Peroneus Longus Research Articles

FUNCTIONAL OUTCOMES OF PERONEUS LONGUS TENDON AUTOGRAFT ARTHROSCOPIC RESTORATION OF AN ANTERIOR CRUCIATE LIGAMENT TEAR

The study was conducted to assess the functional outcome of arthroscopic reconstruction of anterior cruciate ligament tear by using peroneus longus tendon autograft. A prospective study was conducted in the Orthopaedics Department of Bakhtawar Amin Memorial Trust, Multan from 22 June 2021-22 June 2022. A total of 24 patients from the out-patient department were included in the study. Patients were clinically examined, and MRI was performed to confirm the presence of tear. Arthroscopic reconstruction was done. IKDC was used to assess the final outcome after 6 months, MRC was used to evaluate ankle stability with normal side as control. IKDC was normal in 22 patients (91.6%) and abnormal in only 2 patients (20%). The average IKDC score was 82.44. Lachman test showed normal results in 17 (70.8%)patients, 1+ laxity in 4 (16.6%), 2+laxity in (8.3%) and 3+laxity in 1 (4.1%)patient. 14 (58.3%) patients had negative pivot shift and 10 (41.6%)had positive glide. Peroneus longus tendon autograft is an effective option for anterior cruciate ligament reconstruction with less complications and maintains ankle function.

The Effects of Conscious Movement Processing on the Neuromuscular Control of Posture

Maintaining balance is thought to primarily occur sub-consciously. Occasionally, however, individuals will direct conscious attention towards balance, e.g., in response to a threat to balance. Such conscious movement processing (CMP) increases the reliance on attentional resources and may disrupt balance performance. However, the underlying changes in neuromuscular control remain poorly understood. We investigated the effects of CMP (manipulated using verbal instructions) on neural control of posture in twenty-five adults (11 females, mean age = 23.9, range = 18–33). Participants performed 90-s, bipedal stance balance trials in high- and low-CMP conditions, during both stable (solid surface) and unstable (foam) task conditions. Postural sway amplitude, frequency and complexity were used to assess postural control. Surface EMG was recorded bilaterally from lower leg muscles (Soleus, Tibialis Anterior, Gastrocnemius Medialis, Peroneus Longus) and intermuscular coherence (IMC) was assessed for 12 muscle pairs across four frequency bands. We observed significantly increased sway amplitude, and decreased sway frequency and complexity in the high- compared to the low-CMP conditions. All sway variables increased in the unstable compared to the stable conditions. We observed reduced beta band IMC between several muscle pairs during high- compared to low-CMP, but these findings did not remain significant after controlling for multiple comparisons. Finally, IMC significantly increased in the unstable conditions for most muscle combinations and frequency bands. In all, results tentatively suggest that CMP-induced changes in sway outcomes may be facilitated by reduced beta-band IMC, but these findings need to be replicated before they can be interpreted more conclusively.

Ankle-Angle-Adjusting Fibular Osteotomy in Closed Wedge High Tibial Osteotomy

Closed-wedge high tibial osteotomy (CWHTO) may be carried out to realign the knee in patients with knee osteoarthritis who do not meet the criteria for open-wedge high tibial osteotomy or total knee arthroplasty. The procedure involves both fibular and tibial osteotomy, and care is needed to prevent peroneal nerve and vessel injury during fibular osteotomy. Notably, use of a tourniquet may mask the development of hematomas or aneurysms until after surgery. We developed a 3-step ankle-angle-adjusting (triple-A) technique to relax the muscles, allowing easy retraction of the peroneal vessels. Crucially, the procedure does not require a tourniquet, thus allowing bleeding to be detected and stopped during surgery. The process involves adjusting the ankle angle by plantar-flexion and applying varus stress to highlight the tension difference between the lateral and posterior compartments; plantar-flexion of the great toe to loosen the flexor hallucis longus muscle, thus exposing the fibular posterior aspect; and valgus stress to loosen the peroneus longus muscle. The muscles can then be retracted sufficiently to allow distal and proximal osteotomies to be performed, and any bleeding can be detected and resolved before wound closure. This technique may improve the ease and safety of fibular osteotomy in patients undergoing CWHTO.

