Tendoscopy of the peroneal tendons

Minimally Invasive Peroneal Tenodesis Assisted by Peroneal Tendoscopy: Technique and Preliminary Results

Introduction: Peroneal disorders are a common cause of ankle pain and lateral instability and have been described in as much as 77% of patients with lateral ankle instability. Clicking, swelling, pain, and tenderness in the peroneal tendons track are frequent symptoms, but they can be confused with other causes of lateral ankle pain. The management of peroneal disorders can be conservative or surgical. When the conservative treatment fails, surgery is indicated, and open or tendoscopic synovectomy, tubularization, tenodesis or tendon transfers can be performed. The authors present a surgical technique of tendoscopy associated to minimally invasive tenodesis for the treatment of peroneal tendon tears, as well as the preliminary results of patients submitted to this procedure. Methods: Four patients with chronic lateral ankle pain who were diagnosed with peroneal brevis pathology were treated between 2020 and 2022 with tendoscopic-assisted minimally invasive synovectomy and tenodesis. Using a 2.7 mm 30° arthroscope and a 3.0 mm shaver blade, the entire length of the peroneus brevis tendon and most parts of the peroneus longus tendon can be assessed within Sammarco's zones 1 and 2. After the inspection and synovectomy, a minimally invasive tenodesis is performed. Results: All patients were evaluated at least six months after surgery. All of them reported improvement in daily activities and in the Foot Function Index (FFI) questionnaire (pre-surgery mean FFI = 23.86%; post-surgery mean FFI = 6.15%), with no soft tissue complications or sural nerve complaints. Conclusion: The tendoscopy of the peroneal tendons allows the surgeon to assess their integrity, confirm the extent of the lesion, perform synovectomy, prepare the tendon for tenodesis, and perform it in a safe and minimally invasive way, reducing the risks inherent to the open procedure.

Endoscopic Superior Peroneal Retinaculum Reconstruction Using Q-FIX MINI Suture Anchor

Post-traumatic peroneal tendon subluxation or dislocation is most commonly caused by injury to the superior peroneal retinaculum. Classic open surgeries usually require extensive soft-tissue dissection and have potential risks of peritendinous fibrous adhesions, sural nerve injury, limited range of movement, recurrent or persistent peroneal tendon instability, and tendon irritation. The purpose of this Technical Note is to describe the details of endoscopic superior peroneal retinaculum reconstruction using Q-FIX MINI suture anchor. This endoscopic approach has the advantages of minimally invasive surgery, including better cosmesis, less soft-tissue dissection, less postoperative pain, less peritendinous fibrosis, and less subjective tightness at peroneal tendons. Insertion of the Q-FIX MINI suture anchor can be performed inside a drill guide, and trapping of the surrounding soft tissue can be avoided.

Peroneal Sheath Volumes Are Greater in Patients With Peroneal Pathology Compared With Controls

BACKGROUND

Peroneal tendon pathology is common. Several factors have been implicated, including low-lying muscles and accessory tendons. Studies have reported on the presence and length measurements of these structures. This study evaluates volume measurements within the sheath using magnetic resonance images for patients with operatively treated peroneal tendon pathology and control patients without peroneal disease.

METHODS

Fifty-one patients with peroneal tendon pathology and 15 controls were included. The volumes of the peroneal sheath, peroneal tendons, peroneal muscle, and accessory peroneus tendons were measured. The distal extent of the peroneus brevis (PB) muscle was measured. Volume and length measurements were then compared.

RESULTS

The mean PB muscle length from the tip of the fibula was 5.55 ± 2.5 mm (peroneal group) and 11.79 ± 4.07 mm (control) (P = .017). The mean peroneal sheath volume was 7.06 versus 5.12 mL, respectively (P = .001). The major contributors to this increased volume was the tenosynovitis (3.58 vs 2.56 mL, respectively; P = .019), the peroneal tendons (2.17 vs 1.7 mL, P = .004), and the accessory peroneus tendon + PB muscle (1.31 vs 0.86 mL, P = .023).

CONCLUSION

The current study supports that the PB muscle belly is more distal in patients with peroneal tendon pathology. The study also demonstrates increased total volume within the peroneal sheath among the same patients. We propose that increased volume within the sheath, regardless of what structure is enlarged, is associated with peroneal tendon pathology. Further studies are needed to determine if debridement and decompression of the sheath will result in improved functional outcomes for these patients.

LEVELS OF EVIDENCE

Level III: Case control imaging study.

The Role of Peroneal Tendinopathy and the Cavovarus Foot and Ankle

Peroneal tendon pathology is often an overlooked and underdiagnosed condition. It is often confused with chronic ankle instability. It is important when surgically managed to assess the condition of the tendons, muscle viability and strength, and associated cavovarus deformity. Complex reconstruction may be needed, including 2-stage procedures with a silicone rod and tendon transfer.

[Peroneal tendon pathologies : From the diagnosis to treatment]

Peronealsehnenpathologien sind selten, jedoch häufig unterdiagnostiziert. Eine Assoziation mit einer chronisch lateralen Sprunggelenkinstabilität sowie mit einer varischen Rückfußachse kann bestehen. Pathologien der Sehnen lassen sich in 3 Kategorien einteilen: Tendinitis und Tenosynovitis, Sehnenrisse und Rupturen sowie Sehnensubluxation und Sehnenluxation. Die Magnetresonanztomographie ist die Standardmethode zur radiologischen Beurteilung. Die Diagnose und Behandlung basieren jedoch in erster Linie auf Anamnese und klinischer Untersuchung. Eine primär konservative Therapie kann versucht werden, ausgenommen bei Peronealsehnenluxationen des professionellen Sportlers. Die chirurgische Therapie sollte gezielt auf die zugrunde liegende Pathologie abgestimmt werden und kann dementsprechend divers von der tendoskopischen Synovektomie bis zur anatomischen Reparatur des superioren peronealen Retinakulums mit Vertiefung der retromalleolären Rinne ausfallen. Die postoperativen Ergebnisse zeigen eine hohe Patientenzufriedenheit und niedrige Reluxationsraten.

