A lateral ankle stabilization procedure utilizing the peroneus brevis and peroneus tertius tendons

Peroneus tertius revisited: The morphological variability of the bifurcated peroneus tertius insertion - An anatomical study

BACKGROUND

The peroneus tertius muscle (PT) is one of the extensor muscles of the lower leg, often described as a variable separation from the extensor digitorum longus muscle (EDL). According to literature it has six different types of insertion, one of them (Olewnik Type IV) having two tendons inserting to the fifth metatarsal bone (FMTB). Morphometric data about this type of insertion is sparse, especially the relation between the two tendons, albeit the PT is suspected to contribute to stress fractures of the FMTB. Therefore, we examined this type of insertion to give detailed information on the tendons, the insertion points and the respective relations.

METHODS

We examined 27 lower extremities of embalmed human bodies (12 paired, 15 single sided; 12 right and 15 left) with a distinguishable PT with two tendons inserting to the FMTB (Olewnik IV). The specimens were obtained of an undergrad dissection program, which in turn obtained them from a body donation program. After dissection of the PT and photo documentation in situ, resection and measurement of morphological properties of the tendons were performed with the PT attached to the fifth metatarsal bone.

RESULTS

Results of the respective measurements yielded a wide range of variation, especially in the insertion point of the anterior tendon on the fifth metatarsal and the relation between the two tendons, but with no significant difference between sides or sex, except for the length of the posterior tendon between sex. The distance between the base of the FMTB and posterior tendon varies from 0 to 9 mm, with one outlier at 24 mm (mean = 3.9 ± 4.8 mm), the distance between the insertions from 0 to 15 mm (mean = 4.7 ± 4.7 mm), resulting in how far of the FMTB the anterior tendon reaches varying from 17 to 60 mm (mean = 39.6 ± 11.5 mm) or 22-98% (mean = 64 ± 19%).

CONCLUSION

Our findings give a detailed overview of the morphological features the PTT can have, when attached with two tendons to the FMTB. Especially the varying relationship between those two insertions and varying point of the anterior insertion are of interest, as they might support its complex role in the occurrence of fractures of the fifth metatarsal by providing different amounts of torsional stress and its tendons can be used as tendon-grafts.

Assessment of plantaris and peroneus tertius tendons as graft materials for ankle ligament reconstructions - A cadaveric biomechanical study

Both the plantaris tendon and the peroneus tertius tendon are used as auto- and allogenous graft materials to reconstruct the ankle ligament complex. However, it is unclear to what extent these graft materials resemble the load-deformation behavior of the ankle ligaments. A total of 34 human ankle ligaments and 35 tendons were assessed mechanically deploying a quasi-static tensile testing setup. Tendons were significantly stiffer (median elastic moduli: plantaris tendon = 465.7 MPa, peroneus tertius tendon = 338.5 MPa, medial ligament = 61.4 MPa, lateral ligament = 49.3 MPa; p ≤ 0.035), but more distensible (median strain at maximum force: plantaris tendon = 15.1%, peroneus tertius tendon = 15.3%, medial ligament = 9.3%, lateral ligament = 9.6%; p ≤ 0.008) and mechanically tougher (median ultimate tensile strength: plantaris tendon = 51.0 MPa, peroneus tertius tendon = 40.5 MPa, medial ligament = 4.1 MPa, lateral ligament = 3.5 MPa; p ≤ 0.033) when compared to medial and lateral ankle ligaments. The lateral ligaments of the right ankle were significantly tougher compared to the left side (p = 0.015). The elastic modulus of the medial ligament (r = 0.489, p = 0.045) and the peroneus tertius tendon (r = 0.517, p = 0.014) yielded an age-dependent increase. Both tendons seem biomechanically suitable graft materials to replace the medial and lateral ankle ligaments during physiological loading. The age-dependent increase in tissue elastic properties of the medial vs. lateral ankle ligaments, and differences in ultimate tensile strength between the lateral ligaments left vs. right, may reflect the complex asymmetric loading behavior of both ankle ligaments.

Fibularis tertius muscle in women & men: A surface anatomy cross-sectional study across countries

The fibularis tertius muscle (FTM) is a rare anatomic variation. The prevalence of this exclusively human structure, which is found in the anterior compartment of the leg, is often underestimated, and it is believed that foot and ankle conditions are more difficult to manage in patients with an FTM. The aim of this study was to assess the presence of the FTM palpation and determine whether its presence is associated with an individual’s sex, because the exact prevalence in males and females is unclear. An observational cross-sectional study was carried out. The study included 481 people (23.49% men and 76.51% women) with a mean age of 23.51±5.369 years, who were recruited from a Podiatric Medicine and Surgery Clinic (Spain). Data on routine demographic and clinical factors were recorded, and the presence or absence of the FTM was determined based on surface visual or palpated localization of the tendon (using a consistent protocol). The FTM was present in 38.25% (184/481) of the participants. Furthermore, FTM were present in 38.6% (142/481) of females and 37.2% (42/481) of males. The study revealed that the presence of the FTM varies between individuals and does not depend on an individual’s sex. Significant differences in the prevalence of the FTM between countries should be carefully evaluated rather than generalizing the results of this Spanish study to other non-Spanish populations. Larger numbers of participants should be enrolled in future studies in order to meet the statistical criteria.

