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Incidence of Talar Dome Lesions with Concomitant Peroneal Tendon Pathologic Features: A Magnetic Resonance Imaging Evaluation
The Journal of Foot & Ankle Surgery 51 (2012) 579–582
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Incidence of Talar Dome Lesions with Concomitant Peroneal Tendon Pathologic Features: A Magnetic Resonance Imaging Evaluation Peter M. Stasko, DPM 1, C. Keith McSpadden, DPM 1, Rachel Jung, DPM 1, Robert W. Mendicino, DPM, FACFAS 2, Alan R. Catanzariti, DPM, FACFAS 3 1 2 3
Resident, Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, Pittsburgh, PA Chief, Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, Pittsburgh, PA Director of Residency Program, Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, Pittsburgh, PA
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4 Keywords: ankle osteochondral lesion peroneal pathology surgery talus
Few studies have evaluated the incidence of talar dome lesions and injuries to the peroneal tendons occurring concomitantly. The purpose of our research was to evaluate the incidence of osteochondral lesions of the talus (OLT) with peroneal tendon pathologic features according to the magnetic resonance imaging (MRI) findings. A database search was conducted in the Department of Radiology at the Western Pennsylvania Hospital and Forbes Regional Campus for all MRI examinations ordered by attending physicians of the Department of Foot and Ankle Surgery from 2008 to 2010. A total of 810 MRI reports were reviewed, of which 198 contained a diagnosis of peroneal tendon pathologic features (e.g., tenosynovitis, split tears) or OLT (i.e., chondral, osteochondral, subchondral edema, cystic changes), or both. MRI scans were then reviewed to confirm the report findings and findings not identified in the report. A total of 76 patients were identified as having an OLT. Of these 76 patients, 49 had associated peroneal tendon pathologic features. MRI evaluation revealed that 49 (65.3%) of the 76 patients with a talar dome lesion had concomitant peroneal pathologic features. Talar dome lesions with concomitant tears/tendinopathy of the peroneus brevis were associated in 14.6%. The incidence of an OLT with tears/tenosynovitis of the peroneus longus was 10.6%, because tears/tendinopathy of both peroneal tendons was present in 18.6%. Tenosynovitis of the brevis and longus were seen in 21.3% of those with an OLT. Our findings suggest the need for an increased level of suspicion for injuries to the lateral ankle ligaments, peroneal tendon complex, and ankle joint when evaluating a patient with ankle instability and chronic pain. Ó 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.
Inversion injuries of the ankle are a major cause of pain and disability. The mechanism of injury can result in a variety of injuries, including ankle fracture/dislocations, ankle sprains, peroneal tendon tears, intra-articular ankle pathologic features, such as osteochondral lesions of the talus (OLT), and fractures of the foot. Lateral OLTs occur with inversion on a dorsiflexed ankle. The wider anterior talar dome translates posteriorly, causing the talar dome to be compressed into the ankle mortise. As the inversion force occurs, the lateral portion of the talar dome is then compressed against the fibula, producing a lateral OLT. Berndt and Harty (1) described
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Robert W. Mendicino, DPM, FACFAS, Chief, Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, 4800 Friendship Avenue, N1, Pittsburgh, PA 15224. E-mail address: [email protected] (R.W. Mendicino).
a rotational or torsional impaction force on an inverted and plantarflexed ankle as the principal mechanism in creating a medial OLT. Torsional impaction is the external rotation of the tibia on the talus that causes the posterior margin of the tibia to produce a compression lesion on talar dome as it is displaced further medially. Few studies have evaluated the incidence of talar dome lesions and injuries to the peroneal tendons occurring concomitantly. DiGiovanni et al (2) evaluated associated injuries found in chronic lateral ankle instability and reported that peroneal tendon pathologic features occurred in up to 77% of patients. That study also found the incidence of intra-articular loose bodies and talar dome lesions to be 26% and 23%, respectively. However, that study did not correlate the presence of an OLT and peroneal tendon pathologic features occurring concomitantly. Bare and Ferkel (3) evaluated intra-articular pathologic findings associated with peroneal tendon tears. They found that all patients with peroneal tendon tears had intra-articular pathologic features, with most of their patients having more than 1 intra-articular
1067-2516/$ - see front matter Ó 2012 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2012.06.010
580
P.M. Stasko et al. / The Journal of Foot & Ankle Surgery 51 (2012) 579–582
Fig. 1. Medial talar dome lesion with a split tear of the peroneus longus tendon.
