconstruction, peroneus brevis debridement, and peroneus longus tubulurization. No complications were observed during the intra- or perioperative periods. At their 3-mo follow-up, the patient reported near complete resolution of pain and the ability to ambulate without any brace or support. He returned to running and was able to deploy fit for full duty 4.5 mo from injury.

Combined open calcaneocuboid, naviculocuneiform and subtalar dislocation: A case report and literature review

Open dislocations of the midfoot and subtalar joints are extremely rare injuries. Understanding the anatomy of these joints and the various injury patterns is imperative to obtain stable concentric reduction and provide good functional outcome. We present a report of a 26- year old male who was involved in a road traffic accident and sustained open dislocations of the calcaneocuboid, naviculocuneiform and subtalar joints. He initially underwent external fixation in view of the severe soft tissue injury. After improvement of the soft tissue condition, he underwent K-wiring of the calcaneocuboid joint, buttress plating of the talonaviculocuneiform joint, peroneal tendon reconstruction using hamstring allograft and defect coverage with a free anterolateral thigh flap. With appropriate rehabilitation protocols, patient recovered well and was allowed to weight bear as tolerated by 10 weeks. His wounds healed completely by 4 months. We report this case considering the rarity of the combined calcaneocuboid, naviculocuneiform and subtalar dislocations which were successfully managed.

Diagnosis and Operative Treatment of Peroneal Tendon Tears

Peroneal tendon tears are a common but under-recognized source of ankle pain and dysfunction. Recognition of the characteristic symptoms, physical findings, and imaging results of peroneal tendon tears is essential for accurate diagnosis and appropriate treatment. Acute, limited tears of a single peroneal tendon may be debrided and repaired. However, by the time operative treatment is undertaken, many tears of a single tendon are sufficiently advanced that the surgeon may need to consider excision of the nonviable segment and tenodesis of the damged tendon to the to the adjacent peroneal tendon. Irreparable tearing of both peroneal tendons may be treated with flexor tendon transfer and/or allograft reconstruction. This review article focuses on diagnosis and operative treatment of peroneal tendon tears, including the treatment algorithms, operative technique, and published outcomes.

Diagnosis and Operative Treatment of Peroneal Tendon Tears

Peroneal tendon tears are a common but under-recognized source of ankle pain and dysfunction. Recognition of the characteristic symptoms, physical findings, and imaging results of peroneal tendon tears is essential for accurate diagnosis and appropriate treatment. Acute, limited tears of a single peroneal tendon may be debrided and repaired. However, by the time operative treatment is undertaken, many tears of a single tendon are sufficiently advanced that the surgeon may need to consider excision of the nonviable segment and tenodesis of the damged tendon to the to the adjacent peroneal tendon. Irreparable tearing of both peroneal tendons may be treated with flexor tendon transfer and/or allograft reconstruction. This review article focuses on diagnosis and operative treatment of peroneal tendon tears, including the treatment algorithms, operative technique, and published outcomes.

Peroneal groove deepening as the treatment of peroneal tendon subluxation: A case report

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Subluxation of the peroneal tendon is relatively infrequent.

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Subluxation of the peroneal tendon often misdiagnosed as ankle sprain.

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Avulsion of the superior peroneal retinaculum from is the main cause of peroneal tendon subluxation.

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Good outcomes can be achieved by peroneal groove deepening and retinaculum ligament repair.

Introduction

Peroneal tendon subluxation is a relatively rare disorder that is often misdiagnosed as an ankle sprain. It affects mainly young adults, usually during sports activities. It is mostly caused by avulsion of the superior peroneal retinaculum (SPR) from its fibular insertion, which requires surgical intervention, especially for cases of symptomatic chronic peroneal tendon subluxation and/or dislocation. We reported a case of peroneal tendon subluxation of left ankle treated with peroneal groove deepening and retinaculum ligament repair, the objective of which is to illustrate the effectiveness of this procedure.

Case presentation

We present a case of a thirty-four-year old male with peroneal tendon subluxation of left ankle. The patient was injured while exercising two years prior to admission. He now reported pain and instability on the left ankle. We performed peroneal groove deepening and retinaculum ligament repair to treat this patient.

