bilateral peroneus longus tendon rupture …...bilateral peroneus longus tendon rupture through a...

CASE REPORTS

Bilateral Peroneus Longus TendonRupture Through a Bipartite Os Peroneum

Neal M. Blitz, DPM, FACFAS1, and Kristine K. Nemes, DPM2

Peroneus longus rupture with associated involvement of the os peroneum is an uncommon injury, anda small number of cases have been reported. Several mechanisms of injury have been suggested, but themost accepted theory is due to an inversion force placed on a cavovarus foot type. The sesamoid oftenbecomes the focal point of the mechanical stresses and may fracture. Although the purpose of thesesamoid is to protect the tendon from rupture, the os peroneum may actually encourage fatigue(tear/rupture) under certain circumstances. Because this injury occurs at the cuboid notch, primary repairis complicated because of the inability to access the tendon as it courses deep within the midfoot. Wepresent a bilateral case of peroneus longus rupture with involvement of the os peroneum in a patient witha cavovarus foot type. The injuries were sustained from an identical mechanism and occurred almost 1year apart. In both situations, a peroneus longus to peroneus brevis tendon transfer was performedabove the ankle joint in conjunction with partial excision of the fractured os peroneum. To the authors’knowledge, this is the only reported case of peroneus longus rupture associated with fracture of the osperoneum to occur bilaterally. (The Journal of Foot & Ankle Surgery 46(4):270–277, 2007)

Key words: peroneus longus, os peroneum, tendon rupture, fracture, bipartite

Fracture of an os peroneum or fracture through a partite osperoneum both result in discontinuity of the peroneus longustendon and are uncommon injuries. Inversion of the ankle withforced plantarflexion of the first ray in the cavovarus foot typeplaces the peroneus longus at risk for rupture. (1–17). Theperoneus longus tendon is most susceptible to injury at thecuboid notch because of the sharp change in direction of thetendon as it courses toward its insertion on the first ray. As aresult, an intratendinous, fibrocartilaginous thickening or ses-amoid (os peroneum) forms at the cuboid notch to shield theperoneus longus from the increased force at this location.

Address correspondence to: Neal M. Blitz, DPM, FACFAS, AttendingPodiatric Surgeon, Research Director Kaiser North Bay Consortium Res-idency Program, Department of Orthopedics and Foot & Ankle Surgery,Kaiser Permanente Medical Center, 3925 Old Redwood Hwy, Santa Rosa,CA 95403. E-mail: [email protected].

1Attending Podiatric Surgeon, Research Director Kaiser North BayConsortium Residency Program, Department of Orthopedics and Foot &Ankle Surgery, Kaiser Permanente Medical Center, Santa Rosa, CA.

2Submitted Post Graduate Year 2, St. Mary’s Medical Center, SanFrancisco, CA; during rotations through the Kaiser North Bay ConsortiumResidency Program.

Copyright © 2007 by the American College of Foot and Ankle Surgeons
1067-2516/07/4604-0011$32.00/0doi:10.1053/j.jfas.2007.03.006
270 THE JOURNAL OF FOOT & ANKLE SURGERY

When an os peroneum is present, the tendon may be moresusceptible to injury and rupture through the sesamoid becausethe bone is less forgiving than fibrocartilaginous thickening ofthe tendon. A bipartite or multipartite os peroneum may frac-ture through the fibrocartilaginous interval (sychondrosis) be-tween the fragments and result in similar discontinuity of theperoneus longus tendon.

The literature regarding peroneal tendon ruptures withinvolvement of the os peroneum is limited. In 1942, Hadleyreported the first case of a fractured os peroneum with 5 mmof displacement of the fracture fragments (1). Mains andSullivan reported on a patient with an os peroneum fractureand concomitant rupture of the peroneus longus tendon dueto trauma (2). Peacock et al reported a case of peroneuslongus rupture with os peroneum fracture due to a supina-tion injury (3). Cachia et al described a single case ofspontaneous rupture with fracture (4). Saxena and Cassidyreported on 4 patients with peroneus longus tears and osperoneum fracture, but did not define these as longitudinaltears or transverse ruptures of the tendon (5). We report acase of bilateral peroneus longus tendon rupture with abipartite os peroneum fracture that occurred almost exactly1 year apart. To the authors’ knowledge, there are no other
cases of traumatic bilateral occurrence.

Case Presentation

A 37-year-old healthy man presented to the emergencyroom after sustaining an inversion injury of his right foot andankle while running around first base during a baseball game.He recalled a popping sound and had pain, swelling, andbruising to the lateral aspect of his ankle and midfoot. He wasable to bear weight with pain. Before this injury, he related ahistory of chronic lateral ankle pain with sporadic anklesprains, but had never sought medical attention. His past med-ical history was otherwise unremarkable.

Physical examination of the right lower extremity re-vealed obvious swelling to the lateral aspect of the ankleand midfoot. Ecchymosis was present inferior to the lateralmalleolus. Pinpoint tenderness was present over the pero-neal tubercle and at the calcaneocuboid joint. The patientwas able to evert his foot with full strength, which appearedto be through the muscular contraction of peroneus brevis.Peroneus longus function could not be isolated and elicitedpain with testing. A weight-bearing examination was notperformed because of the pain, but loading of the footrevealed a pes cavus foot type. The first ray was stable, andno forefoot callosities were present.

