Peroneus Brevis Tendon Research Articles

Importance of Space-Occupying Anatomical Variations in Peroneal Tendoscopy.

We hypothesized that peroneal tendons disorders are more commonly associated with anatomical variations, which could overcrowd the retrofibular groove. This single-center retrospective case study covered 84 consecutive cases that had undergone peroneal tendoscopy. Peroneal tendoscopy was performed on 82 patients, predominantly female (3:1) with a median age of 46 years. The preoperative evaluation and all the procedures were performed by a single surgeon using a standardized technique. Two patients required revision surgery 8 and 52 months after the index procedure due to persistent posterolateral ankle pain. Peroneal tendoscopy was performed as a solitary procedure in 45.1% (37/82) of cases, while the remaining cases involved peroneal tendoscopy as a supplementary procedure. Low-lying peroneus brevis muscle belly (LLMB) was the most common finding in this series in 53.7% (44/82) of cases. In 41.5% (34/82) of cases, longitudinal tears of the peroneus brevis tendon were noted. Some patients presented with more than 1 concomitant peroneal tendon pathology. The LLMB was observed in 23.5% (8/34) of cases with a longitudinal tear of the peroneus brevis tendon. Peroneal tendon anatomical variations, especially LLMB, were associated with the presence of peroneus brevis tendon ruptures and intrasheath peroneal tendon subluxations as well as posttraumatic posterolateral ankle pain. Due to high rates of undiagnosed and misdiagnosed cases of LLMB preoperatively, we believe special care should be taken to recognize it during tendoscopy. Peroneal tendoscopy is a high-efficiency, low-complication method to treat some peroneal tendon conditions. Level IV, case series.

Biomechanical Comparison of Zone 1 5th Metatarsal Base Fracture Fixation

Category:Basic Sciences/Biologics; Midfoot/ForefootIntroduction/Purpose:Zone 1 5th metatarsal base fractures are more common than zone 2 or 3 fractures, but significant debate still exists as to their optimum management, particularly for large fragments. The objective of this study was to compare the biomechanical strength of two headless compression screws versus a hook plate for fixation of large zone 1 5th metatarsal fractures. We hypothesized that hook plates would be biomechanically superior.Methods:Ten matched pairs of fresh-frozen 5th metatarsal cadaveric specimens were used. Large zone 1 avulsion fractures were simulated. Specimens were randomly assigned to fixation with two 2.5-mm headless compression screws or an anatomic 5th metatarsal hook plate. Specimens were mounted on a test frame and cyclically loaded through the plantar fascia, peroneus brevis tendon, and metatarsal base. Each specimen underwent 100 cycles at 50% physiological load (12 N on bone, 70 N on plantar fascia, 17.5 N on peroneus brevis), 100 cycles at 75% load (18 N on bone, 105 N on fascia, 26.25 N on peroneus brevis), and 100 cycles at 100% load (24 N on bone, 140 N on fascia, 35 N on peroneus brevis). Maximum cycles and maximum force were recorded.Results:The hook plate group had significantly higher cycles to completion of loading or failure compared with the screw group (270.7 +- 66.0 [range 100-300] cycles versus 178.6 +- 95.7 [range 24-300] cycles, respectively; P=0.011). Seven of 10 hook plate specimens and 2 of 10 screw specimens were intact at the maximum 300 cycles. Mean maximum force on the plantar fascia did not differ between the plate and screw groups (133.0 +- 22.1 [range 70-140]) N versus 119.0 +- 4.5 (range 70-140) N, respectively; P=0.098). Nine of 10 plate specimens and 5 of 10 screw specimens were intact at maximum force of 140 N.Conclusion:To our knowledge, this is the first biomechanical study comparing fixation constructs for 5th metatarsal avulsion fractures while loading the plantar fascia, which is the primary deforming force in vivo. These data suggest an anatomic hook plate is biomechanically superior to headless compression screw fixation of large zone 1 5th metatarsal avulsion fractures, which may prove pertinent in the setting of morbid obesity, fracture comminution, and/or fracture nonunion. Limitations include the relatively small sample size and the use of cadaveric bone which imperfectly mimics living tissue.

Anatomic considerations for retrograde fibular medullary screw insertion: a cadaveric study.

