26. flemister acute and chronic · 2/26/2020 · microsoft powerpoint - 26. flemister_acute and...
TRANSCRIPT
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A Samuel Flemister Jr MDUniversity of Rochester
Peroneal Tendon Disorders
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Disclosures NONE
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Anatomy & Biomechanics Peroneus Longus inserts
into the base of first MT Peroneus Brevis into base
of fifth MT
Together 63% of eversion strength, PL(35%), PB (28%)
Manoli et al FAI 2005
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Peroneal Tendon Pathology
Acute Tears(rare)Chronic tears with or without
tendinosisSubluxation alone acute or chronicSubluxation with tears
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Peroneal Tendon Tears
Acute injury-rare usually healthy tendon
Chronic degenerative condition- more common
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Acute tears Lateral sided ankle
pain Often associated with
trauma Frequently involve
peroneus brevis atretro-malloelargroove
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Peroneus Longus TearsUsually distal
Peroneal tubercleTurn at cuboid
Tendinosis Involve os
peroneum
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Diagnosis- acute tears Hx of Acute injury
Tender along peroneals
Pain with resisted eversion
Pain with passive inversion
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Exam – associated conditions Tendon subluxation
Lateral ligament instability
Cavus foot
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Plain RadiographsFoot and Ankle WB?
Alignment Fleck sign
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Plain radiographs
Os Peroneum OS at base of 5th
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MRI 83% sensitive 75 % specific compared
to intraop findingsLamm et al
Helpful to understand extent of disease
Ultrasound operator dependent
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Frequently missed Sammarco et al
7-48 months to diagnosis
Arbab et alAverage 11 months to diagnosis
If patients have peroneal tenderness after trauma I see them back in 2 weeks
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Classification & treatment systems Sobel et al FA 1992
Krause & Brodsky FAI 1998
Redfren & Myerson FAI 2004
Considerations for operative treatment Degree of tendon involvement( length of tear, full vs partial, %
of tendon involved ie 50% cutoff Degree of tendinosis, salvable or not Excursion of the proximal muscle Scarring of the bed
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Lodewijk et al JAAOS 2018
Based on MRI scans patients with PB tendon tears demonstrated markedly higher grades of fatty degeneration in the muscle vs those with no pathology
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Incision Lateral incision along
tendon sheath
Cheat anterior if need to fix lateral ligaments
Lateral decubitus position if only working on tendons
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1. Tear of One repairable tendon Less than 50%
involved Usually PB
One side better than other
Excise worse side
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RepairAt least 50 %
healthy tendon remaining
Middle most involved
PDS runner
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Debridement and Repair Long Term results
Demtracopoulos et al FAI 20146.5 yr fu on 18 pts17/18 returned to full sporting function without limitation
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2. One tendon intact/repairable, one not repairable
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Chronic Degenerative tears Usually slow onset of
symptoms
Swelling along sheath
Tendinosis
Often more distal
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Chronic degenerative tears
Partial Excision and Repair
Complete excision of segment with tenodesis, allograft replacement, FHL tendon transfer
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TenodesisOne tendon viableGood muscle
excursion
Excise diseased portion
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Tenodesis < 50% viable tendon
Sacrifice Longus in Cavus foot
Don’t do as well as repairs
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3. Both tendons not repairableGood muscle excursion
Allograft
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Allograft Grafts PL or Semi-T Fix distally to stump of PB Or with anchors to base of
5th MT
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Tensioning
Fix distally first
Keep foot neutral DF,/PF Inversion/Eversion
Attach tendon proximal at about half the maximal excursion of the muscle
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Allograft Results
Mook et al FAI 201314 pts fu 17 monthsImprovement in VAS, SF-12, LEFS
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3.No muscle excursion
Both tendons cannot be salvaged
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FHL tendon transfer 2 stage procedure using
Hunter rodsWapner 2006
Successful results with single stage also reported
Campbell, Myerson 2016
Jockel, Brodsky 2013
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FHL Transfer
Debride all diseased segments
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FHL Transfer
Harvest at Master Knot of Henry
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FHL Transfer
Hook tendon through lateral incision
DO NOT need 2nd
proximal medial incision
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FHL Transfer
Attach to stump of PB tendon or to base of 5th
metatarsalTenodesis
proximally if possible
Watch sural nerve
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FHL Transfer
Although good results reported clinically
25% loss of inversion and eversion ROM
50% loss of strengthSalvage procedure for severe 2 tendon
disease
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Painful Os Peroneum Syndrome(POPS)
Rupture of PL with Proximal migration Degeneration/tear
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POPS Incision more distal Excise fragment and
repair if adequate tendon
Tenodesis to PB if not Cavus foot favor
tenodesis
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OS at base of 5th MT
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Peroneal subluxation Occurs after inversion
injury
Not recognized at time of sprain
May not follow an injury
Dorsiflexion and eversion reproduce symptoms
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Fleck Sign
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Peroneal Subluxation
Injury to superior retinaculum
Tendon may sublux over fibula
May result in tendon tear
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Associated findings
Peroneus Quartus
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Peroneal Subluxation
Operative Problem
Repair tendon and retinaculum
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Debride tendon, Inspect groove
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Sub periosteal flap on fibula
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Peroneal Subluxation
In chronic cases may be caused by a shallow retromalleolar groove
Groove deepening procedure
Question needCho et al FAI 2014
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Post op
Splint 7-14 days NWBBoot till 6 weeks: WBAT, sagittal
motion only at 1-2 weeksStirrup brace and PTSports 3-4 months
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Correct Cavus Foot
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Outcomes Studies are retrospective, variety of non validated outcome
measures, mix acute and chronic
Most report high patient satisfaction rates and return to sport > 90 %
Next steps:Peroneal Arthroscopic Techniques
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Summary Don’t miss diagnosis Repair healthy tissue Excision and Tenodesis for unhealthy tissue Allograft & FHL tendon transfer if both tendons
not salvageable Correct cavus foot Early motion
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Thank You