Peroneal Tendon Debridement
Main Text
Table of Contents
Tenosynovitis of the peroneal tendons is a common lower extremity problem that is often mistaken for other ankle pathology. Diagnosis is suggested with thorough history and physical examination and confirmed with radiographic studies when necessary. Patients with less acute or more severe presentation may improve with rest and physical therapy alone. When conservative management fails, surgical intervention is aimed at excising inflamed synovium with debridement and repair of any tears in the peroneal tendons. Recent literature has emphasized the increased use of tendoscopic approaches to peroneal pathology, although most studies to date have been too underpowered to suggest superiority to an open approach. We present a case of acute tenosynovitis treated by open surgical debridement and irrigation. Tendoscopy was deferred as the size and nature of this patient’s injury warranted an open repair.
Tenosynovitis; tendon injury; peroneal tendon; tendon debridement; foot and ankle.
Tenosynovitis of the peroneal tendons is a common lower extremity problem that can be difficult to diagnose and treat. Injury to the peroneal tendon is often mistaken for an ankle sprain or other lower extremity pathology, and it is estimated that only 60% of peroneal tendon disorders are accurately diagnosed by the initial evaluation.1 We present a case of acute tenosynovitis treated by open surgical debridement and irrigation. While injury to the peroneal tendons can sometimes be managed surgically with a tendoscopic approach, the size and nature of this patient’s injury warranted an open repair.
Tenosynovitis also presents as chronic disease, and a detailed history and examination can elucidate the presence of injury or entrapment of the peroneal tendons and give clues to suggest the etiology.2 Peroneal tenosynovitis tends to occur both in active, younger populations with repetitive inversion injuries as well as middle-aged or elderly patients with injury to the peroneus longus at the cuboid tunnel.2,3 Pertinent details in the history include a pattern of pain along the trajectory of the peroneus longus that is worsened by activity, and the presence of swelling, grating, tenderness, or crepitus. Peroneal tendon injuries are more commonly seen in individuals with cavus or high-normal medial longitudinal arches.2
This 40-year-old female patient presented with tenosynovitis of the left peroneal tendons. She has no significant past medical history. Both of her feet have normal arches, and she reports minimal daily physical activity, with a BMI of 31 kg/m². An associated infection was suspected due to the acute onset of the patient’s symptoms, which included pain and swelling with limited range of motion at the ankle. The patient had received conservative treatment prior to surgery, including empirical antibiotic therapy with peroral cephalosporins, ice, rest, and NSAIDs, which mostly alleviated the symptoms and clinical signs of acute inflammation. On the day of surgery, her chief complaint was limited range of motion and pain with passive inversion and plantarflexion in her left ankle.
Swelling (especially posterolateral ankle effusion in line with the course of the peroneal tendon) is often present on physical examination, particularly proximal to the base of the fifth metatarsal. Limited range of motion and tenderness are seen, particularly pain with passive inversion and plantarflexion or active eversion and dorsiflexion. The peroneals also serve to plantarflex the ankle, in addition to dorsiflexion and eversion. Therefore, circumduction of the ankle provides a full range of motion and activation to the peroneal tendons during a clinical exam. In rare cases, tenosynovitis may be caused by a pseudotumor created by fibrotic degeneration of the tendon sheath that is palpable at the lateral edge of the foot.2
Physical examination is usually sufficient to confirm the diagnosis of peroneal tenosynovitis, but a variety of radiologic studies may be performed to further characterize the etiology and severity of disease to guide treatment planning.2,4,5 Plain radiographs are used primarily to exclude ankle fractures or small fibular avulsion fractures. They can also be used to identify enthesopathy, which may be an indication of more chronic tendinopathy. A medial oblique view of the foot may reveal an os peroneum at the peroneal groove of the cuboid bone. A calcaneal axial view may demonstrate hypertrophy of the peroneal tubercle. MRI can be used to characterize tendon ruptures or demonstrate fluid collection associated with tenosynovitis. Peroneal tenography may demonstrate anatomical compression of the tendons by the tendon sheath using dye whose course is tracked along the tendon by multiple fluoroscopic films. CT is historically used to identify bony abnormalities, but more recently has been used to identify tendinopathy such as tenosynovitis, as peritendinous fat planes are distorted and the tendons are surrounded in a soft tissue mass on imaging. Finally, ultrasound has some utility in diagnosing tendonitis as hypoechoic regions and tendon thickening will often be seen, and complete ruptures may also be identified. Effusion within tendon sheath can be evaluated sonographically. The ESSKA-AFAS international consensus statement on peroneal pathologies has suggested ultrasound and MRI to be the preferred adjunct imaging studies when diagnosis is unclear.4
Patients may experience resolution or significant improvement in symptoms with conservative management.2 However, patients with stenosis at the tendon sheath, large tears in the tendons, or abnormal bony pathology are unlikely to see improvement, and surgical intervention is advised upon failure of conservative therapies.
