The Efficacy of Anterior Cruciate Ligament Reconstruction with Peroneus Longus Tendon and its Impact on Ankle Joint Function

OBJECTIVE

Peroneus Longus Tendon (PLT), a viable anterior cruciate ligament (ACL) graft, shares similar biomechanics, making it suitable for reconstruction. Controversy exists over whether PLT transplants affects the donor ankle joint. The purpose of this study was to examine the recovery of knee joint function following arthroscopic ACL restoration using autologous PLT and its influence on the donor ankle joint.

METHODS

A retrospective analysis was conducted on 65 patients with ACL rupture who underwent PLT graft reconstruction in our hospital from January 2016 to December 2021. A three-dimensional gait analysis of the bilateral knee and ankle joints was performed postoperatively using an Opti_Knee three-dimensional motion measurement and analysis system-Yidong Medical Infrared Motion Gait Analyzer. Knee function scores and changes in the range of motion of the bilateral knee and ankle joints were collected. The analysis of preoperative and postoperative joint function scores, bilateral knee and ankle mobility was performed by t-tests.

RESULTS

One year after surgery, the patients' International Knee Documentation Committee (IKDC) scores, Knee Injury and Osteoarthritis Outcome Scores (KOOSs), and Lysholm scores were significantly improved compared to preoperative scores, with statistically significant differences (p < 0.05). There was no statistical difference in the American Orthopedic Foot and Ankle Society (AOFAS) score of the donor ankle joint before and after surgery (p > 0.05). During different gait cycles, there was no statistical difference in knee joint mobility between the affected and healthy sides (p > 0.05), but there was a statistical difference in the inversion and eversion angle of the donor ankle joint during the support phase (p < 0.05).

CONCLUSION

ACL reconstruction using the PLT can yield satisfactory knee joint function. However, it does affect inversion and eversion in the donor ankle joint, necessitating postoperative exercises. Similar subjective function ratings for both operated and non-operated feet, despite increased inversion-eversion motion in the operated foot, may be influenced by the subjective nature and margin of error in the AOFAS Ankle-hindfoot score, along with the relatively small variation in ankle inversion-eversion angles.

Migration of the os peroneum: An enigmatic phenomenon explored through radiological perspectives

The os peroneum is an accessory ossicle located along the lateral aspect of the cuboid bone. Its position can serve as an indicator of peroneus longus tendon (PLT) injury. Imaging studies including radiographs and MRI can help detect malposition of the os peroneum and progressive injuries to the PLT and its associated structures. We report a case of a woman with recurrent foot and ankle pain, demonstrating progressive retraction of the os peroneum, implying severe PLT injury which may have ultimately predisposed her to a traumatic fifth metatarsal base fracture. This case highlights the importance of scrutinizing the appearance and position of the os peroneum on radiographs.

The effect of harvesting the anterior half of the peroneus longus tendon on foot morphology and gait

BACKGROUND AND OBJECTIVES

In anterior cruciate ligament reconstruction, the strength of the graft was found to be unsatisfactory usually the anterior half of the peroneus longus tendon was taken for supplementation, but the effect on foot and ankle function and gait in the donor area is unclear. This study aims to explore the changes in the ankle and gait after using the harvested anterior half of the peroneus longus tendon as a reconstruction graft for the anterior cruciate ligament.

METHODS

A total of 20 patients, 6 males and 14 females, aged 18 to 44 years, with unilateral anterior cruciate ligament injuries, underwent reconstruction using the harvested anterior half of the peroneus longus tendon as a graft between June 2021 and December 2021. The part on which the anterior half of the peroneus longus tendon was harvested was considered the experimental group, while the contralateral foot was the control group. At the 6-month follow-up, the Lysholm knee score, AOFAS ankle score, and gait-related data (foot length, arch index, arch volume, arch volume index, and gait cycle parameters: percentage of time in each gait phase, step frequency, step length, foot strike angle, and push-off angle) were assessed using a 3D foot scanner and wearable sensors for both groups.

RESULTS

All 20 patients completed the six-month follow-up. There were no statistically significant differences between the experimental and control groups regarding knee scores, ankle scores, foot length, arch index, arch volume, arch volume index, step frequency, and step length (P > 0.05). However, there were statistically significant differences between the experimental and control groups in terms of the gait cycle parameters, including the percentage of time in the stance, mid-stance, and push-off phases, as well as foot strike angle and push-off angle (P < 0.05).

CONCLUSION

Through our study of the surgical experimental group we have shown that harvesting the anterior half of the peroneus longus tendon does not affect foot morphology and gait parameters; however, it does impact the gait cycle.

Functional Outcomes of Anatomic Single Bundle Primary ACL Reconstruction with Peroneus Longus Tendon (Without a Peroneal Tenodesis) Versus Hamstring Autografts

Objectives

There is a paucity of comparative studies on the Peroneus longus tendon versus conventional hamstring autograft use in primary single-bundle ACL reconstruction. To date, there are no studies that reported donor ankle functional outcomes when a peroneus longus graft is harvested without performing a tenodesis to peroneus brevis.