만성발목관절불안정성을 가진 농구선수의 신경근 훈련이 발목관절 기능에 미치는 영향

The purpose of this study is to verify the effect of 6-weeks of neuromuscular training on ankle joint function and provide useful information on the prevention of chronic ankle instability(CAI) and improvement of performance for university basketball players. A total of 30 university basketball players who are enrolled in Henan Institute of Science and Technology university were divided into 3 groups based on the CAI standards provided by the International Ankle Consortium: CAI-EG(experimental group, n=10), CAI-CG(control group, n=10), and H-CG(healthy control group, n=10). The neuromuscular training was applied to both CAI-EG and H-CG, and the physical training was applied to only CAI-CG for 6 weeks. Ankle joint function was measured before and after 6-weeks training program application. The Ankle joint function was measured by lower extremity muscle reaction time and performing three types of hop tests. The results of this study showed that the reaction time of the tibialis anterior muscle and peroneus longus muscle of the CAI-EG decreased after application of the program compared to before application(respectively, t=4.194, p=.002; t=3.035, p=.014). As a result of confirming the difference in three types of hop tests, the side hop test record decreased after the program application in all three groups compared to before the application(respectively, t=2.297, p=.047; Z=-2.803, p=.005; t=2.598, p=.029), and the figure-of-8 hop test record also decreased after the program application in all three groups compared to before the application (respectively, t=3.859, p=.004; t=2.638, p=.027; Z=-2.803, p=.005). Square hop test record was decreased after program application in the CAI-EG and CAI-CG compared to before application(respectively, t=2.876, p=.018; t=3.012, p=.015), and it was confirmed that the side hop test record after program application was higher in the CAI-CG than in the H-CG(F=8.116, p=.002). The results showed the effect of neuromuscular training on improving ankle joint function of university basketball players with CAI. Therefore, the neuromuscular training may be a useful program for college basketball players with CAI. Further studies that represent a situation similar to an actual basketball game will provide useful information for preventing CAI and improving performance of college basketball players.

Anatomical and biomechanical characteristics of fibularis longus tendon used for cruciate ligaments reconstruction

Abstract Introduction: Arthroscopic reconstruction of the cruciate ligament of the knee becomes routine with modern techniques and special instruments. However, the source of materials for this procedure has always been an eternal issue that affects the surgeons decision. The two peroneal tendons on the lateral side of the lower leg have the same function of plantar flexion and foot eversion. The fibularis longus tendon has been used for reconstruction such as the lateral collateral ligaments of the ankle or the Achilles tendon. Patients and methods: Descriptive cross-sectional study on twenty fresh cadavers were selected randomly for taking the fibularis longus tendon at the Department of Anatomy of the University of Medicine and Pharmacy, Ho Chi Minh City from January to July, 2022. Specimens with intact leg to lower knee segment were not crushed, well preserved and had never been used in previous studies. Results: Fibularis longus tendon length was 29,25 ± 2,1cm; the distances from fibularis longus tendon to deep fibular nerve and superficial fibular nerve was 71.1±8.63mm respectively, no split (longitudinal tear) was observed, the maximum tensile strength was 1170,4 ±203N, the maximum length of rupture 14,29 ± 3,88 mm. Conclusion: There was no split of fibularis longus tendon. Also no sign of impact on adjacent anatomy structures was found. The maximum tensile strength was equivalent to other grafts, such as the Hamstrings and patellar tendons. Its a potential source for arthroscopic reconstruction of the cruciate ligament Keywords: knee arthroplasty, fibularis longus tendon, grafts, Hamstrings tendon

Single-Stage Reconstruction with Innate Chimeric-Free Fibula Flap in Limb-Preserving Excision of Upper Limb Sarcomas