Discussion

Peroneal groove deepening and retinaculum ligament repair shows an excellent clinical outcome; after the procedure, there are no major complications such as infections, wound problems or permanent discomfort. Overall, the result of surgery had been considered satisfactory. Postoperatively, the ankle was placed in a below-knee, non–weight-bearing temporary cast in semi-equinus position for two weeks.

Conclusion

The incidence rate of peroneal tendon subluxation is relatively low, and surgery is the primary treatment of this type of injury, with various available surgical methods available for the performing surgeon. Peroneal groove deepening and retinaculum ligament repair offers a satisfactory outcome.

Treatment of Insertional Peroneus Brevis Tendinopathy by Ultrasound-Guided Percutaneous Ultrasonic Needle Tenotomy: A Case Report

Insertional peroneus brevis tendinopathy is uncommon and treatment options for recalcitrant insertional lesions are rarely described in the literature. Ultrasound-guided percutaneous ultrasonic needle tenotomy has been described for the treatment of recalcitrant tendinopathy in the elbow, knee, and plantar fascia, but has not been described for the treatment of peroneal tendinopathy. We report a case of recalcitrant insertional peroneus brevis tendinopathy successfully treated with an ultrasound-guided percutaneous ultrasonic needle tenotomy. The treatment resulted in a rapid recovery, and the patient remained asymptomatic at the 6-month follow up. No complications were observed during follow up and the minimally invasive percutaneous procedures offers clear advantage over open techniques.

Distal Peroneus Longus Dislocation and Pseudohypertrophy of the Peroneal Tubercle: A Systematic Review

Peroneal tendon injuries at the peroneal tubercle are rare. No systematic research regarding this pathology is currently available. In this systematic literature review, the author evaluated the present knowledge about peroneal tendon lesions at the lateral calcaneal wall. These lesions are predominantly associated with peroneal tubercle enlargement. Information on 25 respective patients (26 cases) has been published in 14 articles. Until now, only 3 reports presented 5 patients with dislocation of the peroneus longus tendon combined with inferior peroneal retinaculum lesions. In these cases, the peroneal tubercle was not enlarged. All reviewed patients were treated surgically. Enlarged peroneal tubercles were resected. Groove deepening and inferior peroneal retinaculum reconstruction addressed distal peroneus longus tendon dislocations. The reported results were either excellent or good. Recurrent dislocations can cause lesions of the peroneus longus tendon at the peroneal tubercle. This pathology is rare and can be addressed surgically. In cases without tendon dislocation, the enlarged peroneal tubercles are removed or shaped, whereas dislocations in normal shaped peroneal tubercles require groove deepening and inferior peroneal retinaculum reconstruction.

Lateral Transfer of the Flexor Digitorum Longus for Peroneal Tendinopathy

BACKGROUND

Few studies have reported midterm outcomes after single-stage flexor digitorum longus (FDL) tendon transfer to the lateral foot for irreparable rupture of the peroneal tendons.

METHODS

Over a 7-year period (2008-2015), 25 consecutive patients underwent transfer of the FDL to the fifth metatarsal for irreparable peroneal tendon tears. Of these, 15 patients were available for inclusion with a mean follow-up of 53.7 ± 23.3 months, mean age at surgery of 48.4 years, and mean body mass index (BMI) of 29.8 kg/m². Patients completed the pain visual analog scale (VAS), Foot Function Index (FFI), Short Musculoskeletal Function Assessment (SMFA), and Foot and Ankle Ability Measure (FAAM) and participated in range of motion, peak force, and peak power testing.

RESULTS

All 15 patients were satisfied with their surgery and reported a reduction in their pain level with a decreased VAS of 5.6 ± 2.5. The mean FFI was 12.8 ± 9.2, the SMFA Function Index was 12.4 ± 8, and the mean SMFA Bothersome Index was 11.5 ± 11. The mean FAAM was 86.4 ± 9.7. Patients had on average 58% less eversion and 28% less inversion compared with the nonoperative side. Isometric peak torque and isotonic peak velocity were 38.4% and 28.8% less compared with the contralateral side, respectively. The average power in the operative limb was diminished by 56% compared with the nonoperative limb.