lesion. Komenda and Ferkel (4) found the incidence of OLTs to be 16.3% in an arthroscopic evaluation of chronic ankle instability. Peroneal pathologic findings were not evaluated in their study. The purpose of our research was to evaluate the incidence of OLTs with peroneal tendon pathologic features according to the magnetic resonance imaging (MRI) findings. We anticipated that a talar dome lesion would have concomitant peroneal tendon pathologic features 20% or more of the time. Patients and Methods A database search was conducted in the Department of Radiology at the Western Pennsylvania Hospital and Forbes Regional Campus for all MRI examinations ordered by attending physicians of the Department of Foot and Ankle Surgery from 2008 to 2010. A total of 810 MRI reports were reviewed, of which 198 contained a diagnosis of peroneal tendon pathologic features (e.g., tenosynovitis, split tears) or OLT (e.g., chondral, osteochondral, subchondral edema, cystic changes), or both. The MRI images were then reviewed to confirm the reported findings and to search for OLT or peroneal tendon pathologic findings not identified in the report. Any equivocal findings were agreed on by all of us before inclusion. The exclusion criteria include avascular necrosis of talus, an infectious process, and any previous surgery involving the talus or peroneal tendons.
these patients, 49 (65.3%) had associated peroneal tendon pathologic features. The pathologic findings within the peroneal tendons included full/partial tears, tenosynovitis, and tendinosis. OLTs, including osteochondritis dissecans, cystic changes, chondral and subchondral edema, and chondral fractures were noted on MRI. The location of the lesions varied and depended on the specific peroneal pathologic features. Talar dome lesions with concomitant tears/tendinopathy of the peroneus brevis were associated 14.6% of the time (Figs. 1 and 2). The incidence of an OLT with tears/tenosynovitis of the peroneus longus was 10.6%, and tears/tendinopathy of both peroneal tendons were present 18.6% of the time. Tenosynovitis of the brevis and the longus were seen 21.3% of the time with an OLT. The 2 pathologic entities occurring together at 65.3% indicate that when an OLT is present, approximately two thirds of these patients will have associated peroneal tendon pathologic features. Our results also show that when 1 of these pathologic entities is suspected, the likelihood is high that the other pathologic entity could be contributing to the symptoms. These MRI findings prove that when an OLT is present and/ or suspected, the lateral soft tissues and, more specifically, the peroneal tendons, should be properly evaluated with physical examination and advanced imaging (Table 1).
Results Discussion A total of 198 MRI scans were evaluated for an OLT and/or peroneal tendon pathologic features. The MRI reports were read and the images evaluated by us. A total of 76 patients were found to have an OLT. Of
Our MRI findings have shown that when an OLT is present, 65.3% of the time peroneal pathologic features will also be present. Full and
Fig. 2. Lateral talar dome lesion with a split tear of the peroneus brevis tendon.
P.M. Stasko et al. / The Journal of Foot & Ankle Surgery 51 (2012) 579–582
Table 1 MRI findings associating talar dome lesions and peroneus brevis tears, peroneus longus tears, tendinosis, and tenosynovitis (N ¼ 198) Finding
%
Total peroneal pathologic findings Peroneus brevis and longus tear/tendinosis Peroneus brevis tear/tendinosis Peroneus longus tear/tendinosis Peroneus brevis and peroneus longus tenosynovitis
65.30 18.60 14.60 10.60 21.30
Abbreviation: MRI, magnetic resonance imaging.