Injury radiographs revealed a displaced fractured right osperoneum (Fig 1). The proximal fragment of the os peroneumretracted proximally to the level of the peroneal tubercle (Fig2). The larger distal fragment of os peroneum remained at thecuboid notch and appeared to have both smooth and roughedges. Small flecks of bone were present at the cuboid notch.A diagnosis of peroneus longus rupture with os peroneumfracture was made. The appearance of the bone fragments aresuggestive that the os peroneum may have been partite andruptured/fractured through the partite site. Because of the pa-tient’s history of chronic lateral ankle pain and sprains, a

FIGURE 1 Lateral nonweightbearing radiograph of right foot dem-onstrating significantly displaced fracture of a large os peroneum.Proximal fragment (black arrow) retracted within the peroneus lon-gus tendon. The distal fragment (white arrow) remains located withinthe stump of peroneus longus at the cuboid notch.

magnetic resonance image (MRI) was obtained to evaluate the

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peroneal tendons for preexisting disease as well as to confirmthe diagnosis of an os peroneum fracture (Fig 3).

Eleven days after the injury, the patient was brought tothe operating room. A curvilinear incision was made di-rectly over the peroneal tendons from the fibular malleolusto the fifth metatarsal base. A subcutaneous hematoma wasencountered consistent with the injury. The peroneal sheathand inferior peroneal retinaculum were incised. The pero-neus longus rupture with fractured os peroneum was imme-diately identified at the peroneal tubercle. The large ossicleencompassed the entire width of the tendon. A 1-cm seg-ment of tendinosis with the peroneus longus tendon wasidentified just proximal to the fracture. The peroneus brevistendon was intact without rupture, longitudinal tear, ortendinosis. The distal fragment of the fractured os peroneumwas identified at the cuboid notch. Because of the size offracture fragments, tendinosis of the peroneus longus ten-don, and inability to access the distal tendon stump, theprospects of performing a primary repair were abandoned.

FIGURE 2 Anteroposterior radiograph of right foot demonstratingos peroneum fracture. The proximal fragment (black arrow) is re-tracted to the level of the inferior peroneal retinaculum. In this view,the fractured ossicle may be mistaken for a hypertrophic peronealtubercle. Distal fragment (white arrow) remains located beneath thecuboid.

Rather, a peroneus longus to peroneus brevis tendon transfer

LUME 46, NUMBER 4, JULY/AUGUST 2007 271

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was performed above the ankle joint. The distal tendon andfragment of os peroneum were left untouched. The incisionwas extended proximally, and the peroneus longus tendonwas sutured to the posterior aspect of the peroneus brevistendon. The peroneus longus tendon was debulked, and theadjoining paratenons were stripped as the tendons weresecured together with an absorbable 2-0 suture. The tendontransfer was positioned with the foot at 90° to the leg. Theperoneal tendon sheath was reapproximated. Subcutaneoustissue and skin closure was performed in the standard tech-nique.

A Jones splint was placed on the operative extremity in theoperating room. The patient would be nonweightbearing for 8weeks total. At the first postoperative visit (2 weeks after theoperation), sutures were removed. The extremity was placedinto a removable cast boot for the remaining 6 weeks ofnonweightbearing. The patient began a gentle range-of-motionprogram twice daily. Weightbearing was initiated after 8weeks as well as a physical therapy program targeting peronealmuscle strength and proprioception. The patient was transi-

FIGURE 3 MRI (fat saturation sequence) of right foot clearly visualiperoneus longus tendon. Note the fusiform thickening of the pertendinosis. Peroneus brevis tendon is visualized and intact (white a

tioned into stable shoes after 10 weeks postoperatively.


Although the postoperative course was uneventful regardingthe operative right side, the patient was complaining of persis-tent lateral ankle pain in the peroneal tendon region of thecontralateral side. He related a sporadic history of lateral anklepain in the past, but this episode was exacerbated by thenonweightbearing status of the contralateral extremity. Physi-cal examination of the left lower extremity revealed minimalpain along the peroneus longus tendon from the fibular mal-leolus to the peroneal tubercle. Peroneus longus strength wasslightly diminished (grade 4�/5) and elicited pain with resis-tance. A weightbearing examination demonstrated a high archfoot with slight heel varus of 2° inverted. Radiographs werenot obtained. Magnetic resonance imaging demonstrated apartite os peroneum extending the entire width of the tendon(Fig 4), minimal intratendinous signal of the peroneus longustendon proximal to the ossicle, and thickening of the tendon atthe peroneal tubercle region—suggestive of a tendinosis and alongitudinal split of the tendon. Surgery was offered to thepatient, but he declined, and a conservative treatment programof physical therapy, antiinflammatories, and an ankle brace

e retracted fractured os peroneum (black arrow) retained within thes longus tendon just proximal to fracture fragment, indicative of).