CONCLUSION

In this small case series with midterm follow-up, FDL transfer to the lateral foot for significant, irreparable peroneal tendinopathy was an effective and durable treatment option.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

[Injuries of the peroneal tendons : Often overlooked]

CLINICAL ISSUE

Injuries of the peroneal tendons are rare and often overlooked. Typical pathologies are tendinitis, tears and dislocation. Accompanying injuries are fractures. They are often associated with instability in the ankle and rearfoot deformities; therefore, these pathologies should be excluded or taken into consideration in the treatment. The clinical examination is crucial for the diagnosis.

DIAGNOSTIC WORK-UP

Ultrasound and magnetic resonance imaging (MRI) examinations are very helpful; however, the true extent of the tendon pathology is often first seen during surgery. Bony injuries and deformities are assessed radiographically and by computed tomography (CT).

PERFORMANCE

Although conservative treatment is generally used at the beginning of therapy, progression is more likely to occur in the case of tears; therefore, the correct timing for an operative therapy should not be missed. Dislocations are the domain of operative therapy. Acute tendinitis, on the other hand, is usually accessible to conservative therapy if it is not the result of a gross deformity.

ACHIEVEMENTS

Rehabilitation after operative treatment is demanding and prolonged especially after operative therapy of peroneal tendon tears. The results to be expected appear promising.

Peroneus Brevis Tenodesis: Side-to-Side or Weave?

Background:

Inversion ankle injuries are extremely common, sometimes causing injury to the peroneus brevis tendon. If more than 50% of the tendon is injured, it oftentimes requires tenodesis to the adjacent peroneus longus tendon. Both Pulvertaft (PT) and side-to-side (SS) techniques have been used for joining the 2 tendons. The purpose of this study was to compare the strength and stiffness of these 2 techniques.

Methods:

Five matched pairs of cadaver ankle specimens were randomized to receive either an SS or PT tenodesis of the peroneus brevis to longus tendons. Following the tenodesis, the specimens were tested for failure load, displacement, energy absorbed at failure, and peak load. Stiffness was also calculated. Paired t tests were performed to detect differences between the 2 conditions.

Results:

There were no statistically significant differences between the SS and PT tenodesis for any of the metrics measured. For stiffness, the techniques were very similar (SS = 10.14 [4.35], PT = 12.85 [1.72]).

Conclusion:

There is no difference in failure load, displacement, energy absorbed at failure, peak load or stiffness between the PT and SS techniques for peroneal tenodesis.

Level of Evidence:

Level V, cadaver study.

Biomechanical Cadaveric Evaluation of Partial Acute Peroneal Tendon Tears

BACKGROUND

No clear guideline or solid evidence exists for peroneal tendon tears to determine when to repair, resect, or perform a tenodesis on the damaged tendon. The objective of this study was to analyze the mechanical behavior of cadaveric peroneal tendons artificially damaged and tested in a cyclic and failure mode. The hypothesis was that no failure would be observed in the cyclic phase.

METHODS

Eight cadaveric long leg specimens were tested on a specially designed frame. A longitudinal full thickness tendon defect was created, 3 cm in length, behind the tip of the fibula, compromising 66% of the visible width of the peroneal tendons. Cyclic testing was initially performed between 50 and 200 N, followed by a load-to-failure test. Tendon elongation and load to rupture were measured.

RESULTS

No tendon failed or lengthened during cyclic testing. The mean load to failure for peroneus brevis was 416 N (95% confidence interval, 351-481 N) and for the peroneus longus was 723 N (95% confidence interval, 578-868 N). All failures were at the level of the defect created.

CONCLUSION

In a cadaveric model of peroneal tendon tears, 33% of remaining peroneal tendon could resist high tensile forces, above the physiologic threshold.

CLINICAL RELEVANCE

Some peroneal tendon tears can be treated conservatively without risking spontaneous ruptures. When surgically treating a symptomatic peroneal tendon tear, increased efforts may be undertaken to repair tears previously considered irreparable.