partial-thickness tears of the peroneus brevis and longus tendons and tendinosis and tenosynovitis were noted on MRI evaluation. Acute and chronic changes to both the peroneal tendons and the talar dome were observed. Osteochondral defects, cystic changes, free floating fragments, and erosions were identified within the talar dome. Various studies have stressed the relationship between chronic lateral ankle instability (5) with other pathologic features, including those of the peroneal tendon and intra-articular abnormalities of the ankle (Table 2). One study demonstrated that surgical management of the unstable ankle, which was found to have a good outcome, was not sufficient to eliminate symptoms in up to 35% of patients (6). Failure to recognize concomitant pathologic features might have contributed to these persistent symptoms. DiGiovanni et al (3) studied 61 patients who underwent lateral ankle stabilization with open inspection of the peroneal tendon complex and open arthrotomy of the ankle joint. They found that none of the 61 patients had isolated lateral ankle instability. The peroneal tendon findings included tenosynovitis (77%), attenuated retinaculum (54%), and peroneus brevis tear (25%). The articular pathologic entities included anterolateral impingement (67%), ankle synovitis (49%), loose bodies (26%), and OLT (23%). Furthermore, they evaluated the correlation of their preoperative examination and MRI findings to the intraoperative findings. They found that clinically suspected peroneal tenosynovitis was confirmed by direct visualization in 94% and peroneal instability or dislocation suspected from the clinical examination findings was confirmed through direct inspection at surgery in 89% of patients. MRI identified 75% of chondral flaps found during surgery, and total OLTs were diagnosed correctly in 79% of cases. Peroneus brevis tears were correctly identified by MRI in 80% with no false-positive results.
581
Bonnin et al (7) surgically evaluated peroneus brevis tears in patients with chronic lateral ankle instability, noting the occurrence in 18 (23%) of 77 patients. Frey et al (6) Reported a slightly greater percentage of peroneal pathologic features in those with acute sprains (27%) with no OLT identified from the MRI findings in 15 cases. Cardone et al (8) found peroneus brevis and longus pathologic features in 44% and osteochondral lesions in 7% in a review of MRI findings of chronic lateral ankle instability. Komenda and Ferkel (4) performed an arthroscopic examination before lateral ankle stabilization and found that 93% of the ankles had intra-articular abnormalities. The incidence of OLTs was 16.3%. In a separate study, Ferkel and Chams (9) found a 95% occurrence rate of intra-articular pathologic features in an arthroscopic examination of 21 patients with lateral ankle instability. The incidence of OLTs was 20%. Taga et al (10) performed an arthroscopic evaluation in 31 patients with lateral ankle ligament injury, 9 with acute injury, and 22 with chronic injury. They found chondral lesions in 89% of those with acute injuries and 95% of those with chronic injuries. Kibler (11) arthroscopically evaluated 46 patients before lateral ankle stabilization and found that 83% of their patients had significant intra-articular findings. They noted that of the 38 cases of significant intra-articular pathologic features, 10 (26%) had not been suspected before arthroscopy. Schimmer et al (12) evaluated the role of arthroscopy as a diagnostic tool for creating a treatment plan for OLT. They found that in patients with an established diagnosis of an OLT, the occurrence of concomitant isolated anterior talofibular ligament tears was 41.7% and the occurrence of combined anterior talofibular ligament and calcaneofibular ligament tears was 22%. The investigators advocated the use of arthroscopy to help determine the stability and integrity of the cartilage, which is sometimes difficult to ascertain using MRI. Ogilvie-Harris et al (13) arthroscopically evaluated 100 patients with chronic pain after a major acute ankle sprain. Of the 27 patients primarily diagnosed with lateral ankle instability, 18 (66.7%) were found to have a significant chondral fracture. They reported that arthroscopy was the only method that could effectively detect chondral lesions but that OLTs were readily seen on computed tomography, bone scan, and MRI. Loren and Ferkel (14) arthroscopically evaluated 48 patients with acute unstable ankle fractures before open reduction internal fixation.
Table 2 Review of published data on lateral ankle instability and associated injuries Study
Articular Pathologic Finding
%
Peroneal Pathologic Finding
%
Source
Anterolateral impingement Synovitis Loose bodies OCD talus
67 49 26 23 (18)
Tenosynovitis Attenuated retinaculum Peroneus brevis tear
77 54 (12) 25 (20)
Open surgery (MRI)
Total pathologic findings OCD talus
93 16.3
d d
d d
Arthroscopy
Total pathologic findings OCD talus
95 20
d d
d d
Arthroscopy
Total pathologic findings
83
d
d
Arthroscopy
Chondral lesion (tibia þ talus)
Acute, 89 Chronic, 95
d
d
Arthroscopy
OCD talus d d
0 d 7
Peroneus brevis tear Peroneus brevis tear Peroneus brevis and peroneus longus tear
27 23 44
MRI Open surgery MRI
DiGiovanni et al (3) (n ¼ 61)
Komenda and Ferkel (4) (n ¼ 55)
Ferkel and Chams (9) (n ¼ 21)
Kibler (11) (n ¼ 46) Taga et al (10) (n ¼ 31)
Frey et al (6) (n ¼ 15) Bonnin et al (7) (n ¼ 77) Cardone et al (8) (n ¼ 43)
Abbreviations: MRI, magnetic resonance imaging; OCD, osteochondritis dissecans.
