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How To Address Complete Peroneal Tendon Dysfunction
The treatment of unsalvageable peroneal tendons can be particularly challenging to surgeons and the literature on this topic is sparse. Using several illustrative case studies, these authors present treatment pearls for Type III peroneal tendon dysfunction.
Much discussion has focused on the “sister” tendon, the tibialis posterior and its dysfunction, but there has been little discussion on the peronei.
Anatomically, the peroneus brevis and longus tendons reside within the lateral compartment of the lower leg. The peroneus brevis originates from the lower two-thirds of the fibula and intermuscular septum, coursing distally immediately posterior to the lateral malleolus to its insertion onto the base of the fifth metatarsal. The peroneus longus originates from the upper two-thirds of the fibula, head of the fibula and tibiotalar intermuscular septum as well as the lateral condyle of the tibia.
In a similar fashion, the peroneus longus tendon courses distally along the posterior aspect of the peroneus brevis tendon. At the level of the cuboid notch, the peroneus longus tendon turns medially toward its insertion on the first metatarsal. The primary blood supply to the peroneal is from the peroneal artery while the nerve innervation occurs from the superficial peroneal nerve.
Due to the tendon courses, three zones of avascularity are present. The peroneus brevis tendon zone of avascularity occurs at the level of the distal aspect of the fibula (Zone A) while peroneus longus avascularity occurs at the peroneal tubercle (Zone B) and the cuboid fossa (Zone C). Typical pathologies of the peroneus brevis and longus tendons tend to occur in these areas.
The incidence of peroneal tendon tears is unknown with the only available figures coming from two cadaveric studies by Sobel and colleagues.1–3 The incidences the authors described were 11.3 percent and 37 percent respectively in the two studies.2,3 Although there has been marked awareness of the pathophysiology and diagnosis of peroneal tendon tears since the early 1990s, the focus of the literature has been in regard to treatment options.4-10 Unfortunately, all studies reporting surgical management of peroneal tendon tears are either small retrospective reviews (Level IV evidence) or case reports (Level V evidence).11-18
The possible scenarios of peroneal tendon pathology one encounters within the surgical setting include:
1) Only one peroneal tendon involved that is amenable to repair;
2) Both tendons are compromised but they are functional after repair;
3) One peroneal tendon is unsalvageable whereas the other is either intact or repairable; or
4) Both tendons are unsalvageable.
Redfern and Myerson proposed an algorithm for peroneal tendon surgery based on intraoperative findings.19 This gives a systematic surgical approach to each form of peroneal pathology. When assessing the peroneal tendons intraoperatively, if both tendons appear grossly intact, the surgeon may perform primary repair (Type 1). If one of the tendons appear ruptured while the other appears usable, one may perform tenodesis (Type II). If both tendons are unusable (Type III), it is then important to determine if the peroneal musculature is intact. If no excursion is present (Type IIIa), incorporation of a tendon allograft is likely to fail and a tendon transfer is recommended. However, if excursion is present (Type IIIb), then one may incorporate a tendon allograft with a silicone Hunter rod as a primary or two-stage procedure depending on the amount of tissue bed scarring present.
With these considerations in mind, let us take a closer look at the proposed treatment strategies for Type III (both irreparable/unsalvageable) peroneal tendon injuries. We will reinforce this with four case studies. Ruptures of both peroneal tendons have been rarely documented and the evidence on treatment options remains limited to a few case reports.4,13,17-20
What You Should Know About Type IIIa Peroneal Tendon Injuries
With Type IIIa injuries, the main issue is dysfunction of both peroneal tendons. A preoperative magnetic resonance image (MRI) may demonstrate fatty infiltration or sclerosis. Clinically, calf atrophy is present and intraoperatively, there is no excursion of the proximal peroneal musculature.1,25 Sammarco, Redfern and Myerson, and Wapner and colleagues advocated tendon transfer in these cases using either the flexor digitorum longus or flexor hallucis longus.1,19–21
A 60-year-old female patient presented with pain that developed in the anterior lateral aspect of her left foot in July 2015. The pain continued to progress and she sought medical care initially, but received no presumptive diagnosis.
Eventually, MRI revealed rupture of the peroneus brevis tendon at the area of the peroneal tubercle. The patient also had advanced peroneus longus tendinopathy with a high grade tear inferior to the cuboid. The MRI also revealed fatty and fibrous infiltration of the peroneal musculature with loss of musculature circumference. The patient developed a significant varus deformity as a result.