A retrograde fibular medullary screw may be utilized in certain fractures about the ankle. The purpose of this study is to investigate the anatomic considerations of a retrograde medullary screw inserted from a lateral starting point to nearby anatomic structures about the distal fibula. Ten fresh-frozen cadaveric lower extremities were utilized. A 1.6-mmKirschner wire was inserted into the distal fibula from a far-lateral starting point. A 3.2-mm cannulated drill bit was then inserted over the Kirschner wire. After placement of the drill bit, dissection of the lateral ankle was undertaken. The proximity of nearby anatomic structures to the drill bit was measured using calipers. A 4.5-mm cortical screw was then inserted using fluoroscopic guidance. Measurements were then taken again to assess the relationship of the screw head to adjacent structures. Mean distance from drill bit to nearby structures is as follows: Peroneus longus tendon 4.56mm, peroneus brevis tendon 6.62mm, sural nerve 4.13mm, superior peroneal retinaculum 7.52mm, inferior peroneal retinaculum 6.61mm, anterior talofibular ligament (ATFL) 6.1mm, calcaneofibular ligament (CFL) 6.7mm. Average distance from 4.5-mm screw head to nearby structures is as follows: peroneus longus tendon 6.79mm, peroneus brevis tendon 6.73mm, ATFL 4.16mm, CFL 5.14mm, lateral talar process 9.41mm. Retrograde medullary fibular screw fixation may be safely carried out through a lateral start point. Anatomic structures about the lateral ankle are nearby but not immediately adjacent to the drill bit.

New aspect of morphometric study of the superior peroneal retinaculum: pertinent data for surgical repair and reconstruction.

This study was conducted to investigate characteristics, attachments and morphometric parameters of the superior peroneal retinaculum (SPR). Morphology and morphometric details including width, length, thickness and angle of alignment of SPR in 109 embalmed cadaveric legs were investigated. The occurrence of peroneal tendon tear was also noted. Most of SPR originated from the fibrocartilaginous ridge of the lateral malleolus. The SPR might be a single band or split into proximal and distal bands inserted on the posterior intermuscular septum and lateral wall of calcaneus, respectively. Based on the characteristics and insertion patterns, the SPR could be divided into 3 types: type I (double band with subtype Ia and Ib), type II (single band) and type III (single band) with the prevalence of 56.88% (12.84%, 44.04%), 1.83%, and 41.28%, respectively. The average coordinate (X, Y axis) of the midpoint of width at origin measured from the tip of fibula in all types was 7.26±3.15 and 10.45±4.52 mm. The average coordinate of the midpoint at insertion on the posterior intermuscular septum was 24.06±4.94 and 13.35±5.18, and those inserted on the lateral wall of calcaneus was 21.45±7.88 and 13.59±6.73 mm. Prevalence of peroneus brevis (PB) tendon tear was 12.84% (14 cases) and was associated with SPR type Ib with statistical significance. Precise information of the characteristics, morphometric data and coordinates of attachment sites of SPR are essential for surgical procedures and reconstruction.

Degenerative tendoachilles tear repaired and augumented by peroneous brevis tendon by dynamic loop technique one year follow up

<p class="abstract"><strong>Background:</strong> Repair of degenerative rupture of tendoachilles is a challenge for orthopaedician. We used peroneus brevis tendon in our patients to augment the repair of degenerated tendoachilles tears by creating a dynamic loop.</p><p class="abstract"><strong>Methods:</strong> In our study, we evaluated 31 patients with Achilles tendon rupture treated by reconstruction using peroneus brevis tendon transfer by dynamic loop suture technique. The patients were from all age groups excluding those lesser than 35 years. The average follow-up being 6 months.<strong></strong></p><p class="abstract"><strong>Results:</strong> In total 31 patient’s majority of patients belong to 41-50 years (15 cases 48.4%). Male patients being 24 (77.4%) constituted the majority, right sided injury was noted in 23 (74.2%) of the patients. Most common symptom of Achilles tendon rupture is pain. The mechanism of injury in most of the patients by stumbling in the fields in 19 (61.3%). Results of testing the patient’s ability to heel raise for 60 seconds 20 patients were able to sustain, while 8 patients were able to stand on toe with heel raised but could not sustain it. 3 patients could not do raise the heel. 5 patients complained of sensory hypoesthesia at 12 months follow-up. By Rupp scoring, 77% patients had excellent or good results and 10% had fair or poor results.</p><p class="abstract"><strong>Conclusions:</strong> Results of reconstruction of Achilles tendon ruptures using peroneus brevis tendon show a strong and stable repair that allows early weightbearing ambulation with favourable clinical results in most patients.</p>