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P.M. Stasko et al. / The Journal of Foot & Ankle Surgery 51 (2012) 579–582
They found 40% of these patients to have a chondral or osteochondral lesion greater than 5 mm on the talus (14). Also, 23% of the patients had a lesion noted on the articular surface of the tibia. Free fragments were found in 27% of patients. Loren and Ferkel (14) noted articular lesions occurred most frequently in fracture patterns that disrupted the syndesmosis. Their results reinforce the finding that increased frontal plane motion of the talus, whether chronic or acute, subjects the talar dome to increased stress and the likelihood of injury. The identification of all the pathologic features contributing to symptoms in a patient with chronic ankle pain can be challenging. The history and physical examination, stress radiographs, MRI, computed tomography, and arthroscopy are important to help establish an accurate diagnosis. In the study by DiGiovanni et al (3), the physical examination identified 94% of patients with peroneal tenosynovitis and 89% of patients with peroneal instability that were confirmed intraoperatively. In the study by Bonnin et al (7), 15 (83%) of 18 patients with peroneus brevis tears had retromalleolar pain with palpation on the clinical examination. The investigators concluded that clinical examination is most important when investigating peroneal tears; however, MRI can be helpful to determine the extent of lateral ankle injury and planning for a modified surgical approach to address the various pathologic features that require surgical intervention. MRI has proved to be a dependable modality for identifying peroneal pathologic features and OLTs (1). In the study by DiGiovanni et al (3), MRI identified 75% of chondral flaps found during surgery, with total osteochondral lesions diagnosed correctly using MRI in 79% of cases and peroneus brevis tears correctly identified by MRI in 80% with no false-positive results. However, Ogilvie-Harris et al (13) reported that in the case of chondral lesions alone, arthroscopy was the only effective modality for establishing the diagnosis. In a retrospective study comparing MRI and surgical correlation of peroneus brevis tears, the MRI diagnosis of peroneus brevis tendon tears showed 83% sensitivity and 75% specificity with the intraoperative findings (15). That study showed that peroneus brevis tears rarely present as isolated injuries and support the need for a comprehensive preoperative clinical evaluation and MRI assessment of the entire lateral ankle complex.
Our study was limited by several factors, including the strict use of retrospective MRI findings. Patient symptoms, arthroscopic evaluation, or other diagnostic modalities were not used. Because of these limitations, our study could only show incidental findings. These findings highlight the importance of a comprehensive evaluation of the ankle when symptoms are present. Also, the study did not include patient outcomes regarding the treatment rendered.