Conservative treatment may be attempted for acute or chronic tenosynovitis upon initial presentation and is often associated with improvement, particularly in acute cases.2 Rest, ice, immobilization, and NSAIDs are employed along with physical therapy aimed at stretching and developing strength in the peroneal tendons. Patients with stenosis at the tendon sheath causing compression of the tendons can undergo tenography as a diagnostic and therapeutic measure; their symptoms will persist beyond conservative management but may respond to the dye injection as the added volume can sometimes release the constriction.2 Corticosteroid injections may be used as a supplementary treatment in these patients with continuing symptoms. Refractory or severe disease is best managed using a surgical approach.
Surgical intervention is employed in more severe cases of tenosynovitis to excise any synovitis, relieve any compression on the peroneal tendons by the tendon sheath, repair or excise medium to large tears in the tendon, and to correct any bony pathology that may lead to recurrence. Patients will undergo 2–4 weeks of non-weight bearing, followed by a strengthening protocol that should lead to resolution of symptoms and return to activity.
This patient underwent open surgical debridement to resolve infection and tenosynovitis of the peroneal tendons. The tenosynovium within the retinaculum was found to be inflamed at various points and was debrided. Additionally, the muscle belly of the peroneus brevis was found to extend down through the retinaculum to the inferior fibular groove and was also debrided to above the level of the fibular groove. Finally, peroneus quartus was identified and debrided. The tendons were found to be stable within the groove with dorsiflexion and eversion. The retinaculum was reconstructed using woven sutures passed through bone and subsequently oversewn with 2-0 Vicryl sutures. Free excursion of the tendons was noted following reconstruction. The patient’s foot was placed in a posterior short leg plaster splint in neutral position for postoperative immobilization. The patient was expected to undergo an uneventful recovery and return to full function following physical therapy. The patient was seen 6 months postoperatively, and she had no complaints, with full range of motion in her left ankle.
De Quervain was the first to describe stenosing tenosynovitis of the wrist in 1895,6 and Hildebrand described tenosynovitis in the lower extremity 12 years later.7 The first procedures to relieve the obstruction in stenosing tenosynovitis were described by Hackenbroch in 1927.8 Since this time, the preferred surgical management of the vast majority of cases of peroneal tenosynovitis refractory to conservative therapy has been via an open approach at the posterolateral aspect of the fibula, with debridement, repair of tendons, reconstruction, or other procedures performed as necessary to resolve the cause of the tendinopathy.9
The majority of outcomes from peroneal surgery are good to excellent, although most studies to date on peroneal debridement are underpowered and varying in scope, therefore further research is needed to evaluate the outcomes. Demetracopoulos et al. (2014) studied 34 patients undergoing peroneal debridement and tendon repair and noted that 17 of 18 follow-up patients returned to full activity and did not require reoperation.10 Another study of 11 patients with stenosing peroneal tenosynovitis demonstrated significant improvements in 4 out of the 5 Foot and Ankle Outcomes Score measures (pain, daily activities, sports activities, quality of life) in all patients.11
More recently, Wertheimer was the first to propose posterior tibial tendoscopy,12 and van Dijk and Kort (1998) described the first tendoscopic procedure of the peronei, an approach that has now increased in popularity in selected cases.13 In a study of 9 patients, tendoscopy was successfully performed, and 3 of 4 patients with identified adhesions were symptom free at a mean follow up of 19 months. A more recent 2018 meta-analysis of 96 tendoscopic procedures of the peroneal tendons reported an overall success rate of 95% with minimal complications.14 Studies aimed at comparing the open and tendoscopic approaches to treating peroneal tenosynovitis are lacking in the literature, although two studies of open debridement for tendon tears have suggested that complication rates may be higher with open surgery (9–54%).15,16 Thus, there is a need for further research examining both approaches to correcting selected and specified peroneal pathology, including tenosynovitis and/or associated tendon tears. Panchbhavi and Trevino have also promoted tendoscopy as a diagnostic tool in a study that uniquely identified peroneal pathology not evident on preoperative MRI.17 However, at this time there is insufficient evidence to suggest that tendoscopic approaches to peroneal disorders are superior to open due to the lack of higher-powered studies.
