Peroneal Tendon Repair

Christopher W. Reb and Gregory C. Berlet

Abstract

Peroneal tendon pathology is common. When this pathology includes a tear, nonsurgical treatment is unlikely to be successful. In the setting of surgical repair, peroneal tendon repair offers reliable pain relief and functional recovery. Careful patient evaluation is required to determine if the procedure should be performed alone or in combination with adjunct procedures to address underlying or related pathology. Often, multiple procedures can be achieved through a well-localized incision. Attention to detail during each step of the procedure key will help achieve the surgical goals while minimizing the risk to adjacent neurologic structures.

Keywords: tendinosis, tendon tear, peroneal tendon, peroneus brevis, peroneus longus, reconstruction, surgical technique

28.1 Indications and Pathology

• Acute peroneal tendon tear.

• Acute peroneal tendon rupture.

• Peroneal tenosynovitis.

• Peroneal tendinosis.

• Peroneal instability.

28.1.1 Clinical Evaluation

• History of pain and swelling along the course of the peroneal tendons.

• Ask about past trauma, including inversion ankle injuries.

• Mechanical symptoms may include snapping, subluxation, or dislocation around the fibula.

• Examine for hindfoot deformity that may only be present when weight-bearing.

• Evaluate all cavovarus feet for flexibility with weight-bearing and hindfoot correction with Coleman’s block testing. Bear in mind that subtle cavovarus deformity may be contributing.

• Evaluate for ligamentous and functional ankle instability.

• Consider associated pathology such as posterior ankle impingement syndrome, anterolateral ankle impingement syndrome, ankle syndesmosis sprain, subtalar varus instability, talus osteochondral defect (OCD), fifth metatarsal base fracture, and symptomatic os peroneum.

28.1.2 Radiographic Evaluation

• Weight-bearing anteroposterior (AP), mortise, and lateral X-rays of the hindfoot to evaluate for deformity, ankle or hindfoot arthritis, and radiographic signs of past trauma, such as previous avulsion fractures.

• Magnetic resonance imaging (MRI) without contrast is indicated to confirm peroneal tendon rupture, to rule out alternative diagnoses, or when peroneal symptoms are refractory to an initial period of conservative treatment.

• Computed tomography (CT) with thin slice reconstruction may be used to confirm peroneal tendon rupture.

• Ultrasound is operator dependent, but can be used to confirm peroneal tendon rupture and is the best real-time modality for assessment of peroneal instability.

28.1.3 Nonoperative Options

• Protected mobilization, rest, ice, compression, elevation (PRICE).

• Oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs).

• Local injection or short course of oral corticosteroids.

• Physical therapy focused on hip, knee, and ankle proprioceptive training and strengthening.

• Bracing.

• Activity avoidance, modification, or retraining.

28.1.4 Contraindications

• Active infection.

• Patient medically unfit for surgery.

• Patient noncompliance anticipated.

• Uncorrected hindfoot deformity.

• Complex regional pain syndrome.

28.2 Goals of Surgical Procedure

• Pain relief.

• Functional improvement.

• Preserve native tissues.

28.3 Advantages of Surgical Procedure

• Peroneal repair can be performed alone or in combination with other procedures.

• Single approach allows multiple procedures.

28.4 Key Principles

• Well-localized incision for adequate visualization.

• Meticulous anatomic dissection.

• Atraumatic soft-tissue handling.

• Address all pathology.

• Restore the superior peroneal retinaculum.

28.5 Preoperative Preparation and Patient Positioning

The patient is positioned laterally on a beanbag with nonsterile ipsilateral thigh tourniquet set to 250 or 300 mm Hg. The nonsurgical limb is outfitted with a pneumatic serial compressive device in a semiflexed position. All bony prominences are well padded. The surgical limb is supported with a stack of blankets or foam platform. The limb is prepped and draped to above the knee.

28.6 Operative Technique

The limb is elevated, exsanguinated with an Esmarch bandage, and tourniquet is inflated. The lateral malleolus, lateral neck of the talus, and fifth metatarsal base are palpated. A curvilinear incision is drawn over the course of the peroneal tendons. If the surgical plan calls for ankle lateral ligament reconstruction, the incision can be modified by orienting it from the peroneal tendons proximal to the lateral malleolus, over the tip of the fibula toward the superior aspect of the anterior process of the calcaneus (Fig. 28.1).

After the skin is divided and hemostasis is achieved, branches of the sural nerve, particularly the dorsal lateral cutaneous nerve to the foot, should be sought and protected as best as possible.

The inferior peroneal retinaculum forms separate sheaths around the peroneus brevis and longus. The tendon sheaths can be longitudinally incised just distal to the tip of the fibula to create a window for evaluating the tendons. Thickened and inflamed tenosynovium is often present and must be excised for best visualization.

The peroneal brevis is often diseased or torn within the retrofibular groove of the fibula. Using this window, the brevis tendon can be distally retracted and inspected to confirm this pathology (Fig. 28.2). In the event that the tendon appears healthy, this maneuver allows the surgeon to avoid taking down the superior peroneal retinaculum.

When peroneal pathology is known or highly suspected in the retrofibular groove, or when peroneal instability is present and superior peroneal retinaculum reconstruction is indicated, it is important to divide the superior peroneal retinaculum, leaving a cuff of tissue on the fibula for later use when reconstructing it. A linear metallic instrument, such a freer elevator, can be used to localize the incision to divide the superior peroneal retinaculum and to protect the peroneal tendons below during this step.

At this point, the posterior leaf of the retinaculum often has tenosynovium adherent to its internal surface. The tenosynovium can be peeled off, revealing the glistening, striated undersurface of the retinaculum (Fig. 28.3). A stay suture is used to mark this posterior leaf for later retrieval.

If a low-lying peroneus brevis muscle belly or a peroneus quartus is present, acting as a space occupying lesion in the retrofibular space, the muscle belly can be dissected away prior to addressing the peroneal tendons.