References 1. Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. JBJS 41-A:988–1363, 1959. 2. DiGiovanni BF, Fraga CJ, Cohen BE, Shereff MJ. Associated injuries found in chronic lateral instability. Foot Ankle Int 21:809–815, 2000. 3. Bare A, Ferkel RD. Peroneal tendon tears: associated arthroscopic findings and results after repair. Arthroscopy 25:1288–1297, 2009. 4. Komenda GA, Ferkel RD. Arthroscopic findings associated with unstable ankle. Foot Ankle Int 20:708–713, 1999. 5. Alparslan L, Chiodo CP. Lateral ankle instability: MR imaging of associated injuries and surgical treatment procedures. Semin Musculoskel Radiol 12:346– 358, 2008. 6. Frey C, Bell J, Teresi L, Kerr R, Feder K. Comparison of MRI and clinical examination of acute lateral ankle sprains. Foot Ankle 17:533–537, 1996. 7. Bonnin M, Tavernier T, Bouysset M. Split lesions of the peroneus brevis tendon in chronic ankle laxity. Am J Sports Med 25:699–703, 1997. 8. Cardone BW, Erickson SJ, Den Hartog BD, Carrera GF. MRI of injury to lateral collateral ligamentous complex of the ankle. J Comput Assist Tomogr 17:102– 107, 1993. 9. Ferkel RD, Chams RN. Chronic lateral instability: arthroscopic findings and longterm results. Foot Ankle Int 28:24–31, 2007. 10. Taga I, Shino K, Inoue M, Nakata K, Maeda A. Articular cartilage lesions in ankles with lateral ligament injury: an arthroscopic study. Am J Sports Med 21:120–127, 1993. 11. Kibler WB. Arthroscopic findings in ankle ligament reconstruction. Clin Sports Med 15:799–804, 1996. 12. Schimmer RC, Dick W, Hintermann B. The role of ankle arthroscopy in the treatment strategies of osteochondritis dissecans lesions of the talus. Foot Ankle Int 22:895–900, 2001. 13. Ogilvie-Harris DJ, Gilbart MK, Chorney K. Chronic pain following ankle sprains in athletes: the role of arthroscopic surgery. Arthroscopy 13:564–574, 1997. 14. Loren GL, Ferkel RD. Arthroscopic assessment of occult intra-articular injury in acute ankle fractures. Arthroscopy 18:412–421, 2002. 15. Lamm BM, Myers DT, Dombek M, Mendicino RW, Catanzariti AR, Saltrick K. Magnetic resonance imaging and surgical correlation of peroneus brevis tears. J Foot Ankle Surg 43:30–36, 2004.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Incidence of Talar Dome Lesions with Concomitant Peroneal Tendon Pathologic Features: A Magnetic Resonance Imaging Evaluation Peter M. Stasko, DPM 1, C. Keith McSpadden, DPM 1, Rachel Jung, DPM 1, Robert W. Mendicino, DPM, FACFAS 2, Alan R. Catanzariti, DPM, FACFAS 3 1 2 3
Resident, Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, Pittsburgh, PA Chief, Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, Pittsburgh, PA Director of Residency Program, Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, Pittsburgh, PA
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4 Keywords: ankle osteochondral lesion peroneal pathology surgery talus
Few studies have evaluated the incidence of talar dome lesions and injuries to the peroneal tendons occurring concomitantly. The purpose of our research was to evaluate the incidence of osteochondral lesions of the talus (OLT) with peroneal tendon pathologic features according to the magnetic resonance imaging (MRI) findings. A database search was conducted in the Department of Radiology at the Western Pennsylvania Hospital and Forbes Regional Campus for all MRI examinations ordered by attending physicians of the Department of Foot and Ankle Surgery from 2008 to 2010. A total of 810 MRI reports were reviewed, of which 198 contained a diagnosis of peroneal tendon pathologic features (e.g., tenosynovitis, split tears) or OLT (i.e., chondral, osteochondral, subchondral edema, cystic changes), or both. MRI scans were then reviewed to confirm the report findings and findings not identified in the report. A total of 76 patients were identified as having an OLT. Of these 76 patients, 49 had associated peroneal tendon pathologic features. MRI evaluation revealed that 49 (65.3%) of the 76 patients with a talar dome lesion had concomitant peroneal pathologic features. Talar dome lesions with concomitant tears/tendinopathy of the peroneus brevis were associated in 14.6%. The incidence of an OLT with tears/tenosynovitis of the peroneus longus was 10.6%, because tears/tendinopathy of both peroneal tendons was present in 18.6%. Tenosynovitis of the brevis and longus were seen in 21.3% of those with an OLT. Our findings suggest the need for an increased level of suspicion for injuries to the lateral ankle ligaments, peroneal tendon complex, and ankle joint when evaluating a patient with ankle instability and chronic pain. Ó 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.
