26. flemister acute and chronic · 2/26/2020 · microsoft powerpoint - 26. flemister_acute and...
TRANSCRIPT
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