A Samuel Flemister Jr MDUniversity of Rochester

Peroneal Tendon Disorders

Disclosures NONE

Anatomy & Biomechanics Peroneus Longus inserts

into the base of first MT Peroneus Brevis into base

of fifth MT

Together 63% of eversion strength, PL(35%), PB (28%)

Manoli et al FAI 2005

Peroneal Tendon Pathology

Acute Tears(rare)Chronic tears with or without

tendinosisSubluxation alone acute or chronicSubluxation with tears

Peroneal Tendon Tears

Acute injury-rare usually healthy tendon

Chronic degenerative condition- more common

Acute tears Lateral sided ankle

pain Often associated with

trauma Frequently involve

peroneus brevis atretro-malloelargroove

Peroneus Longus TearsUsually distal

Peroneal tubercleTurn at cuboid

Tendinosis Involve os

peroneum

Diagnosis- acute tears Hx of Acute injury

Tender along peroneals

Pain with resisted eversion

Pain with passive inversion

Exam – associated conditions Tendon subluxation

Lateral ligament instability

Cavus foot

Plain RadiographsFoot and Ankle WB?

Alignment Fleck sign

Plain radiographs

Os Peroneum OS at base of 5th

MRI 83% sensitive 75 % specific compared

to intraop findingsLamm et al

Helpful to understand extent of disease

Ultrasound operator dependent

Frequently missed Sammarco et al

7-48 months to diagnosis

Arbab et alAverage 11 months to diagnosis

If patients have peroneal tenderness after trauma I see them back in 2 weeks

Classification & treatment systems Sobel et al FA 1992

Krause & Brodsky FAI 1998

Redfren & Myerson FAI 2004

Considerations for operative treatment Degree of tendon involvement( length of tear, full vs partial, %

of tendon involved ie 50% cutoff Degree of tendinosis, salvable or not Excursion of the proximal muscle Scarring of the bed

Lodewijk et al JAAOS 2018

Based on MRI scans patients with PB tendon tears demonstrated markedly higher grades of fatty degeneration in the muscle vs those with no pathology

Incision Lateral incision along

tendon sheath

Cheat anterior if need to fix lateral ligaments

Lateral decubitus position if only working on tendons

1. Tear of One repairable tendon Less than 50%

involved Usually PB

One side better than other

Excise worse side

RepairAt least 50 %

healthy tendon remaining

Middle most involved

PDS runner

Debridement and Repair Long Term results

Demtracopoulos et al FAI 20146.5 yr fu on 18 pts17/18 returned to full sporting function without limitation

2. One tendon intact/repairable, one not repairable

Chronic Degenerative tears Usually slow onset of

symptoms

Swelling along sheath

Tendinosis

Often more distal

Chronic degenerative tears

Partial Excision and Repair

Complete excision of segment with tenodesis, allograft replacement, FHL tendon transfer

TenodesisOne tendon viableGood muscle

excursion

Excise diseased portion

Tenodesis < 50% viable tendon

Sacrifice Longus in Cavus foot

Don’t do as well as repairs

3. Both tendons not repairableGood muscle excursion

Allograft

Allograft Grafts PL or Semi-T Fix distally to stump of PB Or with anchors to base of

5th MT

Tensioning

Fix distally first

Keep foot neutral DF,/PF Inversion/Eversion

Attach tendon proximal at about half the maximal excursion of the muscle

Allograft Results

Mook et al FAI 201314 pts fu 17 monthsImprovement in VAS, SF-12, LEFS

3.No muscle excursion

Both tendons cannot be salvaged

FHL tendon transfer 2 stage procedure using

Hunter rodsWapner 2006

Successful results with single stage also reported

Campbell, Myerson 2016

Jockel, Brodsky 2013

FHL Transfer

Debride all diseased segments

FHL Transfer

Harvest at Master Knot of Henry

FHL Transfer

Hook tendon through lateral incision

DO NOT need 2nd

proximal medial incision

FHL Transfer

Attach to stump of PB tendon or to base of 5th

metatarsalTenodesis

proximally if possible

Watch sural nerve

FHL Transfer

Although good results reported clinically

25% loss of inversion and eversion ROM

50% loss of strengthSalvage procedure for severe 2 tendon

disease

Painful Os Peroneum Syndrome(POPS)

Rupture of PL with Proximal migration Degeneration/tear

POPS Incision more distal Excise fragment and

repair if adequate tendon

Tenodesis to PB if not Cavus foot favor

tenodesis

OS at base of 5th MT

Peroneal subluxation Occurs after inversion

injury

Not recognized at time of sprain

May not follow an injury

Dorsiflexion and eversion reproduce symptoms

Fleck Sign

Peroneal Subluxation

Injury to superior retinaculum

Tendon may sublux over fibula

May result in tendon tear

Associated findings

Peroneus Quartus

Peroneal Subluxation

Operative Problem

Repair tendon and retinaculum

Debride tendon, Inspect groove

Sub periosteal flap on fibula

Peroneal Subluxation

In chronic cases may be caused by a shallow retromalleolar groove

Groove deepening procedure

Question needCho et al FAI 2014

Post op

Splint 7-14 days NWBBoot till 6 weeks: WBAT, sagittal

motion only at 1-2 weeksStirrup brace and PTSports 3-4 months

Correct Cavus Foot

Outcomes Studies are retrospective, variety of non validated outcome

measures, mix acute and chronic

Most report high patient satisfaction rates and return to sport > 90 %

Next steps:Peroneal Arthroscopic Techniques

Summary Don’t miss diagnosis Repair healthy tissue Excision and Tenodesis for unhealthy tissue Allograft & FHL tendon transfer if both tendons

not salvageable Correct cavus foot Early motion

Thank You