Peroneal tenosynovitis may be associated with tears of the peroneal tendon. The treatment algorithm developed by Redfern and Myerson has been utilized to direct intraoperative decision making for tendon repairs.16 For type I tears with both tendons grossly intact but with a tear present, excision of the longitudinal tear is performed followed by tubularization of the tendon. Type II tears in which one tendon is torn are managed via tenodesis. For type III tears in which both tendons are torn and unusable, the surgeon evaluates whether excursion of the proximal muscle is present. When present, the surgeon may attempt a one-stage allograft or tendon transfer assuming there is no scarring of the tissue bed. If scarring is present, a staged allograft with silicone rod may be a preferable alternative. When there is no excursion of the proximal muscle a tendon allograft is unlikely to be successful, and a tendon transfer would be indicated. Overall, this system has been well-received as a diagnostic tool for tendon injuries, as their study reported return to activity within 12 weeks in 70–80% of patients following tenodesis.16
Postoperative rehabilitation is an essential component of recovery from peroneal surgery. The optimal postoperative protocol is determined by whether the superior peroneal retinaculum was repaired during the surgery.4 When repair of the retinaculum is performed, two weeks of non-weight bearing in a lower leg cast followed by four weeks of weight bearing in a cast or boot is appropriate. The peroneal tendons should not be active until six weeks postoperatively. When the retinaculum is not repaired, rehabilitation should be guided by individualized patient-directed goals for recovery with early mobilization being encouraged, rather than a time-based recovery protocol. The presented recommendations are based on our experience and, to our knowledge, there are currently no published studies concluding on the optimal duration of immobilization following peroneal tendon debridement for tenosynovitis.
No special equipment used.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
This article is the companion to the following JOMI articles by Dr. Eric Bluman, MD, PhD:
Citations
- Dombek MF, Lamm BM, Saltrick K, Mendicino RW, Catanzariti AR. Peroneal tendon tears: a retrospective review. J Foot Ankle Surg. 2003;42(5):250-258. doi:10.1016/S1067-2516(03)00314-4.
- Schneider HP, Philips AJ. Peroneal Tenosynovitis: Evaluation and Treatment. Podiatry Institute. Published 2001. Accessed November 28, 2020. Available at: https://www.podiatryinstitute.com/pdfs/Update_2001/2001_16.pdf.
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Thompson FM, Patterson AH. Rupture of the peroneus longus tendon. Report of three cases. J Bone Joint Surg Am. 1989 Feb;71(2):293-5.
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van Dijk PA, Miller D, Calder J, et al. The ESSKA-AFAS international consensus statement on peroneal tendon pathologies. Knee Surg Sports Traumatol Arthrosc. 2018 Oct;26(10):3096-3107. doi:10.1007/s00167-018-4971-x. Epub 2018 May 16. Erratum in: Knee Surg Sports Traumatol Arthrosc. 2018 Oct;26(10):3108. doi:10.1007/s00167-018-5021-4.
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Davda K, Malhotra K, O’Donnell P, Singh D, Cullen N. Peroneal tendon disorders. EFORT Open Reviews. 2017;2(6):281-292. doi:10.1302/2058-5241.2.160047.
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Satteson E, Tannan SC. De Quervain Tenosynovitis. 2023 Nov 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–.
- Sanchez-Mariscal Diaz F, Arce JP, Martin Guinea JE, Navarro FN. Peroneal tenosynovitis caused by peroneal tubercle osteochondroma. Foot Ankle Surg. 2001;7(4):249-252.
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Trevino S, Gould N, Korson R. Surgical treatment of stenosing tenosynovitis at the ankle. Foot Ankle. 1981 Jul;2(1):37-45. doi:10.1177/107110078100200107.
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Marmotti A, Cravino M, Germano M, et al. Peroneal tendoscopy. Curr Rev Musculoskelet Med. 2012;5(2):135-144. doi:10.1007/s12178-012-9123-1.
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Demetracopoulos CA, Vineyard JC, Kiesau CD, Nunley JA. Long-term results of debridement and primary repair of peroneal tendon tears. Foot Ankle Intern. 2014;35(3):252-257. doi:10.1177/1071100713514565.