The vascularization of the peroneal tendons: An anatomic study

BACKGROUND

Arterial 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).

METHODS

Anatomical 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.

RESULTS

Vascularization 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.

CONCLUSION

Peroneal 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.

Importance of Space-Occupying Anatomical Variations in Peroneal Tendoscopy

BACKGROUND

We hypothesized that peroneal tendons disorders are more commonly associated with anatomical variations, which could overcrowd the retrofibular groove.

METHODS

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.

RESULTS

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.

CONCLUSION

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 OF EVIDENCE

Level IV, case series.

Anterior and Posterior Arthroscopic Treatment of Primary Synovial Chondromatosis of the Ankle

BACKGROUND

Primary synovial chondromatosis (PSC) is a progressive disorder of unknown etiology resulting in formation of multiple loose bodies. If left untreated, it may lead to degenerative changes or malignant transformation to chondrosarcoma.

METHODS

Seventeen patients who underwent combined posterior and anterior ankle arthroscopy within the same operative session and had histologically confirmed PSC were included in this retrospective study. American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score was used to evaluate ankle function preoperatively and at a final follow-up. A 3-question survey was used to evaluate patient's satisfaction at the final follow-up.

RESULTS

In 14 patients, loose bodies were found in both compartments of the ankle, in 2 only in the anterior compartment, and in 1 only in the posterior compartment. All patients had evident signs of synovial inflammation in both compartments. The AOFAS Ankle-Hindfoot score increased from the preoperative median score of 65 (range, 29-90) to 95 (range, 65-100) at the final follow-up. Fourteen patients reported they were extremely satisfied with the outcome, 1 was moderately satisfied, and 2 were dissatisfied. No cases of recurrence of synovitis or loose body formation were noted, nor any signs of malignant transformation during the follow-up period.

CONCLUSION

We believe the risk of recurrence of PSC, which is in close relation to malignant transformation, can be minimized by performing a complete synovectomy of the ankle. Our experience and review of literature makes us believe that ankle PSC should be regarded as a whole joint disorder. Performing a combined posterior and anterior arthroscopic procedure within the same operative session should always be considered in patients with ankle PSC.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Role of arthroscopy and endoscopy in management of tuberculosis of the foot and ankle

Tuberculosis of the foot and ankle is rare but destructive. It can affect bones, joints and soft tissue and can mimic a wide range of acute and chronic infections or tumorous conditions. The primary treatment objectives for osteoarticular TB include curing the infection, limiting deformity, maintaining mobility, and reducing discomfort. Chemotherapy remains the mainstay of treatment in acute stage. Indications of surgery include biopsy and debridement in early stages to reduce the tuberculosis load and enable better penetration of anti-tuberculous drugs. Other reported indications for surgery in early stage of TB foot and ankle include resection of lesion not responding to chemotherapy and debridement of lesions close to the articular surface, as surgical debridement might halt progression and joint invasion, avoiding worsening of the prognosis. The success of arthroscopic treatment for infectious arthritis with decreased morbidity and postoperative pain makes arthroscopy an excellent alternative to open surgery. The advantages such as minor trauma, short hospitalization time and short post operative rehabilitation period as well as good cosmetic and therapeutic results should lead to a more frequent use of arthroscopy as early as possible as an adjuvant for the tuberculous joint. However, tuberculosis can involve any joints, bone and soft tissue (tendon) of the foot and ankle and surgeons should equip with various arthroscopic and endoscopic techniques in order to deal with the various situations of tuberculosis of the foot and ankle.

Tendoscopic peroneal retinaculum repair for recurrent peroneal tendon dislocation enables earlier return to sports than the open procedure

PURPOSE

The purpose of this study was to evaluate whether tendoscopic peroneal retinaculum repair for patients with recurrent peroneal tendon dislocation (RPTD) is more useful than an open procedure.

METHODS

Twenty-five patients with RPTD were retrospectively reviewed. Twelve patients (13 ankles) with RPTD underwent the open procedure (Group A) between 2008 and 2014, and 13 patients (14 ankles) underwent the tendoscopic procedure (Group B) between 2014 and 2017. Evaluation parameters included clinical results [the Japanese Society for Surgery of the Foot (JSSF) ankle-hind foot scale], operation time, complications, return to sports, and recurrence.

RESULTS

Postoperative JSSF ankle/hindfoot scale scores were significantly better than the pre-surgical scores in both groups. The mean operation time was significantly longer in Group B than in Group A (75.7 ± 20.5 vs 38.4 ± 10.5 min). There was one recurrence in Group A, but none in Group B. Group A had no complications, and Group B had one wound infection. Group B, excluding the case of infection, could return to sports earlier than Group A, excluding the recurrent case (13.4 ± 1.5 vs 12.2 ± 0.6 weeks).

CONCLUSIONS

This tendoscopic procedure needs longer operation time and is more technically demanding, but it is a useful procedure, because it is less invasive and can accelerate return to sports.

LEVEL OF EVIDENCE

III.

Peroneal Tendinosis and Subluxation

Peroneal tendinosis and subluxation are lifestyle-limiting conditions that can worsen if not properly diagnosed and treated. Adequate knowledge of ankle anatomy and detailed history and comprehensive physical examination is essential for diagnosis. Peroneal tendinopathy is likely to result from overuse, whereas subluxation often precipitates from forceful contraction of peroneals during sudden dorsiflexion while landing or abruptly stopping. In athletes, conservative measures remain first-line treatment of tendinopathy, but surgery is often immediately indicated in cases of recurrent symptomatic subluxation or dislocation. Surgical technique varies on the type, mechanism, and severity of injury, but most procedures have a high success rate.