A rare case of variant morphology of peroneus tertius muscle

Peroneus tertius (PT) is frequently used as a free muscle flap to treat the soft tissue defects and osteomyelitis, in the lower limb as it is functionally insignificant while balancing the foot during walking. The morphology of the PT is highly variable. In the present case we report a rare case of unusual morphology of the PT in a formalin embalmed male cadaver. At the level of ankle, PT divided into three tendons; two of them were inserted to the base of the distal phalanx of the fifth toe and base of the fifth metatarsal bone respectively. The smaller third tendon was attached to the fascia covering the capsule of the ankle joint. Further, extensor digitorum longus (EDL) gave only three tendinous slips for the second, third and fourth toes.

An unique variation of the peroneus tertius muscle

Peroneus tertius (fibularis tertius) is a muscle unique to humans. It often appears to be a part of extensor digitorum longus, and might be described as its "fifth tendon". Although its insertion variation has been reported by many authors, variations of its origin points are not common. A variation of the peroneus tertius muscle was found during routine dissection of a 75-year-old male cadaver. The muscle originated from the extensor hallucis longus. The muscle belly of the extensor hallucis longus arose from the middle two-fourths of the medial surface of the fibula, medial to the extensor digitorum longus, and anterior surface of the interosseous membrane. It lay under the extensor digitorum longus, and lateral to the tibialis anterior muscle. The muscle belly of the extensor hallucis longus divided into medial and lateral parts 17 cm below its origin point. The lateral part, named as peroneus tertius, continued downward to reach the medial part of the dorsal surface of the base of the fifth metatarsal bone. The medial part ran also downward and divided into two tendons reaching the dorsal surface of the base of the distal phalanx of the great toe. This kind of variation may be important during foot or leg surgery.

Fibularis tertius: Revisiting the anatomy

Fibularis tertius (FT) may be used during reconstructive surgery and muscle transposition with retention of function. The muscle was examined in both lower limbs of 41 cadavers. Measurements were made of muscle belly length and width, tendon length and width, and the size of the origin on the fibula. Tendon insertion, nerve and blood supplies were also examined. FT was absent in five (6.1%) lower limbs of three (7.3%) subjects. The size of its origin demonstrated inter- and intra-individual variation. FT arose from the distal fibula and on average occupied (28.4 +/- 9.1)% (mean +/- S. D.) of the total shaft length. In all cases the tendon inserted into the dorsal surface of the shafts of both the fourth and fifth metatarsals. A small nerve branch consistently arose from the deep fibular nerve near the origin of extensor digitorum longus. The nerve ran parallel to the length of this muscle, between it and extensor hallucis longus, before piercing FT. Anatomy textbooks describe FT as inserting into the fifth metatarsal only. This study, supported by data from previous reports, suggests that the "textbook" accounts of FT should be updated to record that most commonly its tendon reaches both the fourth and fifth metatarsals.

Soft-tissue disorders of the ankle: a comprehensive arthroscopic approach

Ankle arthroscopy has dramatically advanced in the past decade. Many ailments of the ankle joint that were previously treated through open approaches are today treated with arthroscopic techniques. Arthroscopy allows for a more rapid recovery, better visualization of soft tissue lesions within the ankle joint and a more thorough examination of intracapsular ankle pathology. This article describes current arthroscopic treatments of ankle pathology limited to soft tissue structures. Additionally, a perspective is presented for the comprehensive treatment of lateral ankle pain including arthroscopic lateral ankle stabilization.

Arthroscopic monopolar radiofrequency thermal stabilization for chronic lateral ankle instability: a preliminary report on 10 cases

This study represents a preliminary review of 10 patients having undergone arthroscopic monopolar thermal stabilization for ankle instability from October 1996 to June 1998. All patients in this study expressed mild to moderate chronic ankle instability complaints and were dissatisfied with their attempts at conservative care. Subjective clinical results were evaluated in all patients having undergone this procedure utilizing a modified version of the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. In addition, eight of these patients underwent pre- and postoperative stress radiographs. The average age of the patient population in this study was 34.5 +/- 9.26 years. The preoperative AOFAS scores averaged 58.3 +/- 8.96 and the postoperative were 88.1 +/- 11.09 points. Patients returned to full activities on the average of 3 months. Postoperative ankle varus stress test reduced on the average of 2.8 degrees +/- 2.77 degrees, while the anterior drawer measurements reduced 4.8 +/- 1.83 mm. The reduction in anterior drawer test amounted to an approximate 60% decrease in talar excursion postoperatively. All patients who underwent this procedure achieved ankle stability and commented that they would undergo the procedure again.