Inversion injuries of the ankle are a major cause of pain and disability. The mechanism of injury can result in a variety of injuries, including ankle fracture/dislocations, ankle sprains, peroneal tendon tears, intra-articular ankle pathologic features, such as osteochondral lesions of the talus (OLT), and fractures of the foot. Lateral OLTs occur with inversion on a dorsiflexed ankle. The wider anterior talar dome translates posteriorly, causing the talar dome to be compressed into the ankle mortise. As the inversion force occurs, the lateral portion of the talar dome is then compressed against the fibula, producing a lateral OLT. Berndt and Harty (1) described
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Robert W. Mendicino, DPM, FACFAS, Chief, Division of Foot and Ankle Surgery, Western Pennsylvania Hospital, 4800 Friendship Avenue, N1, Pittsburgh, PA 15224. E-mail address: [email protected] (R.W. Mendicino).
a rotational or torsional impaction force on an inverted and plantarflexed ankle as the principal mechanism in creating a medial OLT. Torsional impaction is the external rotation of the tibia on the talus that causes the posterior margin of the tibia to produce a compression lesion on talar dome as it is displaced further medially. Few studies have evaluated the incidence of talar dome lesions and injuries to the peroneal tendons occurring concomitantly. DiGiovanni et al (2) evaluated associated injuries found in chronic lateral ankle instability and reported that peroneal tendon pathologic features occurred in up to 77% of patients. That study also found the incidence of intra-articular loose bodies and talar dome lesions to be 26% and 23%, respectively. However, that study did not correlate the presence of an OLT and peroneal tendon pathologic features occurring concomitantly. Bare and Ferkel (3) evaluated intra-articular pathologic findings associated with peroneal tendon tears. They found that all patients with peroneal tendon tears had intra-articular pathologic features, with most of their patients having more than 1 intra-articular
1067-2516/$ - see front matter Ó 2012 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2012.06.010
580
P.M. Stasko et al. / The Journal of Foot & Ankle Surgery 51 (2012) 579–582
Fig. 1. Medial talar dome lesion with a split tear of the peroneus longus tendon.
lesion. Komenda and Ferkel (4) found the incidence of OLTs to be 16.3% in an arthroscopic evaluation of chronic ankle instability. Peroneal pathologic findings were not evaluated in their study. The purpose of our research was to evaluate the incidence of OLTs with peroneal tendon pathologic features according to the magnetic resonance imaging (MRI) findings. We anticipated that a talar dome lesion would have concomitant peroneal tendon pathologic features 20% or more of the time. Patients and Methods A database search was conducted in the Department of Radiology at the Western Pennsylvania Hospital and Forbes Regional Campus for all MRI examinations ordered by attending physicians of the Department of Foot and Ankle Surgery from 2008 to 2010. A total of 810 MRI reports were reviewed, of which 198 contained a diagnosis of peroneal tendon pathologic features (e.g., tenosynovitis, split tears) or OLT (e.g., chondral, osteochondral, subchondral edema, cystic changes), or both. The MRI images were then reviewed to confirm the reported findings and to search for OLT or peroneal tendon pathologic findings not identified in the report. Any equivocal findings were agreed on by all of us before inclusion. The exclusion criteria include avascular necrosis of talus, an infectious process, and any previous surgery involving the talus or peroneal tendons.
these patients, 49 (65.3%) had associated peroneal tendon pathologic features. The pathologic findings within the peroneal tendons included full/partial tears, tenosynovitis, and tendinosis. OLTs, including osteochondritis dissecans, cystic changes, chondral and subchondral edema, and chondral fractures were noted on MRI. The location of the lesions varied and depended on the specific peroneal pathologic features. Talar dome lesions with concomitant tears/tendinopathy of the peroneus brevis were associated 14.6% of the time (Figs. 1 and 2). The incidence of an OLT with tears/tenosynovitis of the peroneus longus was 10.6%, and tears/tendinopathy of both peroneal tendons were present 18.6% of the time. Tenosynovitis of the brevis and the longus were seen 21.3% of the time with an OLT. The 2 pathologic entities occurring together at 65.3% indicate that when an OLT is present, approximately two thirds of these patients will have associated peroneal tendon pathologic features. Our results also show that when 1 of these pathologic entities is suspected, the likelihood is high that the other pathologic entity could be contributing to the symptoms. These MRI findings prove that when an OLT is present and/ or suspected, the lateral soft tissues and, more specifically, the peroneal tendons, should be properly evaluated with physical examination and advanced imaging (Table 1).
Results Discussion A total of 198 MRI scans were evaluated for an OLT and/or peroneal tendon pathologic features. The MRI reports were read and the images evaluated by us. A total of 76 patients were found to have an OLT. Of
Our MRI findings have shown that when an OLT is present, 65.3% of the time peroneal pathologic features will also be present. Full and
Fig. 2. Lateral talar dome lesion with a split tear of the peroneus brevis tendon.