The patient then got a referral to our office for surgical evaluation. Due to the reducibility of the adductovarus deformity, we performed excision of the degenerative peroneal tendons with transfer of the flexor digitorum longus to the remaining peroneus brevis at the base of the fifth metatarsal. In conjunction, we performed a Z-plasty lengthening of the tibialis posterior tendon, a lateral calcaneal slide osteotomy to protect the repair and rebalanced the varus positioning.
Key Insights On Treating Type IIIb Injuries
In the case of Type IIIb dysfunction, both tendons are unsalvageable but remain functional. Preoperative MRI will note no significant fibrosis or fatty infiltration of peroneal musculature. Clinically, there is no muscular atrophy and excursion is present intraoperatively.1 With this in mind, consider the following patient case studies.
A 43-year-old woman with a significant past medical history of rheumatoid arthritis received a referral for surgical evaluation and second opinion. The patient has had two prior operations on her peroneal tendons and her physician told her she would require a lateral calcaneal slide osteotomy. Radiographs and MRI demonstrated a reducible forefoot adductus and extensive tendinosis of the peroneus brevis and longus without rupture, minimal fatty infiltration of peroneal musculature, appropriate musculature circumference and no significant intramuscular fibrosis respectively. In this case, the peroneal musculature was functional but the peroneal tendons were dysfunctional.
We utilized a two-stage approach for peroneal tendon reconstruction. In the first stage, we utilized a silicone Hunter rod replacement in order to establish a peroneal tendon pseudosheath to allow gliding function of the reconstructed tendon allograft. In the second stage, we performed a lateral calcaneal slide osteotomy to correct the varus heel position. We also incorporated the tendon allograft into the peroneus brevis muscle and fifth metatarsal base through minimal incisions with the foot in a maximally-tensioned dorsiflexed and abducted position.
When the peroneal tendon sheath remains intact in patients with Type IIIb injuries, one can utilize tendon allografts in a single-stage procedure as described by Mook and colleagues.22 The authors described reconstruction of either of the peroneus brevis or the peroneus longus or both.
A 59-year-old
male with no significant past medical history presented to the office complaining of left foot and ankle pain that arose seven months prior while teaching ballroom dancing. The patient states he felt a large “pop” that was initially symptomatic. While the pain eventually subsided, the patient did have continued swelling. The patient states he began to notice changes in the shape of his foot and increased walking on the outside of his foot. An MRI did not demonstrate fatty infiltration, fibrosis or loss of musculature circumference of either the peroneus brevis or peroneus longus muscle bellies. However, MRI did demonstrate rupture of both the peroneus longus and brevis tendons.
In this scenario, the gliding function of the peroneal tendon sheath remained intact as well as the peroneal musculature. Thus, we performed excision of the dysfunctional peroneal tendons. We also applied a tendon allograft, performed a Dwyer calcaneal osteotomy and lengthened the posterior tibial tendon as a single-stage procedure.
Addressing The Potential Need For Concomitant Procedures
The question with Type IIIa injuries is the need for concomitant procedures due to the effect of the two antagonists, the tibialis posterior and tibialis anterior. This unbalance can lead to a varus rearfoot and forefoot. Jodd and Brodsky combined their transfer with calcaneal osteotomies and lateral ligament reconstruction to create a favorable mechanical environment for transfer.23
We performed triple arthrodesis for a patient with Type IIIa complete peroneal dysfunction. The resulting “unbalance” of the peroneus longus and tibialis anterior led to a forefoot varus occurring at the navicular-medial cuneiform-first metatarsal joint. We corrected the rearfoot malalignment through the triple arthrodesis so no adjunct rearfoot procedures were necessary. Due to the deforming force of the tibialis anterior on the first ray, we performed a transfer of the tibialis anterior to the lateral cuneiform, resulting in correction of the forefoot varus deformity.
What The Literature Reveals About Peroneal Tendon Dysfunction
Although this condition is rare, surgical management of complete peroneal tendon dysfunction can be challenging. Understanding the presentation of the chronic peroneal tendon is of utmost importance to ensure proper surgical management.
In a clinical study, Krause and Brodsky observed 20 patients over an eight-year period who presented with chronic peroneus brevis tendon tears.25 The authors proposed a classification system to assist in decision-making based on the amount of viable tendon cross-section. In this system, if greater than 50 percent of the tendon is viable after debridement, then one could perform a tendon repair. If less than 50 percent of the tendon is viable, then the authors recommend tenodesis. Krause and Brodsky reported an average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score of 85 using this treatment algorithm for treatment of Type I and Type II peroneal tendon injuries.25 Although this algorithm is useful in the treatment of Type I and II injuries, exercise caution when applying this algorithm to Type III injuries.