IntroductionThe limb-preserving excision is the standard of care in upper limb sarcoma management, but the resulting complex composite defects are exacting the expertise of the reconstructive surgeons. This study was done to evaluate a novel single-stage reconstruction of these defects using an innate chimeric-free fibula flap (a nonfabricated, anatomically available multiple tissue components harvested on independent perforators arising from the same peroneal source vessel). Patients and MethodsTwenty patients (16 male/4 female) with an average age of 29.5 years with upper extremity sarcoma (Enneking IIA/IIB) were treated by wide local excision and innate chimeric-free fibula flap reconstruction from March 2012 to March 2020. All the patients were followed for an average period of 18.3 months. At the end of the follow-up, the outcome was assessed by musculoskeletal tumor score (MSTS). ResultsThe flow-through flap was done in five patients. Muscle-tendon unit defects were reconstructed with a vascularized peroneus longus muscle-tendon unit in 15 patients. Nerve gap reconstruction using vascularized superficial peroneal nerve was done in eight patients. All patients had a segmental defect in the appendicular skeleton that was reconstructed with the vascularized fibular strut component. Soleus chimeric muscle component was used as a void filler and for covering the hardware in seven patients. The average size of the chimeric cutaneous component paddle was 30.7 cm2. The average length of fibula used for reconstruction was 16.6 cm. All flaps survived well, facilitating good hand function at the end of the follow-up. The average outcome score as per the MSTS was 22 (p = 0.035). ConclusionThe innate chimeric-free fibula flap provides all tissue components facilitating a good functional outcome. The advantage is the restoration of a functional hand in a single-stage reconstruction.

Intérêt des greffes au tendon peroneus longus deux brins et aux ischio jambiers quatre brins dans la reconstruction du ligament croisé postérieur

IntroductionPosterior cruciate ligament (PCL) injury hampers the rotational stability and stability front to back of the knee joint, seriously affecting the quality of life of patients. Some studies have reported that the peroneus longus tendon (PLT) has sufficient length and strength. HypothesisWe hypothesized that the PLT can be used as a novel appropriate material for PCL reconstruction therapy. Materials and methodsHerein, we systematically analysed the clinical effect of the double-stranded PLT and the four-stranded hamstring tendon in the reconstruction of the PCL and compared the effectiveness and safety of these two surgical approaches in the reconstruction of PCL injury. A total of 48 patients with complete rupture of the PCL were divided into Group A (reconstructed with the double-stranded PLT, 25 cases) and Group B (reconstructed with the four-stranded hamstring tendon, 23 cases). ResultsThe patients were followed up for more than 1 year. The intraoperative time for tendon extraction was significantly shorter in Group A than Group B. Twenty-four months after operation, patients in the two groups showed the alleviated tibial posterior displacement and the increased IKDC score, Lysholm score and Tegner score. Nevertheless, these scores showed no significant differences between the two groups. Additionally, compared with the therapy using the four-stranded hamstring tendon, therapy using the double-stranded PLT is simpler and safer. DiscussionBoth surgical methods are effective in the treatment of PCL injury. The PLT could be a good choice for PCL injury reconstruction material, especially when the four-stranded hamstring tendon is accidentally damaged or ineffective. Our study may provide guidance for the clinical treatment of PCL injury. Level of EvidenceIII, retrospective study.

Peroneus longus tendon transfer; prospective study of treatment outcome of recurrent fixed clubfoot deformities in children after failed surgical treatment

BackgroundIn childhood, for flexible clubfoot deformity, the transfer of the tendon of the tibialis anterior muscle is widely used. In contrast, extensive surgical procedures are required for fixed clubfoot deformities. MethodsWe describe the peroneus longus tendon transfer to the peroneus brevis tendon, additionally to full surgical release, in cases of recurrent fixed clubfoot deformities. The purpose of this surgical technique was to restore and maintain the dynamic balance of foot inversion-eversion during the gait cycle by augmenting the muscular strength of the weak peroneus brevis tendon. We report the prospective study of treatment outcome of twenty recurrent fixed clubfoot deformities in twelve children (20 feet) after failed surgical treatment they had. Anteroposterior and lateral radiographs under full-body weight-bearing and the AOFAS score pre-and postoperatively were used in all patients. For the estimation of the severity of the recurrent clubfoot deformity in each child and to increase the credibility of the AOFAS rating scale, we additionally used a clubfoot sheet score preoperatively and postoperatively (maximum score 100 points for normal foot appearance clinically and radiologically). ResultsThe mean age at surgery was 6,85 (±1,81; 5–11) years. The mean follow-up time was 5,4 (±1,7; 2–8) years. The mean AOFAS ankle-hindfoot rating score increased from 69,85 (±9,51; 53–82) points preoperatively to 94,4 (±2,43; 91–97) points postoperatively. The mean clubfoot sheet rating score increased from 43,00 (±12,18; 15–55) points, preoperatively to 90,0 (±4,58; 80–95) points postoperatively. The two-tailed p-value was < 0,0001. ConclusionsThe transfer of the peroneus longus tendon to the peroneus brevis tendon is a minimal surgical procedure that acts collaboratively in maintaining the correction of foot deformity, achieved by the complete surgical release. Level of Evidence: IV.

