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Tendoscopy of the Peroneal Tendons
Foot Ankle Clin N Am 11 (2006) 415 – 420
Tendoscopy of the Peroneal Tendons Peter E. Scholten, MDa,T, C. Niek van Dijk, MD, PhDb a
Kliniek Klein Rosendael, Department of Orthopaedic Surgery, Rosendaalselaan 30, 6891 DG Rozendaal, The Netherlands b Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
Post-traumatic lateral ankle pain is seen frequently. Peroneal tendon pathology is not always recognized as a cause of lateral ankle pain. Peroneal tendon disorders are often associated with and secondary to chronic lateral ankle instability. Because the peroneal muscles act as lateral ankle stabilizers, more strain is placed on these tendons in chronic lateral ankle instability, resulting in hypertrophic tendinopathy, in tenosynovitis, and ultimately in (partial) tendon tears [1–3]. Diagnosis may be difficult in a patient who has lateral ankle pain. Peroneal tendon dislocation and tenosynovitis can be established by clinical examination. Supplemental investigations such as MRI and sonography may be helpful in confirming the diagnosis [1] in cases of (subtotal) tears of the peroneus brevis or longus tendons. Postsurgery and post-traumatic adhesions and irregularities in the posterior aspect of the fibula (ie, tendon sliding channel) can also be responsible for symptoms in this region. Pathology consists of tenosynovitis of the peroneal tendons, tendon dislocation or subluxation, and (partial) rupture or snapping of one or both of the peroneal tendons, and accounts for most symptoms at the posterolateral side of the ankle joint [4,5]. Rheumatoid tenosynovitis or a bony spur can also be the cause of posterolateral ankle pain. A differentiation must be made with (fatigue) fractures of the fibula, lesions of the lateral ligament complex, and posterior impingement of the ankle (os trigonum syndrome). The primary indication for treating peroneal tendon disorders is pain. Nonsurgical treatment is usually attempted first. Conservative therapy includes activity modification, footwear changes, temporary immobilization, and corticosteroid injection. Lateral heel wedges can take stress off of the peroneal tendons to allow T Corresponding author. E-mail address: [email protected] (P.E. Scholten). 1083-7515/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.fcl.2006.03.004
foot.theclinics.com
416
scholten
&
van dijk
healing. Failure of conservative measures is an indication for operative intervention. In contrast to arthroscopy, which has become the major technique to treat intra-articular ankle lesions, extra-articular pathology of the ankle has traditionally demanded open surgery. This type of intervention frequently requires postoperative plaster immobilization to prevent equinus malformation and to stimulate wound healing [3,6]. Open ankle surgery may be complicated by injury to the sural nerve or superficial peroneal nerve, infection, scarring, and stiffness of the ankle joint [7–9]. The occurrence of these complications stimulated the development of extra-articular endoscopic techniques. These techniques potentially lack the previously described disadvantages. Extra-articular ankle endoscopy has been developed in the last years, especially hindfoot endoscopy and tendoscopy of the posterior tibial and peroneal tendons [10–12]. Endoscopic ankle surgery is followed by a functional postoperative treatment and offers the advantages of less morbidity, reduction of postoperative pain, and outpatient surgery [12]. An anatomic study was performed to study the local anatomy of the peroneal tendons and its surroundings and to verify portal anatomy [10,11]. In seven cadaver ankles, the relation of the peroneal tendons to each other, to the posterolateral aspect of the distal fibula, and to the lateral aspects of the calcaneus and cuboid was studied. The peroneus brevis tendon is situated dorsomedial of the peroneus longus tendon from its proximal aspect up to the fibular tip with a flattened constitution. Just distally to this lateral malleolus tip, the peroneus brevis tendon gets a round aspect and crosses the round peroneus longus tendon. The posterolateral part of the fibula forms a sliding channel for the two peroneal tendons. This malleolar groove is formed by a periosteal cushion of fibrocartilage that covers the bony groove. The tendons are held in their position within the malleolar groove by the superior peroneal retinaculum. In three of the seven lateral ankle explorations, a bony prominence on the calcaneus was found in between both tendons some 4 to 5 cm distal from the fibula. A 1- to 2-mm thick
Fig. 1. Schematic drawing of a cross-section of the peroneal tendons with their tendon sheath and vincula. A, tendon sheath; B, vincula; C, peroneus longus tendon; D, peroneus brevis tendon.