When peroneal musculature excursion is present (Type IIIa), one may use transfer of either the flexor digitorum longus or flexor hallucis longus. Jockel and Brodsky performed a single-stage flexor digitorum longus or flexor hallucis longus transfer in eight patients over a 15-year time period, and noted an increase in average AOFAS scores from 64 to 86 when treating Type IIIa injuries.23
When deciding which tendon to transfer (the flexor hallucis longus or the flexor digitorum longus), Silver and colleagues noted the flexor hallucis longus has twice the strength and work capacity in comparison to the flexor digitorum longus.26 However, in a retrospective review of nine patients who had a single-stage lateral transfer of the flexor hallucis longus or flexor digitorum longus tendon in treatment of Type IIIa tendon injuries, Seybold and colleagues noted no statistically significant differences between flexor hallucis longus and flexor digitorum longus transfer groups when performing objective muscle strength testing.27
In Type IIIb peroneal tendon injuries, the use of a silicone Hunter rod prior to allograft incorporation may prove beneficial. Classically, Hunter and Salisbury first described this technique in 1971 in hand surgery.28 The indications for silastic rods include extensive scarring of tendon bed, severe tendon sheath damage, primary repair failure and, in the face of complications related to infection, direct end-to-end repair or transfer reconstruction that has resulted in tendon rupture.
In these cases, utilization of a silicone Hunter rod allows for the formation of a pseudosheath, which contains mesothelial cell lining, resulting in the production of hyaluronic acid fluid similar to that of synovial fluid.29 This assists in restoring the gliding function of the tendon within the pseudosheath. In these scenarios, surgeons should perform a two-stage procedure. However, if minimal scarring and adequate gliding function are present, we recommend a single-stage allograft procedure.
When discussing surgical treatment with patients, it is important to note potential post-surgical complications. Steel and DeOrio performed a retrospective review of 30 patients treated according to the Krause and Brodsky classification.30 The authors observed 21 patients with isolated peroneus brevis tendon tears, five with isolated peroneus longus tears and four with concomitant peroneus brevis and longus tears. Upon repair of the Type I and Type II injuries, at one year-follow-up, 58 percent of patients had scar tenderness, 54 percent had lateral ankle swelling, 27 percent had numbness and 31 percent had pain at rest. Likewise, in addition to the primary repair of the peroneal tendons, other adjunct procedures may be necessary, including repair of the superior peroneal retinaculum, peroneal groove deepening, lateral ankle stabilization procedures and/or a Dwyer calcaneal osteotomy.
In Conclusion
Peroneal tendon pathology can be a challenging surgical condition, especially in the case of two unsalvageable tendons. The surgeon’s management approach depends on the remaining existing peroneal function (as indicated on MRI), intraoperative peroneal musculature excursion, the condition of peroneal gliding mechanisms and varus compensation.
Dr. Visser is the Director of the SSM Health DePaul Hospital Foot and Ankle Surgery Residency in St. Louis.
Dr. Wolfe is a second-year resident with the SSM Health DePaul Hospital Foot and Ankle Surgery Residency in St. Louis.
Mr. Wolfe is a fourth-year student at the Des Moines University College of Podiatric Medicine and Surgery.
References
1. Sammarco GJ. Peroneal tendon injuries. Orthop Clin North Am. 1994; 25(1):135-45.
2. Sobel M, Bohne wH, Levy ME. Longitudinal attrition of the peroneus brevis tendon in the fibular groove: an anatomic study. Foot Ankle. 1990; 11(3):124-8.
3. Sobel M, DiCarlo EF, Bohne WH, et al. Longitudinal splitting of the peroneus brevis tendon: an anatomic and histologic study of cadaver material. Foot Ankle. 1991; 12(3):165-70.
4. Bassett FH, Speer KP. Longitudinal rupture of the peroneal tendons. Am J Sports Med. 1993;21(3):354-7.
5. Khoury NJ, el-Koury GY, Saltzman CL, et al. Peroneus longus and brevis tendon tears: MR imaging evaluation. Radiology. 1996;200(3):833-41.
6. Larsen E. Longitudinal rupture of the peroneus brevis tendon. J Bone Joint Surg Br. 1987;69(2):340-1.
7. Munk RL, Davis PH. Longitudinal rupture of the peroneus brevis tendon. J Trauma. 1976;16(10):803-6.
8. Saxena A, Pham B. Longitudinal peroneal tendon tears. J Foot Ankle Surg. 1997;36(3):173-9.
9. Shoda E, Kurosaka M, Yoshiya S, et al. Longitudinal ruptures of the peroneal tendons. A report of a rugby player. Acta Orthop Scand. 1991;62(5):491-2.