Methods

A single-center retrospective comparative study was undertaken to evaluate the functional outcomes (IKDC & Tegner-Lysholm scores) of primary isolated single bundle anatomic ACL Reconstruction with Peroneus Longus tendon (PL group) versus Hamstring (HT group) autografts. Further, an evaluation of donor ankle morbidity using the AOFAS score for the PL group and persistent anteromedial thigh pain and paraesthesia around the knee for the HT group was also performed.

Results

30 patients were evaluated in each group. The mean graft diameter was 8.61 +/- 0.66mm (HT) & 9.6 +/- 0.84mm (PL) and the mean graft length was 7.39cm (HT) & 7.86cm (PL) respectively. The mean IKDC scores were 58.2 (Pre-op) & 89.52 (1 year) for the HT group and 61.8 (Pre-op) & 90.9 (1 year) for the PL group respectively. The mean Tegner-Lysholm scores were 69.83 (Pre-op) & 91.96 (1 year) for the HT group and 70.66 (Pre-op) & 92.36 (1 year) for the PL group respectively.10% of the HT group had residual anteromedial thigh pain & 6.7% had paraesthesia at one-year follow-up. In the PL group, the mean AOFAS score was 96.37 +/- 2.49 at the end of one year. Two cases (6.66%) reported paraesthesia around the harvested site.

Conclusion

Peroneus longus tendon appears to be a better autograft choice than hamstrings for primary ACL reconstruction. Further, without a peroneal tenodesis, the functional outcomes of the donor ankle remained excellent.

Complications of peroneus longus tendon harvesting: a retrospective review of 82 cases

OBJECTIVE

Peroneus longus tendon (PLT) has become a reliable autologous graft option for various ligament reconstructions. But there are potential risks and complications associated with its use as a graft. This retrospective study aimed to examine the complications and donor site morbidity following PLT harvesting.

PATIENTS AND METHODS

A retrospective review was performed on an institutional digital patient database, and all patients who underwent ligament reconstruction using PLT autograft were identified. Intraoperative, early, and late complications were reviewed using digital patient notes and patients underwent a complete physical examination during their final follow-up. Ankle function was assessed using the AOFAS score, and manual ankle muscle testing was performed on both sides. Sural nerve iatrogenic injury was evaluated with a dermatomal light touch examination. Cosmetic satisfaction due to incision scar and footwear complaints were also assessed.

RESULTS

82 patients (74 male, eight female) with a mean age of 31.9 ± 10.4 years (range, 16-66) were included in the final analysis. The mean follow-up time was 46.6 ± 30.3 months (range, 6-109). The mean AOFAS score for the donor side was 98.7 ± 3.3 (range, 87-100), and the contralateral side score was 100, with manual muscle testing graded as 5 in all movements and similar to the contralateral side. Fifteen patients (18.3%) had hypoesthesia over the dorsolateral aspect of the foot distal to the incision scar, two patients (2.4%) had hyperalgesia over the distal incision scar, and one patient (1.2%) had mild ankle instability. There were two cases (2.4%) of compartment syndrome, both of which were treated with fasciotomy and had complete regression of symptoms after 5 days. One patient (1.2%) had a transient peroneal nerve injury and foot drop that resolved in the sixth month.

CONCLUSIONS

The results of this retrospective study suggest that harvesting the PLT is associated with a high rate of complications and donor site morbidity. The most common complication was hypoesthesia around the lateral side of the foot, although the ankle functions were not affected significantly. Two cases of compartment syndrome and one transient peroneal nerve injury were observed. Care should be taken while harvesting PLT autograft, and it should be kept in mind that peroneal nerve injury might occur.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Arthroscopic reconstruction of the medial patellofemoral ligament in skeletally immature patients using the modified sling procedure: a novel technique for MPFL reconstruction

BACKGROUND

Patellar dislocation is common in young people. Although isolated anatomic double-bundle reconstruction of the MPFL is a common and effective surgical treatment for patellofemoral instability, concerns about the risk of injury to the epiphysis remain.

METHODS

A total of 21 children and adolescents (9 males, 12 females; mean age: 10.7 years; range: 8 to 13 years) with recurrent patella dislocation or symptomatic instability following a primary dislocation were enrolled in the study. In all patients, double-bundle medial patellofemoral ligament (MPFL) reconstruction and femoral sling procedure were performed under arthroscopy, using an anterior half peroneus longus tendon (AHPLT) autograft. Functional outcomes were evaluated preoperatively and during follow-ups based on Kujala and Lysholm scores. Radiological examinations including radiographs, 3D-CT, and MRI were performed pre- and post-operatively.

RESULTS

Among two-year postoperative follow-up (range: 24-42 months) showed significant improvement in functional scores (p < 0.01). The Lysholm score increased from 68 (44.5) to 100 (0) and the Kujala score increased from 26 (34.5) to 100 (2) The patellar tilt angel improved significantly (p < 0.01) from 24.3° ± 10.4 preoperatively to 11.9° ± 7.0 postoperatively. MRIs performed 6- and 12-months post operation did not show any signs of dysfunction of the reconstructed MPFL or cartilage degeneration.

STUDY DESIGN

Case Series; Level of evidence, 4.