tendoscopy of the peroneal tendons
417
vinculum-like membrane was found between the peroneus longus and brevis tendons, dorsally attached to the dorsolateral aspect of the fibula (Fig. 1). The distal fibers of the peroneus brevis muscle belly gradually transform to this membraneous layer to end approximately at the tip of the fibula. At the peroneus longus site of this membrane, it is continuously attached to the peroneus brevis tendon, from its distal muscle fibers (6 to 9 cm proximally from the fibular tip), around the tip, and all the way to its distal insertion. It was found that access to the tendon sheath can be made all along the curse of the tendons proximally some 6 cm from the posterior tip of the lateral malleolus and distally about 3 cm from the fibular tip. This article describes the technique and results of peroneal tendoscopy performed in 23 patients between 1995 and 2000.
Surgical technique The patient is placed in supine position. The operation is performed as an outpatient procedure under general, regional, or local anesthesia. Local anesthesia has the advantage of a possible dynamic investigation. Before the anesthesia is administered, the patient is asked to actively evert his or her foot. The tendon can be palpated, and the location of the portals are drawn onto the skin. When local anesthesia is used, the anesthetic is administered around the portals and into the tendon sheath. A support is placed under the ipsilateral buttock, and a tourniquet is inflated. Access to the tendons can be obtained anywhere along the tendons. A distal portal is made first, 2.0 to 2.5 cm distal to the posterior edge of the lateral malleolus. An incision is made through the skin covering the tendons. The tendon sheath is penetrated with an arthroscopic shaft with blunt trocar, and a 2.7-mm 308 inclination angle arthroscope is introduced (Fig. 2). A spinal needle is placed 2.0 to 2.5 cm proximal to the posterior edge of the malleolus under direct vision, creating a proximal portal directly over the tendons. Instruments like a probe, a disposable cutting knife, scissors, or a shaver system can be introduced. Through the distal portal, a complete overview can be obtained of both peroneal tendons. The inspection starts some 6 cm proximal from the posterior tip of the lateral malleolus where a thin membrane splits the tendon compartment into two separate tendon chambers. More distally, both tendons lie in one compartment. By rotating the endoscope over and in between both tendons, the complete compartment can be inspected. When a total synovectomy of the tendon sheath is to be performed, it is advisable to create a third portal more distal or more proximal than the portals described previously. In cases of recurrent dislocation of the peroneal tendons, fibular groove deepening can be performed endoscopically. Inspection typically reveals a partial detachment of the superior peroneal retinaculum and some scarring and tenosynovitis of the peroneal tendons at the level of the tip of the distal fibula. Using a probe, the tendons can be dislocated to inspect the distal retromalleolar groove. A small burr (3.2 mm) is introduced distally with the arthroscope proximally, and the retromalleolar groove is deep-
418
scholten
&
van dijk
Fig. 2. Peroneal tendoscopy of the left ankle: the two main portals are located 2.0 to 2.5 cm proximal and 2.0 to 2.5 cm distal to the posterior edge of the lateral malleolus. 1, proximal portal; 2, lateral malleolus; 3, distal portal.
ened approximately 3 mm in depth and 5 mm in width. By relocating the tendons into the groove, the operator can check whether sufficient bone has been removed. At the end of the procedure, the tendons cannot be dislocated out of the groove. Because the superior peroneal retinaculum is partially stripped off the fibula and not torn, it can be expected to heal at its anatomic site without requiring further reattachment or postoperative plaster cast immobilization. Both portals are sutured to prevent sinus formation, and a bandage is placed. Full weight bearing is allowed as tolerated. Active range of motion is advised immediately post surgery.
