Split Lesion Research Articles

A Biomechanical Analysis of Peroneus Brevis Split Lesions, Repair, and Partial Resection.

Peroneus brevis tendon tears are associated with chronic ankle pain and instability following sprain injuries. The aim of this study is to elucidate the biomechanical changes induced by a peroneus brevis split and surgical treatment by tubularizing suture or partial resection. Nine human lower leg specimens were biomechanically tested. Preexisting tendon pathology was ruled out by magnetic resonance imaging and histology. Specimens were subjected to sequential testing of 4 conditions of the peroneus brevis tendon: (1) native, (2) longitudinal lesion, (3) tubularizing suture, and (4) 50% resection. The outcome parameters were the tendon stiffness (N/mm) and the length variation of the split portion at 5 N load. The median specimen age at death was 55.8 years (range 50-64 years). The longitudinal tendon split led to an elongation by 1.21 ± 1.15 mm, which was significantly reduced by tubularizing suture to 0.24 ± 0.97 mm (P = .021). Furthermore, 50% resection of the tendon elongated it by a mean 2.45 ± 1.9 mm (P = .01) and significantly reduced its stiffness compared to the intact condition (4.7 ± 1.17 N/mm, P = .024) and sutured condition (4.76 ± 1.04 N/mm, P = .011). Longitudinal split and 50% resection of the peroneus brevis tendon led to elongation and loss of tendon stiffness. These properties were improved by tubularizing suture. The significance of these changes in the clinical setting needs further investigation. Tubularizing suture of a peroneus brevis split can restore biomechanical properties to almost native condition, potentially aiding ankle stability in symptomatic cases. A split lesion and partial resection of the tendon showed reduced stiffness and increased elongation.

Successful reconstruction of distal peroneus longus tendon dislocation associated with a split lesion \u2013 a case report

BackgroundPeroneal tendon injuries are one of the differential diagnoses in lateral ankle and rearfoot pain. While partial tears are not uncommon, peroneal tendon dislocation at the peroneal tubercle is very rare. Until now, only three papers have been published, presenting five cases of peroneus longus tendon dislocation over the peroneal tubercle. This report adds a previously undescribed case of a peroneus longus tendon split tear that was partially dislocated and entrapped over the peroneal tubercle. The respective operative approach and the outcome are described.Case presentationA 25-year-old international top-level speed skater developed a painful mass over the lateral calcaneal wall. There was no specific inducing injury in his medical history. In contrast to previous reports, according to the patient’s history, a snapping phenomenon was not present. Conservative treatment was not effective. By inspection and palpation an enlarged peroneal tubercle was assumed. During operative exploration, we found an incomplete longitudinal split tear of the peroneus longus tendon, which was partially dislocated and entrapped over the peroneal tubercle. This mimicked an enlarged peroneal tubercle. A portion of the split tendon was resected. A deepening procedure of the flat groove of the peroneus longus tendon below the peroneal tubercle and a transosseous reconstruction of the avulsed inferior peroneal retinaculum were performed. After six months, the patient had completely reintegrated into his elite sport and has been free of symptoms since then.ConclusionsFrom the presented case it can be speculated that the inferior peroneal retinaculum was overused, worn out, detached, or ruptured due to overpronation and friction the lateral edge of the low-cut speed skating shoe. Then the peroneus longus tendon experienced substantial friction with the peroneal tubercle with possible dislocation during ankle motion. This frictional contact may have finally led to further degeneration and a longitudinal tear of the tendon. Obviously, dislocations can develop insidiously resulting in lesions of the peroneus longus tendon at the peroneal tubercle, ultimately leading to a tendon entrapment. This mimics an enlarged tubercle. The pathology is very rare and can be successfully addressed surgically.

