Peroneal Tendon Pathology: Treatment and Reconstruction of Peroneal Tears and Instability

Minimally Invasive Peroneal Tenodesis Assisted by Peroneal Tendoscopy: Technique and Preliminary Results

Introduction: Peroneal disorders are a common cause of ankle pain and lateral instability and have been described in as much as 77% of patients with lateral ankle instability. Clicking, swelling, pain, and tenderness in the peroneal tendons track are frequent symptoms, but they can be confused with other causes of lateral ankle pain. The management of peroneal disorders can be conservative or surgical. When the conservative treatment fails, surgery is indicated, and open or tendoscopic synovectomy, tubularization, tenodesis or tendon transfers can be performed. The authors present a surgical technique of tendoscopy associated to minimally invasive tenodesis for the treatment of peroneal tendon tears, as well as the preliminary results of patients submitted to this procedure. Methods: Four patients with chronic lateral ankle pain who were diagnosed with peroneal brevis pathology were treated between 2020 and 2022 with tendoscopic-assisted minimally invasive synovectomy and tenodesis. Using a 2.7 mm 30° arthroscope and a 3.0 mm shaver blade, the entire length of the peroneus brevis tendon and most parts of the peroneus longus tendon can be assessed within Sammarco's zones 1 and 2. After the inspection and synovectomy, a minimally invasive tenodesis is performed. Results: All patients were evaluated at least six months after surgery. All of them reported improvement in daily activities and in the Foot Function Index (FFI) questionnaire (pre-surgery mean FFI = 23.86%; post-surgery mean FFI = 6.15%), with no soft tissue complications or sural nerve complaints. Conclusion: The tendoscopy of the peroneal tendons allows the surgeon to assess their integrity, confirm the extent of the lesion, perform synovectomy, prepare the tendon for tenodesis, and perform it in a safe and minimally invasive way, reducing the risks inherent to the open procedure.

Snapping ankles: peroneal tendon subluxation and dislocation

Peroneal tendon dislocation or subluxation is an orthopaedic condition that usually occurs as a result of injury to the superior peroneal retinaculum. The peroneal muscles are located in the lateral compartment of the leg, and their tendons run in the retromalleolar groove anchored by the superior peroneal retinaculum. Peroneal instability is usually classified using the Eckert and Davies classification, which was modified by Oden into a four-point grading system. The mechanism of injury is typically sudden forced dorsiflexion, resulting in aggressive tautness of the peroneal tendons, combined with a forced eversion of the hindfoot. Plain X-ray, ultrasound and magnetic resonance imaging are useful for imaging of the injury and in planning for surgery. Operative management has high success rates and there are multiple surgical techniques available, including superior peroneal retinaculum repair, tenoplasty, bone block procedures, groove deepening and endoscopic approaches, with little variation in outcome found between the approaches.

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.

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.