CONCLUSION

Arthroscopic reconstruction of the MPFL using the modified sling procedure is an effective procedure for the treatment of patellar instability in skeletally immature patients.

Preoperative ultrasound can accurately predict the diameter of double-stranded peroneus longus tendon autografts

PURPOSE

This study aimed to determine the correlation between the intraoperative diameter of double-stranded peroneus longus tendon (2PLT) and length of the PLT autograft and preoperative ultrasound (US) measurements, as well as radiographic and anthropometric measurements. The hypothesis was that US can accurately predict the diameter of 2PLT autografts during operation.

METHODS

Twenty-six patients underwent ligament reconstruction with 2PLT autografts were included. Preoperative US was used to calculate the in situ PLT cross-sectional area (CSA) at seven levels (0, 1, 2, 3, 4, 5, 10 cm proximal to the harvest start point). Femoral width, notch width, notch height, maximum patellar length, and patellar tendon length were determined on preoperative radiographs. Intraoperative measurements of PLT were made, including all fiber lengths of PLT and diameters of 2PLT using sizing tubes calibrated to 0.5 mm.

RESULTS

CSA at 1 cm proximal to the harvest site had the highest correlation with the diameter of 2PLT (r = 0.84, P < 0.001). Calf length had the highest correlation with PLT length (r = 0.65, P < 0.001). The diameter of the 2PLT autografts could be predicted by the following formula: 4.6 + 0.2 × [sonographic CSA of PLT at 1 cm level]; the length of PLT could be predicted by the following formula: 5.6 + 0.5 × Calf length.

CONCLUSION

The diameter of 2PLT and length of PLT autografts can be accurately predicted by preoperative US and calf length measurements, respectively. Accurate preoperative prediction of the diameter and length of autologous grafts can provide the most suitable and individualized graft for patients.

LEVEL OF EVIDENCE

IV.

A cadaveric study

Introduction

Many kinds of grafts were used for single-bundle reconstruction of the posterior cruciate ligament (PCL). Recently, the peroneus longus tendon (PLT) was used in some clinical reports. This study aimed to test the best position of the femoral insertion in the case of using PLT for PCL reconstruction.

Methods

Seventeen fresh frozen cadaveric knees were randomized into three groups. Group AL (6 knees): the femoral insertion in PCL reconstruction was at the footprint center of the anterolateral bundle (ALB). Group PM (5 knees): at the footprint center of the posteromedial bundle (PMB). And group MC (6 knees) was at the midpoint of the center of the anterolateral bundle and posteromedial bundle. The PCL of all knees was cut and a PCL reconstruction procedure was performed with autologous peroneus longus tendon (PLT). The stability of each knee was tested in three conditions: PCL was intact, PCL was resected, and PCL was reconstructed. The KT-1000 machine was used to measure the maximum posterior displacement of the tibia under force with the knees at 0, 30, 60, 90, and 120 degrees of flexion.

Results

Average posterior displacement of the tibia under force for intact PCL of group AL was 1.6 mm, group MC was 1.2 mm, and group PM was 1.3 mm. After PCL was resected, the knee laxity was increased remarkably: posterior displacement of the tibia of group AL was 8.9 mm, group MC was 9.4 mm, and group PM was 13.6 mm. After PCL was reconstructed, group AL was 1.5 mm, group MC was 2.0 mm, and group PM was 5.6 mm. The results showed that after PCL reconstruction the group AL and group MC give better stability to the knee (p < 0.05, except knee at 120 degrees of flexion). Group AL got more stability than group MC, but the difference was not significant (p ≥ 0.164).

Conclusion

In a single-bundle reconstruction of the PCL with the graft PLT, the femoral insertion at the footprint center of the ALB and the midpoint of the center of the ALB and PMB showed better stability than that at PMB.

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

PURPOSE

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.

METHODS

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.

RESULTS

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 ± 1.7 mm. There was no significant difference from the end of the tendon stripper to the SPN between full extension or 90° flexion of the knee.

CONCLUSION

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.

Low to moderate risk of nerve damage during peroneus longus tendon autograft harvest

PURPOSE

This study aims to evaluate the proximity of the tendon stripper to both the peroneal and sural nerves during peroneus longus tendon (PLT) autograft harvesting.

METHODS

Ten fresh-frozen human cadaveric lower extremities were used to harvest a full-thickness PLT autograft using a standard closed blunt-ended tendon stripper. The distance to the sural nerve from the PLT (at 0, 1, 2 and 3 cm proximal to lateral malleolus (LM), and the distance to the peroneal nerve and its branches from the end of the tendon stripper were measured by two separate observers using ImageJ software.

RESULTS

The average distance from the PLT to the sural nerve increased significantly from 0 to 2 cm proximal to LM. The average distance to the sural nerve at the LM was 4.9 ± 1.5 mm and increased to 10.8 ± 2.4 mm (2 cm proximal to LM). The average distance from the tendon stripper to the deep peroneal nerve was 52.9 ± 11.4 mm. The average distance to the PLT branch of peroneal nerve was 29.3 ± 4.2 mm. The superficial peroneal nerve, which coursed parallel and deep to the tendon stripper, was on average 5.2 ± 0.7 mm from the end of the stripper. No transection injuries of the nerves were observed in any of the ten legs after harvesting.