Results Between 1995 and 2000, a peroneal tendoscopy was performed in 23 patients, with a minimum of 2 years’ follow-up (Table 1). Eleven patients had a longitudinal rupture of the peroneal brevis tendon. In these patients, there was a history of an acute lateral ankle ligament rupture. Eight of these patients presented with pain and swelling over the posterior aspect of the lateral malleolus;
tendoscopy of the peroneal tendons
419
Table 1 Diagnosis and treatment of 23 patients in whom peroneal tendoscopy was performed between 1995 and 2000 No. of patients
Indication
Procedure
11
Longitudinal rupture of the peroneal brevis tendon Chronic tenosynovitis after operative treatment Recurrent peroneal tendon dislocation
Tendoscopic synovectomy and suturing (miniopen) Tendoscopic synovectomy (one removal of an exostosis) Tendoscopic fibular groove deepening
10 2
three presented a snapping sensation at the level of the lateral malleolus. Ten patients had persisting symptoms after operative treatment of a lateral malleolar fracture, a lateral ankle ligament reconstruction, or a surgical repair for recurrent tendon dislocation. Surgery consisted of an endoscopic tenosynovectomy, adhesiolysis, removal of an exostosis, and suturing a longitudinal rupture when indicated by way of a miniopen procedure. Two patients had a tendoscopic deepening of the fibular groove for recurrent peroneal tendon dislocation. In one patient, the malleolar groove was concave; in the other patient, it was flat. The superior retinaculum was stripped off with the periosteum from the fibula (Fig. 3) and was not torn. This finding is in concordance with the earlier findings of peroneal tendon dislocation by Eckert and Davis [13]. After deepening the malleolar groove, peroneal tendon dislocation could no longer occur, allowing the superior retinaculum and fibular periosteum to attach at its original anatomic site and not require any further reattachment. Both patients did not require a plaster cast and after treatment were functional. In these patients, the authors found no complications and no recurrence of the preoperative pathology.
Fig. 3. Endoscopic view of the superior retinaculum and fibula on the left and the peroneal tendons on the right.
420
scholten
&
van dijk
Summary Tendoscopy of the peroneal tendons is a useful tool to diagnose and treat peroneal tendon disorders. Synovectomy, adhesiolysis, or removal of an exostosis can be performed endoscopically with low morbidity and an excellent functional outcome. Fibular groove deepening for recurrent tendon dislocation was successful in the two patients in whom this procedure was performed.
References [1] Yao L, Tong JF, Cracchiolo A, et al. MR findings in peroneal tendopathy. J Comput Assist Tomogr 1995;19:460 – 4. [2] Myerson M. Tendons and ligaments. In: Decker BC, editor. Current therapy in foot and ankle surgery. St. Louis7 Mosby-Yearbook Inc.; 1993. p. 87 – 123. [3] Richardson EG. Disorders of tendons. In: Grenshaw AH, editor. Campbell’s operative orthopaedics. St. Louis (MO)7 CV Mosby Co.; 1992. p. 2851 – 73. [4] Roggatz J, Urban A. The calcareous peritendinitis of the long peroneal tendon. Arch Orthop Trauma Surg 1980;96:161 – 4. [5] Schweitzer GJ. Stenosing peroneal tenovaginitis. Case reports. S Afr Med J 1982;4:521 – 3. [6] Lapidus PW. A note on the fracture of the os trigonum. Bull Hosp Joint Dis 1972;33:150 – 4. [7] Marotta JJ, Micheli LJ. Os trigonum impingement in dancers. Am J Sports Med 1992;20:533 – 6. [8] Hamilton WG, Geppert MJ, Thompson FM. Pain in the posterior aspect of the ankle in dancers. J Bone Joint Surg Am 1996;78:1491 – 500. [9] Abramowitz Y, Wollstein R, Barzilay Y, et al. Outcome of resection of a symptomatic os trigonum. J Bone Joint Surg Am 2003;85:1051 – 7. [10] van Dijk CN, Scholten PE, Kort NP. Tendoscopy (tendon sheath endoscopy) for overuse tendon injuries. Oper Techn Sports Med 1997;5:170 – 8. [11] van Dijk CN, Kort NP. Tendoscopy of the peroneal tendons. Arthroscopy 1998;14(5):471 – 8. [12] van Dijk CN. Hindfoot endoscopy. Sports Med Arthrosc Rev 2000;8:365 – 71. [13] Eckert WR, Davis Jr EA. Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976;58(5):670 – 2.