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Watson GI, Karnovsky SC, Levine DS, Drakos MC. Surgical treatment for stenosing peroneal tenosynovitis. Foot Ankle Intern. 2019;40(3):282-286. doi:10.1177/1071100718809077.
- Frascone ST, Loder BG, Calderone DR, Calderone DR, Frascone ST. The role of endoscopy in treatment of stenosing posterior tibial tenosynovitis. Foot Ankle Surg. 1995;34(1):15-22. doi:10.1016/S1067-2516(09)80097-5.
- van Dijk CN, Kort N. Tendoscopy of the peroneal tendons. Arthrosc J Arthrosc Rel Surg. 1998;14(5):471-478. doi:10.1016/S0749-8063(98)70074-X.
- Bernasconi A, Sadile F, Smeraglia F, Mehdi N, Laborde J, Lintz F. Tendoscopy of achilles, peroneal and tibialis posterior tendons: an evidence-based update. Foot Ankle Surg. 2018;24(5):374-382. doi:10.1016/j.fas.2017.06.004.
- Steel MW, DeOrio JK. Peroneal tendon tears: return to sports after operative treatment. Foot Ankle Intern. 2007;28(1):49-54. doi:10.3113/FAI.2007.0009.
- Redfern D, Myerson M. The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Intern. 2004;25(10):695-707. doi:10.1177/107110070402501002.
- Panchbhavi VK, Trevino SG. The technique of peroneal tendoscopy and its role in management of peroneal tendon anomalies. Tech Foot Ankle Surg. 2003;2(3):192-198.
Cite this article
Hogan WB, Bluman EM. Peroneal tendon debridement. J Med Insight. 2024;2024(24). doi:10.24296/jomi/24.
Procedure Outline
Table of Contents
- IV antibiotics were administered, and a popliteal and saphenous nerve blocks were placed.
- Patient was placed in supine position.
- General anesthesia was administered, and a tourniquet was placed on left upper extremity.
- The patient was then turned onto a lateral position and a beanbag (deflated with a vacuum) held the patient in this position.
- Standard sterile prep and draping of the left lower extremity was done.
- The peroneal nerve of the left leg was padded, and the medial prominences of the lower extremities were padded with foam.
- A curvilinear incision was marked out over the posterolateral aspect of the fibula following the path of the peroneous brevis tendon.
- The foot was then exsanguinated using an Esmarch bandage, and the tourniquet was inflated.
- The incision was made from approximately 4 cm above the distal tip of the patient's medial malleolus to the level of the tip of the medial malleolus.
- Great care was taken not to injure the peroneal nerve. Once it was identified, it was swept inferiorly and posteriorly.
- Soft tissue dissection was performed down to the retinaculum of the peroneal tendons.
- Sharp dissection was used to open this retinaculum. Within the retinaculum there was a significant amount of inflamed tenosynovium surrounding the peroneal tendons. Also a low-lying muscle belly of the peroneus brevis was present. This extended down through the retinaculum to the level of the inferior fibular groove.
- The tenosynovium was debrided back and the low-lying muscle belly was resected to a level above the start of the fibular groove.
- Peroneus quartus was also debrided.
- Inspection of the fibular groove showed that it was shallow and almost flat. The tendons showed good stability within the groove even with dorsiflexion and eversion.
- Three woven sutures were then passed through the bone to fashion the retinaculum back to the posterior portion of the fibula. This was then oversewn with 2-0 Vicryl sutures.
- The peroneal tendon excursion was tested in the reconstructed groove and retinaculum. There was no catching. Free excursion of the tendons was noted.
- The wound was thoroughly irrigated and the skin was then closed in layered fashion.
- The wound was then cleaned and dressed using Xeroform, fluffs, and Webril.
- A posterior short leg plaster splint was applied in neutral position.
- The tourniquet was released, and the splint held in place until its hardening.
- After emergence from general anesthesia, the patient was extubated by the anesthesiologist and taken to the postanesthesia recovery unit.