P.M. Stasko et al. / The Journal of Foot & Ankle Surgery 51 (2012) 579–582
Table 1 MRI findings associating talar dome lesions and peroneus brevis tears, peroneus longus tears, tendinosis, and tenosynovitis (N ¼ 198) Finding
%
Total peroneal pathologic findings Peroneus brevis and longus tear/tendinosis Peroneus brevis tear/tendinosis Peroneus longus tear/tendinosis Peroneus brevis and peroneus longus tenosynovitis
65.30 18.60 14.60 10.60 21.30
Abbreviation: MRI, magnetic resonance imaging.
partial-thickness tears of the peroneus brevis and longus tendons and tendinosis and tenosynovitis were noted on MRI evaluation. Acute and chronic changes to both the peroneal tendons and the talar dome were observed. Osteochondral defects, cystic changes, free floating fragments, and erosions were identified within the talar dome. Various studies have stressed the relationship between chronic lateral ankle instability (5) with other pathologic features, including those of the peroneal tendon and intra-articular abnormalities of the ankle (Table 2). One study demonstrated that surgical management of the unstable ankle, which was found to have a good outcome, was not sufficient to eliminate symptoms in up to 35% of patients (6). Failure to recognize concomitant pathologic features might have contributed to these persistent symptoms. DiGiovanni et al (3) studied 61 patients who underwent lateral ankle stabilization with open inspection of the peroneal tendon complex and open arthrotomy of the ankle joint. They found that none of the 61 patients had isolated lateral ankle instability. The peroneal tendon findings included tenosynovitis (77%), attenuated retinaculum (54%), and peroneus brevis tear (25%). The articular pathologic entities included anterolateral impingement (67%), ankle synovitis (49%), loose bodies (26%), and OLT (23%). Furthermore, they evaluated the correlation of their preoperative examination and MRI findings to the intraoperative findings. They found that clinically suspected peroneal tenosynovitis was confirmed by direct visualization in 94% and peroneal instability or dislocation suspected from the clinical examination findings was confirmed through direct inspection at surgery in 89% of patients. MRI identified 75% of chondral flaps found during surgery, and total OLTs were diagnosed correctly in 79% of cases. Peroneus brevis tears were correctly identified by MRI in 80% with no false-positive results.
581
Bonnin et al (7) surgically evaluated peroneus brevis tears in patients with chronic lateral ankle instability, noting the occurrence in 18 (23%) of 77 patients. Frey et al (6) Reported a slightly greater percentage of peroneal pathologic features in those with acute sprains (27%) with no OLT identified from the MRI findings in 15 cases. Cardone et al (8) found peroneus brevis and longus pathologic features in 44% and osteochondral lesions in 7% in a review of MRI findings of chronic lateral ankle instability. Komenda and Ferkel (4) performed an arthroscopic examination before lateral ankle stabilization and found that 93% of the ankles had intra-articular abnormalities. The incidence of OLTs was 16.3%. In a separate study, Ferkel and Chams (9) found a 95% occurrence rate of intra-articular pathologic features in an arthroscopic examination of 21 patients with lateral ankle instability. The incidence of OLTs was 20%. Taga et al (10) performed an arthroscopic evaluation in 31 patients with lateral ankle ligament injury, 9 with acute injury, and 22 with chronic injury. They found chondral lesions in 89% of those with acute injuries and 95% of those with chronic injuries. Kibler (11) arthroscopically evaluated 46 patients before lateral ankle stabilization and found that 83% of their patients had significant intra-articular findings. They noted that of the 38 cases of significant intra-articular pathologic features, 10 (26%) had not been suspected before arthroscopy. Schimmer et al (12) evaluated the role of arthroscopy as a diagnostic tool for creating a treatment plan for OLT. They found that in patients with an established diagnosis of an OLT, the occurrence of concomitant isolated anterior talofibular ligament tears was 41.7% and the occurrence of combined anterior talofibular ligament and calcaneofibular ligament tears was 22%. The investigators advocated the use of arthroscopy to help determine the stability and integrity of the cartilage, which is sometimes difficult to ascertain using MRI. Ogilvie-Harris et al (13) arthroscopically evaluated 100 patients with chronic pain after a major acute ankle sprain. Of the 27 patients primarily diagnosed with lateral ankle instability, 18 (66.7%) were found to have a significant chondral fracture. They reported that arthroscopy was the only method that could effectively detect chondral lesions but that OLTs were readily seen on computed tomography, bone scan, and MRI. Loren and Ferkel (14) arthroscopically evaluated 48 patients with acute unstable ankle fractures before open reduction internal fixation.
