Allograft reconstruction of peroneal tendons: operative technique and clinical outcomes

Dual Semitendinosus Allograft Reconstruction of Chronic Achilles Tendon Ruptures: Operative Technique and Outcomes

BACKGROUND

Dual semitendinosus allograft reconstruction of chronic Achilles tendon ruptures has several potential benefits including superior tensile strength compared with a turndown construct and avoidance of the morbidity and operative time associated with autograft augmentation. We present a series of chronic Achilles tendon ruptures reconstructed with dual semitendinosus allograft.

METHODS

We retrospectively reviewed the charts of patients aged 18 years and older who underwent reconstruction of chronic Achilles tendon ruptures using dual semitendinosus allograft. The primary outcome of this study was to evaluate the need for revision surgery. Secondary outcomes included patient-reported outcomes, for which Achilles Tendon Rupture Scores (ATRS) were collected at final follow-up. Nine patients with a mean age of 58.9 (range, 43-75) years met inclusion criteria.

RESULTS

Median follow-up was 66 months (range, 27-121 months). One patient (11.1%) required revision reconstruction after sustaining graft failure 9.5 years after her index procedure, and 1 patient reported a poor ATRS score at the 27-month final follow-up despite an intact surgical repair. At final follow-up, no patient required the use of an assistive device for ambulation or a walking boot. The median ATRS at final follow-up was 93 (range, 30-100).

DISCUSSION

Good clinical outcomes without rerupture were observed in 7 of 9 patients (77.8%) at short- to midterm follow-up, suggesting that dual semitendinosus allograft reconstruction is a viable option for the reconstruction of chronic Achilles tendon tears.

LEVEL OF EVIDENCE

Level IV, case series.

Ankle Instability

Ankle sprains are a common injury among physically active populations and occur with an incidence of around 2.15 per 1000 person-years. This article discusses various surgical procedures used to treat chronic lateral ankle instability, including direct ligament repair, anatomic reconstruction, and nonanatomic reconstruction. We focus our discussion on the most common and challenging complications of ankle stabilization, both in our experience and as supported by the existing literature, including recurrent instability, superficial peroneal nerve injury, and unaddressed pathology that continues to cause symptoms and limit function. We offer possible methods to manage these conditions as well as available outcome data.

Preoperative Gait Analysis of Peroneal Tendon Tears

BACKGROUND

Little is known regarding the impact of peroneal tendon tears on function. This study quantifies gait changes associated with operatively-confirmed peroneal tendon tears.

METHODS

Sixty-five patients with unilateral peroneal tendon tears were prospectively evaluated using preoperative 3D multisegment gait analysis of both limbs. Data were analyzed according to pattern/severity of tears, as confirmed surgically: peroneus brevis tears, reparable (PBR); peroneus brevis tears, irreparable (PBI); peroneus longus tears, irreparable (PLI); and concomitant irreparable tears of both tendons (PBI+PLI). The following parameters were analyzed: ankle sagittal motion, coronal motion, axial rotation, foot progression angle, sagittal power, sagittal moment.

RESULTS

Twelve patients (18.5%) had the PBR pattern, 37 (56.9%) PBI, 10 (15.4%) PLI, and 6 (9.2%) PBI+PLI. Compared with the contralateral, nonpathologic extremities, limbs with peroneal tears had diminished ankle sagittal motion (mean 23.14 vs 24.30 degrees, P = .012), ankle/hindfoot axial rotation (6.26 vs 7.23 degrees, P = .001), sagittal moment (1.16 vs 1.29 Nm/kg, P < .001), and sagittal power (1.24 vs 1.47 W/kg, P < .001). The most severe tear patterns had the greatest derangements in multiple parameters of gait (PBI+PLI > PBI or PLI > PBR). For example, all groups except PBR had loss of ankle sagittal moment and/or power in the affected limb, and the greatest losses in moment and power were in the PBI+PLI group (1.22 vs 0.91 Nm/kg, P = .003 for moment; 0.73 vs 1.31 W/kg, P < .001 for power). The PBI+PLI group had a >10-degree varus shift in coronal motion on the affected side (P = .002).

