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Peroneal Tendon Debridement

    Overview

    Learn the Peroneal Tendon Debridement surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Peroneal Tendon Debridement surgical procedure.
    A straightforward surgical technique with a high success rate which is indicated if conservative management of the degenerate tendon fails.
    It is not clearly defined what percentage involvement of the tendon is better treated with either tendon transfer or allograft so a debridement and repair can be used as primary surgical management for all but the severest of cases.
    Patients may in most cases commence light weight-bearing in a post-operative boot from after 2 weeks post-operatively and return to most normal daily function after 3 months.

    Indications

    INDICATIONS.
    Peroneal tendinosis of one or both tendons that has not settled with conservative intervention.
    SYMPTOMS & EXAMINATION.
    Patients will have well localised swelling and discomfort to the region of the peroneal tendons. Usually activity related (in particular on uneven ground) pain can progress to be present at rest and night also.
    Though pain on uneven ground is common overt instability as a symptom is not.
    On occasion the presentation may be as part of an ankle sprain that has failed to settle . The pain and tenderness will be posterior and inferior to the fibula tip rather than at the lateral margin of the ankle(which is of course very close). The finding of tears and degenerative change to these tendons in conjunction with their chronic subluxation is not unusual either
    INVESTIGATION.
    Ultrasound is more commonly used if the diagnosis of peroneal tendon disease is suspected as it leaves open the possibility of intervention at the time of investigation with an ultrasound guided injection of steroid and local anaesthetic.
    Neither MRI nor ultrasound however are entirely specific as to the nature of the tendon pathology , in particular whether tears or splits are present .Tears may make a difference with respect to how likely conservative treatment is to be successful (though tears are not prognostic with respect to the success of surgical treatment).
    Inflammatory change limited to the tendon sheath is best identified with Ultrasound and can be intercurrently treated with steroid infiltration into the paratenon.
    Imaging is indicated generally after conservative management to assist in making more informed decisions on more invasive management. See the results section for relevant published papers on imaging.
    NON-OPERATIVE TREATMENT.
    Initial management is usually physio based using passive and active modalities (including exercise based treatment , ultrasound and ( often held in reserve) shock-wave therapy. In general terms it can be expected to produce adequate response in 2/3rds of patients.
    Hindfoot/midfoot stabilisation with orthotics and appropriately stable boots & ankle braces can also help.
    As already detailed ultrasound guided injections are of use in the absence of degenerative tendon change.
    SURGICAL ALTERNATIVES.
    There is no good evidence to back up what proportion of the tendon/tendons need to be effected for a debridement and repair type operation not to work and a transfer being more appropriate.
    If a single tendon is un-reconstructable by nature of the quality of its tissue or extent of involvement then it can be piggy-backed (radically debrided and its remnants sewn ) into the remaining healthier peroneal tendon.
    Alternatives to consider when both tendons are severely degenerate (or in revision cases) are either transfer of the Flexor digitorum or Flexor Hallucis longus tendon or the use of an Allograft tendon. References for both are included in the results section.
    CONTRAINDICATIONS.
    The general ones of vascular compromise , poor patient compliance and issues with the local soft tissue cover .

    Setup

    GA or Regional Anaesthetic and Popliteal block for post operative pain relief.
    The incision used most sensibly is postero-lateral & just skirting anterior to the tendon
    One or two side supports should be placed on the non-operated side at thigh and trunk level whilst several sandbags are placed under the operated buttock , thus turning the operated leg into internal rotation
    The further addition of rolled up sterile towels behind the calf allow extra degrees of rotation.
    Thigh tourniquet to be used and Flowtron calf-pump on non-operated calf.
    Prophylactic antibiotics and LMWHeparin peri-operatively & post-operatively
    Bipolar diathermy.

    Operation

    Pre-operatively the area of tenderness should be marked and cross-referenced to the changes seen on imaging. The skin incision should be made directly over the line of the peroneal tendons which are easily palpable through most of their course.

    The skin incision usually need to run both above and below the level of the lateral malleolus. Care should be taken not to incise too deeply beneath the skin , especially posterior to the line of the peroneal tendons due to the proximity of the sural nerve.

    The superficial fat layer should be carefully scissors dissected off the underlying peroneal sheath. Attention in particular should be given to the posterior aspect of the sheath , where the sural nerve should be identified , carefully defined and then avoided.
    Even if this is done some level of temporary sensory disturbance from the Sural nerve post-operatively is common and my advice is that all patients are warned of this.

    The Sural nerve is usually easy to identify , as seen here , should be carefully handled and once located not too extensively mobilised.
    It is very prone to produce unpleasant sensory symptoms if abused and these can be resistant to treatment.

    The sheath overlying the tendons is opened by scalpel dissection above the level of the malleolus and preserved.

    The sheath is also opened inferior to the malleolus. Ideally one should aim to preserve a small section of the sheath ( as here) posterior to the lateral malleolus to aid post-operative stability of the tendons.

    The peroneus brevis is the more degenerate of the two tendons in this case. It can be fairly well inspected by everting the subtalar joint to allow more tendon to be delivered . Note how distally the two tendons are housed in distinct fibrous tunnels which will also require careful division (and later repair).
    All aspects of each tendon should be inspected which is aided by dorsi-flexion and eversion of the foot to produce some slack in the tendons and allow easy traction upon them.

    Division of the separate tunnels housing the brevis and longus tendons.

    The central thick , fibrous common wall needs to be dissected close to on both sides to allow easy reconstruction.

    The amount of tendon visible can be easily increased by a combination of subtalar eversion and direct traction upon the tendon with a tendon hook or similar. Here a tear is visible within the Peroneus Brevis tendon.