Tendoscopy of the Peroneal Tendons Peter E. Scholten, MDa,T, C. Niek van Dijk, MD, PhDb a
Kliniek Klein Rosendael, Department of Orthopaedic Surgery, Rosendaalselaan 30, 6891 DG Rozendaal, The Netherlands b Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
Post-traumatic lateral ankle pain is seen frequently. Peroneal tendon pathology is not always recognized as a cause of lateral ankle pain. Peroneal tendon disorders are often associated with and secondary to chronic lateral ankle instability. Because the peroneal muscles act as lateral ankle stabilizers, more strain is placed on these tendons in chronic lateral ankle instability, resulting in hypertrophic tendinopathy, in tenosynovitis, and ultimately in (partial) tendon tears [1–3]. Diagnosis may be difficult in a patient who has lateral ankle pain. Peroneal tendon dislocation and tenosynovitis can be established by clinical examination. Supplemental investigations such as MRI and sonography may be helpful in confirming the diagnosis [1] in cases of (subtotal) tears of the peroneus brevis or longus tendons. Postsurgery and post-traumatic adhesions and irregularities in the posterior aspect of the fibula (ie, tendon sliding channel) can also be responsible for symptoms in this region. Pathology consists of tenosynovitis of the peroneal tendons, tendon dislocation or subluxation, and (partial) rupture or snapping of one or both of the peroneal tendons, and accounts for most symptoms at the posterolateral side of the ankle joint [4,5]. Rheumatoid tenosynovitis or a bony spur can also be the cause of posterolateral ankle pain. A differentiation must be made with (fatigue) fractures of the fibula, lesions of the lateral ligament complex, and posterior impingement of the ankle (os trigonum syndrome). The primary indication for treating peroneal tendon disorders is pain. Nonsurgical treatment is usually attempted first. Conservative therapy includes activity modification, footwear changes, temporary immobilization, and corticosteroid injection. Lateral heel wedges can take stress off of the peroneal tendons to allow T Corresponding author. E-mail address: [email protected] (P.E. Scholten). 1083-7515/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.fcl.2006.03.004
foot.theclinics.com
416
scholten
&
van dijk
healing. Failure of conservative measures is an indication for operative intervention. In contrast to arthroscopy, which has become the major technique to treat intra-articular ankle lesions, extra-articular pathology of the ankle has traditionally demanded open surgery. This type of intervention frequently requires postoperative plaster immobilization to prevent equinus malformation and to stimulate wound healing [3,6]. Open ankle surgery may be complicated by injury to the sural nerve or superficial peroneal nerve, infection, scarring, and stiffness of the ankle joint [7–9]. The occurrence of these complications stimulated the development of extra-articular endoscopic techniques. These techniques potentially lack the previously described disadvantages. Extra-articular ankle endoscopy has been developed in the last years, especially hindfoot endoscopy and tendoscopy of the posterior tibial and peroneal tendons [10–12]. Endoscopic ankle surgery is followed by a functional postoperative treatment and offers the advantages of less morbidity, reduction of postoperative pain, and outpatient surgery [12]. An anatomic study was performed to study the local anatomy of the peroneal tendons and its surroundings and to verify portal anatomy [10,11]. In seven cadaver ankles, the relation of the peroneal tendons to each other, to the posterolateral aspect of the distal fibula, and to the lateral aspects of the calcaneus and cuboid was studied. The peroneus brevis tendon is situated dorsomedial of the peroneus longus tendon from its proximal aspect up to the fibular tip with a flattened constitution. Just distally to this lateral malleolus tip, the peroneus brevis tendon gets a round aspect and crosses the round peroneus longus tendon. The posterolateral part of the fibula forms a sliding channel for the two peroneal tendons. This malleolar groove is formed by a periosteal cushion of fibrocartilage that covers the bony groove. The tendons are held in their position within the malleolar groove by the superior peroneal retinaculum. In three of the seven lateral ankle explorations, a bony prominence on the calcaneus was found in between both tendons some 4 to 5 cm distal from the fibula. A 1- to 2-mm thick
Fig. 1. Schematic drawing of a cross-section of the peroneal tendons with their tendon sheath and vincula. A, tendon sheath; B, vincula; C, peroneus longus tendon; D, peroneus brevis tendon.