Treatment of Insertional Peroneus Brevis Tendinopathy by Ultrasound-Guided Percutaneous Ultrasonic Needle Tenotomy: A Case Report

Insertional peroneus brevis tendinopathy is uncommon and treatment options for recalcitrant insertional lesions are rarely described in the literature. Ultrasound-guided percutaneous ultrasonic needle tenotomy has been described for the treatment of recalcitrant tendinopathy in the elbow, knee, and plantar fascia, but has not been described for the treatment of peroneal tendinopathy. We report a case of recalcitrant insertional peroneus brevis tendinopathy successfully treated with an ultrasound-guided percutaneous ultrasonic needle tenotomy. The treatment resulted in a rapid recovery, and the patient remained asymptomatic at the 6-month follow up. No complications were observed during follow up and the minimally invasive percutaneous procedures offers clear advantage over open techniques.

Distal Peroneus Longus Dislocation and Pseudohypertrophy of the Peroneal Tubercle: A Systematic Review

Peroneal tendon injuries at the peroneal tubercle are rare. No systematic research regarding this pathology is currently available. In this systematic literature review, the author evaluated the present knowledge about peroneal tendon lesions at the lateral calcaneal wall. These lesions are predominantly associated with peroneal tubercle enlargement. Information on 25 respective patients (26 cases) has been published in 14 articles. Until now, only 3 reports presented 5 patients with dislocation of the peroneus longus tendon combined with inferior peroneal retinaculum lesions. In these cases, the peroneal tubercle was not enlarged. All reviewed patients were treated surgically. Enlarged peroneal tubercles were resected. Groove deepening and inferior peroneal retinaculum reconstruction addressed distal peroneus longus tendon dislocations. The reported results were either excellent or good. Recurrent dislocations can cause lesions of the peroneus longus tendon at the peroneal tubercle. This pathology is rare and can be addressed surgically. In cases without tendon dislocation, the enlarged peroneal tubercles are removed or shaped, whereas dislocations in normal shaped peroneal tubercles require groove deepening and inferior peroneal retinaculum reconstruction.

The distance from the peroneal tendons sheath to the sural nerve at the posterior tip of the fibula decreases from proximal to distal

PURPOSE

The aim of this study is to compare the distance from the peroneal tendons sheath to the sural nerve in different points proximally and distally to the tip of the fibula.

METHODS

Ten fresh-frozen lower extremities were dissected to expose the nerves and tendons. Having the posterior tip of the fibula as a reference, the distance between the tendons sheath and the sural nerve was measured in each point with a tachometer with three independent different observers. Two measures were taken distally at 1.5 and 2 cm from fibula tip and 3 measures were performed proximally at 2, 3, and 5 cm from fibula tip. Data were described using means, standard deviations, medians, and minimum and maximum values.

RESULTS

The average distance between distance between the fibula tip and sural nerve is 16.6 ± 4.4 mm. The average distance between peroneal tendons sheath and the sural nerve at 5 cm, 3 cm, and 2 cm from the proximal fibular tip was 29.6 ± 3.2 mm, 24.2 ± 3.6 mm, and 19.7 ± 2.7 mm, respectively. The average distance between the peroneal tendons sheath and the sural nerve at 2 cm and 1.5 cm distal to fibular tip was 9.1 ± 3.5 mm and 7.8 ± 3.3 mm, respectively.

CONCLUSION

The distance from the peroneal tendons sheath to the sural nerve decreases from proximal to distal. As the distance between the peroneal tendons sheath and the sural nerve decreases from proximal to distal, performing the tendoscopy portal more distally would increase the risk of nerve iatrogenic injury.

Chronic Disorders of the Peroneal Tendons: Current Concepts Review of the Literature

Chronic disorders of the peroneal tendons are a common cause of posterolateral ankle pain, including tendinopathy, tendon instability, and chronic tendon tears. They are often preceded by ligamentous instability or predisposing anatomic abnormalities such as a shallow fibular groove or a cavovarus foot deformity. Given the substantial disability associated with chronic peroneal tendon disorders, it is important for orthopaedic surgeons to optimize the diagnostic and treatment strategies of these entities based on contemporary studies. This article reviews both classic and recent scientific evidence regarding the diagnosis and treatment of patients with chronic peroneal tendon disorders.

Arthroscopic and Endoscopic Management of Common Complications After Displaced Intra-Articular Calcaneal Fractures

The list of late complications after calcaneal fracture that can be treated through arthroscopic and/or endoscopic approach continues to expand. The late complications of calcaneal fractures can be classified into 3 groups: (1) those causing focal hindfoot or ankle pain, (2) those causing functional deficit, and (3) those present with diffuse and poorly localized pain. Many group 1 and some group 2 complications can be managed arthroscopically and/or endoscopically. There are usually multiple coexisting sources of the pain. Careful evaluation and analysis of a problem and detailed surgical planning with combination of arthroscopic/endoscopic and open procedures are key to success.

The distance from the peroneal tendons sheath to the sural nerve at the posterior tip of the fibula decreases from proximal to distal

PURPOSE

The aim of this study is to compare the distance from the peroneal tendons sheath to the sural nerve in different points proximally and distally to the tip of the fibula.

METHODS

Ten fresh-frozen lower extremities were dissected to expose the nerves and tendons. Having the posterior tip of the fibula as a reference, the distance between the tendons sheath and the sural nerve was measured in each point with a tachometer with three independent different observers. Two measures were taken distally at 1.5 and 2 cm from fibula tip and 3 measures were performed proximally at 2, 3, and 5 cm from fibula tip. Data were described using means, standard deviations, medians, and minimum and maximum values.