Transcription
CHAPTER 1
So I'm gonna - I'm gonna draw some anatomy so that you guys can see it. So we've got the patient in a full lateral position - held in place with a bean bag. She's got an axillary roll in for protection of the nervous structures to the upper extremity. We've also got the peroneal nerve on the down leg free from any pressure to prevent any per - common peroneal nerve palsy. And we've got padding between the bony prominences of the leg so that there's no pressure-associated complications intraoperatively. There's a stack of blankets underneath her foot to get her leg into a good position, and we also have a well-padded high thigh tourniquet on for hemostasis during the case. This is the lateral aspect of the ankle and the foot. We've got the fibular prominence right here in the distal fibula, and of course, the peroneal tendons lie right behind here. We'll just draw some rudimentary anatomic surface structures here to help us orient the case and make sure that we’re in the proper position throughout the - during the approach. I'm outlining the anterior portion of the fibula here and posteriorly the - the back edge of the fibula, and I'll put some hash marks here to indicate that that's bone. And the peroneal tendons live right behind here, and the incision will be right in line with this. And the peroneal tendons, of course, extend from the tip of the fibula down - at least the peroneus brevis goes down directly to the base of the 5th, and so if we need to do an extended incision down there to look, we can do that. And the peroneus longus, we'll reflect underneath the cuboid - lateral portion of the cuboid - right about there. And you just want to be posterior at the posterior aspect of the - of the fibula - yeah - actually, we can go probably a bit little anterior to that. And just take it off the anterior portion here. Do you want - do you want me to do the approach? Yeah - it’s probably better. Alright, so we're gonna - so we're gonna need some skins hooks. Okay. Alright. Alright, so let's do a pause, please. I'll shape this up a little bit, okay? So you want more to be on bone? Not necessarily, I mean… So we're using a - an Esmarch dressing to exsanguinate the lower extremity and give us a bloodless field. Then we've got a micro sagittal saw, guys? No it will not. Okay, can we get the tourniquet up to 250, please?
CHAPTER 2
Good. Starting. Skin hooks, please. And forceps, please. Bovie. These are some just cutaneous vessels that we're gonna electrocauterize to maintain hemostasis, both during this portion of the procedure and - and postoperatively. We can advance through the tissues here using the electrocautery on cut to help maintain that hemostasis. Now I'm just gonna feel here to make sure that we got the right plane and that we're staying in the right approach to the sheath. Right - right back here we’re on bone.
CHAPTER 3
So I'm gonna make a full thickness cut and enter his sheath right here. So that's pretty much where you cut through the superior... Yeah, in the - we’re - we’re - we're going right through the superior peroneal retinaculum. And you can see here - now the tendons are exposed. Let me have a Metzenbaum scissors, please. It’s the posterior here where you have to be a little bit careful about tearing into the sural nerve? Yeah, the sural nerve is running, you know, generally in this direction. It's not - if you're in the plane that we’re in, it's not too much of a problem. Certainly, you need to be vigilant for it when you're - when you're doing your exposure. We’re just opening up the retinaculum a little farther, and you can see the tendons in here. Now, this yellow tissue in here is nah - is a little abundant, and that's - this is some tenosynovium, which is a nourishing tissue for the tendon. A little bit is normal and desirable, but this is - this is, you know again, pretty abundant here, and although it looks yellow right now, if we hadn't exsanguinated the limb, this would be much more pink and would show much more clear signs of inflammation. Let me have a Freer elevator. So one of the things that you can notice here as we open this up a little farther is this - this more pinkish red tissue is actually the - the inferior extent or extension of the peroneus brevis tendon, and you'll see this when I lift the peroneus longus out of the way. You'll see there's a lot of tenosynovitis tenosynovium associated with it and even some adhesions, and when I reflect this out of the way and - and demonstrate, you can see this lowline peroneus brevis a little more clearly. And that - that peroneus brevis is in somewhat of a mass-occupying lesion. You've only got so much space in your fibular groove and the - in the - within the sheath here, and as the tendons have excursion back and forth, that can get driven down farther and create somewhat of a stenotic lesion. And so in these cases we - we remove that lowline peroneus brevis muscle belly to give the peroneal tendons a little bit more room to move. Metzenbaum scissors, please. You can see with this - this is the peroneus brevis tendon here. It is - it's effaced and flattened out, and there is some curvature to it. This is not too abnormal. It's a bit thin. There's a small tear here within the tendon. I don't know if you guys can make that out. The good news for this patient is that this is less than - at a point that is less than 50% the diameter of the tendon, and it is very superficial. And I think that in her case it would be advantageous - rather than try and repair this and put suture material in there - is just too excise this portion. It's not going to weaken the tendon significantly, and it's going to get rid of the tear and - and help her in pain control. The tear is right here. And this is a good reason why this case, you know, probably - if we had done this tendoscopically, you know, with a scope - this is very hard to - it'd be easy - easily identifiable, but to go in there and remove this through either biters or arthroscopic instruments is a little more difficult - and it would require a lot of shaving. It’s a pretty tenacious tissue, so it's - this has worked out for the best that this woman did not have a tendoscopic procedure. You can see more of this low-lying peroneus brevis here. And back here - this is the peroneal groove on the backside of the fibula. Normally, there's a nice cradle here - curvature on the backside of the fibula - fibular groove - to hold these peroneal tendons. She's very flat, so we're going to reevaluate after we debride all the tendons and - and all of the tenosynovitis to see how her tendons move and how they lay within the sheath at the end of the procedure. She may need to have a groove deepening procedure, but we're gonna reevaluate that once we clean out this low-lying peroneus brevis and some of this tissue here. Okay, Arvind, go ahead and release that. So first thing I'm gonna do is to take some forceps and the Metzenbaum scissors, and I'm going to come down here. I'm gonna try and find the most distal extent of this - of this tenosynovitis. It seems to be going down a little farther. I'm gonna to actually extend my incision so that I can get a good view of that. The other thing that we can do before we go ahead and do that is actually try and move the tendons - actually try and pull on them manually. Let me have a little retractor, please. Let’s see if we can find the most distal extent without extending the skin incision. It's going down pretty far, and I think it's probably advantageous for us to just go ahead and extend it a little bit. Okay. Let me have a knife, please. Again, the sural nerve should be inferior anatomically to where we are, and - but we - we do need to be careful of branches here. You can see. Let me have Metzenbaum scissors. Luckily, we haven't encountered any components of the sural nerve yet. That's looking pretty better - that's better. You can see how - how distal this - this stuff extends. And there's the retinaculum again. Is that also where you would expect the vincula or that's more on the surface? The vincula to the... To the tendons? Yeah. You - you would expect to see them. You can see them in here. Not - not - not such a common finding down here. Okay. Let me have some skin hook retractors. So what Arvind’s doing here is he's going to hold back the retinaculum, and what I'm going to do right now is free up some of this tissue. I'm gonna keep my tips down so that I'm not - I’m staying away from the tendon. I do have to be careful that I do not buttonhole the superior peroneal retinaculum. But I am staying right on it, and I'm trying to remove as much of this inflammatory tissue as I can. Again, being very careful not to buttonhole. I'm going to turn my scissors over there. I don't want a buttonhole that, and I'm in a safe place in terms of the tendon. You can see here, there are some - there’s a little bit of blood supply here. We're gonna buzz that with the electrocautery, so that she doesn't develop any hematoma within the sheath at the conclusion of the case. And that's pretty clear. That's the end. You can see here, it's very much cleared up now, and this is pretty much the end of what we’re seeing. And we're taking this off of the peroneus longus here. And a lot of this may indeed be attached to the peroneus brevis as well, so we're gonna try and do this as much en bloc as possible. You can see there now - now the peroneus brevis looks to be pretty clear of it. I'm going to just elevate it, and that's pretty good. You can see now, there's still some attachments here to the - the peroneus brevis muscle belly as well as the peroneus brevis tendon, so we're gonna work on that. Gonna have Arvind just reflect this posteriorly so that we can go ahead and work on the peroneus brevis. And there you go. You get a good view of - this is a very effaced tendon. It's very flattened, which is not uncommon, and - but this is a - is a pretty distal extension of this peroneus brevis muscle belly. And again - and may, in her, represent a mass-occupying lesion, and so we're just gonna - we're gonna clear it right off the tendon and take it as a single block with that inflammatory tissue. And then - again, so. Greg, can I have you put a hand here? So again, peroneus brevis is now anterior - peroneus longus, posterior. We've got the muscle belly being resected here from - from - from the tendon itself, and this inflammatory tissue still is a little bit adherent to the superior peroneal retinaculum. I've turned my scissors around to - to prevent any buttonholing of the superior peroneal retinaculum. And we got a little bleeder there, and we’ll elect - that is not at all an uncommon effect. That's almost always there. Again, to prevent any postoperative hematoma within the sheath, we’ll electrocauterize that. And it may bleed again as we advance up a little bit, but we can always go back and obtain hemostasis. Can I get a little Kocher, please? So what I'll do is apply a little Kocher clamp on this, and then because we're not going to continue up much farther... Good. And you don't have to take it up too far just - just basically to the terminus of the groove, and once we're there, I'm gonna have Greg and Arvind hold the muscle - the tendon - out of the way. I'm gonna take the electrocautery and cut, and I'm just going to then transect or amputate this muscle belly here. And again in, an effort to obtain and maintain hemostasis because there will be a cut surface of muscle within the sheath, and so minimizing blood within the sheath in postoperative period is good. Take that Greg. I got that. So now you can see, there's the transected face of the low-lying peroneus brevis. Peroneus brev - peroneus longus, peroneus brevis muscle. We still have to deal with the small tear here, and we’ll do that now. Right there. Okay. Do you have a malleable? And I'll take a fresh 15 blade, please. And at this point, you know, all that inflammatory tissue has been cleared off. You can see there's a lot more room in here, so I'm gonna use the backside of this - this forceps as a malleable. This is good. This is good. Alright, and you can see here that the tear is located right here. It's about a third of the distance in the tendon, so - and it's very superficial. I don't think that putting suture in this is gonna be - it's gonna introduce foreign body and - and - it maybe a source of irritant. There is a lot of effacement in this tendon, so I think it's just easier to do a transaction here and cut out the torn section. And that's what we're doing right here. Again this type - this amount of tendon being resected - that - this is - this would be difficult through a 2 - 2.7-mm scope with a rotary shaver - just because this tissue is so tenacious. So it's a lot easier to do this open. And then we’ll complete it here - removal of the - the diseased portion of the tendon.
