Prevalence of Peroneal Tendon Instability in Calcaneus Fractures: A Systematic Review and Meta-Analysis

Prevalence and Predictors of Peroneal Tendon Instability Accompanying Calcaneal Fractures

BACKGROUND

We aimed to find the prevalence of peroneal tendon instability (PTI) accompanying different types of calcaneal fractures and to determine predictors of PTI based on preoperative CT scanning.

METHODS

In a retrospective cross-sectional study, preoperative CT scans of 400 consecutive calcaneal fractures undergoing surgery were reviewed for comminuted fragments in the lateral gutter of the ankle, fractures at the tip of the lateral malleolus, dislocated peroneal tendons, excessive displacement of the lateral calcaneal wall, calcaneal fracture-dislocation, superior peroneal retinaculum (SPR) avulsion fracture (fleck sign), and shape of the retromalleolar groove. The correlation of these variables with intraoperative SPR stress test, defined as the diagnostic criteria for PTI in calcaneal fractures, was evaluated.

RESULTS

In total, 369 patients (mean age, 39 ± 13; range, 11-72 years), with 321 (87.0%) of them male, were included. Among all calcaneal fractures, 67 cases (16.7%) had associated PTI as confirmed intraoperatively by an SPR stress test. A statistically significant association was found between PTI in calcaneal fractures and comminuted fragments in the lateral gutter of the ankle (P = .03), dislocated peroneal tendons (P < .001), calcaneal fracture-dislocation (P < .001), SPR avulsion fracture (P < .001), and Sanders type IV of calcaneal fracture (P = .02). There was no statistically significant relationship between PTI and the mechanism of injury (P = .98), side of fracture (P = .30), uni- or bilateral calcaneal fractures (P = .27), a fracture at the tip of lateral malleolus (P = .69), shape of the retromalleolar groove (P = .78), or excessive displacement of the lateral calcaneal wall (P = .06). The most specific CT finding to predict PTI accompanying calcaneal fractures was calcaneal fracture-dislocation (99.1%).

CONCLUSION

Following calcaneal fracture fixation, PTI was confirmed with intraoperative SPR stress test in one-sixth of cases. With the exception of calcaneal fracture-dislocation, preoperative findings on CT scanning and calcaneal fracture pathoanatomy are insufficient to diagnose PTI accompanying calcaneal fractures.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Clinical Outcomes Following Suturing of Sheath of Peroneal Tendons to the Calcaneal Plate as an Innovative Technique for Reduction of Peroneal Tendon Instability Accompanying Calcaneal Fracture

BACKGROUND

The aim of the study was to evaluate the clinical and functional outcomes following suturing of sheath of peroneal tendons to the calcaneal plate as an innovative technique for reduction of peroneal tendon instability (PTI) accompanying calcaneal fracture surgically treated via extensile lateral approach (ELA).

METHODS

In a retrospective comparative study, among 245 operatively treated calcaneal fractures through ELA, we had 33 cases with PTI who underwent relocation of the peroneal tendons with ethibond suture in a figure-of-8 shape, passed through 2 parts of sheath of peroneal tendons and stitched to the calcaneal plate. Of the 33 cases, 12 were evaluated in the experimental group. Twelve surgically treated calcaneal fractures without PTI were matched as the control group. The outcome of the patients was assessed by American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, Foot Function Index (FFI) percentage, Visual Analog Scale (VAS) pain, changes in Tegner activity level, maximal peroneal muscles strength testing, modified Star Excursion Balance Test (mSEBT), and triple hop for distance (THD) test. For the last 3 tests, the difference between operated and normal feet was calculated for each patient and this difference was compared between the 2 groups.

RESULTS

There was no statistically significant difference between the 2 groups for AOFAS Ankle-Hindfoot Scale (P = .09), FFI percentage (P = .12), VAS pain (P = .73), changes in Tegner activity level (P = .87), maximal peroneal muscles strength testing (P = .45), mSEBT (P > .05), and THD (P = .87) tests. We had a case with point tenderness on retromalleolar groove and 4 cases with paresthesia in the territory of the sural nerve in the experimental group in contrary to one case of sural nerve paresthesia in the control group (P = .31).

CONCLUSIONS

Relocation of peroneal tendons in PTI accompanying calcaneal fractures by fixing sheath of peroneal tendons to the calcaneal plate could be an acceptable procedure with good outcomes but may have increased chance of sural nerve injury.

LEVELS OF EVIDENCE

Therapeutic, Level III: Retrospective.