Tendoscopic-Assisted Repair of Distal Peroneus Longus Rupture: A Novel Approach and 2 Case Reports.

Level IV: Case Series.

Modulation of Lower-Limb Muscle Activity in Maintaining Unipedal Balance According to Surface Stability, Sway Direction, and Leg Dominance.

Determining temporal similarity in shape between electromyographic (EMG) and center-of-pressure (COP) signals reflects neuromuscular control in terms of which relevant muscles are involved in maintaining balance. The current study aimed to investigate a cross-correlation between seven lower-limb EMG activities and COP displacements, simultaneously measured in 25 young adults unipedally balancing on stable and multiaxial-unstable surfaces. The effect of surface stability, sway direction, and leg dominance was then tested on two EMG–COP correlation levels: individual muscles and groups (patterns) of multi-muscles involved in postural sway, as determined by principal component analysis (PCA). The results show that two factors demonstrate their effects only at the level of individual muscles: sway direction (p ≤ 0.003) and leg dominance (p = 0.003). Specifically, the semitendinosus, tibialis anterior, peroneus longus, and soleus correlate more with the mediolateral postural sway than with the anteroposterior postural sway, except for the gastrocnemius medialis. Additionally, balancing on the non-dominant leg shows a lower correlation between the semitendinosus and postural sway than on the dominant leg. The current findings suggest that when achieving unipedal equilibrium, the postural control system may be constrained the most in the specific muscles of the least steady conditions, e.g., the frontal plane and non-preferred leg.

Minimizing risk of iatrogenic nerve injury during peroneus longus tendon autograft harvest: a cadaveric study at different ankle or knee positions.

To evaluate the distances using ultrasound between the superficial peroneal nerve (SPN) and sural nerve along the peroneus longus tendon (PLT) autograft harvest path at different ankle or knee positions in order to minimize risk of iatrogenic nerve injury during PLT autograft harvest. Twenty-four fresh-frozen human cadaveric lower extremities were used to harvest a full-thickness PLT autograft with a tendon stripper. Four specimens were utilized to validate correct identification of nerves under ultrasound. Sonographically guided perineural injections were performed at the start point and end point of the PLT harvest path using coloured latex, followed by dissection with gross inspection. Using ultrasound, the distance from the peroneus brevis muscle to the sural nerve at different ankle positions (20° dorsiflexion, neutral, and 20° plantarflexion) was measured, and the distance from the end of the tendon stripper to the SPN at different knee positions (full extension and 90° flexion) was also measured. Measurements were performed by two separate observers using ImageJ software. Cadaveric dissection showed the presence of latex around nerves in all four specimens. The average distance from the brevis muscle to the sural nerve increased significantly from dorsiflexion to plantarflexion. The shortest distance from the tenodesis site to the sural nerve was 5.8 ± 1.7mm. There was no significant difference from the end of the tendon stripper to the SPN between full extension or 90° flexion of the knee. When harvesting the PLT, it is recommended to place the ankle at plantarflexion. The knee at full extension or 90° flexion had no effect. Joint positions at the time of graft harvest should be monitored to reduce risks of iatrogenic nerve injury.