tendoscopy of the peroneal tendons
417
vinculum-like membrane was found between the peroneus longus and brevis tendons, dorsally attached to the dorsolateral aspect of the fibula (Fig. 1). The distal fibers of the peroneus brevis muscle belly gradually transform to this membraneous layer to end approximately at the tip of the fibula. At the peroneus longus site of this membrane, it is continuously attached to the peroneus brevis tendon, from its distal muscle fibers (6 to 9 cm proximally from the fibular tip), around the tip, and all the way to its distal insertion. It was found that access to the tendon sheath can be made all along the curse of the tendons proximally some 6 cm from the posterior tip of the lateral malleolus and distally about 3 cm from the fibular tip. This article describes the technique and results of peroneal tendoscopy performed in 23 patients between 1995 and 2000.
Surgical technique The patient is placed in supine position. The operation is performed as an outpatient procedure under general, regional, or local anesthesia. Local anesthesia has the advantage of a possible dynamic investigation. Before the anesthesia is administered, the patient is asked to actively evert his or her foot. The tendon can be palpated, and the location of the portals are drawn onto the skin. When local anesthesia is used, the anesthetic is administered around the portals and into the tendon sheath. A support is placed under the ipsilateral buttock, and a tourniquet is inflated. Access to the tendons can be obtained anywhere along the tendons. A distal portal is made first, 2.0 to 2.5 cm distal to the posterior edge of the lateral malleolus. An incision is made through the skin covering the tendons. The tendon sheath is penetrated with an arthroscopic shaft with blunt trocar, and a 2.7-mm 308 inclination angle arthroscope is introduced (Fig. 2). A spinal needle is placed 2.0 to 2.5 cm proximal to the posterior edge of the malleolus under direct vision, creating a proximal portal directly over the tendons. Instruments like a probe, a disposable cutting knife, scissors, or a shaver system can be introduced. Through the distal portal, a complete overview can be obtained of both peroneal tendons. The inspection starts some 6 cm proximal from the posterior tip of the lateral malleolus where a thin membrane splits the tendon compartment into two separate tendon chambers. More distally, both tendons lie in one compartment. By rotating the endoscope over and in between both tendons, the complete compartment can be inspected. When a total synovectomy of the tendon sheath is to be performed, it is advisable to create a third portal more distal or more proximal than the portals described previously. In cases of recurrent dislocation of the peroneal tendons, fibular groove deepening can be performed endoscopically. Inspection typically reveals a partial detachment of the superior peroneal retinaculum and some scarring and tenosynovitis of the peroneal tendons at the level of the tip of the distal fibula. Using a probe, the tendons can be dislocated to inspect the distal retromalleolar groove. A small burr (3.2 mm) is introduced distally with the arthroscope proximally, and the retromalleolar groove is deep-
418
scholten
&
van dijk
Fig. 2. Peroneal tendoscopy of the left ankle: the two main portals are located 2.0 to 2.5 cm proximal and 2.0 to 2.5 cm distal to the posterior edge of the lateral malleolus. 1, proximal portal; 2, lateral malleolus; 3, distal portal.
ened approximately 3 mm in depth and 5 mm in width. By relocating the tendons into the groove, the operator can check whether sufficient bone has been removed. At the end of the procedure, the tendons cannot be dislocated out of the groove. Because the superior peroneal retinaculum is partially stripped off the fibula and not torn, it can be expected to heal at its anatomic site without requiring further reattachment or postoperative plaster cast immobilization. Both portals are sutured to prevent sinus formation, and a bandage is placed. Full weight bearing is allowed as tolerated. Active range of motion is advised immediately post surgery.