Hindfoot Fractures: Injury Patterns and Relevant Imaging Findings

The hindfoot consists of the talus and calcaneus, spans the tibiotalar to transverse tarsal joints, and is critical for support of body weight and absorption and transfer of physiologic loads during bipedal movements. Hindfoot fractures account for approximately 17% of foot and ankle fractures, with calcaneal fractures being more common than talar fractures. Hindfoot fractures are usually caused by high-impact axial loads such as falls from heights and motor vehicle accidents, and understandably, they are often seen in patients with polytrauma. Long term, these fractures have implications in development of posttraumatic osteoarthrosis with associated pain and stiffness, affecting daily living activities. An overview of the talus and calcaneus is presented, with emphasis on fractures with articular involvement-namely, the tibiotalar and subtalar joints. Articular talar and calcaneal injuries can also alter hindfoot alignment, causing ankle and foot function abnormalities. Optimal treatment-that is, restoration of articular surfaces and hindfoot alignment followed by rigid fixation until fracture union-is dependent on an accurate understanding of the injury that is well depicted with imaging, radiography and CT in particular. The discussion of talar and calcaneal fractures includes a review of the normal anatomy, epidemiologic factors, classification systems, and imaging and pathologic-anatomic features of common injury patterns. This review is intended to aid surgical management and restoration of articular and hindfoot alignment for optimal ankle and foot function, thereby reducing patient morbidity in these often devastating injuries. ^©RSNA, 2022.

Peroneus Longus and Peroneus Brevis: A Review on Pathology and Updated Treatments

»

Peroneus longus (PL) and peroneus brevis (PB) pathologies involve a variety of etiologies and degrees of dysfunction, which complicates their diagnoses.

»

Patient presentation includes a spectrum of disease; however, despite advanced imaging, a misunderstanding of the pathology and diagnostic algorithms has contributed to continued misdiagnoses.

»

This article summarizes the anatomy and the pathophysiology of the PL and the PB; it also provides updated treatment options and their associated outcomes in order to illuminate an often-misunderstood topic.

Osteosynthesis or primary arthrodesis for displaced intra-articular calcaneus fractures Sanders type IV - A systematic review

BACKGROUND

Displaced intra-articular calcaneus fractures (DIACF) Sanders type IV represent a challenge in its management and questions remain about the best treatment option available. This study aimed to compare the outcomes of primary subtalar arthrodesis (PSTA) and osteosynthesis in these fractures.

METHODS

Studies concerning DIACF Sanders type IV, from 2005 to 2020 were systematically reviewed. Only studies evaluating functional outcomes with American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS) score were admitted allowing for results comparison.

RESULTS

In total, 9 studies met the inclusion criteria. These reported on the results of 142 patients, from which 41 submitted to PSTA and 101 to osteosynthesis, with an average follow-up period over 2 years. We found a significant moderate negative correlation between the reported AOFAS score and the Coleman Methodology Score obtained. Late subtalar arthrodesis was 13.63% of the total osteosynthesis performed.

CONCLUSIONS

Clinical outcomes after PSTA and osteosynthesis, for the treatment of Sanders type IV fractures, do not seem very different, yet careful data interpretation is crucial. Additional powered randomized controlled trials are necessary to assess which surgical strategy is better.

Influence of tendon injuries on the clinical outcome of ankle and hindfoot fractures

BACKGROUND

Associations of tendon injuries with ankle and hindfoot fractures is a current concern and recent research has linked specific fractures with specific tendon injuries, despite its functional impact being unknown. The purpose of this study is to assess that impact.

METHODS

Computed tomography scans of patients with ankle and hindfoot fractures were reviewed for tendon injuries. Patients were clinically evaluated with the Visual Analogue Scale (VAS) and the Manchester-Oxford Foot Questionnaire (MOXFQ), via a telephonic interview.

RESULTS

Eighty-five patients were included in the study. The mean age was of 49.9 ± 16.5 (14-80) years and there were 43 females (50,6%). Mean follow-up was of 43,7 ± 15,1 (24,4-82,2) months. Tendon injuries were identified in 23 patients (27,1%) and the most common lesion was tendon entrapment. The tibialis posterior tendon (TP) was injured in 18 patients (21,2%) and comprised 58,1% of all tendon injuries. Tendon injuries were mostly associated with pilon fractures, which was the most common fracture type (44,7%). There was no clinical difference between patients with a tendon injury [VAS of 4,3 ± 2,6 (0-8) and MOXFQ score of 35,1 ± 22,4 (5-80)], and those without [VAS of 3,9 ± 2,5 (0-10) and MOXFQ of 34,3 ± 26,0 (0-95), respectively (p = 0,281 and 0,689)].

CONCLUSION

Tendon injuries were present in 27% of patients with ankle and hindfoot injuries. The most frequently injured tendon was the TP in association with pilon fractures, with entrapment being the most common lesion. These lesions, however, do not seem to reflect in a worse functional outcome at two years of follow-up.

Computed Tomography for Calcaneal Fractures: Adding Value to the Radiology Report

Computed tomography (CT) is nowadays the cornerstone for fracture pattern delineation in calcaneal fracture, and for operative planning. It is often challenging for radiologists in generating clinically oriented and meaningful CT reports to the orthopedic surgeon. The article aims to review the commonly encountered calcaneal injuries and highlight the key points in the description of these injuries and implications of the underlying classification system with respect to the surgeon's perspective. A thorough understanding of the pathoanatomy and potential complications of calcaneal fractures also helps radiologists in tailoring the radiology report in contribution to overall patient's management and prognostication. By doing so, we suggest ways in which the radiologists can add value to the radiology report.