A Study of the Functional Outcome of Supplementation of Hamstring Graft With Anterior Half of the Peroneus Longus Tendon in Arthroscopic Anterior Cruciate Ligament Reconstruction

The present study was done to analyze the functional outcome, donor site morbidities, and associated parameters when using the anterior half of the peroneus longus for augmentation of an inadequate hamstring graft when performing arthroscopic anterior cruciate ligament (ACL) reconstruction. Thirty patients with complete ACL tears were operated on. In all these patients, the thickness or length of the hamstring graft takenwas found to be inadequate (less than 8 mm and 7.5 cm, respectively). So, additionally, the anterior half of the peroneus longus tendon (AHPLT) graft was harvested to reach an optimum size of the final graft. Functional outcome was assessed using the International Knee Documentation Committee (IKDC) score at six weeks, three months, and six months. The Foot and Ankle Disability Index (FADI) score at six months was used to assess ankle stability. The mean age in our study was 28.8 years with male predominance (73.33%). The mean operative time was 86.4 minutes. The mean hamstring graft thickness in our study was 6.5 mm, which improved to 9.12 mm after augmentation. The mean graft length after AHPLT augmentation was 9.38 cm. The mean IKDC score at six months was 87.35. At the end of six months, FADI scores were found within normal limits(range: 135-136) in all the patients. No complications were noted in any of the patients. The AHPLT graft was always found to be sufficient enough for augmenting the hamstring graft to reach an acceptable thickness and length. There was no graft site morbidity and the ankle functional levels remained the same as preoperative levels, making it an excellent choice for augmentation of inadequate hamstring grafts.

Calcaneofibular ligament may act as a tensioner of peroneal tendons as revealed by a contactless three-dimensional scan system on cadavers

The ligaments are believed to have a role in stabilizing joints and regulating joint motion. Here, we propose a novel function of the calcaneofibular ligament (CFL), which stabilizes the ankle joint. In human bipedal locomotion, the peroneal muscles maintain mediolateral stability and prevent involuntary ankle inversion. To investigate the functional relationship between the peroneal longus tendon (PLT), brevis tendon (PBT), and CFL, we quantitatively analyzed the positional changes of the tendons by using a contactless three-dimensional optical scan system. Eighteen cadaveric specimens were included in the study. Interestingly, with increased tension of the CFL, the tendons significantly moved toward the lateral direction (P < 0.001), compared with their position when the CFL was detached. The actual lift amount reached 2.0 ± 0.8 mm for the PLT and 1.9 ± 1.0 mm for the PBT. These results strongly suggest that a tensed CFL can lift the peroneal tendons and may act as a “tensioner” for the effective transmission of muscle contraction. This phenomenon contributes to postural control, especially in regaining balance on uneven terrain, and provides a new perspective for the exercise methods or understanding the ankle joint instability due to sprains.

Heightened tone and stiffness with concurrent lowered elasticity of peroneus longus and tibialis anterior muscles in athletes with chronic ankle instability as measured by myotonometry

In a recent study, myotonometry revealed adverse alterations in the mechanical properties of ankle periarticular muscles in soldiers reporting previous lateral ankle sprain (LAS) incidents. This knowledge, if confirmed in athletes with developed chronic ankle instability (CAI), may have important diagnostic and therapeutic implications in sports medicine and rehabilitation.Consequently, the purpose of the study was to explore mechanical properties of the peroneus longus (PL), tibialis anterior (TA), and the lateral and medial gastrocnemius (LG and MG, respectively) muscles in athletes suffering CAI.Fourteen adult male athletes with developed CAI (International Ankle Consortium selection criteria) and 15 healthy male athletes without any LAS incidence as the control group (CO) participated in the study. The CAI and CO groups were characterized by similar anthropometric parameters and weekly training volume. In both the groups of athletes, we performed resting state (controlled with electromyographic recordings) myotonometric measurements (using a MyotonPRO® device) in the PL, TA, LG and MG muscles and calculated the following five myotonometric parameters: frequency (F-MYO), stiffness (S-MYO), decrement (d-MYO), relaxation time (R-MYO) and creep (C-MYO).Athletes from the CAI group (compared to the CO group) exhibited significantly higher values of F-MYO and S-MYO as well as lower values of R-MYO and C-MYO in the PL and TA muscles. No significant inter-group differences were found in the remaining myotonometric parameters.Using myotonometry, our study is the first to reveal that athletes with developed CAI are characterized by heightened tone and stiffness with concurrent lowered elasticity of the PL and TA muscles.