The vascularization of the peroneal tendons: An anatomic study

BackgroundArterial vascularization is intimately related to the peroneal tendon ruptures. Our purpose is to describe the vascular anatomy of peroneal tendons and assess differences in the vascularization patterns between peroneus brevis tendon (PBT) and peroneus longus tendon (PLT). MethodsAnatomical study of 22 cadaveric lower extremities. We exposed tendons’ vascularization by injecting latex. To systematize the vascular description, we considered four anatomical regions in the PBT and six in the PLT. ResultsVascularization was supplied by the peroneal, anterior tibial and lateral plantar arteries and from the deep plantar arch through the vincula connecting the tendons. No avascular areas were found in the PLT. 22.7% of specimens had avascular areas in the PBT. Two visual vascularization patterns were found (arcuate and weblike). Increasing age and a web-like vascularization were associated with a lower number of blood vessels at the tendons’ post malleolus area. ConclusionPeroneal tendons are well vascularized throughout their course, running through a common vincula, with vascularization provided by various arteries. Avascular areas were observed in the PBT, but none at the PLT.

ACCESSORY PERONEUS BREVIS TENDON - A CASE REPORT

Introduction: The development of limb musculature takes place between the fifth and seventh weeks of intrauterine life. The genes MYO-D and MYF5 regulate the limb musculature development and any defect in these may lead to either a partial or complete loss or an addition to the normal muscle morphology. This case report presents the observation of an accessory tendon of the Peroneus brevis muscle in the left lower limb of a 70 year old male cadaver during the routine dissection for undergraduate students at Government Medical College, Miraj. The variant insertion of the Peroneus brevis tendon on the calcaneal tubercle is clinically important to note in cases of lateral ankle pain and instability. The presence of an accessory tendon of the peroneus brevis muscle may also be a cause of the longitudinal splitting of the muscle which should be taken into consideration while making a diagnosis and planning surgeries around the lateral aspect of the ankle.

Peroneus brevis as source of instability in Jones fracture fixation

PurposeIntramedullary screw fixation is currently considered the gold standard treatment for Jones fractures in the athlete. Besides biological factors (i.e., poor vascularization), mechanical instability induced by the pull of the peroneus brevis tendon (PBT) contributes to deficient Jones fracture healing. This biomechanical study aimed to simulate loads induced by the PBT at the fifth metatarsal and to compare the stability of two intramedullary screw constructs in a Jones fracture fixation model.MethodsJones fractures were created in 24 human paired specimens, and fixation was achieved with either a solid Jones fracture specific screw (JFXS) (Jones Screw; Arthrex Inc., Naples FL, USA) or a cannulated headless compression screw (HCS) (HCS; DePuySynthes, Solothurn, Switzerland). The PBT was fixed to a mechanical load frame by the use of a cryoclamp. Constructs were loaded in tension for 1000 cycles, followed by an ultimate load test. Construct failure was defined by exceeding 10° of dorsal angulation.ResultsPreliminary failure occurred more often in HCS constructs (33%) compared to JFXS constructs (0%) (P = 0.044). Mean tensile load to failure reached 123.8 ± 91.4 N in the JFXS group and 91.5 ± 62.2 N in the HCS group (P = 0.337). The mean slope of the load-displacement curve was 24.2 ± 10.4 N/mm for JFXS constructs and 24.7 ± 5.5 N/mm for HCS constructs, respectively (P = 0.887).ConclusionThis is the first study evaluating the effect of PBT pull on the mechanical stability of Jones fracture fixation. Higher preliminary failure rates of HCS were found under cyclic loading conditions compared to JFXS.