A classification for partial subscapularis tendon tears

PurposeThe aim of the study was to analyze partial subscapularis tendon (SSC) tears and provide a descriptive classification.MethodsThe retrospective study included 50 patients with arthroscopically confirmed partial SSC tears. Internal rotation (IR) force measurements and IR ROM have been made and compared to the healthy contralateral side. Then the footprint of the SSC was routinely investigated by arthroscopy with standardized measurement of the bony footprint lesion. The partial tears were classified according to the mediolateral and craniocaudal extension of the rupture in the transverse and coronal plane, respectively.ResultsPartial SSC tears could be classified into split lesions (type 1, n = 11) and 3 further groups depending on the mediolateral peeled-off length of the bony footprint (type 2: < 10 mm, n = 20; type 3: 10–15 mm, n = 10; type 4: > 15 mm, n = 9). Type 2–4 could be further divided depending on the craniocaudal peeled-off length of the bony footprint (group A: < 10 mm, group B: 10–15 mm, group C: > 15 mm). Significantly decreased IR strength was shown for types 2–4 (p < 0.05) but not for split lesions as compared to healthy side. Types 1–4 showed significant decreased active IR ROM and all except type 3 (n.s.) which showed decreased passive IR ROM compared to the healthy side (p < 0.05).ConclusionWe present a novel classification for partial SSC tears for a more detailed and reproducible description. This can help to improve the current knowledge about the appropriate treatment. It could be shown that partial tears of the subscapularis can have an impact on IR strength and motion.Level of evidenceIII

The Role of MRI in the Assessment of Chronic Lateral Ankle Instability

Category: Ankle, Arthroscopy, Sports Introduction/Purpose: Chronic lateral ankle instability is a common problem in foot and ankle surgery, especially in patients with neutral or varus alignment of the hindfoot. Peroneal tendinopathy is a common associated condition with reported incidence as high as 77%. Not all surgical approaches allow for assessment of the peroneal tendons intraoperatively, and so physical exam and imaging, by either ultrasound or MRI, often plays an important role in pre-operative planning. We evaluated the usefulness of MRI reports in identifying peroneal tendon pathology in patients with lateral ankle instability. Specifically, we aimed to identify the most commonly missed lesions, as well as the sensitivity of an MRI report at detecting any peroneal pathology, as we reason this finding to have the great effect on preoperative planning. Methods: We performed a retrospective chart review of all patients who had undergone surgery for lateral ankle instability at our institution in the past 7 years (January 1, 2009 to December 31, 2015). We used intraoperative peroneal pathology as our gold standard for diagnosis, and identified cases via the operative report. We defined peroneal pathology as peroneal brevis/longus rupture, split lesion, tenosynovitis, or tendinopathy not otherwise specified. Additionally, we assessed for low insertion of the peroneus brevis muscle belly. Then we examined all cases of intraoperative peroneal pathology that had a preoperative MRI report. We correlated MRI reports to intraoperative peroneal findings aiming to assess the accuracy of MRI reports in diagnosing peroneal pathology in patients undergoing surgical treatment for chronic lateral ankle instability. Results: We identified 76 patients with intraoperative peroneal pathology and preoperative MRI reports. Forty-six had some form of peroneal pathology noted on their MRI report (60.5% sensitivity, 39.5% false negatives). MRI report had a 53.3% (16/30) sensitivity for detecting peroneus brevis split lesions, and a 46.2% (30/65) sensitivity for peroneal tenosynovitis or tendinopathy not otherwise specified. Additionally, 41 cases of low insertion of the peroneus brevis muscle belly were found intraoperatively, but MRI report failed to identify any of these specifically. Of the 30 patients who had intraoperative peroneal pathology without such findings on their MRI report, 93.3% (28/30) had peroneal tenosynovitis or tendinopathy not otherwise specified, while 26.7% (8/30) had a peroneus brevis split lesion and 6.7% (2/30) had a peroneus longus split lesion. Conclusion: Our findings suggest that MRI reports may not be accurate in describing the presence of peroneal tendons pathology in patients with chronic lateral ankle instability. With a false-negative rate of nearly 40%, it is likely that MR imaging underestimates peroneal pathology in these patients. This is clinically significant as certain limited surgical approaches such as the “smile” incision, do not allow intraoperative assessment of the peroneal tendons. Our study findings encourage surgeons to review MR images preoperatively and to use a surgical approach that allows peroneal tendon assessment when repairing the lateral ankle ligaments.

Revisiting the Prevalence of Associated Co-Pathologies in Chronic Lateral Ankle Instability