Outcome and donor site morbidity in trans-portal single bundle ACL reconstruction using peroneus longus tendon graft

Background: Hamstring and peroneus longus tendon auto graft has similar biomechanical strength. Peroneus longus is a potential graft in reconstructive orthopaedic procedures. There was few study in evaluation of peroneus longus usage in ACL reconstruction. We aimed to quantify the outcome and donor site morbidity in ACL reconstruction using peroneus longus tendon auto graft.Methods: Patients who suffered isolated ACL injury were enrolled in the study and underwent trans-portal single bundle ACL reconstruction using peroneus longus auto graft. Functional score (IKDC, Modified Cincinnati, and Tegner-Lysholm score) were assessed at pre-operative and 2-years after surgery. Graft diameter was measured at the time of graft harvest. Thigh circumference, ankle score (AOFAS and FADI) and serial hop test were assessed to evaluate donor site morbidities. Results: Sixty-eight patients fulfilled inclusion criteria. Peroneus longus graft diameter was 8.16±0.65 mm. There was significant difference between pre and 2-years post-operative functional score in IKDC, Modified Cincinnati and Tegner-Lysholm score. Mean of AOFAS was 93.98±2.95 and FADI was 94.80±0.56 with no significant decrease of thigh circumference, and good serial hop test result.Conclusion: ACL reconstruction with peroneus longus auto graft has excellent functional score in IKDC, Modified Cincinnati, Tegner-Lysholm score at 2-years follow up with the advantages of larger graft diameter, less thigh hypotrophy, good serial hop test result, and excellent ankle function based on AOFAS and FADI score.

Toward the definition of a minimum input model for an EMG analysis in clinics

Neuro-musculoskeletal (NMS) modeling based on electromyographic (EMG) signals allows for a better understanding of the principles of human movement [1]. Through appropriate modeling software (CEINMS) it is possible to estimate the muscular forces and joint moments calibrated on the single individual. The possibility of having highly subject-specific models allows an improvement in the treatment of a great variety of neurodegenerative diseases and can be fundamental for the general understanding of the neuro-mechanics of human locomotion. Fifteen walking trials of four able body subjects (mean age = 60 ± 2.16, mean BMI = 26.66 ± 4.13) were acquired with a motion capture system (BTS, 60 Hz), synchronized with a force plate (Bertec, 960 Hz) and a 15 channels surface electromyography (sEMG) system (FreePocketEMG, 1000 Hz). The CAST protocol was adopted as marker set, while the following muscles were acquired: Gluteus Maximus, Gluteus Medius, Tensor Fasciae Latae, Sartorius, Adductor Longus, Rectus Femoris, Biceps Femoris, Semitendinosus, Vastus Lateralis, Vastus Medialis, Tibialis Anterior, Peroneus Longus, Gastrocnemius Lateralis, Gastrocnemius Medialis and Soleus. The data were processed in MatLab for the extraction of four muscle synergies by applying the ‘Non-negative Matrix Factorization’ method [2]. Then, 'Statistical Parametric Mapping' [3] and 'Cosine Similarity' were used as metrics to assign each synergy to the EMG signals of just one muscle for each different muscle groups (Ankle Plantar-flexors, Ankle Dorsi-flexors, Knee Extensors and Knee Flexors). Afterwards data were processed in OpenSim; scaling, inverse kinematics, inverse dynamics, muscle analysis were run. Finally, CEINMS was executed to calculate muscle activations and torques first by informing the model with a complete setup of experimental EMGs data then with a reduced setup (the foru EMGs that best matched with muscle synergies). Activation signals of the muscle-tendon units and the angular moments of the knee and ankle obtain from models developed by CEINMS were compared for different setup with the experimental EMG signals. Comparison was done for both different muscle setups for each subject. In Fig. 1a are shown the values of cosine similarities of the muscles able to better approximate each primitive for one subject. In Fig. 1 b-e are displayed the pattern of primitives and the chosen experimental EMG signals for the same subject during one walking trial. The implemented methodology allowed the analysis of the muscular forces developed during walking with an acquisition protocol that includes a reduced number of EMG signals, and a sensitivity analysis for the adoption of NMS models based on a limited number of inputs was conducted. Results seem promising but a validation on a wider sample of subjects including pathological subjects is needed.