Magnetic resonance imaging of normal anatomy and injury of the peroneal tendon

Objective: To explore the MR characteristics of normal anatomy and injured peroneal tendon and the diagnostic value of MR in the peroneal tendon injuries. Methods: From February 2018 to December 2018, a total of 20 healthy volunteers (40 ankle joints) were selected, 10 males and 10 females, with an age range of 20-30 (26±3) years. Retrospective analyzed 62 patients with ankle sprain and peroneal tendon injuries confirmed by operation, 34 males and 28 females, with an age range of 14-78(41±14) years. All volunteers and patients underwent MR examination. The MRI characteristics of the normal anatomy of peroneal tendon were analyzed. The patients were classified according to the MR diagnostic criteria of injury. Then the MRI features of different types of injured peroneus longus tendon and peroneus brevis tendon were analyzed. At last, imaging findings were compared with surgical results. Results: The peroneal tendon of 20 healthy volunteers showed oval and elliptical band-like structures on T(1)WI and PD-FS sequences, with natural alignment, clear boundary and uniform low signal. The whole length of the peroneal tendon can't be displayed completely on the same imaging plane. It needed multi-dimensional observation combined with axial, coronal and sagittal directions. There were 62 cases of peroneal tendon injury, including 46 cases of peroneal tendon tear (7 cases of partial-thickness tear, 11.3% of the total injuries, 39 cases of full-thickness tear, 62.9% of the total injuries), 16 cases of peroneal tendon dislocation (15 cases of intrathecal dislocation, 24.2% of the total injuries, 1 case of extrathecal dislocation, 1.6% of the total injuries). In 7 cases of partial-thickness tear (4 cases of peroneus brevis tendon tear, 3 cases of peroneus longus tendon tear), MR showed irregular tendon shape and local continuity interruption. In 39 cases of full-thickness tear (31 cases of peroneus brevis tendon tear, 8 cases of peroneus longus tendon tear), MR showed that the tear was penetrated through the whole layer of tendon from dorsolateral side to plantar side of foot, and the range of tear was different. The torn tendon could be accompanied by tendinitis or effusion of tendon sheath; 15 cases of intrathecal dislocation (3 cases of type A, 12 cases of type B), MR findings of type A dislocation showed that the peroneus longus tendon was located in the deep part of the peroneus brevis tendon, MR findings of type B dislocation showed that the peroneus longus tendon was displaced into the longitudinal tear of peroneus brevis tendon. In 1 case of extrathecal dislocation (type Ⅲ), MR showed that the SPR and the attached cortex of lateral malleolus were avulsed together, and the peroneal tendon was displaced under the avulsed fracture piece. Conclusion: MR can accurately demonstrate the fine anatomical structure of peroneal tendon and the imaging features of injuries. It has important clinical application value for the early diagnosis and accurate treatment of peroneal tendon injuries.

2-Mm Diameter Operative Tendoscopy of the Tibialis Posterior, Peroneal, and Achilles Tendons: A Cadaveric Study.

Background:Technical innovation now offers the possibility of 2-mm-diameter operative tendoscopy with disposable arthroscopes and tablet-like control units. The promises of new technology should be critically scrutinized. Therefore, this study assessed whether 2-mm-diameter operative tendoscopy of the tibialis posterior, peroneal, and Achilles tendons was safe and effective in a cadaveric model.Methods:A 2-mm-diameter arthroscopic system was used to perform a tendoscopic procedure in 10 nonpaired, fresh-frozen, human ankles. Standard tendoscopic portals were utilized. Visual examination and operative reach with tailored tendoscopic instruments within the tendon sheaths were recorded and documented. Adhesiolysis and vincula resections were performed. After dissection, distances between portal tracts and neurovascular structures were measured and the tendons were inspected for signs of iatrogenic damage.Results:The entire tendon sheath and tendon of the tibialis posterior, peroneus brevis, and Achilles tendons were visualized and reached with tailored operative instruments. The proximal part of the peroneus longus tendon was visible and reachable from proximally up to the cuboid bone distally. Adhesiolysis and vincula resections were successfully performed in all specimens. The mean distances between portal tracts and local neurovascular structures ranged between 9.4 and 19.2 mm and there were no cases of contact. None of the tendons showed signs of iatrogenic damage.Conclusion:Two-millimeter-diameter operative tendoscopy provided safe and effective visualization and operative reach of the tibialis posterior, peroneal, and Achilles tendons.Clinical Relevance:Compared with current practice, 2-mm-diameter operative tendoscopy has the potential to make tendoscopy around the ankle less invasive and more accessible. Diagnostic, interventional, and second-look procedures might be performed at substantially reduced risk, time, and costs.