CONCLUSION

This cadaver study found during a full-thickness PLT harvest, the distances between the tendon stripper and the nerves were greater than 5 mm with an initial incision at 2 cm proximal to LM which is recommended.

Peroneus longus tendon autograft has functional outcomes comparable to hamstring tendon autograft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis

PURPOSE

This review aimed to assess whether peroneus longus tendon (PLT) autograft would have comparable functional outcomes and graft survival rates when compared to hamstring tendon (HT) autograft for anterior cruciate ligament (ACL) reconstruction.

METHODS

PubMed, Web of Science, Cochrane Library, Ovid (MEDICINE), and EMBASE databases were queried for original articles from clinical studies including the keywords: ACL reconstruction and PLT autograft. Studies comparing PLT autograft versus HT autograft were included in this analysis and the following data were extracted from studies meeting the inclusion criteria: graft diameter, functional outcomes (Tegner activity scale, Lysholm score, and International Knee Documentation Committee (IKDC) subjective score), knee laxity (Lachman test), and complications (donor site pain or paresthesia, graft failure). Besides, the American Orthopaedic Foot and Ankle Society (AOFAS) scale and the Foot and Ankle Disability Index (FADI) pre-operation and at last follow-up were also compared among patients using PLT autograft. Meta-analysis was applied using Review Manager 5.3 and p < 0.05 was considered statistically significant.

RESULTS

Twenty-three studies including 925 patients with ACL reconstruction met inclusion criteria. Of these, 5 studies included a direct comparison of PLT autograft (164 patients) versus HT autograft (174 patients). No significant difference was observed between PLT and HT autografts for Tegner activity scale, Lachman test, donor site pain, or graft failure. However, PLT groups demonstrated better Lysholm score (mean difference between PLT and HT groups, 1.55; 95% CI 0.20-2.89; p = 0.02) and IKDC subjective score (mean difference between PLT and HT groups, 3.24; 95% CI 0.29-6.19; p = 0.03). No difference of FADI was found (n.s.) but AOFAS was slightly decreased at last post-operative follow-up for patients with PLT autograft compared with pre-operative scores (mean difference of 0.31, 95% CI 0.07-0.54, p = 0.01).

CONCLUSION

PLT autograft demonstrated comparable functional outcomes and graft survival rates compared with HT autograft for ACL reconstruction. However, a slight decrease in AOFAS score should be considered during surgical planning. Hence, the PLT is a suitable autograft harvested outside the knee for ACL reconstruction to avoid the complication of quadriceps-hamstring imbalance which can occur when harvesting autografts from the knee.

LEVEL OF EVIDENCE

Level II.

Peroneus longus tendon graft for anterior cruciate ligament reconstruction: A case report and review of literature

INTRODUCTION

The anterior cruciate ligament (ACL) is one of the most frequently injured structures of the knee joint. Anterior cruciate ligament reconstruction (ACLR) provides surgical restoration of the injured ACL using the placement of graft material. The choice of graft is principal in providing optimal knee stability after surgery. Peroneus longus tendon (PLT) is an autograft modality that offers unique benefits for ACL reconstruction cases.

PRESENTATION OF CASE

We present a case of ACL reconstruction surgery using PLT graft in a patient with a confirmed ACL rupture. Assessment of post-surgical pain, knee stability, and ankle function were performed to determine functional outcome and donor site morbidity. The follow-up results revealed favorable recovery and improvement in all objective parameters.

DISCUSSION

Post-operative biomechanical outcomes were evaluated using the International Knee Documentation Committee (IKDC) and the American Orthopedic Foot and Ankle Score (AOFAS) score. The use of PLT in ACL reconstruction established an excellent potential for its satisfactory result and comparable to other graft modalities in widely used evidence-based findings.

CONCLUSION

Peroneus longus tendon may be considered the first-option graft in ACL reconstruction as it indicated the absence of significant post-operative morbidity.

Posterior cruciate ligament reconstruction with peroneus longus tendon versus hamstring tendon: a comparison of functional outcome and donor site morbidity

PURPOSE

This study aimed to evaluate the differences in clinical outcome and donor site morbidity between the Peroneus Longus Tendon (PLT) and Hamstring Tendon (HT) in single-bundle Posterior Cruciate Ligament (PCL) reconstruction.

METHODS

Patients with an isolated PCL injury underwent single-bundle PCL reconstruction using consecutive sampling. Patients were allocated into two groups (PLT and HT) and prospectively observed. The tendon graft diameter was measured intraoperatively. Functional scores (IKDC, Lysholm, and modified Cincinnati scores) were recorded preoperatively and 2 years postoperatively. The thigh circumference and functional score according to the Foot and Ankle Disability Index (FADI) and American Orthopedic Foot and Ankle Society (AOFAS) were recorded to evaluate the morbidities in the ankle.