Single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata: A case report

Reconstruction of complex soft tissue defects in the distal lower leg remains challenging, since anatomical constraints limit the local options available in this area. In this report, we present a case of single stage functional reconstruction of both peroneal tendons and overlying skin with an anterolateral thigh flap and vascularized fascia lata. A 55-year-old patient underwent wide excision of a synovial sarcoma in the distal lower leg, which resulted in a complex defect including the peroneus longus and brevis tendons (10 cm), and the overlying skin (14 × 8 cm). Functional reconstruction was achieved in a single stage with a composite anterolateral thigh flap with vascularized fascia lata of similar dimensions to those of the defect. The fascia lata component of the flap was longitudinally split in two segments. Each of them was rolled up, and that way, two separate vascularized neotendons were created. The neotendons bridged the gap of peroneal tendons, whereas the skin paddle of the flap provided stable soft tissue coverage to the reconstructed tendons. Flap pedicle was anastomosed to the anterior tibial vessels. Early and late postoperative periods were uneventful. Follow up at 1 year postoperatively showed excellent neotendon incorporation, as well as a very good functional and aesthetic outcome. The use of the method described may be a useful alternative in single stage functional reconstruction of composite defects comprising two or even more tendons and the overlying skin.

Chronic Rupture of the Peroneal Tendons

Chronic rupture of the peroneal tendons can be a functionally limiting condition with a multitude of causes. Conservative and operative interventions are heterogenous and tailored to the functional demands of the patient. Surgical plans are based on muscle viability, patient preference, and surgeon expertise. Clinical outcomes evidence remains limited in this domain, and further well-designed studies are warranted to guide treatment.

CT and MR Imaging of the Postoperative Ankle and Foot

A variety of surgical procedures exist for repair of both traumatic and degenerative osseous and soft-tissue pathologic conditions involving the foot and ankle. It is necessary for the radiologist to be familiar with these surgical procedures, so as to assess structural integrity, evaluate for complicating features, and avoid diagnostic pitfalls. Adequate interpretation of postoperative changes often requires access to surgical documentation to evaluate not only the surgery itself but the expected timeline for resolution of normal postoperative changes versus progressive disease. Appropriate use of surgical language in radiology reports is another important skill set to hone and is instrumental in providing a high-quality report to the referring surgeons. The pathophysiology of a myriad of surgical complaints, beginning from the Achilles tendon and concluding at the plantar plate, are presented, as are their common appearances at computed tomography and magnetic resonance imaging. Commonly encountered entities include Achilles tendon tear, spastic equinus, nonspastic equinus, talar dome osteochondral defect, tarsal tunnel syndrome, plantar fasciitis, pes planovalgus, pes cavovarus, peroneal tendinosis, lateral ligament complex pathology, Morton neuroma, plantar plate tear, and metatarsophalangeal joint instability. Computer-generated three-dimensional models are included with many of the procedures to provide a more global view of the surgical anatomy. Correlation with intraoperative photographs is made when available. When appropriate, discussion of postoperative complications, including entities such as infection and failure of graft integration, is presented, although a comprehensive review of postoperative complications is beyond the scope of this article. Notably absent from the current review are some common foot and ankle procedures including hallux valgus and hammertoe corrections, as these are more often evaluated radiographically than with cross-sectional imaging. ^©RSNA, 2016.

Proximal peroneus longus tear: rare case in a teenage athlete and review of the literature

We present the case of a 15-year-old teenager who sustained an ankle inversion injury while playing American football, which yielded only minimal pain, but also foot numbness and a lateral leg bulge. Magnetic resonance imaging evaluation revealed a proximal peroneal tear. These rare injuries are often associated with compartment syndrome, a surgical emergency, which was ultimately excluded clinically in this patient. Relevant anatomy, mechanism of injury, and clinical manifestations are discussed.

Effectiveness of Allograft Reconstruction vs Tenodesis for Irreparable Peroneus Brevis Tears: A Cadaveric Model

BACKGROUND

Irreparable peroneus brevis tendon tears are uncommon, and there is scant evidence on which to base operative treatment. Options include tendon transfer, segmental resection with tenodesis to the peroneus longus tendon, and allograft reconstruction. However, the relative effectiveness of the latter 2 procedures in restoring peroneus brevis function has not been established.