PO 18205 - Case report

Introduction: Anterior tibial tendon ruptures are quite rare. All studies found in the literature refer to the adult population, with no reports of this injury in the pediatric population. The literature on the treatment of this injury is scarce. Objective: To report the case of a child subjected to peroneus brevis tendon transfer for the sequela of a severe anterior tibial and extensor hallucis longus tendon injury. Methods: Male patient, 8 years of age, was run over by a car and sustained an exposed tibial fracture and major soft-tissue injury of the foot. Anterior tibial, posterior tibial and extensor hallucis longus tendon rupture were detected. Damage control, soft-tissue cover and conservative treatment of the anterior tibial and extensor hallucis longus tendons were initially performed; however, the conservative treatment failed, and valgus deformity and pronation developed. Subsequently, tenoplasty (posterior tibial tendon), the Strayer procedure (gastrocnemius recession of the Achilles tendon) and elongation of the peroneus longus and brevis tendons were also performed, but the patient experienced deformity recurrence. Subcutaneous peroneus brevis tendon transfer to the navicular was then chosen, with postoperative use of an ankle-foot orthosis (AFO) and physical therapy. Results: The deformity was improved. The patient progressed with satisfactory gait and strength. He currently walks without support using an AFO. Both the patient and his family were satisfied with the functional outcome of the tendon transfer. Conclusion: Reconstruction of anterior tibial and extensor hallucis longus tendon rupture through peroneus brevis tendon transfer is a viable and reliable treatment option. No complications such as adhesions or correction failure were observed, thus corroborating the viability of this method.

PO 18145 - Anatomical structures at risk in proximal fifth metatarsal fracture fixation

Introduction: Proximal fifth metatarsal fracture fixation is usually treated conservatively, but when chosen for surgical treatment, percutaneous fixation with screws is the most used. This study aims to evaluate the presence of injury of the structures at risk and to measure the distance of these structures to the entry point. Methods: Eleven fresh-frozen below-the-knee specimens underwent standard operative fixation for a Jones fracture via the “High and inside” percutaneous technique. A guide wire was placed through the medullary canal and confirmed on fluoroscopy. The cannulated drill with a drill sleeve was then placed over the wire and advanced to the diaphysis. The guide wire was left, and the skin and subcutaneous tissues were carefully removed from the lateral midfoot to fully expose the structures at risk. The guidewire was then removed, and then the solid screw was placed. Neurovascular and tendinous structures were assessed for any injury. The distance of the wire in the base of the fifth metatarsal and these structures was measured and documented, including the branches of the sural nerve, cuboid, fourth metatarsal, peroneus longus, and peroneus brevis tendons. Results: The structure with the shortest average distance from the pin was the peroneus brevis, measuring 0.91 mm (±1.22 mm S.D.), followed by the cuboid articular surface, sural nerve, peroneus longus, and base of the fourth metatarsal, respectively. The pin had damaged the peroneus brevis in 5 of 11 cadavers. The average distance from the tendon insertion point was 7.2 mm. The furthest measured distance was 10 mm, while the closest was 3 mm. The screw head contacted the articular surface of the cuboid in 3 of 11 cadavers. There were no instances of pin contact with or damage to the peroneus longus, sural nerve, or fourth metatarsal head. Conclusion: We conclude that percutaneous fixation of fractures of the base of the fifth metatarsus presents a risk of partial lesion of the peroneus brevis tendon and lateral aspect of the cuboid. Therefore, specific care with these structures should be taken during the procedure.

A Comparison of Split Peroneus Brevis Tendon and Semitendinosus Allograft Tendon for Lateral Ankle Ligament Reconstruction

Lateral ankle instability is a debilitating condition that is often unresponsive to conservative therapy. Many techniques for operative repair have been proposed, most commonly performed as the Broström or modified Broström procedure. In patients with failed primary repair, hereditary collagen disorders, strenuous work activity, obesity, or ligamentous laxity, the Broström repair is less likely to be successful, and anatomic or nonanatomic reconstruction should be considered. The purpose of this study was to compare the functional outcomes and patient satisfaction between anatomic and nonanatomic reconstruction of the lateral ankle ligament complex for lateral ankle instability using a retrospective cohort study. We evaluated 64 ankles in 62 patients who underwent either a split peroneus brevis tendon (n = 36) or semitendinosus allograft tendon reconstruction (n = 28) for lateral ankle instability performed by the same surgeon. Postoperative American Orthopedic Foot and Ankle Society (p = .943) and patient satisfaction (p = .279) found no significant difference between either technique. Our results suggest that both split peroneus brevis and semitendinosus allograft may be viable alternatives for lateral ankle instability when primary ligamentous repair is not attainable.