Table 2 Review of published data on lateral ankle instability and associated injuries Study
Articular Pathologic Finding
%
Peroneal Pathologic Finding
%
Source
Anterolateral impingement Synovitis Loose bodies OCD talus
67 49 26 23 (18)
Tenosynovitis Attenuated retinaculum Peroneus brevis tear
77 54 (12) 25 (20)
Open surgery (MRI)
Total pathologic findings OCD talus
93 16.3
d d
d d
Arthroscopy
Total pathologic findings OCD talus
95 20
d d
d d
Arthroscopy
Total pathologic findings
83
d
d
Arthroscopy
Chondral lesion (tibia þ talus)
Acute, 89 Chronic, 95
d
d
Arthroscopy
OCD talus d d
0 d 7
Peroneus brevis tear Peroneus brevis tear Peroneus brevis and peroneus longus tear
27 23 44
MRI Open surgery MRI
DiGiovanni et al (3) (n ¼ 61)
Komenda and Ferkel (4) (n ¼ 55)
Ferkel and Chams (9) (n ¼ 21)
Kibler (11) (n ¼ 46) Taga et al (10) (n ¼ 31)
Frey et al (6) (n ¼ 15) Bonnin et al (7) (n ¼ 77) Cardone et al (8) (n ¼ 43)
Abbreviations: MRI, magnetic resonance imaging; OCD, osteochondritis dissecans.
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They found 40% of these patients to have a chondral or osteochondral lesion greater than 5 mm on the talus (14). Also, 23% of the patients had a lesion noted on the articular surface of the tibia. Free fragments were found in 27% of patients. Loren and Ferkel (14) noted articular lesions occurred most frequently in fracture patterns that disrupted the syndesmosis. Their results reinforce the finding that increased frontal plane motion of the talus, whether chronic or acute, subjects the talar dome to increased stress and the likelihood of injury. The identification of all the pathologic features contributing to symptoms in a patient with chronic ankle pain can be challenging. The history and physical examination, stress radiographs, MRI, computed tomography, and arthroscopy are important to help establish an accurate diagnosis. In the study by DiGiovanni et al (3), the physical examination identified 94% of patients with peroneal tenosynovitis and 89% of patients with peroneal instability that were confirmed intraoperatively. In the study by Bonnin et al (7), 15 (83%) of 18 patients with peroneus brevis tears had retromalleolar pain with palpation on the clinical examination. The investigators concluded that clinical examination is most important when investigating peroneal tears; however, MRI can be helpful to determine the extent of lateral ankle injury and planning for a modified surgical approach to address the various pathologic features that require surgical intervention. MRI has proved to be a dependable modality for identifying peroneal pathologic features and OLTs (1). In the study by DiGiovanni et al (3), MRI identified 75% of chondral flaps found during surgery, with total osteochondral lesions diagnosed correctly using MRI in 79% of cases and peroneus brevis tears correctly identified by MRI in 80% with no false-positive results. However, Ogilvie-Harris et al (13) reported that in the case of chondral lesions alone, arthroscopy was the only effective modality for establishing the diagnosis. In a retrospective study comparing MRI and surgical correlation of peroneus brevis tears, the MRI diagnosis of peroneus brevis tendon tears showed 83% sensitivity and 75% specificity with the intraoperative findings (15). That study showed that peroneus brevis tears rarely present as isolated injuries and support the need for a comprehensive preoperative clinical evaluation and MRI assessment of the entire lateral ankle complex.
Our study was limited by several factors, including the strict use of retrospective MRI findings. Patient symptoms, arthroscopic evaluation, or other diagnostic modalities were not used. Because of these limitations, our study could only show incidental findings. These findings highlight the importance of a comprehensive evaluation of the ankle when symptoms are present. Also, the study did not include patient outcomes regarding the treatment rendered.
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