CONCLUSION

This is the first study to demonstrate diminished biomechanical function in patients with peroneal tendon tears. In vivo 3-dimensional gait analysis found significant changes in hindfoot motion, ankle motion, and ankle power. Impairments were related to the pattern and severity of the tears, and demonstrated a strong association of peroneal tendon tears with diminished ankle plantarflexion strength.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Clinical and Patient-Reported Outcomes Following Peroneus Brevis Reconstruction With Hamstring Tendon Autograft

BACKGROUND

Peroneal tendon injuries are a common cause of lateral ankle pain and instability. While the use of hamstring autograft has been proposed as a viable surgical option for peroneus brevis reconstruction, reported outcomes with this technique are limited in the literature. We present patient-reported and clinical outcomes for patients who underwent peroneus brevis reconstruction with hamstring autograft.

METHODS

Thirty-one patients were retrospectively identified who underwent a procedure including peroneus brevis reconstruction with hamstring autograft for peroneal tendinopathy between February 2016 and May 2019. All patients who had a peroneus brevis reconstruction were included, and all concomitant procedures were noted. Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were prospectively collected preoperatively and at a minimum of 1 year postoperatively (mean, 24.3; range, 12-52.7) months. Retrospective chart review was performed to evaluate the incidence of postoperative complications and reoperations.

RESULTS

When evaluating pre- and postoperative patient-reported outcome surveys (n = 26; 84%), on average, patients reported improvement in every PROMIS domain evaluated, with significant improvement in Physical Function (+5.99; P = .006), Pain Interference (-8.11; P < .001), Pain Intensity (-9.02; P < .001), and Global Physical Health (+7.29; P = .001). Three patients reported persistent pain at a minimum of 1 year postoperatively, of whom 2 required reoperation. No patient reported persistent pain or discomfort at the harvest site of the hamstring autograft.

CONCLUSION

Patients undergoing peroneus brevis reconstruction with hamstring autograft experienced clinically significant improvement in patient-reported and clinical outcomes. Few postoperative complications were observed, and patients reported improvements across all patient-reported outcome domains, with significant improvements for pain and function domains. Reconstruction with hamstring autograft represents a viable surgical option in the setting of peroneal tendinitis or tears.

LEVEL OF EVIDENCE

Level IV, case series.

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.

Clinical Outcomes of Peroneal Tendon Tears: A Systematic Review

The purpose of this study was to provide an overview of the available evidence on peroneal tendon tears and the outcomes after surgical intervention. A systematic review of the literature was performed using MEDLINE, Embase, and Cochrane. Criteria for inclusion were clinical studies reporting outcomes after treatment for peroneal tendon tear within the last 10 years. Nine studies evaluating 336 patients (146 males/190 females) and 336 ankles were included in this review. The mean age of included patients was 46.3 years (range, 46-56.9 years). The weighted mean follow-up was 23.82 months (range 9.2-78 months. Five surgical interventions were reported: primary repair with tenodesis, primary repair without tenodesis, FDL tendon transfer, FHL tendon transfer, and allograft reconstruction. Four studies recorded the AOFAS score, with a weighted mean preoperative score of 69.58 and a weighted mean postoperative score of 88.82. Six studies measured the VAS score showing an improvement from a mean weighted preoperative score of 4.68 to a mean weighted postoperative score of 1.2. FAAM score was measured in 3 studies, which showed an improvement from 41.1 preoperatively to 84.4 postoperatively. The average overall complication rate was 38.7% (130/336) with the most commonly reported minor complication being ankle pain, which made up 46.2% of all minor complications (56/121). Primary repair without tenodesis was associated with a higher complication rate compared to any other surgical intervention (p=.001176). The current systematic review showed that overall clinical outcomes were positive in lieu of the different modalities of surgical intervention for peroneal tendon tears.

Posterior Tibial Tendon Allograft Reconstruction for Stage II Adult Acquired Flatfoot: A Case Series