Anatomical Structures at Risk in Proximal Fifth Metatarsal Fracture Fixation: A Cadaver Study

Category:Sports, Trauma, Cadaver studyIntroduction/Purpose:Jones fractures are fractures of the proximal fifth metatarsal involving the metaphyseal-diaphyseal junction. They have an increased risk for refracture, delayed union and nonunion secondary to poor blood supply to this área. They are usually treated conservatively, but when chosen for surgical treatment percutaneous fixation with screws is the most used. Few studies have evaluated the complications of injury to nearby structures during the percutaneous fixation. It has been shown, however, that the peroneal brevis and longus, the cuboid, and the sural nerve lie in close proximity to this starting point and are, therefore, at theoretical risk of injury. The study aims to evaluate the presence of injury of the structures at risk and to measure the distance of these structures to the entry point.Methods:Eleven fresh-frozen below-the-knee specimens underwent standard operative fixation for a Jones fracture via the “High and inside” percutaneous technique. A guide wire was placed through the medullary canal and confirmed on fluoroscopy. The cannulated drill with drill sleeve was then placed over the wire and advanced to the diaphysis. The guide wire was left and the skin and subcutaneous tissues were carefully removed from the lateral midfoot to fully expose the structures at risk. The guidewire was then removed, and then the solid screw was placed.Neurovascular and tendinous structures were assessed for any injury. The distance of the wire in the base of fifth metatarsal and these structures was measured and documented, including the branches of the sural nerve, cuboid, fourth metatarsal, peroneus longus, and peroneus brevis tendons.Results:The structure with the shortest average distance from the pin was the peroneus brevis, measuring 0.91 mm (±1.22 mm S.D.), followed by the cuboid articular surface, sural nerve, peroneus longus, and base of the fourth metatarsal, respectively. The pin had damaged the peroneus brevis in 5 of 11 cadavers. However, it did not damage at the tendon insertion point in any specimen. The average distance from the tendon insertion point was 7.2 mm. The furthest measured distance was 10 mm, while the closest was 3 mm. The screw head contacted the articular surface of the cuboid in 3 of 11 cadavers. There were no instances of pin contact with or damage to the peroneus longus, sural nerve, or fourth metatarsal head.Conclusion:This is the only study that evaluated the risk of injury the structures after a procedure that simulated an actual surgical act. It is also the only one that was aware of the risk of tendon injury not only in its insertion but also in its path during the placement of the wire and drill. We conclude that percutaneous fixation of fractures of the base of the fifth metatarsus presents a risk of partial lesion of the peroneus brevis tendon and lateral aspect of the cuboid. Therefore, specific care with these structures can be taken during the procedure.

Pes Cavus and Hindfoot Varus Alignment Are Associated with Increased Rates of Peroneal Tendon Pathology

Category:Hindfoot, Midfoot/ForefootIntroduction/Purpose:Cavovarus foot alignment has been significantly associated with increased rates of chronic ankle instability and osteochondral lesions of the talus. Clinical wisdom suggests that cavovarus foot alignment causes varus stress to the ankle and also predisposes individuals to peroneal tendon pathology. However, no studies have specifically explored this relationship. The purpose of this research is to investigate the association between foot alignment and peroneal tendon pathology.Methods:A retrospective case-control study was conducted of all adult patients in whom a magnetic resonance image (MRI) of the ankle was obtained for any reason at a single institution from 2015-2017. Patients were excluded if they had a charcot foot deformity or if they had undergone prior peroneal tendon, ankle, or hindfoot surgery. Arch alignment was evaluated on lateral weightbearing radiographs of the foot by measuring the adjusted navicular height. Hindfoot alignment was assessed using the Saltzman apparent moment arm method. Peroneal tendon pathology including tears, tendinosis, and tenosynovitis was documented by a fellowship-trained musculoskeletal radiologist using the MRI scan. All numerical variables were converted to categorical variables (e.g. varus, valgus, and normal alignment). Chi-square testing was utilized to determine the association between variables.Results:195 patients were included in the study (average age 47 years, 61% female). Patients with hindfoot varus had significantly higher rates of peroneus longus (PL) and peroneus brevis (PB) tendon pathology than patients with neutral or valgus alignment (Figure 1 A, B)(PL 39% vs. 31% vs. 20%, p=0.01; PB 44% vs 27% vs. 27%, p=0.04). Patients with pes cavus demonstrated extremely high rates of peroneal tendon pathology, which was significantly higher than patients with neutral or pes planus alignment (Figure 1 C, D)(PL 71% vs. 28% vs. 9%, p<0.0001; PB 75% vs 30% vs. 26%, p<0.0001). Amongst patients with peroneal tendon pathology, there was no difference in the rates of symptomatic vs. asymptomatic findings based on hindfoot or pes alignment.Conclusion:This is the first study to demonstrate a statistically significant association between cavus foot alignment, hindfoot varus alignment, and peroneal tendon pathology. Interestingly, this study demonstrates that patients with cavovarus alignment are not more likely to be symptomatic than patients with normal and planovalgus alignment. This study also reinforces the idea that peroneal pathology found on MRI may not necessarily need surgery, as it is frequently seen in patients without symptoms. This information may be useful in counseling patients considering operative treatment for peroneal tendon pathology and alignment abnormalities.