The Position and Morphology of the Peroneus Longus Tubercle in Hallux Valgus: A Weight-Bearing CT Assessment

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The peroneus longus is one of the main dynamic stabilisers of the first ray acting through its primary insertion at the first metatarsal base and has the theoretical possibility to be defunctioned in hallux valgus (HV). In this study, our primary objective was to report and compare the position and morphology of the peroneus longus tubercle (PLT) in feet with and without HV, using weightbearing CT (WBCT). Methods: A retrospective analysis of WBCT scans was completed using 40 feet in 23 patients. Feet were divided into two equal groups - the normal, 'non-hallux valgus' (non-HV) group and the 'HV' group (Mean age 60.45 and 60.60 respectively). The morphology and position of the PLT was assessed between groups. The intermetatarsal angle (IMA) and metatarsal pronation angle (MPA) were assessed. We also introduce and have assessed the novel measurements of tubercle-to-floor distance (T-F distance), the bisecting angle of the PLT, tubercle-to-metatarsals angle (T-MT angle) as well as the metatarsal cross-sectional area. Results: Between the non-HV group and the HV group, significant differences were found in the T-F distance (mean 26.7mm and 23.35mm respectively, p = .001), illustrating a lower medial column in HV. There was a moderate correlation between IMA and T- F distance (r = -.475, p &lt; .001) confirming depression of the first ray with increasing IMA. The bisecting angle was lower in the HV group as compared to non-HV (mean 61.65 degrees and 66.60 degrees respectively, p=0.017), demonstrating pronation of the PLT in relation to the floor in the HV. We found a significant difference in T-MT angle between the HV and non-HV groups (mean 31.85 degrees and 35.85 degrees respectively, p=0.041) and a strong correlation between the T-MT angle and bisecting angle (r = .817, p&lt; .001) suggesting the pronation occurred in the first metatarsal to a larger degree than the remainder of the forefoot. Conclusion: In this study we have demonstrated a difference in the position of the PLT between HV and non-HV individuals, with a pronated PLT noted in individuals with HV.

Anatomic Structures at Risk When Utilizing Percutaneous Intramedullary Fibular Screw Fixation for Lateral Malleolus Fractures: A Cadaveric Study

Category: Ankle Introduction/Purpose: Isolated lateral malleolus fractures are a common ankle fracture that a foot and ankle surgeon will encounter. Retrograde intramedullary fixation for unstable lateral malleolus fractures has become a viable option for patients at higher risk for potentially devastating wound complications. The aim of this cadaveric study was to assess the relative risk of injuring adjacent anatomic structures with percutaneous implantation of an intramedullary fibular screw for lateral malleolus fractures to minimize iatrogenic injury. Methods: Seven fresh-frozen below-the-knee cadaver specimens were used for this study. Prior to investigations, specimens were inspected with fluoroscopic radiographs for preexisting pathology or prior surgical intervention. Lateral dissection of the lateral malleolus was performed after screw placement to determine the proximity of the peroneus longus (PL), peroneus brevis (PB), and sural nerve (SN) to the inserted hardware. The mean, standard deviation, and range for distances were calculated for all structures. Analysis of variance (ANOVA) was used to determine statistical significance. Results: Percutaneous intramedullary fibular screw placement was performed in seven specimens, six females and one male, with an average age of 79.3 +- 8.1 years. Amongst the seven specimens, only one resulted in an injury to a structure of interest (sural nerve). The peroneus longus and peroneus brevis were not injured in any of the specimens. Table 1 shows the average distance between the guidewire and each structure of interest. Conclusion: This study shows the potential risks to lateral structures when placing an intramedullary fibular screw for unstable lateral malleolus fractures. We suggest that orthopedic surgeons exercise caution when performing critical steps of the procedure to minimize avoidable injury to structures of importance that may increase the morbidity of the patient.