Surgical treatment for a stage II adult acquired flatfoot has consisted of reconstruction of the diseased posterior tibial tendon with flexor digitorum longus tendon transfer, combined with osteotomies to address the underlying deformity. This case series presents an alternative to tendon transfer using allograft tendon for posterior tibial tendon reconstruction. Four patients who underwent stage II flatfoot reconstruction with posterior tibial tendon allograft transplantation were included. All patients had preoperative radiographs demonstrating flatfoot deformity and magnetic resonance imaging showing advanced tendinopathy of the posterior tibial tendon. Allograft tendon transplant was considered in patients demonstrating adequate posterior tibial tendon excursion during intraoperative assessment. Additional procedures were performed as necessary depending on patient pathology. Postoperatively, all patients remained non-weightbearing in a short leg cast for 6 weeks. Radiographs performed during the postoperative course demonstrated well-maintained and improved alignment. No complications were encountered. Each patient demonstrated grade 5 muscle strength and were able to perform a single-limb heel rise at the time of final follow-up. The average follow-up duration was 19.0 months. Flexor digitorum longus transfer has been studied extensively for stage II adult acquired flatfoot. However, the flexor digitorum longus has been shown to be much weaker relative to the posterior tibial tendon, and concern remains regarding its ability to recreate the force of the posterior tibial tendon. Our results demonstrate that posterior tibial tendon allograft reconstruction combined with flatfoot reconstruction is a reasonable option. This alternative has the advantage of preserving the stronger muscle without disturbing regional anatomy.

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.

Pathologies of the Peroneals: A Review

Peroneal tendon disorders remain an often overlooked source of lateral hindfoot pain and tenderness. Medical professionals who specialize in foot and ankle care are still far more likely to diagnose a peroneal tendon disorder as an ankle injury. In fact, acute peroneal dislocations are misdiagnosed in up to 40% of cases. The major subsets of peroneal disorders include peroneal tendonitis and tenosynovitis, painful os peroneum syndrome, subluxation, and tearing of the peroneal tendons. Proper history and physical exam maneuvers must be performed to help identify the source of the injury and differentiate these categories. Detailed imaging through X-ray and magnetic resonance imaging must also be used to diagnose the etiology of the patient's condition in order to direct management. Currently, there is very limited knowledge on peroneal pathologies, and treatment protocol is highly variable and limited to expert opinion. Despite the individual preferences and nuances held by each surgeon when it comes to operating, the overarching principles that guide appropriate management of tendonitis, subluxation, and tendon tear should maintain a higher level of consistency. Therefore, the authors of this review aim to elucidate the most current methods to diagnose these disorders as well as evidence-based practices for optimal management.Levels of Evidence: Level V.

Load to Failure and Stiffness of Interference Screw vs Pulvertaft Weave for Distal Fixation in Peroneal Allograft Reconstruction

BACKGROUND

Allograft reconstruction of the peroneal tendons is an option for treatment of major tears of 1 or both peroneal tendons. No consensus on a superior distal fixation method has been reported. The purpose of the study was to compare load to failure and stiffness of a Pulvertaft weave (PTW) through a residual tendon stump to direct-to-bone interference screw (IS) fixation.

METHODS

Fifteen pairs of long leg cadaver specimens were used. All grafts were secured proximally to the peroneus brevis myotendinous junction via a PTW technique. Distally, the tendons were either sutured to the peroneus brevis stump via PTW or secured to the base of the fifth metatarsal via IS. Stiffness (slope of force/displacement) was measured for the intact tendon and after reconstruction, and finally each specimen was loaded to failure.

RESULTS

Mean load to failure was significantly higher in the PTW group compared with the IS group (373.6 ± 265.5 N vs 150.1 ± 93.1 N; P = .01). The PTW and IS groups had significantly lower stiffness compared with the intact specimens (P < .001). There was no statistical significance in stiffness between the 2 techniques (P = .96).

CONCLUSION

The PTW technique yielded higher load to failure in comparison to IS. There was no difference in overall construct stiffness between both techniques. Both constructs demonstrated 19% decrease in stiffness compared to the intact state.

CLINICAL RELEVANCE

The PTW and IS constructs were biomechanically similar, and these results suggest that both should be moderately overtensioned to compensate for an inherent decreased initial stiffness.

Revision Surgery for Peroneal Tendon Tears

Peroneal tendon tears that require revision are rare and often present a unique challenge for foot and ankle surgeons. Biomechanical issues that may be present or missed initially need to be addressed and evaluated thoroughly for an optimized outcome. Tendon degeneration is usually present, and planning for tendon transfer or tendon graft is necessary to improve mechanical strength. The use of MRI can aid in preoperative planning and identification of concomitant disorders that may be present. The postoperative rehabilitation is often longer and patient education is imperative to manage expectations of 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.

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.