10. Thompson FM, Patterson AH. Rupture of the peroneus longus tendon. J Bone Joint Surg Am. 1989;71(2):293-5.
11. Dombek MF, Lamm BM, SaltrickK, et al. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg. 2003; 42(5):250-8.
12. Grant TH, Kelikian AS, Jereb SE, et al. Ultrasound diagnosis of peroneal tendon tears. A surgical correlation. J Bone Joint Surg Am. 2005;87(8):1788-94.
13. Pelet S, Saglini M, Garofalo R, et al. Traumatic rupture of both peroneal longus and brevis tendons. Foot Ankle Int. 2003:24(9):721-3.
14. Saxena A, Cassidy A. peroneal tendon injuries: an evaluation of 49 tears in 41 patients. J Foot Ankle Surg. 2003;42(4);215-20.
15. Steel MW, DeOrio JK. Peroneal tendon tears: return to sports after operative treatment. Foot Ankle Int. 2007;28(1):49-54.
16. Cooper ME, Selesnick FH, Murphy BJ. Partial peroneus longus tendon rpture in professional basketball players: a report of 2 cases. Am J Orthop. 2002;31(12):691-4.
17. Verheyen CP, Bras J, van Dijk CN. Rupture of both peroneal tendons in a professional athlete. A case report. Am J Sports Med. 2000;28(6):897-900.
18. Wind WM, Rohrbacher BJ. Peroneus longus and brevis rupture in a collegiate athlete. Foot Ankle Int. 2001;2292):140-3.
19. Redfern D, Myerson M. The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int. 2004;25(10):695-707.
20. Borton DC, Lucas P, Jomha NM, et al. Operative reconstruction after transverse rupture of the tendons of both peroneus longus and brevis. Surgical reconstruction by transfer of the flexor digitorum longus tendon. J Bone Joint Surg Br. 1998; 80(5):781-4.
21. Wapner Kl, Taras JS, Lin SS, et al. Staged reconstruction for chronic rupture of both peroneal tendons using Hunter rod and flexor hallucis longus tendon transfer: a long-term followup study. Foot Ankle Int. 2006; 27(8):591-7.
22. Mook WR, Parekh SG, Nunley JA. Allograft reconstruction of peroneal tendons: operative technique and clinical outcomes. Foot Ankle Int. 2013;34(9):1212-20.
23. Jockel JR, Brodsky JW. Single-stage flexor tendon transfer for the treatment of severe concomitant peroneus longus and brevis tendon tears. Foot Ankle Int. 2013;34(5):666-72.
24. Stamatis ED, Georgios CK. Salvage options for peroneal tendon ruptures. Foot Ankle Clin N Am. 2014;87-95.
25. Krause JO, Brodsky JW. Peroneus brevis tendon tears: pathophysiology, surgical reconstruction, and clinical results. Foot Ankle Int. 1998;19(5):271–9.
26. Silver RL, de la Garza J, Rang M. The myth of muscle balance: a study of relative strengths and excursions of normal muscles about the foot and ankle. J Bone Joint Surg Br. 1985;67(3):432-437.
27. Seybold J, Campbell J, Jeng C, Short K, Myerson M. Outcome of lateral transfer of the FHL or FDL for concomitant peroneal tendon tears. Foot Ankle Int. 2016; 37(6):576-581.
28. Hunter JM, Salisbury RE. Flexor-tendon reconstruction in severely damaged hands. A two-stage procedure using a silicone-dacron reinforced gliding prosthesis prior to tendon grafting. J Bone Joint Surg Am. 1971;53(5):829-58.
29. Hagberg L, Tengblad A, Gerdin B. Hyaluronic acid in flexor tendon sheath fluid after sheath reconstructions in rabbits: a comparison between tendon sheath transplantation and conventional two stage procedures. Scand J Plast Reconstr Surg Hand Surg. 1991; 25(2):103-107.
30. Steel, MW, DeOrio JK. Peroneal tendon tears: return to sports after operative treatment. Foot Ankle Int. 2007; 28(1):49–54.
For further reading, see “How To Manage Peroneal Tendon Subluxation” in the September 2013 issue of Podiatry Today, “How To Address Failed Peroneal Tendon Surgery” in the August 2007 issue or “Conquering Peroneal Tendinopathy In Athletes” in the September 2011 issue.