Can We Release All Calcaneal Attachments of the Superior Peroneal Retinaculum During Extensile Lateral Approach to the Calcaneus?

During extensile lateral approach to the calcaneus, in order to see all fractured fragments and subtalar joint, all soft tissues including insertion site of superior peroneal retinaculum (SPR) on the calcaneus should be released. The aim of this study was to evaluate the probability of peroneal tendon dislocation by releasing all soft tissues attached to the calcaneus. In 10 fresh cadavers, after standard extensile lateral approach to the calcaneus in right side, all soft tissues attached to the lateral wall of the calcaneus were excised. In the left side of each cadaver, all soft tissues inserted to the superior border of calcaneal tuberosity in addition to the lateral wall of the calcaneus were cut out. Probable anterior dislocation of peroneal tendons in the retromalleolar groove was assessed by placing a clamp into the peroneal tendon sheath from distal to proximal and advancing it to the retromalleolar groove. Also by careful dissection, any instability of peroneal tendons was visualized. Not any anterior dislocation of peroneal tendons to the lateral malleolus tip was seen in any stage of the procedure. Insertions of the SPR to the fascia of the deep posterior compartment of the leg and the Achilles tendon sheath are the main soft tissue stabilizer of the peroneal tendons in the retromalleolar groove. So resection of the insertion site of the SPR to the calcaneus might not result in the peroneal tendon instabilities.

Combined subtalar distraction arthrodesis with peroneus brevis tenotomy for posttraumatic subtalar arthritis

BACKGROUND

Subtalar distraction arthrodesis is advocated as a salvage procedure for isolated posttraumatic subtalar arthritis. This study aimed at evaluating combined subtalar distraction arthrodesis with peroneus brevis tenotomy for such cases.

METHODS

Twenty patients with isolated posttraumatic subtalar arthritis managed by combined subtalar distraction arthrodesis and peroneus brevis tenotomy were reviewed for a retrospective study. The American orthopaedic foot and ankle society [AOFAS] hindfoot scoring, talocalcaneal height [TCH], talocalcaneal angle [TCA] and heel valgus angle [HVA] were used for both pre and postoperative assessments.

RESULTS

The mean postoperative [TCH] [70.3±1.9mm] was statistically better than the preoperative value [64.7±2.2mm] [p<0.001]. There was a statistically significant decrease in [HVA] [p<0.001]. On the contrary, there was a statistically significant increase in both [AOFAS] hindfoot scoring and the [TCA] [p<0.001].

CONCLUSIONS

Applying this technique for isolated posttraumatic subtalar arthritis with peroneal tendinitis improved both lateral retromalleolar swelling and deformity correction.

Peroneal tendon dislocation in talus fracture and diagnostic value of fleck sign

Introduction

Talus fractures are not uncommon and one of the serious fractures in the foot and ankle. Peroneal tendon dislocation is one of the commonly missed soft tissue injuries which may have significant impact on the outcomes including persistent pain and swelling. They have been reported to be associated with calcaneum as well as talus fractures.

Aim

To report the incidence of peroneal tendon dislocation in talus fracture and the significance of fleck sign in the diagnosis of peroneal tendon dislocation.

Methods

We retrospectively reviewed 93 consecutive talus fractures in the period between 1/1/2011 to 1/11/2018. Inclusion criteria were: The patient underwent open reduction and internal fixation, had pre-operative CT scan that is available for review and three view ankle plain radiographs. Two independent authors review the radiographs for peroneal tendon dislocation, fleck sign and fracture classification, if any. Any dispute was resolved by the senior author.Patient records were reviewed for laterality, age, sex,mode of injury, associated injuries and operative interventions. 50 ankles met the inclusion criteria. 49 were males, mean age was 32.5 year and the predominant mode of injury was a fall from height.

Results

Peroneal tendon dislocation was found in ten patients out of 50 (20%). Risk of dislocation increased with severity of the fracture and neck fractures. Most of the dislocations were missed by surgeons and radiologist, and no additional procedures were done to address such an injury. The Fleck sign had a statistically significant correlation with peroneal tendons dislocations (p=.005)

Conclusion

Peroneal tendons dislocation is associated with as high as 20% of talus fractures. The authors recommend carefully reviewing CT scans by surgeons and radiologists alike to avoid missing such injury and allow for appropriate surgical approach utilization. The Fleck sign is a highly specific radiographic sign that has a statistically significant correlation with PT dislocation and hence we recommend intra-operative assessment of peroneal tendons in patients with the fleck sign.

Clinical Management of Acute, Closed Displaced Intra-Articular Calcaneal Fractures

Performing a thorough clinical evaluation following an acute displaced intra-articular calcaneal fracture is paramount for optimal surgical timing and long-term outcome. Initial survey must entail a comprehensive evaluation to rule out concurrent injuries. Focused lower extremity examination must involve a complete neurovascular and soft tissue evaluation to identify such conditions as compartment syndrome or compromised integument, which necessitate urgent intervention. Establishing baseline radiographs and advanced imaging is vital for surgical planning. Once deemed stable, protocol-driven treatment is best to ensure proper control of pain and edema and adequate management of economic and patient safety concerns.