CHAPTER 4
So now we'll reevaluate the tendons after they’re put back into the groove, and let me have another forceps if you will, Greg. So we'll just come over here. That seems pretty stable to me. We're gonna move the tendons around a little bit to make sure that dynamically they're stable, and they stay in that groove even with - you know, this is with flexion and eversion. You can see it trying to roll out, but I think, you know, there's no frank dislocation. And this is with the sheath completely open, so once we do a repair of the sheath back - back up, it's gonna be even more stable. I - and I don't think we need to do a groove deepening on her. She did not have any preoperative sublex - dislocation, and so I think once we've removed that tissue and the mass from within the sheath, we're gonna be - she's going to feel much better. And she's not gonna certainly not going to be unstable once we do our repair, so there's no - no need to do a groove deepening on this patient. Alright, let's irrigate, please. I'm a take one more check down here to make sure we've got all of that inflammatory tissue gone and got nice clean tendons down there.
CHAPTER 5
So now we're gonna finish the case with a closure. It's gonna be a repair of the superior peroneal retinaculum here, and then we're gonna do a skin closure after that. I've left a little cuff of tissue here off of the fibula to sew to so that we're not selling directly to bone or periosteum and that makes the closure a bit easier. Because she didn't have any prior dislocation preoperatively, we don’t really also have to think about a retinaculum-plasty, right? Yeah, and that - that would be for cases where, at least for my algorithm, in terms of peroneal instability, if - if you do your groove deepening and you still, even with the groove deepening, then have some indication that you're going to have problems maintaining the tendons in the groove then that's when you think about that. Or if it's a revision case where they've already had a groove deepening and some other - some other effort to keep the tendons in an anatomic position has failed, and you need something stronger to reinforce what was done previously. And that's a fairly unusual occurrence. So would you say most people would aproach this open or tendoscopic? I think we are still in the infancy for tendoscopy as a whole. So yeah, you know, I think that not only - at most centers it's just not available, and - and the places where it is - in case it's like this - if you had started out with tendoscopy, I think that there would be certainly good indications to open because of the presence of the tear. You think you would have - if we would have scoped her and saw the tear, do you think you would have opened her? I think that in the end, probably. If - if we had gone ahead and done that, I think that you obviously make an effort to try and resect that diseased portion of tendon, and - and you can do that with some end-biters and - and a manual - endoscopic instruments and then finish up with a rotary shaver. But whether we would have been able to complete it at tendoscopically, that's a - that's a good question. I think this was certainly - this was a good move for her - having it done open. When you reapproximate, is it just anatomic or do you imbricate some - a little bit? You - you can. You can imbricate. It's - I think it’s difficult to create a stenotic condition that’s iatrogenic, but it certainly can be done if you really - you really imbricate too much, you can have it. I've seen it happen, but in - in some of these tissues will - they will shrink postoperatively because she's got a lot less volume within that sheath now than she had preoperatively. And I think you can - you can see that. And I'm just using some figure-of-eight sutures, interrupted sutures, here to close this. I'm using absorbables. Certainly you can - depending on the situation, you can use non-absorbable sutures, but I don't think it's necessary in every case. Another thing to think about - this is - she's - she’s very thin, and - and her skin is - she's got thin skin. She's fair-skinned, and so, you know, you would - some of these sutures are green or blue in color. And you go right underneath the skin, and even if there's - even if there's no mechanical irritation from the suture, you can sometimes see the suture through the skin. And - and again, she's got so much more room now, and I - I - she doesn't - she's not gonna have any healing problems. And I don't think we need to really reinforce the repair with nonabsorbable sutures. She's going to do great with just with these monocryls. Another thing to just be careful of - it’s obvious - but you need