RESULTS

The average distance between distance between the fibula tip and sural nerve is 16.6 ± 4.4 mm. The average distance between peroneal tendons sheath and the sural nerve at 5 cm, 3 cm, and 2 cm from the proximal fibular tip was 29.6 ± 3.2 mm, 24.2 ± 3.6 mm, and 19.7 ± 2.7 mm, respectively. The average distance between the peroneal tendons sheath and the sural nerve at 2 cm and 1.5 cm distal to fibular tip was 9.1 ± 3.5 mm and 7.8 ± 3.3 mm, respectively.

CONCLUSION

The distance from the peroneal tendons sheath to the sural nerve decreases from proximal to distal. As the distance between the peroneal tendons sheath and the sural nerve decreases from proximal to distal, performing the tendoscopy portal more distally would increase the risk of nerve iatrogenic injury.

Results of Peroneal Tendoscopy With a Technical Modification

BACKGROUND:

The aim of this study was to evaluate the role of tendoscopy in the diagnosis and treatment of peroneal tendon (PT) pathologies, and to evaluate the results of our technical modification.

METHODS:

Twenty ankles of 18 patients with retrofibular pain, operated on between 2006 and 2012, were included in this study. Peroneal tendoscopy was performed diagnostically for the patients who were diagnosed as having "peroneal tendinopathy" with physical examination, x-ray, or magnetic resonance imaging (MRI). After being diagnosed by peroneal tendoscopy, patients were definitively treated with either tendoscopy or open surgery.

RESULTS:

Thirteen of 20 ankles had accompanying ankle pathology with PT pathology, and the other 7 ankles had no concomitant pathology. We detected peroneal tenosynovitis (PTS) in 13 patients, PT tear in 7 patients, and vincula thickening in 1 patient. The American Orthopaedic Foot & Ankle Society (AOFAS) score was 76 preoperatively, and after 2 years' follow-up the AOFAS score was 96.

CONCLUSION:

Tendoscopy is a useful method for the diagnosis and treatment of PT pathologies. The patients with clinical suspicion of PT pathology were treated or diagnosed by peroneal tendoscopy with our technical modification.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

Treatment of Chronic Subluxation of the Peroneal Tendons Using a Modified Posteromedial Peroneal Tendon Groove Deepening Technique

The present study investigated the clinical efficacy of a modified approach for the treatment of chronic subluxation of the peroneal tendons using posteromedial peroneal tendon groove deepening. We retrospectively analyzed the data from 21 patients who had undergone posteromedial peroneal tendon groove deepening combined with repair of the tendon sheath for the treatment of chronic subluxation of the peroneal tendons from March 2006 to October 2012. The lateral edge of the peroneal tendon groove was left untouched. A posterior osteocartilaginous flap was detached from the posterior fibula from medially to laterally. The retromalleolar groove was deepened through impaction of the posterior fibula. A visual analog scale and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale were used. All patients achieved healing after the first surgery. No postoperative complications developed. Sixteen patients were followed up for 24 to 69 months. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score improved from 55.0 to 93.6 points after surgery. The mean visual analog scale score decreased from 5.3 to 1.2 points. Five patients had moderate hindfoot rigidity and achieved improvements after rehabilitation training. None of the patients had specific requirements for shoes and ground flatness. All patients had a normal gait. No case of recurrent subluxation developed. These results indicate that posteromedial peroneal tendon groove deepening combined with repair of the tendon sheath can achieve satisfactory efficacy.

Peroneal Tendoscopic Debridement and Endoscopic Groove Deepening in the Prone Position

Tendoscopy of the peroneal tendon is a promising procedure for the treatment of peroneal tendon pathology and its disorders. This procedure is minimally invasive with less physical morbidity and early functional rehabilitation. The present report demonstrates the techniques of peroneal tendoscopic debridement and endoscopic groove deepening in the prone position to treat peroneal tenosynovitis and low-lying muscle belly of peroneus brevis with a shallow and flat surface of the retro-malleolar groove. The prone position provided better ergonomics during this procedure compared with the supine position.

Ankle Arthroscopic Surgery

Ankle arthroscopy is a diagnostic and therapeutic surgical procedure which was first attempted on cadavers by Dr Burman in 1931 and first successfully described in patients by Dr Takagi in 1939. Two general approaches to ankle arthroscopy currently exist: (1) anterior ankle arthroscopy and (2) posterior ankle arthroscopy. The indications for ankle arthroscopy have expanded as increased experience has been obtained treating various pathologic entities and as the surgical results have been reported in the literature. There has been significant progress in ankle arthroscopic surgery over the past decades, notably allowing surgical procedures to be performed with fewer complications and with quicker return to work and play. We anticipate that expanding indications for arthroscopic ankle surgical procedures combined with further development of biomedical devices to enhance these procedures will result in improved patient outcomes in the future.

Tendoscopy of Achilles, peroneal and tibialis posterior tendons: An evidence-based update

BACKGROUND

Tendoscopy has been proposed in treating several conditions affecting tendons around the ankle. We reviewed literature to investigate the efficacy of Achilles, peroneal and tibialis posterior tendoscopy.

METHODS

Following the PRISMA checklist, the Medline, Scopus and EMBASE databases were searched, including studies reporting patients affected by disorders of Achilles, peroneal and tibialis posterior tendons and treated by tendoscopy (or tendoscopic-assisted procedures). The tendoscopic technique, rehabilitation protocol, clinical scores, patient satisfaction, success and failure rates and complications were evaluated.