Category: Ankle, Hindfoot, Sports Introduction/Purpose: Ankle sprains are the most common athletic injury with an estimated 30% risk of developing chronic lateral ankle instability. Up to 20% of these patients will require surgical management after trial of conservative treatment for chronic disease. Current literature suggests that the presence and type of co-pathologies associated with chronic lateral ankle instability can serve as important predictors of surgical outcomes. As the occurrence of these co-pathologies varies in the literature, providers may underestimate their presence which may lead to suboptimal surgical approach. The purpose of this study is to re-examine the prevalence of common associated lesions in patients who underwent surgical treatment for chronic lateral ankle instability. Methods: We retrospectively reviewed medical charts for 389 cases of lateral ankle instability repair surgery at our institution between June 2006 and November 2016. All patients had undergone at least 6 months of conservative therapy such as ankle stabilizing orthosis or physical therapy with no improvement. All operations were performed by senior orthopaedic surgeons. Exclusion criteria included age less than 18 at time of surgery, gross traumatic event, and history of ipsilateral subtalar arthrodesis. Demographic information such as age, gender, body mass index, and race/ethnicity were collected. 166 surgical notes accessible through the electronic medical record were reviewed for specific intra-operative findings including presence of peroneal pathology (including tendon split lesion), talar osteochondral defects, anterior or posterior ankle impingement, low lying muscle belly of the peroneus brevis and surgical approach. Simple descriptive statistics were used to examine means and frequencies of the collected data. Results: 166 cases (48 males, 118 females) were included (mean age = 39 ±13.4 years, mean body mass index = 31.41 ± 7.5 kg/m2, mean follow-up = 44 ± 46 weeks). 95 cases involved the left foot while 71 cases involved the right foot. Two senior surgeons accounted for 87% (145/166) of the cases. 20 cases were revisions. 72.3% (120/166) of all cases had associated peroneal pathology (36.6% (44/120) peroneus brevis split lesion and 5.8% (7/120) with peroneus longus split lesion). 41% (69/166) of the patients had ankle impingement (anterior = 32; posterior = 19. combined = 17), 37% (62/166) had a low lying muscle belly of the peroneus brevis and 19% (32/166) had osteochondral lesions of the talus. Conclusion: Surgical approach and long-term outcomes can be affected by the knowledge and proper diagnosis of chronic lateral ankle instability associated lesions. Our study reinforces the need for vigilant exploration of chronic ankle instability patients who require surgical treatment. More specifically, surgical exploration for peroneal pathology and ankle impingement may be crucial as our findings reveal a high intraoperative rate of their occurrence. While the role of a low-lying peroneus brevis muscle belly in the development or course of chronic lateral ankle instability remains to be elucidated, we report a significant percentage of its occurrence.

Nonablative Fractional Laser Resurfacing for the Treatment of Hypertrophic Scars: A Randomized Controlled Trial

Nonablative fractional laser (NAFL) therapy is a noninvasive procedure that has been suggested as a treatment option for hypertrophic scars. To evaluate the efficacy and safety of 1540-nm NAFL therapy in the treatment of hypertrophic scars. An intraindividual randomized controlled trial (RCT) with split lesion design and single-blinded outcome evaluations. Patients received four NAFL treatments at monthly intervals. Primary endpoint was a blinded on-site visual and palpable Physician Global Assessment (PhGA). Adverse event registration and pain evaluation were used to evaluate safety. Patient global assessment (PGA) was a secondary endpoint to additionally evaluate efficacy. The PhGA did not find a statistically significant difference between the treated and untreated control side of 18 patients, although there was significant difference on the PGA 1 (p=.006) and 3 (p=.02) months after last treatment (Wilcoxon signed rank test). Patients experienced moderate pain during treatment and mild adverse events. In this trial, blinded PhGA could not confirm the clinical efficacy of 1540-nm nonablative fractional laser in the treatment of hypertrophic scars, but the treatment is safe, and patients judged that the treated part had a better global appearance.

Nonablative fractional laser resurfacing for the treatment of scars and grafts after Mohs micrographic surgery: a randomized controlled trial

Mohs micrographic surgery is a tissue sparing surgical technique for removal of skin cancer. To optimize the cosmetic result of scars and skin grafts after surgery non invasive procedures as non-ablative fractional laser (NAFL) resurfacing are attractive. To evaluate efficacy and safety of 1540 nm NAFL in the treatment of scars and skin grafts after Mohs micrographic surgery. An intra-individual randomized controlled trial (RCT) with split lesion design and single blinded outcome evaluations. Patients receive four treatments at monthly interval with NAFL [StarLux-300 with Lux 1540 nm fractional handpiece (Palomar technologies)]. Primary endpoint to evaluate efficacy is a blinded on site visual and palpable Physician Global Assessment (PhGA). Adverse event and pain registration are used to evaluate safety. Patient's global assessment (PGA) and skin reflectance measurements are secondary endpoints. The PhGA score comparing the treated to the untreated control side of 24 patients is significant different 1 (P = 0.009) and 3 (P = 0.001) months after treatment (Wilcoxon signed rank test). Patients experienced mild to moderate pain. Four days after the treatments patients reported erythema (67%), oedema (31%), crusts (22%), burning sensation (14%), purpura (9%) and vesicles (4%). No long term adverse events are reported. PGA is significant different 1 (P < 0. 001) and 3 months (P < 0. 001) after the last treatment. Skin reflectance do not show significant difference. This study shows that nonablative 1540 nm fractional laser is a safe and effective treatment for the improvement of scars and grafts after Mohs surgery.