Morphometric study of inferior peroneal retinaculum and contents of inferior peroneal tunnel.

The aims of this study are to investigate the inferior peroneal retinaculum (IPR) regarding morphometric parameters, and contents in the inferior peroneal tunnel (IPT). One hundred and nine embalmed cadaveric legs were dissected in prone position. The extension band of the IPR was found in 31.19% of cases. The mean of length, width at the origin, width at the middle part, width at the insertion, and thickness of the IPR [mm] were 23.42 ± 3.54 (17.05-33.68), 13.29 ± 2.56 (5.83-20.92), 14.50 ± 2.37 (6.68-21.34), 10.10 ± 2.63 (4.59-19.17) and 0.48 ± 0.16 (0.20-0.87), respectively. The angle of the IPR to the horizontal axis was 38.51 ± 7.07 (11.67-54.00) degrees. The IPT was divided into the upper and lower tunnels. The normal contents were the tendons of peroneus brevis and peroneus longus in the upper and lower tunnels, respectively. However, additional contents were found in the upper tunnel in 2 cases. One was the tendon of peroneus digiti quinti, and peroneus quartus in the other one. Moreover, an unusual accessory peroneal muscle coursed into the lower tunnel and inserted on the peroneal tubercle. Tears of the peroneus brevis tendon were observed in 2 cases. These morphometric data might be beneficial in surgical repair for IPR injury.

A PROSPECTIVE STUDY OF SURGICAL MANAGEMENT OF CHRONIC NEGLECTED TENDOACHILLES RUPTURE USING PERONEUS BREVIS TENDON

Objective of the study is to find out functional outcome and complications associated with surgical reconstruction of chronic degenerative tendoachilles rupture using peroneus brevis tendon and role of local steroid injection in chronic rupture of tendon. We studied 10 cases with chronic degenerative Achilles tendon rupture who were treated with peroneus brevis tendon augmentation procedure. In 8 cases rupture of tendon was secondary to local corticosteroid injection given for retro calcaneal bursitis. Patients came to hospital with pain over the Achilles tendon and difficulty in walking, climbing stairs, diagnosed of Achilles tendon rupture through physical examination and subjected to USG for confirmation. Patients have undergone operative treatment in the form end to end suturing of ruptured tendon using Krakow technique and augmentation of tendon using peroneus brevis tendon as explained by Teuffer. Post operatively patient immobilized in above knee cast with foot in 15-20 plantar flexion and 45 degree of knee flexion. Suture removal done after 14 days of surgery. After 4 weeks cast converted to short leg cast. Mobilization started after 6 weeks on the cast. Cast discontinued after 8 weeks and full weight bearing started at 8-12 weeks. Follow up done for 18 months. Of 10 patients 7 patients were male and 3 were female. Age range was 30-60 years with mean age of 45 years. 7 patients had right tendon rupture, 3 had left tendon rupture. 8 patients gave previous history of corticosteroid injection given for retro calcaneal bursitis. Postoperatively 2 patients had skin necrosis which healed by secondary intention and scar. According to AOFAS scoring system for functional outcome of patients increased from preoperatively 65 to postoperatively 95(range 90-100). There is increased risk of Achilles tendon rupture after local steroid injection for inflammatory lesions of tendon or around the tendon, so it’s better to avoid giving local steroid injections in or around the Achilles tendon. Peroneus brevis can be easily used for Achilles tendon augmentation with good functional outcome. Keywords: Achilles tendon rupture, peroneus brevis tendon, corticosteroid, Teuffers technique, AOFAS scoring system.

