Addressing Peroneal Tendon Pathology With A Novel Suture Device: One Surgeon’s Experience

Peroneal tendon pathology can include tenosynovitis, tendonitis, subluxation and peroneal tears. Mechanisms of injury linked to peroneal tendon tears include: inversion ankle sprains, chronic ankle ligamentous laxity, and peroneal subluxation. In addition, predisposing anatomic factors such as a convex or flat fibular groove, low-lying or anomalous muscle belly, superior peroneal retinaculum incompetence, posterior lateral fibular spurring, and a high-arch foot type have all been directly associated with peroneal tendon injury.¹ The severity of the pathologic involvement dictates operative intervention. Tubularization of the tendon is recommended for tears involving less than 50 percent of the cross-sectional area. If more than 50 percent of the tendon is injured, oftentimes tenodesis to the adjacent peroneus longus tendon becomes required.² Biomechanical studies show that there is no significant difference between side-to-side anastomosis and tendon weave.³

In this blog, I will share a surgical technique that utilizes a new needlesuture technology (EasyWhip, Winter Innovations). This suture has a two-part needle which allows the surgeon to whip-stitch a tendon a still attached tendon. In this case, we used the technology to simultaneously perform a tubularization and tenodesis of the peroneus brevis to longus tendon.

Pertinent Preoperative Findings 

The patient is a 51-year-old male who presented with a 5-year history of posterior lateral ankle pain. Physical exam revealed edema to the peroneal tendon complex with direct pain on palpation to the area. We noted preserved muscle strength and no lateral ankle instability. He did not have a varus heel on weight-bearing exam. He failed conservative measures including physical therapy, bracing, immobilization, and prescription anti-inflammatories. Serial MRI studies show worsening tenosynovitis of both the peroneus longus and brevis with peroneus brevis tearing. The patient has type II diabetes (HbA1c 6.1) with a BMI of 52. 

A Closer Look At the Surgical Technique

We began with a curvilinear incision over the peroneal tendon complex, carrying dissection down to the peroneal retinaculum, which we incised and preserved. Next we incised the peroneal tendon sheath and sharply excised any tenosynovitis off the peroneus longus tendon. We noted that the peroneus brevis tendon was significantly flattened with a longitudinal tear. We chose this novel suture

technology for our experience with its strength and ability to repair the tendon while tubularizing and tendonesing the tendons simultaneously. The suture also allows for a both a traditional and locking whip-stitch. We initially used a locking whip-stitch technique where the tendon was most diseased, then transitioned to a traditional whip-stitch for the remainder of the tendon.

After concluding the case, we splinted the patient, who remained non-weight-bearing for 3 weeks. He then transitioned to partial weight-bearing, then full weight-bearing as tolerated in a CAM boot. Formal physical therapy began at 4 weeks postop. At 4 months follow-up, the patient was back to regular shoe gear and activities with significant improvement in function and swelling. He rated his overall pain a 2/10 on the VAS pain scale postoperatively, compared to a 9/10 preoperatively.

In Conclusion 

EasyWhip is a novel suture product with a two-part detachable needle. The product allows for suturing of both peroneal tendons in-situ. Release of the tendon was not required to access a free end so that it could be whip stitched. Instead, EasyWhip provided the ability to anastomose the tendons while they were both still attached. Further, the nature of the two-part needle provided flexibility to switch between stitch methods (simple and locking whip stitches) without having to switch needles. Due to the design of the product, in my observation and experience, half as many needle passes through the tissue were required to create the locking stitch compared to a Krackow method. This stitch technique is not possible with any other needle products, and the construct provided superior strength in a patient with a large BMI.

Dr. Butto is Fellow of the American College of Foot and Ankle Surgeons and practices at Advanced Foot and Ankle Specialists in Avon, CT.

References 

1. Dombek M, et al. Peroneal tendon repairs: a retrospective review. J Foot Ankle Surg.  2003;42(5):250-8.

2. Cerrato R, et al. Tenodesis and transfer procedures for peroneal tears and

tendinosis. Tech Foot Ankle Surg. 2009;8(3):119-125.

3. Janney C, et al. Peroneus brevis tenodesis: side-to-side or weave? Foot Ankle Orthop. 2018;3(4):1-5.

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