RESULTS

Fifty-five patients (hamstring n = 27, peroneus n = 28) met the inclusion criteria. The diameter of the PLT graft (8.2 ± 0.6 mm) was comparable to that of the HT graft (8.3 ± 0.5 mm). Both groups had excellent postoperative knee functional outcome scores. The mean AOFAS and FADI scores were excellent, with no difference in thigh circumference between the groups.

CONCLUSION

PLT is a good choice as a graft in PCL reconstruction at the 2-year follow-up, with minimal donor site morbidity.

LEVEL OF EVIDENCE

II.

[Study on reconstruction of posterior cruciate ligament with autologous peroneus longus tendon under arthroscopy]

Objective

To discuss the effectiveness of posterior cruciate ligament (PCL) reconstruction with autologous peroneus longus tendon under arthroscopy.

Methods

Between January 2016 and December 2018, 46 patients with PCL injuries were enrolled. There were 34 males and 12 females, with an average age of 40.7 years (range, 20-58 years). There were 43 cases of acute injury and 3 cases of old injury. The anterior drawer test and the posterior tibia sign were positive in 4 cases, the posterior drawer tests and the posterior tibia sign were positive in 46 cases, the varus stress tests were positive in 10 cases, and the valgus stress tests were positive in 6 cases. The difference of dial-test at 30° knee flexion between affected and healthy sides was (5.20±3.91)°. The tibia posterior displacement under posterior stress position was (12.03±2.38) mm. The Lysholm score of the knee joint was 36.68±7.89, the International Knee Documentation Committee (IKDC) score was 33.58±5.97, and the American Orthopaedic Foot and Ankle Association (AOFAS) score of the ankle joint was 97.60±1.85. PCL was reconstructed with autologous peroneus longus tendon under arthroscopy, and the combined meniscus injury, posterolateral complex injury, and anterior cruciate ligament injury were all treated according to the degree of injury.

Results

All incisions healed by first intention. Forty patients were followed up 12-26 months, with an average of 16.0 months. At last follow-up, the Lysholm score of the knee joint was 84.85±7.03, and the IKDC score was 87.13±6.27, which were significant different from preoperative ones ( t=-13.45, P=0.00; t= -39.12, P=0.00); the AOFAS score of ankle joint was 93.98±2.14, which was not significant different from preoperative one ( t=8.09, P=0.90). The tibia posterior displacement under posterior stress position was (2.75±1.76) mm and the difference of dial-test at 30° knee flexion between affected and healthy sides was (1.75±2.09)°, which were significant different from preoperative ones ( t=29.00, P=0.00; t=4.96, P=0.00). The posterior drawer test and the posterior tibia sign were positive in 1 case and negative in 39 cases; the anterior drawer test and the varus and valgus stress tests were all negative.

Conclusion

Reconstruction of PCL with autologous peroneus longus tendon under arthroscopy can significantly improve the stability and function of the knee joint, with satisfactory clinical results.

Combined hamstrings and peroneus longus tendon for undersized graft in anterior cruciate ligament reconstruction: A report of two adolescence female patients

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Unpredictable graft size for anterior cruciate ligament reconstruction.

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Plan for graft augmentation is of great importance.

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Combined graft from hamstring and peroneus longus tendon for undersized graft.

Introduction

Anterior cruciate ligament (ACL) rupture is a common injury in young and active population and reconstruction is the mainstay treatment to maintain stability of the knee. Hamstring tendon (HT) is the most popular graft for ACL reconstruction. In certain patient, particularly in women, the size of tendon graft to reconstruct the ACL is unpredictable. In the case of unqualified donor, we need a combined graft from another source to match the size requirement.

Case presentation

We present two cases of ACL reconstruction using combination of HT and PLT graft in adolescent female. We evaluate knee functional score and ankle donor site morbidity. In the second case we also did second look for the ACL graft integrity arthroscopically. This study has been reported in line with the Surgical Case Report (SCARE) criteria.

Discussion

One year after surgery, International Knee Documentation Committee (IKDC) score for both cases were improved and no ankle-donor site morbidity with good motoric power and 100% American Orthopedic Foot Ankle Score (AOFAS).

Conclusion

Additional peroneus longus tendon can be considered as an alternative in undersized hamstring tendon graft without significant donor site morbidity.

[Arthroscopic reconstruction of anterior cruciate ligament with autologous ipsilateral peroneus longus tendon]

Objective

To investigate the effectiveness of anterior cruciate ligament (ACL) reconstruction with the autologous ipsilateral peroneus longus tendon (PLT) under arthroscopy.

Methods

A retrospective study was conducted on 35 patients with ACL rupture who underwent ACL reconstruction with autologous ipsilateral PLT under arthroscopy between October 2017 and October 2018. There were 19 males and 16 females with an average age of 43.4 years (range, 18-60 years), with 20 cases of left knee and 15 cases of right knee. The causes of injury included traffic accident in 14 cases, falling injury in 13 cases, and sports injury in 8 cases. The time from injury to operation ranged from 3 to 9 days (mean, 4.7 days). The patients suffered from swelling, pain, and limited mobility of knee joint before operation. The anterior drawer test, Lachman test, and pivot-shift test were positive before operation, whereas MRI was taken to confirm the ACL rupture. After operation, the patients were followed up every 3 months until the knee joint's function returned to normal. MRI and X-ray films were used to observe the tendon-bone healing as well as the position of Endobutton suspension plate and hollow nail. The anterior drawer test, Lachman test, and pivot-shift test were conducted to observe the improvement of knee joint mobility. The functional improvements were evaluated by the International Knee Documents Committee (IKDC) score, Lysholm score, knee injury and osteoarthritis (KOOS) score.