METHODS

Custom-made strain gage-based tension transducers were implanted into the peroneus longus and brevis tendons near their distal insertions in 10 fresh-frozen cadaver feet. Axial load was applied to the foot, and the peroneal tendons and antagonistic tibialis anterior and posterior tendons were tensioned to 50% and 100% of physiologic load. Distal tendon tension was recorded in this normal condition and after sequential peroneus brevis-to-longus tenodesis and peroneus brevis allograft reconstruction. Measurements were made in 5 foot inversion/eversion and plantarflexion/dorsiflexion positions.

RESULTS

Distal peroneus brevis tendon tension after allograft reconstruction significantly exceeded that measured after tenodesis in all tested loading conditions (P ≤ 0.022). With 50% of physiologic load applied, peroneus brevis tension was 1% to 28% of normal (depending on foot position) after tenodesis and 73% to 101% of normal after allograft reconstruction. Under the 100% loading condition, peroneus brevis tension was 6% to 43% of normal after tenodesis and 88% to 99% of normal after reconstruction with allograft. Distal peroneus longus tension remained within 20% of normal under all operative and loading conditions.

CONCLUSION

Allograft reconstruction of a peroneus brevis tendon tear in this model substantially restored distal tension when the peroneal tendons and their antagonists were loaded to 50% and 100% of physiologic load. Tenodesis to the peroneus longus tendon did not effectively restore peroneus brevis tension under the tested conditions.

CLINICAL RELEVANCE

Because tenodesis was demonstrated to be ineffective for restoration of peroneus brevis function, this procedure may result in an imbalanced foot clinically.

Management of sports injuries of the foot and ankle

Sporting injuries around the ankle vary from simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover and may threaten the career of a professional athlete. Some of these injuries can be easily overlooked altogether or misdiagnosed with potentially devastating effects on future performance. In this review article, we cover some of the common and important sporting injuries involving the ankle including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:874–83.

Outcome of Lateral Transfer of the FHL or FDL for Concomitant Peroneal Tendon Tears

BACKGROUND

Concomitant tears of the peroneus longus and brevis tendons are rare injuries, with literature limited to case reports and small patient series. Only 1 recent study directly compared the results of single-stage lateral deep flexor transfer, and no previous series objectively evaluated power and balance following transfer. The purpose of this study was to evaluate clinical outcomes, patient satisfaction, and objective power and balance data following single-stage flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendon transfers for treatment of concomitant peroneus longus and brevis tears.

METHODS

Over an 8-year period (2005-2012), 9 patients underwent lateral transfer of the FHL or FDL tendon for treatment of concomitant peroneus longus and brevis tears. All but 1 patient underwent additional procedures to address hindfoot malalignment or other contributing deformity at the time of surgery. Mean age was 56.9 years, and average body mass index was 27.9. Lateral transfer of the FHL was performed in 5 patients, and FDL transfer performed in 4 with mean follow-up 35.7 months (range: 11-94). Eight of 9 patients completed SF-12 and Foot Function Index (FFI) scores, and 7 returned for range of motion (ROM) and manual strength testing of the involved and normal extremities. These 7 patients also completed force plate balance tests, in addition to peak force and power testing on a PrimusRS machine with a certified physical therapist.

RESULTS

All patients were satisfied with the results of the procedure. Mean SF-12 physical and mental scores were 32 and 55, respectively; mean FFI total score was 56.7. No postoperative infections were noted. Two patients continued to utilize orthotics or braces, and 2 patients reported occasional pain with weightbearing activity. Three patients noted mild paresthesias in the distribution of the sural nerve and 2 demonstrated tibial neuritis. All patients demonstrated 4/5 eversion strength in the involved extremity. Average loss of inversion and eversion ROM were 24.7% and 27.2% of normal, respectively. Mean postoperative eversion peak force and power were decreased greater than 55% relative to the normal extremity. Patients demonstrated nearly 50% increases in both center-of-pressure tracing length and velocity during balance testing. There were no statistically significant differences between the FHL and FDL transfer groups with regards to clinical examination or objective power and balance tests.