Proximal Flexor Hallucis Longus Transfer to Peroneus Brevis for Treatment of Peroneal Muscle Paralysis

Category: Hindfoot; Ankle; Other Introduction/Purpose: Equinovarus foot deformities typically present with equinus contractures, hindfoot varus, dorsiflexion of the medial midfoot, and adduction deformities of the forefoot. Whether of neurologic or muscular origin, all forms result muscular imbalance. Flexor hallucis longus (FHL) transfer to peroneus brevis (PB) is indicated when both peroneal muscles are in unrepairable condition to restore active eversion. However, in cases of muscle paralysis where the PB is still in continuity, we recommend a novel technique where FHL is tenodesed proximal to the peroneal retinaculum within the leg to avoid the additional morbidity associated with more distal fixation or tenodesis. Methods: Surgical intervention first involved a posterolateral approach to the ankle and an Achilles tendon Z-lengthening to fix her equinus contracture. The ankle and subtalar joint capsules were contracted requiring release. Flexor digitorum longus (FDL) and FHL were tenotomized, which immediately corrected her claw toes. Since the tendon had already been released, we were able to deliver the FHL tendon into the posterolateral leg wound. The peroneal fascia and sheath were opened proximal to the superior peroneal retinaculum to prevent tendon subluxation. PB was identified by confirming that it produced foot eversion and by visualizing the peroneus longus (PL). The tension of PB was confirmed by observing that it did not cause tension at PL insertion on the plantar 1st ray. FHL was then transferred to the PB utilizing a Pulvertaft weave technique with the tendon appropriately tensioned in mid eversion in the middle of the Blix curve (Figure 1). Results: After FHL transfer, the patient was immediately allowed to weight bear as tolerated in a short leg cast. This was due to her deconditioned state to limit atrophy and the effects of prolonged recumbency in this medically fragile young woman. The patient ultimately was casted for 10 weeks total as she was unable to tolerate a CAM boot or other orthotic due to the weight and problems with the fit. At 4 months follow up, her foot is corrected and she is able to stand in a neutral, plantigrade position. Using a new AFO, she can walk without issue. Her foot remains well balanced and plantigrade. Conclusion: This simple FHL transfer technique decreases morbidity since the transfer occurs within the leg, proximal to the superficial peroneal retinaculum (SPR). The transfer pulls on the paralyzed, but intact PB instead of routing the FHL to the 5th metatarsal base or PB stump. This technique is only recommended if PB is intact but non-functional. It should be noted that adequate tensioning is essential for a successful transfer. Benefits of this procedure include no cluttering under the SPR and no risk of scarring that region which can lead to decreased tendon excursion.

Comparison of Ultrasound and MRI with Intraoperative Findings in the Diagnosis of Peroneal Tendinopathy, Tears, and Subluxation

Category: Ankle Introduction/Purpose: Suspected peroneal tendinopathy, tears, and subluxation are often confirmed using magnetic resonance imaging (MRI) or diagnostic ultrasound (US). The choice between these two imaging modalities is commonly based on surgeon preference as the accuracy of these tests for the diagnosis of peroneal tendinopathy, tears, and subluxation is not known. The purpose of this study was to compare MRI and US to the intraoperative findings in patients who underwent surgery for the treatment of suspected peroneal tendinopathy, tears, and subluxations to determine the diagnostic accuracy of each imaging modality. Methods: The operative records and diagnostic images for 21 patients who underwent surgery for suspected peroneal tendinopathy, tears, or subluxation were retrospectively reviewed. Two fellowship trained musculoskeletal radiologists conducted a systematic blinded review of the stored MRI and US images. The results of this review were compared with the intraoperative findings to yield the sensitivity and specificity for each imaging modality. Results: For the diagnosis of peroneus brevis tears, both MRI and ultrasound were equally good at detecting tears. In the diagnosis of peroneus brevis tears, MRI was marginally better with a sensitivity and specificity of 100% versus ultrasound, which had a sensitivity of 90% and specificity of 100%. In the diagnosis of peroneal subluxation, ultrasound had a sensitivity of 100% and a specificity of 100% compared to MRI, which had a sensitivity of 33% and specificity of 100%. Conclusion: In comparing MRI and US to intraoperative findings for the diagnosis of peroneal tendinosis, tears and subluxation, we found ultrasound to be more effective at diagnosing peroneal tendinopathy and subluxation, while MRI was found to be slightly more accurate in the diagnosis of peroneus brevis tendon tears. Both MRI and ultrasound were effective for the diagnosis of peroneus longus tears.