RESULTS

Sixteen studies (319 procedures) dealt with Achilles tendoscopy, nine (108) and six (78) about peroneal and tibialis posterior, respectively. Wound healing, cosmetic results, complication rate, work and sport resumption delay were satisfactory. Clinical scores, classification methods and rehabilitation protocols adopted were heterogeneous.

CONCLUSIONS

The recent scientific evidence suggests that tendoscopy and endoscopic-assisted percutaneous procedures are a safe and effective treatment in chronic and acute disorders of tendons around the ankle.

Measuring Visualized Tendon Length in Peroneal Tendoscopy

BACKGROUND

Despite multiple studies outlining peroneal tendoscopy, no study exists to evaluate how effective tendoscopy is at visualizing the peroneal tendons without missing a lesion. We sought to measure the length of the peroneal tendons that could be visualized using tendoscopy.

METHODS

Ten fresh cadaveric specimens were evaluated using standard peroneal tendoscopy techniques. Peroneus longus and brevis tendons were pierced percutaneously with Kirschner wires at the edge of what could be seen through the camera. The tendon sheaths were then dissected and the distances from anatomic landmarks were directly measured. During zone 3 peroneus longus tendoscopy, a more distal portal site was created for the final 5 specimens.

RESULTS

The peroneus brevis could be visualized through the entirety of zone 1 and up to an average of 19.5 mm (95% confidence interval, 16.5-22.5) from its insertion onto the base of the fifth metatarsal in zone 2. Peroneus longus could be visualized through the entirety of zones 1 and 2 and up to an average of 9.7 mm from its insertion onto the base of the first metatarsal in zone 3. This distance was decreased significantly with a more distal portal. The muscle belly of peroneus brevis terminated an average of 1.8 mm (-3.7 to 7.3) above the tip of the lateral malleolus.

CONCLUSIONS

Despite limitations, these results suggest that the vast majority of the length of the peroneal tendons can be seen during routine peroneal tendoscopy. A more distal skin portal site may improve visualization of zone 3 of peroneus longus.

CLINICAL RELEVANCE

This study confirms the ability of peroneal tendoscopy to see the entire tendon length with appropriate portal placement.

Peroneus Longus Tendoscopy at the Sole

Different pathologies can occur in the peroneus longus tendon at the sole. Many of them can be dealt with by peroneus longus tendoscopy of the sole. The purpose of this Technical Note is to describe the details of this minimally invasive approach to the peroneus longus tendon of the sole. This has the advantages of better cosmesis, less soft tissue dissection, less postoperative pain, and less peritendinous fibrosis.

Endoscopic Superior Peroneal Retinaculum Reconstruction

Post-traumatic peroneal tendon subluxation or dislocation is most commonly due to injury to the superior peroneal retinaculum. Acute repair of the retinaculum is an option for active athletes who desire quick return of sport activity. In general, conventional open surgeries require extensive exposure of the injured superficial peroneal retinaculum and have potential risks of scar formation, sural nerve injury, limited range of movement, peroneal tendon re-subluxation, and tendon irritation. The purpose of this Technical Note is to describe the details of endoscopic superior peroneal retinaculum reconstruction. This has the advantages of minimally invasive surgery of better cosmesis, less soft tissue dissection, less postoperative pain, less peritendinous fibrosis, and less subjective tightness at peroneal tendons. The endoscopic view allows better assessment of retinaculum integrity, grading of injury, and detection of coexisting pathology.

Arthroscopic and Endoscopic Management of Posttraumatic Hindfoot Stiffness

Ankle, hindfoot, and toe stiffness can result from hindfoot trauma. It can be due to capsular fibrosis, tendon adhesion, muscle fibrosis, or malunion. For symptomatic stiffness that is resistant to nonoperative treatment, operative treatment should be considered. It is important to tackle the sources of stiffness, and careful preoperative clinical assessment is the key for proper formulation of the surgical plan. Whenever possible, arthroscopic/endoscopic surgery is preferable to open surgery because less extensive dissection and small surgical incisions allow immediate vigorous mobilization of the foot and ankle.

Endoscopic Resection of Peroneal Tubercle

Symptomatic hypertrophy of the peroneal tubercle can result in pain, clicking sensation, and limitation of ambulation. Surgical resection is indicated for symptomatic hypertrophied tubercle that is recalcitrant to conservative treatment. The purpose of this Technical Note is to report the details of tendoscopic resection of the hypertrophied peroneal tubercle. This is performed through zone 2 peroneus longus tendoscopy. Any associated hindfoot deformity and peroneal tendon pathology should also be addressed.

Endoscopic Synovectomy of Peroneal Tendon Sheath

Peroneal tenosynovitis usually responds to conservative therapy. Early diagnosis and management are imperative because improper or delayed diagnosis and treatment of peroneal tenosynovitis may lead to progression of the tenosynovitis to peroneal tendon rupture, ultimately limiting the benefit of nonoperative treatment. For refractory cases, endoscopic tenosynovectomy is indicated. The purpose of this Technical Note is to report a minimally invasive approach to perform a synovectomy of zones 1 and 2 of the peroneal tendon sheath.

Peroneal tendon disorders

Pathological abnormality of the peroneal tendons is an under-appreciated source of lateral hindfoot pain and dysfunction that can be difficult to distinguish from lateral ankle ligament injuries.

Enclosed within the lateral compartment of the leg, the peroneal tendons are the primary evertors of the foot and function as lateral ankle stabilisers.

Pathology of the tendons falls into three broad categories: tendinitis and tenosynovitis, tendon subluxation and dislocation, and tendon splits and tears. These can be associated with ankle instability, hindfoot deformity and anomalous anatomy such as a low lying peroneus brevis or peroneus quartus.

A thorough clinical examination should include an assessment of foot type (cavus or planovalgus), palpation of the peronei in the retromalleolar groove on resisted ankle dorsiflexion and eversion as well as testing of lateral ankle ligaments.