to make sure that you're not - you're not sewing the tendons into the sheath. It goes without saying, but always something to keep in mind. One of the things that we've - I don't know. There's not much in the literature regarding it - only a paper or two talking about this low-lying peroneus brevis. It's a - it - you can imagine, you know, you're - you're adding another lane of traffic, if you will, in the tunnel, and that - that creates stenosis. So you know and that - that will create increased pressure on each of the tendons, and you know, the peroneus brevis has already got a lot of pressure exerted on it by the longus. And so you add a muscle belly down in there, and you've - you know, you've created - you’ve created additional - additional problems. And so again we'll - we’ll test her now, and this would be the risk - risk position - high-risk position for dislocation, dorsiflexion, and eversion. And she's - she's good. So really the biggest concerns when you do this procedure is - is not to disrupt the retinaculum when you do the approach or when you repair the part - appropriately, so you don't cause any iatrogenic subluxation or dislocation? Yeah. She's quite good. Yeah.
CHAPTER 6
So this is - could be pretty mundane, but I - I really consider this a big important part of each of the surgeries for foot and ankle orthopedics, and it’s basically construction of a splint. Some of my trainees will say that this is - my hang up. The splint has to be done well and done uniformly each time. So I basically take 6 inch Webril, make a very healthy posterior padding. And then I use a 6 inch and two - two 4 inches - actually two 6 inches, we’ll use. And they're the same - the same length as this. It’s just wrapped end-over-end. So that's going to be the back slab, and then there’s gonna be two side gussets - each of the same length and also wrapped end-over-end. And then the second side gusset right here. Again, same length - wrapped end-over-end. That's okay. I'll be happy to - to mop or sweep or whatever. And then in addition to that, on the outside we use a 6-inch Ace bandage and a 4-inch Ace bandage - and of course, use some 4-inch Webril to hold it in place right here. Okay, so this is the posterior padding that's going to go on. And Arvind, the most important part of this whole process is the - is the holder. If you don't have a good holder, the splint can't - can't go on that well, so... You can see his - his right hand is over the top of the right arm is over the top of the knee, and his left is holding the foot in pos - foot and ankle in position. I'm just cutting some notches here so that we don't get any dog ears in the - in the padding, and then I'm gonna form fit the padding with some Webril here. That's good. Yep, okay. And then another one in the foot just to make sure we've got everything well conforming to her foot and well-padded. Nice. No, that's enough. Yeah, that's enough. So next thing we do is use some 6 inch. And this is called delamination. We don't want any - we want to make it all uniform, and all the plaster layers to be sticking together. So I'm sort of squeegeeing out the the water, pressing the - the plaster together. And again, Arvind's key here. You're holding it. And then I'm going to make sure that it adheres to the underlying padding, so that it’s completely custom fit to her leg. And then the side gussets are gonna go on. We’re going to do the same thing - make sure that these are - there's no lamina present. There's no - no layers. Make everything a single layer here - and again, just making sure it's perfectly conformed to her anatomy. And then the last side gusset on the lateral side. And then the next thing we do is put on the Ace bandages. Start above the level of the - of the splint, so you can tuck it in at the end. And work your way down. 4 inch goes first, followed by the 6 inch. Around the heel. Slightly over the toes. Go ahead. Come on up on top again. 3, yeah - yeah, please. You can put them on. It’s taped off right on the bottom. One more up there. And then - and then it's put right on your sternum. Putting it on your sternum makes it flat. There's no rocker bottom to it. If you put it in your abdomen, it will press in and become curved, and you don't want that. You want to give them a nice flat foot plate. Yeah please, and what I'll do is just tuck this in right here. And then just pop this so that they don't get too tight if there's an postoperative swelling. And we'll do the same down here after the splint has set completely. Now you just wait until it hardens. No, no, please. Yeah. Last step is we just free up the toes here. Pop it right here so that she’s got enough room. That’s it.