CONCLUSION

The FHL and FDL tendons were both successful options for lateral transfer in cases of concomitant peroneus longus and brevis tears. Objective measurements of strength and balance demonstrated significant deficits in the operative extremity, even years following the procedure. These differences, however, did not appear to alter or inhibit patient activity levels or high satisfaction rates with the procedure. Although anatomic studies have demonstrated benefits of FHL transfer over the FDL tendon, further studies with increased patient numbers are needed to determine if these differences are clinically significant.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Audit of foot and ankle surgeons' management of acute peroneal tendon tears and review of management protocols

INTRODUCTION

The aim of this audit was to identify whether there is consistent and successful management of acute peroneal tendon tears within orthopaedic foot and ankle consultants in the Wessex area of the UK. It was suspected that there was an absence of consistency between surgeons' practices and a more evidenced based management protocol could be developed.

MATERIALS AND METHODS

A questionnaire of the orthopaedic surgeons in Wessex investigated whether there was consistency in surgical management of peroneal tears.

RESULTS

Our results demonstrate that each of the nine surgeons' management of acute peroneal tendon tears varied greatly.

CONCLUSION

The evidence in the literature was examined in an attempt to produce a protocol to aid surgical decision-making. A randomised controlled trial is required for consistent evidenced based surgical management of peroneal tendon tears.

Rehabilitation after surgical treatment of peroneal tendon tears and ruptures

PURPOSE

The purpose of this study was to provide an overview of the available evidence on rehabilitation programmes after operatively treated patients with peroneal tendon tearsand ruptures.

METHODS

A systematic review was performed, and PubMed and EMBASE were searched for relevant studies. Information regarding the rehabilitation programme after surgical management of peroneal tendon tears and ruptures was extracted from all included studies.

RESULTS

In total, 49 studies were included. No studies were found with the primary purpose to report on rehabilitation of surgically treated peroneal tendon tears or ruptures. The median duration of the total immobilization period after primary repair was 6.0 weeks (range 0-12), 7.0 weeks (range 3.0-13) after tenodesis, 6.3 weeks (range 3.0-13) after grafting, and 8.0 weeks (range 6.0-11) after end-to-end suturing. Forty one percent of the studies that reported on the start of range of motion exercises initiated range of motion within 4 weeks after surgery. No difference was found in duration of immobilization or start of range of motion between different types of surgical treatment options.

CONCLUSION

Appropriate directed rehabilitation appears to be an important factor in the clinical success of surgically treated peroneal tendon tears and ruptures. There seems to be a trend towards shorter immobilization time and early range of motion, although there is no consensus in the literature on best practice recommendations for optimizing rehabilitation after surgical repair of peroneal tendon tears or ruptures. It is important to adjust the rehabilitation protocol to every specific patient for an optimal rehabilitation.

LEVEL OF EVIDENCE

Systematic Review, Level IV.

High-resolution US and MR imaging of peroneal tendon injuries

Injuries of the peroneal tendon complex are common and should be considered in every patient who presents with chronic lateral ankle pain. These injuries occur as a result of trauma (including ankle sprains), in tendons with preexisting tendonopathy, and with repetitive microtrauma due to instability. The peroneus brevis and peroneus longus tendons are rarely torn simultaneously. Several anatomic variants, including a flat or convex fibular retromalleolar groove, hypertrophy of the peroneal tubercle at the lateral aspect of the calcaneus, an accessory peroneus quartus muscle, a low-lying peroneus brevis muscle belly, and an os peroneum, may predispose to peroneal tendon injuries. High-resolution 1.5-T and 3-T magnetic resonance (MR) imaging with use of dedicated extremity coils and high-resolution ultrasonography (US) with high-frequency linear transducers and dynamic imaging are proved to adequately depict the peroneal tendons for evaluation and can aid the orthopedic surgeon in injury management. An understanding of current treatment approaches for partial- and full-thickness peroneal tendon tears, subluxation and dislocation of these tendons with superior peroneal retinaculum (SPR) injuries, intrasheath subluxations, and peroneal tendonopathy and tenosynovitis can help physicians achieve a favorable outcome. Patients with low functional demands do well with conservative treatment, while those with high functional demands may benefit from surgery if nonsurgical treatment is unsuccessful. Radiologists should recognize the normal anatomy and specific pathologic conditions of the peroneal tendons at US and MR imaging and understand the various treatment options for peroneal tendon and SPR superior peroneal retinaculum injuries. Online supplemental material is available for this article.