Imaging including radiographs, ultrasound and MRI will help determine the diagnosis. Treatment recommendations for these disorders are primarily based on case series and expert opinion.

The aim of this review is to summarise the current understanding of the anatomy and diagnostic evaluation of the peroneal tendons, and to present both conservative and operative management options of peroneal tendon lesions.

Cite this article: EFORT Open Rev 2017;2:281-292. DOI: 10.1302/2058-5241.2.160047

Foot and ankle tendoscopies: current concepts review

Tendoscopy is an apparently safe and reliable procedure to manage some foot and ankle disorders.The most common foot and ankle tendoscopies are: Achilles; peroneal; and posterior tibial tendon.Tendoscopy may be used as an adjacent procedure to other techniques.Caution is recommended to avoid neurovascular injuries.Predominantly level IV and V studies are found in the literature, with no level I studies still available.There are many promising and evolving endoscopic techniques for tendinopathies around the foot and ankle, but studies of higher levels of evidence are needed to strongly recommend these procedures. Cite this article: EFORT Open Rev 2016;1:440-447. DOI: 10.1302/2058-5241.160028.

The Peroneus Quartus Muscle in a Locking Phenomenon of the Ankle: A Case Report

We present the case of a 64-year-old female who was referred to us with an unexplained clicking and locking phenomenon of the right ankle. The magnetic resonance imaging findings suggested a longitudinal tear of the peroneus brevis tendon. During tendoscopy, not only was a Raikin type B intrasheath tendon subluxation visible, but also a peroneus quartus muscle. The peroneus brevis tear was tubularized and the peroneus quartus muscle resected, which resolved the patient's complaints.

Ultrasound Guidance in Performing a Tendoscopic Surgery to Treat Posterior Tibial Tendinitis: A Useful Tool?

A 25-year-old man with a pronation-external rotation type of fracture was surgically treated using a fibular plate. Five years later, he underwent resection of bone hyperplasia because of the ankle pain and limitation of range of motion. Thereafter, the left ankle became intermittently painful, which persisted for about one year. He presented at the age of 43 with persistent ankle pain. Physical and image analysis findings indicated a diagnosis of posttraumatic posterior tibial tendinitis, which we surgically treated using tendoscopy. Endoscopic findings showed tenosynovitis and fibrillation on the tendon surface. We cleaned and removed the synovium surrounding the tendon and deepened the posterior tibial tendon groove to allow sufficient space for the posterior tibial tendon. Full weight-bearing ambulation was permitted one day after surgery and he returned to his occupation in the construction industry six weeks after surgery. The medial aspect of the ankle was free of pain and symptoms at a review two years after surgery. Although tendoscopic surgery for stage 1 posterior tibial tendon dysfunction has been reported, tendoscopic surgery to treat posttraumatic posterior tibial tendinitis has not. Our experience with this patient showed that tendoscopic surgery is useful not only for stage 1 posterior tibial dysfunction, but also for posttraumatic posterior tibial tendinitis.

Tendoscopic Double-Row Suture Bridge Peroneal Retinaculum Repair for Recurrent Dislocation of Peroneal Tendons in the Ankle

Traumatic dislocation of peroneal tendons in the ankle is an uncommon lesion that mainly affects young adults. Unfortunately, most cases lead to recurrent dislocation of the peroneal tendons of the ankle (RPTD). Therefore, most cases need operative treatment. One of the most common operative procedures is superior peroneal retinaculum (SPR) repair. Recently, surgery for RPTD has been achieved with less invasive arthroscopic procedures. In this article, tendoscopic surgery for RPTD using a double-row suture bridge technique is introduced. This technique consists of debridement of the lateral aspect of the fibula under an intrasheath pseudo-cavity, suture anchor insertion into the fibular ridge, and reattachment of the SPR to the fibula using a knotless anchor screwed into the lateral aspect of the fibula. This technique mimics the double-row suture bridge technique for rotator cuff tear repair. The double-row suture bridge technique requires more surgical steps than the single-row technique, but it provides a wider bone-SPR contact surface and tighter fixation than the single-row technique. This procedure is an attractive option because it is less invasive and has achieved results similar to open procedures.

Functional outcomes after peroneal tendoscopy in the treatment of peroneal tendon disorders

PURPOSE

The primary purpose of this study was to evaluate clinical outcomes following peroneal tendoscopy for the treatment of peroneal pathology. Correlation between pre-operative magnetic resonance imaging (MRI) and peroneal tendoscopic diagnostic findings was also assessed.

METHODS

Twenty-three patients with a mean age of 34 ± 8.8 years undergoing peroneal tendoscopy were pre- and post-operatively assessed with the foot and ankle outcome score (FAOS) and the Short Form-12 (SF-12) outcome questionnaires. Follow-up was over 24 months in all patients. The sensitivity and specificity of MRI were calculated in comparison with peroneal tendoscopy, including the positive predictive value (PPV).

RESULTS

Both the FAOS and the SF-12 improved significantly (p < 0.05) at a mean follow-up of 33 ± 7.3 months significantly. MRI showed an overall sensitivity of 0.90 (95% confidence interval (CI) = 0.82-0.95) and specificity of 0.72 (95% CI 0.62-0.80). The PPV for MRI diagnosis of peroneal tendon pathology was 0.76 (95% CI 0.68-0.83).

CONCLUSIONS

The current study found good clinical outcomes in patients with peroneal tendon disorders, treated with peroneal tendoscopy. Although a relatively small number of patients were included, the study suggests good correlation between tendoscopic findings and pre-operative MRI findings of peroneal tendon pathology, supporting the use of MRI as a useful diagnostic modality for suspected peroneal tendon disorders.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Peroneal tendons well vascularized: results from a cadaveric study

PURPOSE

Peroneal tendon tears are relatively common injuries that seem to have a poor healing tendency. The discussion goes that peroneal tendons have avascular zones, contributing to the poor healing of those tears. The purpose of this study was to provide evidence on the vascularization pattern of the peroneal tendons.