Results Between 1995 and 2000, a peroneal tendoscopy was performed in 23 patients, with a minimum of 2 years’ follow-up (Table 1). Eleven patients had a longitudinal rupture of the peroneal brevis tendon. In these patients, there was a history of an acute lateral ankle ligament rupture. Eight of these patients presented with pain and swelling over the posterior aspect of the lateral malleolus;
tendoscopy of the peroneal tendons
419
Table 1 Diagnosis and treatment of 23 patients in whom peroneal tendoscopy was performed between 1995 and 2000 No. of patients
Indication
Procedure
11
Longitudinal rupture of the peroneal brevis tendon Chronic tenosynovitis after operative treatment Recurrent peroneal tendon dislocation
Tendoscopic synovectomy and suturing (miniopen) Tendoscopic synovectomy (one removal of an exostosis) Tendoscopic fibular groove deepening
10 2
three presented a snapping sensation at the level of the lateral malleolus. Ten patients had persisting symptoms after operative treatment of a lateral malleolar fracture, a lateral ankle ligament reconstruction, or a surgical repair for recurrent tendon dislocation. Surgery consisted of an endoscopic tenosynovectomy, adhesiolysis, removal of an exostosis, and suturing a longitudinal rupture when indicated by way of a miniopen procedure. Two patients had a tendoscopic deepening of the fibular groove for recurrent peroneal tendon dislocation. In one patient, the malleolar groove was concave; in the other patient, it was flat. The superior retinaculum was stripped off with the periosteum from the fibula (Fig. 3) and was not torn. This finding is in concordance with the earlier findings of peroneal tendon dislocation by Eckert and Davis [13]. After deepening the malleolar groove, peroneal tendon dislocation could no longer occur, allowing the superior retinaculum and fibular periosteum to attach at its original anatomic site and not require any further reattachment. Both patients did not require a plaster cast and after treatment were functional. In these patients, the authors found no complications and no recurrence of the preoperative pathology.
Fig. 3. Endoscopic view of the superior retinaculum and fibula on the left and the peroneal tendons on the right.
420
scholten
&
van dijk
Summary Tendoscopy of the peroneal tendons is a useful tool to diagnose and treat peroneal tendon disorders. Synovectomy, adhesiolysis, or removal of an exostosis can be performed endoscopically with low morbidity and an excellent functional outcome. Fibular groove deepening for recurrent tendon dislocation was successful in the two patients in whom this procedure was performed.
References [1] Yao L, Tong JF, Cracchiolo A, et al. MR findings in peroneal tendopathy. J Comput Assist Tomogr 1995;19:460 – 4. [2] Myerson M. Tendons and ligaments. In: Decker BC, editor. Current therapy in foot and ankle surgery. St. Louis7 Mosby-Yearbook Inc.; 1993. p. 87 – 123. [3] Richardson EG. Disorders of tendons. In: Grenshaw AH, editor. Campbell’s operative orthopaedics. St. Louis (MO)7 CV Mosby Co.; 1992. p. 2851 – 73. [4] Roggatz J, Urban A. The calcareous peritendinitis of the long peroneal tendon. Arch Orthop Trauma Surg 1980;96:161 – 4. [5] Schweitzer GJ. Stenosing peroneal tenovaginitis. Case reports. S Afr Med J 1982;4:521 – 3. [6] Lapidus PW. A note on the fracture of the os trigonum. Bull Hosp Joint Dis 1972;33:150 – 4. [7] Marotta JJ, Micheli LJ. Os trigonum impingement in dancers. Am J Sports Med 1992;20:533 – 6. [8] Hamilton WG, Geppert MJ, Thompson FM. Pain in the posterior aspect of the ankle in dancers. J Bone Joint Surg Am 1996;78:1491 – 500. [9] Abramowitz Y, Wollstein R, Barzilay Y, et al. Outcome of resection of a symptomatic os trigonum. J Bone Joint Surg Am 2003;85:1051 – 7. [10] van Dijk CN, Scholten PE, Kort NP. Tendoscopy (tendon sheath endoscopy) for overuse tendon injuries. Oper Techn Sports Med 1997;5:170 – 8. [11] van Dijk CN, Kort NP. Tendoscopy of the peroneal tendons. Arthroscopy 1998;14(5):471 – 8. [12] van Dijk CN. Hindfoot endoscopy. Sports Med Arthrosc Rev 2000;8:365 – 71. [13] Eckert WR, Davis Jr EA. Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976;58(5):670 – 2.