Anatomical Variations of Peroneal Muscles

Persistent lateral ankle pain is a common presentation in clinics. Various studies on anatomical variations of the peroneal compartment muscles, including the peroneus quartus muscle, have been reported in different populations. However, such studies are rarely from India. Hence, the present study was undertaken on cadavers in an Indian population. The lateral compartments of the legs were dissected in 70 specimens to study the presence, origin, and insertion of accessory muscles. Different peroneal tendons were observed for tears and splits. Three of 70 specimens (4.3%) showed prevalence of the peroneus quartus muscle. Twenty specimens (28.6%) had split or tear lesions of the peroneus brevis muscle. Presence of the peroneus quartus muscle in this Indian population was relatively low compared with that in previous reports in English and American populations (6.6%-21.9%). Racial differences, cultural variations, and postural habits, along with different stages of evolution, may be factors contributing to different observations. Split lesions of the peroneus brevis tendon were six to seven times more prevalent than was presence of the peroneus quartus muscle, which implies that split or tear lesions of the peroneus brevis tendon are more frequently involved in the manifestation of persistent retromalleolar pain compared with complications arising out of presence of the peroneus quartus muscle. Hence, accurate knowledge of presence of the peroneus quartus muscle in different populations is important because it can also be used in grafting and reconstruction in foot and ankle surgery.

Long-Term Outcome of Fibrous Dysplasia: Reconstruction With Dysplastic Bone -Case Report-

A 10-year-old girl presented with facial asymmetry associated with bulging of the right fronto-orbital region with no symptoms. Computed tomography demonstrated enlargement of the right zygomatic, frontal, ethmoid, and sphenoid bones. Abnormal proliferation of the bone had obliterated the sphenoid, right frontal sinus, and right ethmoid sinuses. These radiological findings suggested right optic nerve compression due to fibrous dysplasia. Right optic canal decompression was performed. In preparation for recurrence, the resulting bone defect in the right orbital roof was reconstructed using the outer table of the split lesion bone. The removed frontal bone was divided into intact and lesioned parts, and the intact part was returned. The lesioned part was split and the outer table graft used to reconstruct the frontal region. A temporal musculopericranial flap was used to form a barrier between the opened ethmoid sinus and cranial cavity. A protrusion appeared on the left forehead 10 years later, and was shaved to improve the aesthetic appearance. The patient was followed up for a total of 23 years. The use of dysplastic bone involves the risk of recurrence, but the period of recurrence is delayed and the progression stops after adolescence, so the second operation involved only shaving for aesthetic appearance. This procedure is one of the treatments of choice because of easy reconstruction, easy revision, and good results.

Syndrome fissuraire du tendon du muscle court fibulaire secondaire à un muscle fibulaire surnuméraire

The authors report a case of fibularis muscle syndrome in a 37-year-old man with no history of trauma to or chronic instability in the ankle. Surgical exploration discovered a split lesion in the fibularis brevis tendon, associated with the supernumerary muscle. Based on clinical history and perioperative observations, the fissure syndrome appears to have resulted from a retromalleolar conflict in the fibularis retinaculum secondary to anatomi- cal abnormality. Tendon repair and accessory muscle excision allowed complete recovery.

Split lesions of the peroneus brevis tendon in the Japanese population: an anatomic and histologic study of 112 cadaveric ankles

Split lesions of the peroneus brevis tendon are believed to be rare and have received little attention in populations of Asian countries. The purpose of this study was to investigate the incidence of split lesions in the Japanese population. The peroneus tendons of 112 ankles from 30 male and 26 female adult human embalmed cadavers with an average age of 76.9 years (range, 55–93) were dissected. The presence of split lesions, determined by either thinning or longitudinal splitting of the peroneus brevis tendon, was examined. Forty-two ankles (37.5%) had split lesions, of which 21 (50%) showed a thinning appearance without splitting, and 12 (28.6%) had well-defined, full-thickness longitudinal tears. The incidence of split lesions of the peroneus brevis tendon in the Japanese population was similar to that in studies of the U.S. population, but the condition of the lesions was less severe. Although the clinical presence is expected to be extremely rare, we must consider a neglected split lesion of the peroneus brevis tendon when residual pain is observed in the retrofibular location.