METHODS

Ten adult fresh-frozen cadavers were obtained from a university-affiliated body donation programme. The femoral artery was injected with natural coloured latex at the level of the knee. Macroscopic and microscopic dissections were performed to visualize the vascularization towards the peroneal tendons. To expose intratendinous vascularity, the tendons were cleared using a modified Spälteholz technique.

RESULTS

In all specimens, blood was mainly supplied by the peroneal artery through a posterolateral vincula connecting both tendons. Branches were bifurcated every 3.9 ± 1.8 cm, starting 24 ± 5.3 cm proximal to the tip of the fibula. Eight out of 10 (80%) specimens had poor vascularized zones in the peroneus longus tendon. No avascular zones were found in the peroneus brevis tendon.

CONCLUSION

The peroneal tendons are well vascularized by the peroneal artery, via vessels running through a common vincula for both tendons. In the peroneus brevis, no avascular zones were found. To keep the tendons well vascularized and therefore improve tendon healing, surgeons should be careful leaving the vincula intact during surgical procedures.

Peroneal Tendon Disorders

Peroneal tendon pathology is often found in patients complaining of lateral ankle pain and instability. Conditions encountered include tendinosis; tendinopathy; tenosynovitis; tears of the peroneus brevis, peroneus longus, and both tendons; subluxation and dislocation; and painful os peroneum syndrome. Injuries can be acute as a result of trauma or present as chronic problems, often in patients with predisposing structural components such as hindfoot varus, lateral ligamentous instability, an enlarged peroneal tubercle, and a symptomatic os peroneum. Treatment begins with nonoperative care, but when surgery is required, reported results and return to sport are in general very good.

Peroneus Longus Tendoscopy at the Sole: A Cadaveric Study

PURPOSE

The aim of this study was to investigate the safety of tendoscopy of the peroneus longus (PL) at the sole in a cadaveric model.

METHODS

Twelve fresh-frozen foot and ankle specimens were used. The locations of the plantar medial and plantar lateral portals were studied. The relationships of the medial and lateral plantar nerves to the tendon sheath of the PL at the sole were also studied.

RESULTS

The plantar lateral portal was located on average 11 mm (6 to 16 mm) proximal and 9 mm (6 to 15 mm) plantar to the fifth metatarsal styloid. The plantar medial portal was located on average 1 mm (12 mm proximal to the joint to 7 mm distal to the joint) proximal to the first tarsometatarsal joint. The lateral plantar nerve touched the PLT sheath in 8 specimens. The nerve was separated from the tendon sheath by a thin layer of muscle in 4 specimens. The medial plantar nerve was separated from the tendon sheath of the PL by the flexor digitorum longus and flexor hallucis longus tendons in all specimens.

CONCLUSIONS

Tendoscopy of the PL at the sole of the foot is described; however, the lateral plantar nerve can be at risk and the tendoscopy should be performed with caution.

CLINICAL RELEVANCE

This cadaveric study provides the anatomic basis of the PL tendoscopy of the sole.

Peroneal tendoscopy--more than just a solitary procedure: case-series

This study presents a series of 13 patients who underwent peroneal tendoscopy as a solitary or accessory procedure at our department in 2013. Patients were clinically diagnosed with peroneal tendons disorders and underwent an additional radiological assessment. Peroneal tendoscopy was carried out in a standard manner before any other arthroscopic or open procedure. Postoperative management depended on the type of pathology. We found 3 peroneus brevis tendon partial tears, 4 cases of a low-lying peroneus brevis muscle belly, 5 cases of tenosynovitis, and 1 case of an intrasheath peroneal tendon subluxation. In 5 patients peroneal tendoscopy was performed as a solitary procedure and in 8 patients as an accessory procedure – together with anterior or posterior ankle arthroscopy, combined posterior and anterior ankle arthroscopy, or open surgery. Both as a solitary and accessory procedure, peroneal tendoscopy was safe and successful, ie, all patients were without any symptoms at one-year follow-up. Our series of patients showed that peroneal tendoscopy can be used both as an independent procedure as well as a valuable accessory procedure.

Peroneal tendoscopy

Peroneal tendoscopy is indicated for peroneal tenosynovitis, subluxation or dislocation, snapping, partial tears requiring debridement, and postoperative adhesions and scarring. Peroneal tendoscopy was also found to be valuable as a diagnostic tool in some instances. It is generally reported to have good to excellent outcomes in most patients with a relatively low occurrence of complications.

Arthroscopic ganglionectomy of the foot and ankle

PURPOSE

To study the efficacy of arthroscopic ganglionectomy in the management of ganglia of the foot and ankle.

METHODS

From 2006 to 2010, arthroscopic ganglionectomy was performed for 89 ganglia in the foot and ankle of 88 patients. Clinical and intra-operative details were reviewed retrospectively.

RESULT

Ganglion stalk was identified in 6 % of the cases. The overall rate of presence of pathology was 26 %. The overall rate of recurrence or residual lesion was 12 % with high recurrent rate for extensor tendon ganglia and toe pulp ganglia.

CONCLUSIONS

Arthroscopic ganglionectomy of the foot and ankle ganglion by either internal drainage or complete resection is a feasible approach. Good results can be achieved in case of adequate internal drainage of the ganglion to the joints or fibrous tendon sheath.

Foot and ankle tendoscopy: evidence-based recommendations

PURPOSE

The purpose of this study was to provide a comprehensive review of the current literature on tendoscopy of the foot and ankle and assign an evidence-based grade of recommendation for or against intervention.