Results

All the 35 patients were followed up 12-18 months, with an average of 14.2 months. The incisions healed by first intention, and no complications such as infection, joint stiffness, and rerupture occurred. Postoperative anterior drawer test, Lachman test, and pivot-shift test turned to be negative of all patients. MRI showed that the ACL was continuous, and the tendon-bone in the distal femur tunnel and proximal tibia tunnel recovered well after operation. X-ray films showed that the positions of Endobutton suspension plate and hollow nail were stable. The IKDC, Lysholm, and KOOS scores at 3, 6, and 12 months after operation were significantly improved when compared with those before operation, and the scores were further improved with time after operation ( P<0.05).

Conclusion

For patients with ACL rupture, ACL reconstruction with the autologous ipsilateral PLT under arthroscopy has satisfactory effectiveness of quick recovery, good function, and great stability.

Minimally invasive tenodesis for peroneus longus tendon rupture: A case report and review of literature

BACKGROUND

Peroneal tendon disorders are common causes of lateral hindfoot pain. However, total rupture of the peroneal longus tendon is rare. Surgical treatment for this condition is usually a side-to-side tenodesis of the peroneal longus tendon to the peroneal brevis tendon. While the traditional procedure involves a long lateral curved incision, this approach is associated with damage to the lateral soft tissues (up to 24% incidence).

CASE SUMMARY

A 50-year-old female had developed pain at the lateral aspect of the hindfoot 1 mo after an ankle sprain while walking in the street. Previous treatments were anti-inflammatory drugs, ice, rest and Cam-walker boot. At physical exam, there was pain and swelling over the course of the peroneal tendons. Ankle instability and cavovarus foot deformity were ruled out. Eversion strength was weak (4/5). Imaging showed complete rupture of the peroneal longus tendon associated with a sharp hypertrophic peroneal tubercle. Surgical repair was indicated after failure of conservative treatment (physiotherapy, rest, analgesics, and ankle stabilizer). A less invasive approach was performed for peroneal longus tendon debridement and side-to-side tenodesis to the adjacent peroneal brevis tendon, with successful clinical and functional outcomes.

CONCLUSION

Peroneus longus tendon tenodesis can be performed through a less invasive approach with preservation of the lateral soft tissue integrity.

Satisfactory functional and MRI outcomes at the foot and ankle following harvesting of full thickness peroneus longus tendon graft

AIMS

To evaluate the donor site morbidity and tendon morphology after harvesting whole length, full-thickness peroneus longus tendon (PLT) proximal to the lateral malleolus for ligament reconstructions or tendon transfer.

METHODS

A total of 21 eligible patients (mean age 34.0 years (standard deviation (SD) 11.2); mean follow-up period 31.8 months (SD 7.7), and 12 healthy controls (mean age, 26.8 years (SD 5.9) were included. For patients, clinical evaluation of the donor ankle was performed preoperatively and postoperatively. Square hop test, ankle strength assessment, and MRI of distal calf were assessed bilaterally in the final follow-up. The morphological symmetry of peroneal tendons bilaterally was evaluated by MRI in healthy controls.

RESULTS

Among the patients, the mean pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Karlsson-Peterson score were 98.7 (SD 2.5; p = 0.480) and 98.5 (SD 2.4; p = 0.480), and 98.3 (SD 2.4; p = 0.162) and 97.9 (SD 2.5; p = 0.162), respectively. There was no significant difference between square hop test bilaterally (p = 0.109) and plantar flexion peak force bilaterally (p = 0.371). The harvested limb had significantly less eversion peak force compared to the contralateral limb (p < 0.001). Evidence of probable tendon regeneration was observed in all the patients by MRI and the total bilateral peroneal tendon index (mean ratio of harvested side cross-sectional area of peroneal tendon compared with the contralateral side) was 82.9% (SD 17.4). In 12 healthy controls, peroneal tendons (mean 99.4% (SD 4.3) were found to be morphologically symmetrical between the two sides.

CONCLUSION

The current study showed satisfactory clinical foot and ankle outcomes after full-thickness PLT harvesting and indicated the regenerative potential of PLT after its removal. Level of Evidence: Level IV, therapeutic retrospective case series. Cite this article: Bone Joint J 2020;102-B(2):205-211.

Biomechanical and geometric characterization of peroneus longus allografts with respect to age

BACKGROUND

Anterior cruciate ligament injuries are among the most common injuries in high impact sports, and reconstruction is the standard surgical procedure for these ruptures. Reconstructions are often performed using allografts rather than autografts on a case-by-case basis. Controversy exists as to whether or not age of donor tissue plays a factor in the mechanical properties of allografts.