Minimally invasive tenodesis for peroneus longus tendon rupture: A case report and review of literature

BACKGROUND

Peroneal tendon disorders are common causes of lateral hindfoot pain. However, total rupture of the peroneal longus tendon is rare. Surgical treatment for this condition is usually a side-to-side tenodesis of the peroneal longus tendon to the peroneal brevis tendon. While the traditional procedure involves a long lateral curved incision, this approach is associated with damage to the lateral soft tissues (up to 24% incidence).

CASE SUMMARY

A 50-year-old female had developed pain at the lateral aspect of the hindfoot 1 mo after an ankle sprain while walking in the street. Previous treatments were anti-inflammatory drugs, ice, rest and Cam-walker boot. At physical exam, there was pain and swelling over the course of the peroneal tendons. Ankle instability and cavovarus foot deformity were ruled out. Eversion strength was weak (4/5). Imaging showed complete rupture of the peroneal longus tendon associated with a sharp hypertrophic peroneal tubercle. Surgical repair was indicated after failure of conservative treatment (physiotherapy, rest, analgesics, and ankle stabilizer). A less invasive approach was performed for peroneal longus tendon debridement and side-to-side tenodesis to the adjacent peroneal brevis tendon, with successful clinical and functional outcomes.

CONCLUSION

Peroneus longus tendon tenodesis can be performed through a less invasive approach with preservation of the lateral soft tissue integrity.

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.

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.

Reconstruction of the Peroneus Brevis Tendon Tears with Semitendinosus Tendon Autograft

Peroneal tendon disorders are common causes of lateral and retromalleolar ankle pain. For irreparable tears of the tendon, a salvage procedure is indicated with segmental resection followed by reconstruction with tenodesis, tendon transfer, or bridging the defect using allograft or autograft. Although there is insufficient evidence to guide which of these treatment options provides the best outcomes, reconstruction with tendon allograft has provided satisfactory clinical results and is effective for pain relief and restoration of tendon function. However, there are concerns about the use of tendon allografts which include its cost and availability, disease transmission, delayed incorporation, and stretching of the graft. The aim of this study is to present the surgical technique for the reconstruction of the peroneus brevis tendon tears using semitendinosus tendon autograft as an alternative to the allograft and report the short-term results of three cases.

Anatomic Reconstruction of Lateral Ankle Ligaments and Both Peroneus Tendons After Open Fracture Dislocation of the Ankle: A Case Report

Extensive soft tissue defects of the ankle are an uncommon but challenging problem that require a combination of reconstructive options. We report the case of a complex injury involving the skin, lateral ankle ligaments, and peroneal tendons that were anatomically reconstructed. A 15-year-old girl was injured in an automobile accident resulting in extensive soft tissue defects and marked instability of her right ankle. The lower two-thirds of the anterior talofibular ligament (ATFL) had segmental defects, and calcaneofibular ligament (CFL) was completely torn, and both peroneal longus and brevis tendons were severely damaged. Initial debridement was performed on the day on injury. Two weeks after injury, the ATFL and CFL were reconstructed using a semitendinosus autograft and suture tape augmentation. Both peroneal tendons were reconstructed using a gracilis autograft. The skin defect (10 × 10 cm) was covered with an anterolateral thigh flap. After removing a short leg cast at 3 weeks postoperatively, the patient started range of motion exercises without using any brace. Weightbearing was allowed at 4 weeks. At the 24-month follow-up examination, she had returned to her preoperative level of work and sports activities.

Use of Cadaveric Graft in Reconstruction of Peroneus Brevis Rupture and Lateral Ankle Instability A Case Report

This case study presents a novel technique of end-to-end implantation of cadaver graft for the repair of a complete transversely torn peroneus brevis tendon and partially torn peroneus longus tendon in a 58-year-old woman with chronic lateral ankle instability and associated lateral collateral tears. She had a history of multiple ankle sprains and had previously undergone a failed peroneus brevis tendon retubularization procedure. The use of cadaver graft is well documented in the literature for tendon repairs but not well documented in end-to-end repair of the peroneal tendons. A review of the literature revealed only one 2013 study reporting on the benefits and clinical outcomes of cadaver allograft use in peroneal reconstruction.