    The degenerate tendon tear is excised by sharp dissection. Not all degenerate tissue need be excised, just the worst effected. Any degenerate tendon left in-situ is prepared by carefully placing longitudinal incisions in the line of the tendon fibres.

    The tendon is repaired with a continuous 2.0 vicryl (absorbable) suture and its surface layers tightly re-opposed. Care is taken to leave the tendon surface as flush as possible and any prominent areas excised (such as the raised “dog-ear” seen bottom left of the repair).
    Not all areas of tendon debridement require closure. This is a matter of experience.

    The subtalar joint is put through a range of movement to ensure smooth running of the tendons in their bed and through the section of sheath earlier left intact.

    Some more minor areas of degenerative change , above the level of the Fibula , are treated by longitudinal incisions in the line of the tendon fibres.

    Distally the individual tunnels are each repaired using interrupted 2.0 vicryl sutures.

    Distally the individual tunnels are each repaired using interrupted 2.0 vicryl sutures. The rest of the sheath is then repaired with a continuous 2.0 vicryl suture.

    This coronal T2 MRI clearly shows a degenerate Peroneus brevis , with associated lateral soft tissue swelling, sitting above a normal Peroneus Longus

    The same patient, viewed on saggital T2 MRI, providing a better idea of the extent of the Peroneus Brevis change.

    Not all swelling from the peroneal tendons is due to tendinitis or tendinosis. This picture (and the following one) show an intra-tendinous ganglion effecting the Peroneus brevis (following MRI imaging).

    As the dissection proceeds it is far more evident what the nature of the pathology is. Following comprehensive debridement of the ganglion attention will be turned to reconstructing the defect produced which may require a tendon transfer (or “piggy-backing” the Brevis to the Longus tendon).

    Post Operative

    The first two weeks are spent in a lightweight cast , limited weight bearing
    After two weeks into long post-operative boot and commence weight bearing using crutches.
    Usually by the end of 4 weeks post op it is comfortable to weight-bear just in the boot without the need for crutches.
    From 5 weeks commence weight-bearing rehab (strength & balance) and Non-weight bear strengthening and range of motion excercises.
    Static bike from 5 weeks
    Cross-training from 7 weeks
    Light Full weight bearing jog on treadmill from 10 weeks
    (sooner on Alter-G treadmill or in pool)
    Of upmost importance through-out the post-operative period is that the wound is looked after . Wound infection and small areas of breakdown occur easily in a freshly healed wound that is allowed to rub on socks/shoewear.
    Any exudate from the wound which is allowed prolonged contact with the wound will further excacerbate any skin breakdown . Dressing changes may therefore need to be frequent if such a complication ensues.
    Once out of cast I advise another month of daytime dressings when in shoes and also nocturnal dressings whilst any of the wound remains unhealed
    Showering & bathing is from when out of cast.
    Late onset hyper-sensitivity can occur from the Sural nerve as post-operative scar tissue matures and should be treated by an aggressive desensitisation regime.

    Recommended Reading

    Ultrasound diagnosis of peroneal tears: A surgical correlation .
    J Bone Joint Surg.2005.87-A;1788-1794.
    T.H.Grant, A.S.Kelikian , S.E.Jereb , R.J.McCarthy
    60 tendons imaged , 25 with tears were operatively treated and 100% sensitivity found with respect to those with tears but a 25% false positive rate also.
    Long-term results of debridement and primary repair of peroneal tendon tears.
    Foot Ankle Int. 2014 Mar;35(3):252-7.
    Demetracopoulos CA, Vineyard JC, Kiesau CD, Nunley JA.
    Eighteen patients treated with debridement and primary operative repair average follow-up 6.5 years. There was significant improvement in pain scores in all and 17 returned to full sporting activity no reoperations
    Allograft reconstruction of peroneal tendons: operative technique and clinical outcomes.
    Foot Ankle Int. 2013 Sep;34(9):1212-20.
    Mook WR , Parekh SG, Nunley JA
    Fourteen patients who underwent allograft reconstruction were followed up for a mean of 17 months .
    The authors felt that allograft reconstruction predictably improved strength and decreased pain and all patients returned to previous activity levels.
    No tendon failures or revision procedures (though 2 patients with Sural nerve numbness).
    Single stage flexor tendon transfer for the treatment of severe concomitant peroneus longus and brevis tendon tears.
    Foot Ankle Int. 2013 May;34(5):666-72
    Jockel JR, Brodsky JW.
    Eight patients were treated with a single-stage flexor tendon transfer (FDL or FHL) for severe peroneus longus and brevis tears over a 15-year period. Mean follow-up time from surgery was almost 5 years. Mean pain scores decreased significantly. Seven patients reported a return to preoperative activity levels and rated their outcomes as good or excellent.
    Reliability of MRI findings of peroneal tendinopathy in patients with lateral chronic ankle instability.
    Clin Orthop Surg 2010 Dec;2(4):237-43. Park HJ et al
    MRI scans of the peroneal tendons were compared with intra-operative findings at the time of lateral ligament reconstruction surgery.
    39 peroneal tendinopathies diagnosed from MRI, 14 had partial tears, 15 tenosynovitis, 3 dislocations, 17 low-lying muscle bellies, and 6 peroneus quartus muscles.
    Of the 82 MRI scans reviewed (& compared with operative findings) sensitivity and specificity of MRI for peroneal tendinopathy was 8o% ish and 70 ish %, respectively.
    Operative treatment for peroneal tendon disorders.
    J Bone Joint Surg Am. 2008 Feb;90(2):404-18.
    Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG.
    Operative treatment of peroneal tendon tears is based on the amount of remaining viable tendon. The authors recommend primary repair (including tubularization ) if tears or degenerate change involves less than 50% of the tendon, and tenodesis for tears involving more than 50% of the tendon.
    This advice though sound is not supported by anything objective .



    Reference

    • orthoracle.com

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