METHODS

38 peroneus longus (PL) tendons were prepared using the two-strand graft technique and then subjected to a cyclic loading test regimen of 1000 cycles to determine material properties. Specimens were grouped based on age to ascertain whether donor age affects the material properties of PL tendons.

FINDINGS

Secant modulus of the first cycle was determined to be 150.43 (SD 40.24) MPa. The average magnitude of the dynamic modulus was determined to be 82.81 (SD 24.65) MPa. Specimens were grouped into three distinct groups for analysis (x < 40 yo, 40 yo ≤ x < 60 yo, 60 yo < x).

INTERPRETATION

The need for using intrinsic material properties is highlighted. There is no significant difference in any intrinsic material property with respect to age or the fatigue of the tendon as the cycle count increases. Conversely, the measured stiffness of a tendon decreased as function of age with a large effect size. Based on analysis of graft geometries, it was determined that PL tendons become significantly more slender with increased age which result in the observed decrease in stiffness.

Posterior Cruciate Ligament reconstruction with peroneus longus tendon graft: 2-Years follow-up

Background

Several study that evaluate the usage of peroneus longus tendon (PLT) autograft in Anterior Cruciate Ligament reconstruction shows good result. Regardless the potential, there was no study about the use of PLT autograft in Posterior Cruciate Ligament (PCL) reconstruction. The purpose of this study is to evaluate the functional outcome and donor site morbidity after single bundle PCL reconstruction using PLT autograft.

Methods

Patient who met inclusion criteria, enrolled to this study and underwent single bundle PCL reconstruction using PL tendon autograft. Clinical outcomes were assessed with International Knee Documentation Committee (IKDC), Modified Cincinnati scoring systems, Lysholm score, and Serial hop test (single hop test and triple hop test) 2-year after surgery. Donor site morbidity was assessed with Foot and Ankle Disability Index (FADI) and American Orthopaedic Foot and Ankle (AOFAS) scoring system.

Results

Fifteen patients fulfilled the inclusion criteria (11 males and 4 females). PLT graft diameters were 7.5–10 mm (mean: 8.30 ± 0.65 mm). Significant increase of functional score (p < 0.05) were found two years after surgery. Mean score of IKDC was 47.58 ± 11.75 pre-operative; 78.17 ± 4.52 post-operative, Modified Cincinnati was 48.86 ± 12.22 pre-operative; 79.00 ± 4.82 post-operative, Lysholm score was 49.26 ± 11.54 pre-operative; 80.20 ± 5.04 post-operative. FADI and AOFAS at donor site ankle was 93.00 ± 3.04 and 93.26 ± 4.20, respectively. Serial hop test showed good result.

Conclusion

PCL reconstruction using peroneus longus tendon autograft shows good functional outcome of the knee based on IKDC, Modified Cincinnati, Lysholm score, with preservation of ankle function based on AOFAS and FADI score at 2-years follow-up.

Reconstruction of the lateral ankle ligaments using the anterior half of peroneus longus tendon graft

BACKGROUND

This study aimed to report our institution's experience in the treatment of chronic lateral ankle instability using the anterior half of the peroneus longus tendon (AHPLT) to reconstruct the lateral ligament.

METHODS

This retrospective study included 32 consecutive patients with chronic lateral ankle instability who underwent surgery from January 2013 to December 2014. All patients had failed to resolve with conservative treatment. A total of 32 ankles underwent AHPLT transfer. Patients returned for a clinical and radiologic follow-up evaluation at an average of 28 (range, 24-35) months postoperatively. Outcomes were assessed by comparison of pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analog scale pain scores, and Karlsson scores, and the radiographic assessment including talar tilt and anterior talar translation.

RESULTS

Thirty-two patients (32 ankles) (100%) returned for final evaluation. All patients had an excellent or good outcome on patient subjective self-assessment, pain scores, AOFAS scores, and Karlsson scores at final follow-up. Ankle range of motion was not affected by lateral ankle reconstruction. The talar tilt was significantly reduced from a preoperative mean of 14.1±4.2° to 3.4±1.3° postoperatively (P<.001), and the anterior drawer was significantly reduced from a preoperative mean of 13.8±3.4mm to 3.6±1.5mm after lateral ankle ligamentous reconstruction (P<.001).

CONCLUSIONS

AHPLT transfer to reconstruct the lateral ligament resulted in a high percentage of successful results, with excellent ankle stability and not affected of ankle motion.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

The location of the peroneus longus tendon in the cuboid groove: sonographic study in various positions of the ankle-foot in asymptomatic volunteers

OBJECTIVE

To evaluate the normal location of the peroneus longus tendon (PL) in the cuboid groove in various ankle-foot positions by ultrasonography in asymptomatic volunteers.

MATERIALS AND METHODS

Ultrasonographic assessment of the PL in the cuboid groove was performed in 20 feet of ten healthy volunteers. Each PL was examined in five ankle-foot positions (i.e., neutral, dorsiflexion, plantar-flexion, supination, and pronation). The PL location was qualitatively categorized as "inside" when the PL was entirely within the cuboid groove, as "overlying" when some part of the PL was perched on the cuboid tuberosity, and as "outside" when the PL was entirely on the cuboid tuberosity. For quantitative evaluation of the PL location, the distance between the PL and the cuboid groove was measured. The width of the cuboid groove was measured in the neutral position.