A quality improvement pilot assessment of the safety and associated outcomes of a viable cryopreserved umbilical tissue allograft as an adjunct surgical wrap in peroneus brevis tendon repair

Surgical tendon repairs of the lower extremity are frequently associated with post-operative (post-op) risks that result in poor patient outcomes. Initially, increased pain levels may contribute to extended post-op rehabilitation while the development of tissue adhesions and fibrosis limit long-term functionality through reduced range of motion. Several surgical methods describing incorporation of various augmentative graft materials in tendon repair exist. However, reports demonstrating technique and both short- and long-term patient outcomes are lacking. Recently, advances in tissue preservation technology have led to the commercialization of human placental allografts. Of these available allogeneic biomaterials, the components found in human placental membranes may provide anti-inflammatory, antimicrobial, anti-adhesive, and antifibrotic properties to benefit surgical outcomes.Here, the authors introduce and technically describe the use of a viable cryopreserved umbilical tissue (vCUT) (Stravix, Osiris Therapeutics, Inc., Columbia, MD) as a complementary surgical wrap in primary tendon repair, with particular focus on the peroneus brevis. A pilot study was undertaken to assess the safety and potential for secondary rehabilitative outcomes associated with the use of vCUT in 5 tendon repair cases. The use of vCUT as a surgical tendon wrap was evaluated via the following primary endpoints at post-op day 7:Secondary investigative endpoints included clinical and rehabilitative outcome measures for comparative pain reduction and transition times to both controlled ankle movement (CAM) boot and normal shoe ambulation.All patients were followed for an average of 24.15 months (range 16.75-26.5 months) after surgery. For primary safety measures, erythema, tenderness, drainage, heat, and swelling was absent in all 5 surgical sites. None of the patients required post-op use of narcotics past day 7. The potential for long-term rehabilitative improvement with adjunct use of vCUT was also demonstrated through reduced pain and reduced transition times to functional and non-assisted ambulation in normal shoewear as compared to historical controls managed without vCUT.This surgical technique is simple and safe for patients and preliminary findings have demonstrated favorable clinical and rehabilitative outcomes over historically observed controls.

Chronic Achilles Ruptures: Reconstructive Options

Achilles tendon ruptures, if neglected or identified late, lead to impairments in function and gait. Surgical reconstruction is typically required to restore the resting length and tension to the gastrocnemius-soleus complex. A variety of reconstructive options have been described, depending on several factors, including chronicity, residual gap size, remaining tissue quality and vascularity, location of tendon rupture or deficiency, and patient-specific factors. Despite the many surgical options described from local soft-tissue rearrangements and tendon transfers, to the use of allograft tissue and synthetic material augmentation, there is understandably a paucity of evidence-based guidelines available to direct surgeons in the optimal procedure for each patient-specific situation. Reconstructive options for the patient with a chronic Achilles rupture are detailed and reviewed here, to serve as a framework for the treating surgeon in these complex cases.

Soft Tissue Reconstruction with Artelon for Multiple Foot and Ankle Applications

Surgical repair of tendons of the foot and ankle is performed utilizing various methods, including autografts, allografts, and synthetic grafts. Artelon is a synthetic biomaterial that is fabricated from wet-spun fibers of PCL-based polyurethane urea, and has, optimal mechanical properties compared with other grafting options. Because of excellent results of Artelon in ACL reconstruction, its use was explored in 3 foot and ankle cases: repair of Achilles, posterior tibial, and peroneal tendons. Artelon has proven to be a successful alternative for tendon repairs, with all 3 cases returning to full function within 8 to 16 weeks and with no complications related to the graft.

Postoperative Imaging of the Ankle

OBJECTIVE

The purpose of this article is to review imaging after commonly encountered surgical interventions of the ligaments, tendons, and soft tissues around the ankle. Intraoperative images, when available, are provided to improve conceptual understanding of these complex procedures.

CONCLUSION

Surgical interventions in the ankle are becoming more prevalent with increasing athletic demands and emerging focus on techniques for prevention of joint injury. Knowledge of the surgical techniques, imaging appearances, and complications in the postoperative ankle is necessary for the accurate diagnosis of postoperative complications and for optimal patient care.

Clinical results of peroneal tendon repair in a retrospective series of 30 patients

INTRODUCTION

Peroneal tendinopathy is an under-diagnosed pathology, mainly triggered by ankle sprain. Failure of medical treatment often leads to surgery, with modalities adapted to the lesion type. The present study aimed to assess clinical and functional results of tendon repair and to analyze the influence of hindfoot alignment on quality of outcome. The study hypothesis was that hindfoot varus impairs medium-term results.