Peroneal Tendon Disorders

Peroneal tendon pathology is often found in patients complaining of lateral ankle pain and instability. Conditions encountered include tendinosis; tendinopathy; tenosynovitis; tears of the peroneus brevis, peroneus longus, and both tendons; subluxation and dislocation; and painful os peroneum syndrome. Injuries can be acute as a result of trauma or present as chronic problems, often in patients with predisposing structural components such as hindfoot varus, lateral ligamentous instability, an enlarged peroneal tubercle, and a symptomatic os peroneum. Treatment begins with nonoperative care, but when surgery is required, reported results and return to sport are in general very good.

Peroneal Tendon Reconstruction and Coverage for Treatment of Septic Peroneal Tenosynovitis: A Devastating Complication of Lateral Ankle Ligament Reconstruction With a Tendon Allograft

Septic peroneal tenosynovitis is a rare and significant challenge. A search of peer-reviewed published studies revealed only 5 case reports to guide treatment, none of which resulted in significant loss of both peroneal tendons necessitating reconstruction. No clear guidance is available regarding how to provide reliable reconstruction of both peroneal tendons after a significant loss secondary to septic tenosynovitis. In the present report, we describe the case of a young, active-duty soldier who underwent lateral ankle ligament reconstruction with a tendon allograft whose postoperative course was complicated by septic peroneal tenosynovitis resulting in significant loss of both peroneal tendons. Reconstruction was achieved in a staged fashion with the use of silicone rods and external fixation to maintain physiologic tension and preserve peroneal tendon function, followed by reconstruction of both peroneal tendons and the superior peroneal retinaculum with a tensor fascia lata autograft. Soft tissue coverage was obtained with an anterolateral thigh free tissue transfer and a split-thickness skin graft. The patient returned to full activity as an active-duty soldier with minimal pain and no instability of the right lower extremity. The muscle strength of both peroneal tendons remained at 5 of 5, and no objective findings of ankle instability were seen at 3.5 years postoperatively.

Long-term results of debridement and primary repair of peroneal tendon tears

BACKGROUND

Peroneal tendon tears are relatively common; however, there are few reports on the long-term success of operative treatment. The purpose of this study was to review the long-term clinical and patient-reported outcomes of a cohort of patients with peroneal tendon tears treated with debridement and primary repair.

METHODS

Patients who underwent debridement and primary repair of tears of the peroneus longus and brevis from 1994 to 2008 were included in the study. A chart review was performed to determine patient demographics, postoperative complications, and return to sport. Clinical outcomes scores used to assess patients preoperatively and at most recent follow-up included a visual analog scale (VAS) for pain, the SF-12 Health Survey, and the Lower Extremity Functional Scale (LEFS) questionnaire.

RESULTS

We identified 34 patients with a tear of one or both peroneal tendons treated operatively by a single surgeon. Eighteen patients participated in the follow-up survey with an average follow-up time of 6.5 years (range, 2-14 years). There was significant improvement in mean VAS pain scores at the time of final follow-up (P < .001) from a mean of 39 (range, 0-80) preoperatively to a mean of 10 (range, 0-52) postoperatively. In addition, there was a significant increase in the LEFS score from a mean of 45 (range, 23-70) preoperatively to a mean of 71 (range, 24-80) postoperatively (P < .001). Of the 18 patients who responded, 17 returned to full sporting activity without limitation. There were no reoperations or operative failures during this time interval.

CONCLUSIONS

Our study found excellent long-term functional outcomes for patients with tears of the peroneal tendons treated with debridement and primary operative repair. Moreover, we observed that the majority of patients returned to their previous level of activity without the need for reoperation or revision of the repair.

LEVEL OF EVIDENCE

Level IV, case series.

Tear of peroneus longus in long distance runners due to enlarged peroneal tubercle

Background

Tear of the Peroneus longus in association with a prominent peroneal tubercle is rare.

Case presentation

Recently we treated two long distance runners who developed lateral ankle pain. Maximum tenderness was located over the lateral surface of the heel in the area of the peroneal tendons. Imaging disclosed a tear of the peroneus longus at the area of the peroneal tubercle.