RESULTS

The PL location did not significantly change with changes in the ankle-foot position. Qualitatively, an "overlying" PL was the most common type, regardless of the ankle-foot position. "Inside" PLs were found in only 35, 20, 30, 25, and 35% of feet in neutral, dorsiflexion, plantar-flexion, supination, and pronation positions, respectively. The quantitative PL location was also not significantly different among all ankle-foot positions and it was significantly negatively correlated with the cuboid groove width.

CONCLUSIONS

In healthy volunteers, 65% or more of the PLs were partially or completely located outside of the cuboid groove, regardless of the ankle-foot position. The PL location relative to the cuboid groove was related to the cuboid groove width.

Percutaneous fixation of avulsion fracture at the plantar lateral base of the first metatarsal using ZipTight Fixation System: A case report

Isolated avulsion fracture of the peroneus longus tendon insertion at the base of the first metatarsal without injury of the tarsometatarsal joint is very rare. Similar to most avulsion fractures, this type of injury is caused by strong tension exerted by the peroneus longus tendon. The mechanism leading to this lesion and treatment options are not clearly defined. Several surgical techniques have been advocated for this fracture, including excision of an avulsion fragment and open reduction for internal fixation through the medial aspect of the foot or minimal plantar incision. We have described a method of percutaneous fixing of the avulsion fracture at the plantar lateral base of the first metatarsal using the ZipTight Fixation System (Zimmer Biomet Warsaw, Indiana, USA), which offers the advantage of allowing a rigid fixation and minimal invasive surgical technique for a small fragment.

Isolated avulsion fracture of the first metatarsal base at the peroneus longus tendon attachment: a case report

Avulsion fractures of the first metatarsal (MT1) base at the peroneus longus (PL) tendon attachment are rare and may be undiagnosed during an emergency visit. If the injury is not treated properly, chronic pain or persistent impairment for inversion and plantar-flexion of the first ray may occur. This case report presents a 30-year-old woman who presented 10 weeks post trauma to a foot and ankle surgeon due to a swollen right midfoot with diffuse tenderness over the medial Lisfranc joint. Further evaluation showed an isolated avulsion fracture of the first metatarsal, which was undiagnosed during the emergent visit following the accident. In this case, the patient was successfully treated conservatively. The goal of this article is to raise awareness of this rare injury for radiologists and orthopedic surgeons.

Os peroneum imaging: normal appearance and pathological findings

The os peroneum (OP) is a small sesamoid bone located inside the peroneus longus tendon (PLT), close to the cuboid. The OP can be the cause of pain and can be associated with lesions of the PLT. OP involvement in PLT disorders is frequently misdiagnosed by radiologists. Painful os peroneum syndrome (POPS) refers to a variety of conditions presenting with pain localized on the lateral aspect of the cuboid area. The syndrome can be observed as a consequence of local acute trauma such as ankle sprains or chronic overuse. Because of its intra-tendinous location, in tears of the peroneus longus tendon, the OP can show changes in its morphology or position, depending on the location of the tendon’s tear. Based on the level of the PLT tears, we propose a classification in three subtypes: tears localized proximal to the os peroneum (type I), at its level (type II) or distal to it (type III). These tears present with different changes on OP morphology or location. The aim of this article is to review the normal anatomy, imaging appearance and differential diagnosis of disorders of the OP as well as post-treatment imaging.

Teaching points

• PLT tears can be classified in three subtypes according to OP location.

• POPS is characterized by pain on the lateral aspect of the cuboid.

• OP involvement in PLT disorders is frequently misdiagnosed by radiologists.

Isolated inferior peroneal retinculum tear in professional soccer players

INTRODUCTION

Peroneal tendon dislocations are rare injuries that can easily be misdiagnosed. Up to date literature mostly describes proximal peroneal tendon dislocations due to superior peroneal retinaculum (SPR) tear. In this article, we present the assessment, diagnostic algorithm and a new therapeutic option for the distal dislocation of the long peroneal tendon due to isolated inferior peroneal retinaculum (IPR) tear.

PATIENTS AND METHODS

Between 2001 and 2011 three patients with distal peroneal tendon dislocation were operated. All of them were competitive athletes in the national soccer league. They presented with an ankle sprain and prolonged problems on the lateral side of the foot with no improvement after conservative therapy measures. Coleman block test was performed; ultrasound and MRI showed a tendon dislocation under the IPR. The patients underwent surgical repair that consisted of peroneal tubercle excision, a new lateral calcanear groove formation for both peroneal tendons and IPR plasty.

RESULTS

At the two year follow up the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score showed a significant increase. The decrease of painful stimuli assessed by a Visual Analogue Scale (VAS) was significant as well. At an average of 12 weeks after the surgery, the patients returned to their level of sport activity before injury and didn't report similar problems later.

CONCLUSION

Description of distal peroneal tendon dislocations is limited in the literature. This topic should be considered in differential diagnostics of an acute and chronic ankle sprain which leads to chronic ankle pain and instability. The authors recommend surgical treatment as a method of choice especially in professional athletes.