METHODS

A comprehensive review of the literature was performed on May 26, 2013, using the PubMed, Cochrane, and Scopus databases. Studies focusing on the use of foot and ankle tendoscopy were isolated, and these articles were then reviewed and assigned a Level of Evidence (I through V). The literature was then analyzed, and a grade of recommendation was assigned for tendoscopy of the tendons of the foot and ankle on which the procedure is generally performed.

RESULTS

There is weak evidence (grade Cf) to support the use of tendoscopy on the Achilles, flexor hallucis longus, and peroneal tendons. Insufficient evidence (grade I) exists to assign a grade of recommendation for tendoscopy of the tibialis posterior, tibialis anterior, flexor digitorum longus, extensor hallucis longus, and extensor digitorum longus.

CONCLUSIONS

A comprehensive review of the literature on foot and ankle tendoscopy has shown predominantly Level IV and V studies, with just 1 Level II study. On the basis of the current literature available, there is poor evidence (grade Cf) in support of Achilles, flexor hallucis longus, and peroneal tendoscopy for the common indications. There is insufficient evidence to make a recommendation (grade I) for or against tendoscopy of the tibialis posterior, tibialis anterior, flexor digitorum longus, extensor hallucis longus, and extensor digitorum longus. Although current literature suggests that tendoscopy is a safe and effective procedure, original scientific articles of higher levels of evidence are needed before a stronger recommendation can be assigned.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, IV, and V studies.

Peroneal tenodesis with the use of tendoscopy: surgical technique and report of 1 case

Peroneus brevis tendon injury is the most common lesion of the peroneal tendons. The initial treatment is conservative, and surgical treatment is indicated if conservative treatment fails. It is often necessary to open the entire upper and lower retinaculum to obtain adequate visualization of the structures. We present a case in which the peroneus brevis tenodesis was used with the aid of tendoscopy. This technique should be used for patients with lesions affecting more than 50% of the tendon diameter. We found that, by making small incisions, the patient recovered well, quickly, with resolution of pain.

Treatment of recurring peroneal tendon subluxation in athletes: endoscopic repair of the retinaculum

Traumatic peroneal tendon subluxation is a rare lesion that occurs most frequently during sporting activities and generally after an ankle sprain. There is consensus regarding the need for surgical stabilization in symptomatic patients, but there is also a general agreement that acute subluxation or dislocations may require surgery in the athlete. Many surgical techniques have been described to treat this lesion. Overall, studies have reported excellent or good results in 90% of cases, although there have been reports of significant complications following open surgical procedures. Endoscopic anatomical retinacular repair offers an attractive alternative to open repair and may reduce complications and allow early return to sports.

Arthroscopic management of late complications of calcaneal fractures

PURPOSE

To review retrospectively the results of arthroscopic management of late complications of calcaneal fractures.

METHODS

Fifty patients (32 males, 18 females) with late complications of calcaneal fractures were managed arthroscopically. The median age at the time of arthroscopic surgery was 45 (19-63) years old. Detailed history taking, physical examination, standing lateral radiograph of the foot and axial view of the calcaneus and computed tomogram study were performed in all of the patients in order to identify the sources of symptoms. The arthroscopic treatment was then planned accordingly. The patients were assessed according to the AOFAS ankle-hindfoot score and the standing radiographs of the foot and ankle, both preoperatively and at the latest follow-up consultation.

RESULT

A median of 1 arthroscopic procedure was performed for each patient (range, 1-4). The median follow-up after the latest arthroscopic surgery was 49 (range, 24-85 months) months. In all of the cases, the symptoms improved after the arthroscopic surgery and all the arthrodesis sites healed. The overall median preoperative AOFAS ankle-hindfoot score was 60.5 (27-75). The overall median AOFAS ankle-hindfoot score at the time of latest follow-up was 90 (73-100).

CONCLUSIONS

The arthroscopic approach focuses on the patient's symptoms. It is a feasible approach to alleviate patient's symptoms. Detailed history taking and clinical examination to determine the sources of the patient's symptoms are the keys to success.

Tendoscopic groove deepening for chronic subluxation of the peroneal tendons

INTRODUCTION

Recurrent subluxation of the peroneal tendons over the lateral malleolus is an uncommon disabling condition in young people involved in sports. Injury to the superior peroneal retinaculum, sometimes in association with a shallow fibular groove, can lead to this condition. There are several surgical treatments for recurrent peroneal tendon subluxation, but no tendoscopy technique has been reported to date. The aim of this study was to describe a tendoscopic groove-deepening technique and its results for treating patients with recurrent subluxation of the peroneal tendons.

METHODS

Seven patients (3 women and 4 men; mean age 26.4 [21-32] years) with chronic subluxation of the peroneal tendons were treated with a tendoscopic procedure. All patients experienced pain at the lateral retromalleolar area and recurrent subluxation of the peroneal tendons. The right ankle was affected in 4 patients. Mean follow-up was 15.4 (8-25) months.

RESULTS

On tendoscopic examination, all patients had a flat fibular groove, and the superior peroneal retinaculum was found to be detached in 4 cases. Three patients had a superficial injury of the peroneus brevis tendon which was debrided. Tendoscopic deepening of the peroneal groove without superior peroneal retinaculum repair was performed in all cases. None of the patients experienced recurrent subluxation during follow-up. The AOFAS score increased from 75 preoperatively to 93 at final follow-up. No complications were reported in any case.

CONCLUSION

Tendoscopic deepening of the fibular groove was a reproducible, minimally invasive technique that provided a favorable outcome for recurrent subluxation of the peroneal tendons in our limited number of patients.

LEVEL OF EVIDENCE

Level IV, retrospective case series.