Complete encasement of the peroneal tendons by the peroneal tubercle

Are enlarged peroneal tubercle and accessory anterolateral talar facet associated with calcaneal spur?

BACKGROUND

As the anatomical variations of the foot, enlarged peroneal tubercle (EPT) and accessory anterolateral talar facet (AALTF) have attracted the attention of foot surgeons in recent years. However, EPT and AALTF have not been examined for a relationship with calcaneus spur (CS) as a common osteophyte.

METHODS

The subjects were 369 individuals who died in northeastern Thailand and were preserved as skeletal specimens. The authors examined for the presence of left and right EPT, AALTF, and calcaneus spur (CS). We divided the EPT (+) group with EPT and the EPT (-) group without it and also divided the AALTF (+) group with AALTF and the AALTF (-) group without it. The age at death and the presence of CS were compared statistically between the EPT (+) and EPT (-) groups and between the AATLF (+) and AALTF (-) groups.

RESULTS

Out of the total 369 cases, EPT was found in 117 cases (31.7%), AALTF was positive in 91 cases (24.7%), and CS was found in 194 cases (52.3%). In comparison between EPT (+) and EPT (-) groups, CS was significantly higher (p < 0.0001) in the EPT (+) group, but there was no significant difference in age at death. In comparison between AALTF (+) and AALTF (-) groups, there was no significant difference in age at death or CS.

CONCLUSION

This study showed a strong relationship between EPT and CS, and the prevalence of EPT and AALTF by age in Thailand was first reported. We believe it helps to know the pathogenesis and biomechanism of EPT and AALTF.

TRIAL REGISTRATION

Not applicable.

Fifth Metatarsal Base Fracture Combined With Fracture of the Os Peroneum

Fracture of the os peroneum is rare, and displacement of the fracture can be indicative of a tear in the peroneal longus tendon. A fifth metatarsal base fracture is a common injury caused by sudden inversion and plantar flexion of the hindfoot. We observed a rare case of a fifth metatarsal base zone I fracture combined with a displaced os peroneum fracture in a 34-year-old woman. The patient was treated with resection of the os peroneum and repair of the peroneal longus tendon, as well as open reduction and internal fixation of the fifth metatarsal base. After exposing the fragment of the fifth metatarsal base, the distal part of the fractured os peroneum was found to be located just under the fracture site. There were no complications or discomfort of the foot or ankle at 2 years postoperatively. Resection of the os peroneum and direct repair of the peroneal longus tendon were easily performed after the fifth metatarsal base fragment was exposed. This was an innovative method for performing peroneal longus tendon repair in the deep portion of the midfoot.

CT scan assessment of the dimensions and morphological variations of the peroneal tubercle

PURPOSE

The hypertrophied peroneal tubercle may result in lateral ankle pain with peroneal tendon tenosynovitis and rupture. The aim of this study was to evaluate different configurations and dimensions of the normal peroneal tubercle using two-dimensional CT scan.

METHODS

Totally, 100 normal CT scans of cases older than 18 years of age were assessed to determine the shape of the peroneal tubercle. Moreover, height, length and width of different configurations of the normal peroneal tubercle were measured in axial and coronal sections of the ankle CT scans.

RESULTS

Four different configurations based on the axial cut of the calcaneus were found; single-convex (59%), double-convex (24%), plateau (9%), and convex-concave (8%) without statistically significant difference between genders (p-value: 0.526). Totally, mean of height, length and width were 4.42 ± 1.38 mm, 28.88 ± 6.58 mm and 17.17 ± 3.85 mm, respectively. Although mean of the height in the single-convex and the double-convex types were 4.5 ± 1.4 mm and 5.0 ± 1.4 mm, respectively, the highest peroneal tubercle in the single-convex and the double-convex group were 10.2 mm and 8.5 mm, respectively.

CONCLUSIONS

In cases with lateral ankle pain and suspicious to hypertrophied peroneal tubercle, two-dimensional CT scan can be an available practical modality to identify the pathological type of the peroneal tubercle based on the presented classification and normal values. As previously reported in the literature, considering cut-off point of 5 mm could result in overdiagnosis of the hypertrophied peroneal tubercle, especially in single-convex type; however, clinical correlation is always paramount.

LEVEL OF EVIDENCE

Level IV.

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.

Surgical Treatment for Stenosing Peroneal Tenosynovitis

BACKGROUND:

Stenosing peroneal tenosynovitis (SPT) is an uncommon entity that is equally difficult to diagnose. We evaluated our outcomes with a local anesthetic diagnostic injection followed by surgical release of the sheath and calcaneal exostectomy.

METHODS:

Eleven patients diagnosed with SPT underwent surgery between 2006 and 2014. Upon initial presentation, all patients reported a persistent history of pain along the ankle. Ultrasound-guided injections of anesthetics were administered into the peroneal tendon sheath to confirm the diagnosis. In patients with a confirmed diagnosis of SPT, we proceeded with surgical intervention with release of the peroneal tendon sheath and debridement of the calcaneal exostosis. Retrospective chart review was performed, and functional outcomes were assessed using the Foot and Ankle Outcome Score (FAOS). FAOS results were collected pre- and postoperatively and were successfully obtained at 1 year or greater.

RESULTS:

Of these patients, all showed significant improvements ( P < .05) in 4 of 5 categories of the FAOS (pain, daily activities, sports activities, and quality of life).

CONCLUSION:

We present a case series in which the peroneal tendon sheath was diagnostically injected with anesthetic to confirm a diagnosis of SPT. In each of these cases, symptomatic improvement was obtained following the injection. With the fact that many of these patients had advanced imaging denoting no significant tears, we believe that this diagnostic injection is paramount for the success of surgical outcome.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

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.