Tunneling Away Lateral Ankle Pain

TITLE: Tunneling Away Lateral Ankle Pain AUTHORS: Geoffrey M. Dreher, DO; David Webner, MD; Kevin DuPrey, DO ACSM Sponsor (if you accept): Thomas Kaminski, PhD, ATC ([email protected]) HISTORY: 60-year-old boilermaker presented with 2-month insidious onset left lateral ankle pain, localized to the lateral malleolus, described as achy and throbbing, 7/10, worse with walking, stairs and climbing ladders. No relief with Acetaminophen or NSAIDs. PHYSICAL EXAMINATION: Left ankle: no edema or ecchymosis, full range of motion with pain in active dorsiflexion and plantarflexion. Strength 5/5, gross sensation intact and 2+ dorsalis pedis and posterior tibial pulses. Tenderness to palpation along the lateral malleolus extending distally approximately 5 cm along lateral ankle. DIFFERENTIAL DIAGNOSIS: 1. Chronic lateral ankle instability 2. Peroneal tendinosis with subluxation 3. Lateral malleolar stress fracture 4. Ankle osteoarthritis 5. Talar osteochondral lesion TEST AND RESULTS: •Left ankle 3 view x-ray: Normal. •Left ankle MRI: Anatomic variant involving conjoined peroneus brevis and longus tendons, located along the anterolateral aspect of distal fibula. Deficient/absent peroneal groove along posterior fibula, which also suggests congenital abnormality. Mild conjoined tendinosis, without surrounding edema. •Left lateral ankle ultrasound: Intact peroneal tendon overlying the lateral maleolus with trace fluid in sheath. The peroneal tendons split just before brevis insertion onto base of 5th metatarsal. FINAL/WORKING DIAGNOSIS: 1. Conjoined left peroneal tendon subluxation with tenosynovitis and absence of fibular groove. TREATMENT AND OUTCOMES: 1. Physical therapy for 6 weeks led to improved balance and walking mechanics, but no change in pain. 2. Immobilization in CAM boot for 6 weeks caused no improvement in pain or swelling out of boot. 3. Corticosteroid injection to peroneal tendons at level of lateral malleolus lead to no improvement. 4. Podiatry referral and surgery including tubularization of peroneal tendons, creation of 6mm fibular groove and repair of peroneal retinaculum. 3 months post-operatively, the patient was full weight bearing pain free with daily activities in lace-up ankle brace.

Peroneus brevis tendon rupture in ankle fracture: a case report

This study shows the case of a patient with peroneus brevis tendon rupture in ankle fracture. The patient com-plained of swelling, pain and activity limitation in her right ankle caused by sprain. She was diagnosed with ankle fracture, supina-tion-adduction (Lauge-Hansen typing) by medical history, physical examination and imaging. The peroneus brevis tendon was not-ed complete ruptured when suturing the incision after ORIF, which was then repaired by 8 shaped suture. Based on literature re-view, the injury mechanism of the case may be because of overload inversion force toward to lateral inferior from the fracture of fib-ula on the peroneus brevis tendon. Additional attention should be paid to patients who suffered from an supination-adduction ankle fracture for whether peroneus brevis tendon tears before and during surgery.

Posterior ankle impingement syndrome in athletes

Objective: This study sought to evaluate the results of 10 athletes diagnosed with posterior ankle impingement syndrome (PAIS) treated with arthroscopy between 2016 and 2017 by the Sports Traumatology Center of our University. Methods: Patients were evaluated with regard to the presence of associated lesions, the etiology of PAIS, and treatment outcomes using a visual analog scale (VAS) and the American Foot and Ankle Society (AOFAS) scores. All cases were treated using an arthroscopic approach to the posterior ankle. Results: Six patients presented with ankle instability and were treated with Brostrom-Gould ligament repair as an adjuvant procedure. One patient had sinus tarsi syndrome, and this space was debrided. Injury of the peroneus brevis tendon was identified in two cases, and Achilles tendinopathy was identified in one individual. Only three patients did not receive adjuvant treatment. During surgery, five cases of trigonal processes, three cases of Stieda process, one case of hallux saltans, and one case of accessory ossicle of the fibula were identified as the causes of the impingement. The mean VAS score was 1.28 (0.6-2.5), and the mean AOFAS score was 88.6 (72-100). No complications were reported. Conclusion: Arthroscopic resection of the cause of the impingement, alone or in combination with the treatment of secondary conditions, was used to effectively treat pain and reestablish function. Level of Evidence IV; Therapeutic Studies; Case series.