Conclusion

Following resection of the peroneal tubercle and repair of the peroneus longus, both patients regained full activity with no pain. This report describes the clinical presentation and surgical management of this rare injury.

Anatomic comparison of lateral transfer of the long flexors for concomitant peroneal tears

BACKGROUND

Lateral transfers of the flexor hallucis longus (FHL) or flexor digitorum longus (FDL) tendons have been described for treatment of concomitant, irreparable peroneal tears. This study evaluated the anatomic benefits and constraints of lateral FHL and FDL tendon transfers with regard to available tendon length, diameter, and proximity to the posterior neurovascular bundle.

METHODS

In 9 cadaveric specimens, the FHL and FDL tendons were transected through a medial approach distal to the knot of Henry. Each tendon was transferred into a lateral incision, passing the FDL tendon both posterior and anterior to the tibial neurovascular bundle. The tendons were individually secured to the base of the fifth metatarsal with the foot in maximal eversion and dorsiflexion. The length of donor tendon available for fixation at the fifth metatarsal was measured. After the FDL tendon transfer was secured, the posterior neurovascular bundle was examined for signs of compression.

RESULTS

Average FHL tendon diameter measured 5.1 mm; the FDL measured 4.5 mm. After passage through a bone tunnel, an additional 4.9 cm of FHL tendon remained to suture to itself; only 0.5 cm remained for the posterior and anterior FDL transfers. Transfer of the FHL did not increase muscle bulk within the retrofibular groove. Every FDL transfer posterior to the neurovascular bundle produced obvious visual compression of the tibial nerve with plantar flexion and inversion of the foot.

CONCLUSION

Use of the FHL tendon for lateral transfer consistently provided sufficient length of tendon for multiple fixation options and a stronger muscle for transfer. Fixation options for the FDL were limited due to its shorter length. Lateral transfer of the FDL tendon posterior to the neurovascular bundle caused visible compression on the tibial nerve with ankle and hindfoot range of motion.

CLINICAL RELEVANCE

This anatomic study confirmed several advantages for the use of the FHL tendon transfer in cases of concomitant peroneal tears.

Isolated inferior peroneal retinculum tear in professional soccer players

INTRODUCTION

Peroneal tendon dislocations are rare injuries that can easily be misdiagnosed. Up to date literature mostly describes proximal peroneal tendon dislocations due to superior peroneal retinaculum (SPR) tear. In this article, we present the assessment, diagnostic algorithm and a new therapeutic option for the distal dislocation of the long peroneal tendon due to isolated inferior peroneal retinaculum (IPR) tear.

PATIENTS AND METHODS

Between 2001 and 2011 three patients with distal peroneal tendon dislocation were operated. All of them were competitive athletes in the national soccer league. They presented with an ankle sprain and prolonged problems on the lateral side of the foot with no improvement after conservative therapy measures. Coleman block test was performed; ultrasound and MRI showed a tendon dislocation under the IPR. The patients underwent surgical repair that consisted of peroneal tubercle excision, a new lateral calcanear groove formation for both peroneal tendons and IPR plasty.

RESULTS

At the two year follow up the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score showed a significant increase. The decrease of painful stimuli assessed by a Visual Analogue Scale (VAS) was significant as well. At an average of 12 weeks after the surgery, the patients returned to their level of sport activity before injury and didn't report similar problems later.

CONCLUSION

Description of distal peroneal tendon dislocations is limited in the literature. This topic should be considered in differential diagnostics of an acute and chronic ankle sprain which leads to chronic ankle pain and instability. The authors recommend surgical treatment as a method of choice especially in professional athletes.

Endoscopic management of recalcitrant retrofibular pain without peroneal tendon subluxation or dislocation

Peroneal tendon pathology is not uncommonly encountered behind the lateral malleolus and presented as retrofibular pain. The three primary categories of peroneal tendon disorders include tendinitis and tenosynovitis, tendon subluxation and dislocation, and tendon tears and ruptures. We described an approach of endoscopic groove deepening and endoscopic assisted repair of longitudinal peroneal tendon tears in management of recalcitrant retrofibular pain without peroneal tendon subluxation or dislocation.

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.