Split lesions of the peroneus brevis tendon in chronic ankle laxity.

Between 1993 and 1995, we operated on 18 patients for split lesions of the peroneal brevis tendon associated with chronic ankle instability. Five patients were competitive athletes, seven were recreational athletes, and six were persons. Symptoms developed in three phases: ankle sprain, chronic instability, and posterolateral pain. The mean delay between sprain and posterolateral pain was 6 years. At the time of surgery the main complaint was retromalleolar pain in nine patients, pain and instability in eight patients, and instability only in one patient. Diagnosis of tendinous lesions was based on clinical examination in three cases, preoperative magnetic resonance imaging in eight cases, preoperative tenography in one case, and surgical exploration in six cases. The lesion was localized at the tip of the lateral malleolus and was visible only after opening the peroneal retinaculum. In three cases an accessory peroneal muscle was present. A Chrisman-Snook procedure was performed in 13 cases and a simple tendinous repair in 5 cases. The split lesion of the peroneus brevis tendon may be the result of chronic ankle laxity. This lesion needs a specific surgical treatment and the peroneal tendon must be checked in case of surgical procedure for ankle laxity. After ligamentous repair, residual pain can be due to a neglected peroneus brevis tear.

Epiluminescent Light Microscopy of Melanocytic Lesions after Dermoepidermal Split

In vivo epiluminescent light microscopy (ELM) of pigmented skin lesions reveals numerous elementary structures. Among them, the pigment network (PN), black dots (BD) and brown globules (BG) constitute important semiologic features. Based on histological extrapolations, it has been postulated that PN should reflect the presence of melanin in the epidermis and its honeycomb aspect should result from the dermoepidermal architecture. To demonstrate this directly by analyzing separately by ELM the epidermal and dermal sides of melanocytic lesions. We split the epidermis from the dermis of 10 pigmented lesions (6 lentigos, 4 nevocytic nevi) by incubation with dispase. ELM images were done in vivo before excision, then ex vivo on the whole specimen and separately on the split epidermis and dermis. Epidermal and dermal specimens were finally controlled by histology. PN was observed only on the epidermal side of the split. Its organization was remarkably conserved after the procedure as compared with prior in vivo images. In contrast, pigmentation observed on dermal sides of the splits showed no organized pattern and corresponded to melanophages. BG were found on the dermal side and BD on the epidermal side of the split lesions, which confirms previous hypotheses. By subtracting the dermal pigmentation and vessels from the image, the split technique has thus established the epidermal origin of the PN and given a more detailed ELM analysis of network components.

Machine Vision Detection of Early Split Pistachio Nuts

Computer vision was used to detect early split lesions on the hull of pistachio nuts. Gray scale intensity profiles were computed across the width of the nut (perpendicular to the suture along the longitudinal axis). If the profile crossed an early split lesion, a deep and narrow valley on the profile at the early split location was observed. Profiles were computed every 0.5 mm along the longitudinal axis of the nut and the number of adjacent profiles with deep and narrow valleys was recorded. Early split nuts contained a significantly higher count of these adjacent profiles than normal nuts. Combining unhulled nut cross-sectional area with the adjacent profile data, 100% of the early split nuts and 99% of the normal nuts were correctly classified of the total of 180 nuts tested.

Correlation of Glomerular Basement Membrane Alterations With Clinical Data in Progressive Hereditary Nephritis (Alport's Syndrome)

Electron microscopic examination of glomerular basement membrane (GBM) was performed in 19 patients whose morphological changes as well as clinical features indicated the diagnosis of progressive hereditary nephritis (Alport's syndrome). The percentage of characteristically thickened and split and of thin GBM portions was determined in all the cases. The clinical course was more severe in males, which corresponded to higher rate of GBM alterations. In males, 58% of GBM was thickened and split and 24% was thin, while in females, the reverse was true, 28% was split and 48% of GBM was thin. There was a positive correlation of the split lesions and age in males, but not in females. The degree of splitting was directly proportional to the grade of proteinuria, while GBM thinning did not significantly correlate with proteinuria.