MATERIALS AND METHODS

A retrospective series of 30 patients undergoing peroneal tendon repair or tenodesis was analyzed at a mean 20 months' follow-up. All patients had preoperative ultrasound scan or NMRI. Clinical assessment was based on AOFAS and FAAM scores. Hindfoot alignment was assessed on Méary view; 2 groups were distinguished: valgus (n=11) and varus (n=17).

RESULTS

Mean AOFAS score improved, from 74.5±11.2 preoperatively to 86.7±9.4 at follow-up. There was a significant intergroup difference (p=0.0003) in AOFAS at follow-up: valgus, 93/100; varus, 82/100. There was no significant intergroup difference in FAAM score. Time to surgery, lesion type and surgical technique did not influence clinical results.

DISCUSSION/CONCLUSION

Clinical results for surgical repair of peroneal tendons were satisfactory and in line with literature reports. However, hindfoot varus was associated with poorer results, raising the possibility of correction by opening wedge calcaneal osteotomy.

LEVEL OF EVIDENCE

IV, retrospective case series.

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.

Treatment of Neglected Achilles Tendon Ruptures with Interpositional Allograft

Although most astute clinicians can diagnose Achilles tendon ruptures by physical examination alone, more than 20% are not accurately diagnosed in a timely fashion. The definition of a "chronic" Achilles tendon rupture in foot and ankle literature varies widely: from 4 to 10 weeks status after injury. Neglected or chronic Achilles tendon ruptures can be significantly disabling to patients if the muscle-tendon unit is stretched beyond its normal passive limit. There are a variety of treatment options that all have valid uses but have not been proven to be superior to one another.

Peroneus Quartus Muscle AutograftA Novel Approach to the Repair of a Split Peroneus Brevis Tendon Tear

This case report highlights a novel approach to strengthening the repair of a split peroneus brevis tendon tear with a peroneus quartus muscle autograft. We describe a 51-year-old woman with a longitudinal split tear of the peroneus brevis tendon confirmed by magnetic resonance imaging. Intraoperatively, a peroneus quartus muscle was appreciated, resected, and used as an autograft in the repair of the peroneus brevis tendon. Use of a peroneus quartus muscle as an autograft in peroneal tendon repair has not been documented in the literature, to our knowledge.

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.

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.

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.

Allograft reconstruction of peroneus longus and brevis tendons tears arising from a single muscular belly. Case report and surgical technique

Anatomic variants of the peroneal tendons may cause tendon disorders. Moreover, there is a lack of evidence on how to address chronic tendon pathology when a variant of the peroneal tendons is causing the patient's symptoms. We present a patient with an uncommon peroneal muscle presentation: a single muscular belly dividing into both the peroneus longus and brevis tendons. After extensive debridement of tendinopathic tissue, primary repair or tenodesis was not possible; therefore a unique solution for this problem was performed, reconstructing both peroneal tendons using a semitendinosus allograft.

Reversal of Peroneal Tenodesis With Allograft Reconstruction of the Peroneus Brevis and Longus: Case Report and Surgical Technique

Chronic peroneal tendinopathy and tears represent a challenging clinical situation. Traditionally, tenodesis of the torn tendon to the remaining healthy tendon has been advocated if more than half of the tendon is compromised. Allograft reconstructions have been reserved for patients with functional muscles and both peroneal tendons extensively compromised. We report a unique case of a peroneal tenodesis takedown and reconstruction of both peroneal tendons using semitendinosus allograft. A description of the surgical technique and tips are provided. Peroneal tendon function is crucial to maintain a balanced hindfoot. To the best of our knowledge, reconstruction of both peroneal tendons after a tenodesis has not been previously reported. Allograft reconstruction of the peroneal tendons arises as a feasible alternative in patients with residual pain and weakness after a failed tenodesis surgery LEVELS OF EVIDENCE: Therapeutic Level IV, case study.

Salvage options for peroneal tendon ruptures

Reports have demonstrated that peroneal tendon tears can be successfully treated by direct repair or debridement and tubularization, based on the extent and nature of the pathology. Irreparable peroneal tendon tears or completely unsalvageable tendons after failure of previously attempted repairs are rare, and as a result there is a lack of high-level evidence to guide the management of these complex injuries. When irreparable tears are encountered the salvage options include tenodesis, bridging of the defect using allografts or autografts, and tendon transfers. The choice of treatment strategy depends on the presence of a functioning tendon or tendons and the viability and excursion of the peroneal musculature.