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was implemented.

Almost exactly 1 year from the previous injury and fromsimilar activity, the patient injured his left ankle whilesliding into a base during a baseball game. The patientrecalled a popping sound within the ankle. He related ahistory of pain and discomfort involving the peroneal areafor 1 week before this injury.

Physical examination of the left lower extremity revealedlocalized swelling to the lateral aspect of the ankle and mid-foot. There was ecchymosis over the peroneal tubercle. Pin-point tenderness was present over the peroneal tubercle and atthe calcaneocuboid joint. The patient was able to evert his footwith full strength, which appeared to be through the muscularcontraction of peroneus brevis. Peroneus longus function couldnot be isolated and elicited pain with testing.

Injury radiographs revealed a fractured right os peroneum(Fig 5). The bone fragments were significantly displaced,with a large fragment retracted proximally to the level of theperoneal tubercle and a smaller waferlike fragment as wellas a bone fleck of the os peroneum remaining at the cuboid

FIGURE 4 MRI (fat saturation sequence) of left lower extremity 1 yeat the cuboid notch and appears to be partite.

notch. A diagnosis of peroneus longus rupture with os

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peroneum fracture was made. An MRI was obtained toevaluate any further intratendinous damage to the peroneuslongus compared with the patient’s study 1 year before onthe same extremity (Fig 6). The radiographic appearance ofthe fracture fragments and MRI suggest that os peroneumwas partite and fractured/ruptured through the partite site.

The patient was brought to the operating room, and a per-oneus longus to peroneus brevis tendon transfer above the levelof the ankle joint was performed on the left lower extremity. Acurvilinear incision was made directly over the peroneal ten-dons, beginning proximal and posterior to the fibular malleolusextending past the peroneal tubercle. The peroneal sheath andinferior peroneal retinaculum were incised. The peroneus lon-gus rupture with fractured os peroneum was located at theperoneal tubercle (Fig 7). The large ossicle encompassed theentire width of the tendon. In addition, a 1-cm segment oftendinosis within the peroneus longus tendon was identifiedjust proximal to the fracture. The peroneus brevis tendon wasintact without rupture, longitudinal tear, or tendinosis. Because

fore injury. The intact os peroneum (white circle) is clearly visualized
ar be
of the size of the proximal fracture fragments, tendinosis of the


peroneus longus tendon and inability to access the distal ten-don stump, the prospects of performing a primary repair wereabandoned. A peroneus longus to peroneus brevis tendontransfer was performed above the ankle joint. The distal tendonand fracture fragment of the os peroneum were left untouched.The peroneus longus tendon was sutured to the posterior aspectof the peroneus brevis tendon. The peroneus longus tendonwas debulked, and the adjoining paratenons were stripped asthe tendons were secured together with an absorbable 2-0suture. The tendon transfer was positioned with the foot at 90°to the leg. The peroneal tendon sheath was reapproximatedwith 3-0 absorbable suture. Subcutaneous tissue and skin clo-sure was performed in the standard technique.

At follow-up 1 year after surgery on the patient’s left sideand 2 years after surgery on the patient’s right side, he wassatisfied with his outcome. Clinically, the incisions were wellhealed, and there was no pain at the surgical sites. As expected,the patient is unable to plantarflex the first ray bilaterally. Thefirst ray remained stable, and first ray elevatus did not develop.In addition, his chronic lateral ankle pain has been resolved as

FIGURE 5 Lateral radiograph of left foot demonstrating signifi-cantly displaced fracture of the os peroneum. Larger proximal frag-ment (black arrow) is retracted within the peroneus longus tendon.Distal fragment (white arrow) is waferlike and remains located at thecuboid notch.

a result of this injury and reconstruction.


Discussion

Several etiologic factors have been associated with per-oneus longus injuries. Forced inversion may place the per-oneus longus at risk for injury. Advanced age, inflammatoryarthritis, obesity, and metabolic disease may be contributingfactors (6, 7, 19–23). Previous steroid injection(s) or oralagents known to elicit tendon rupture (for example, Cipro-floxacin) should not be overlooked (8, 24). Some of theanatomic and mechanical factors that play a role in peroneusbrevis injuries are also suggested to occur with peroneuslongus injuries. These include a flat fibular groove, hyper-trophic peroneal tubercle, giant lateral malleolus, peronealsubluxation, and lateral ankle instability (8–14, 19, 20,25–27). Although mechanical lateral ankle instability haslong been linked to peroneal tendon pathology, Bassett andSpeer state that ankle instability is not a requirement foreither peroneus brevis or longus tendon injury (9–12, 25–28). It is thought that a cavovarus foot type places increasedstress on the peroneal tendons, which may predispose thetendons to injury and/or degeneration (6–10, 13, 14, 16–19). A watershed area (hypovasular zone) has been sug-gested to predispose the tendon to rupture as well (29–31).

The presence of an os peroneum, especially an enlargedossicle, is associated with peroneus longus tendon ruptures (8,17, 32). Although the purpose of the sesamoid is to protect thetendon from rupture, the os peroneum may actually encouragefatigue (tear/rupture) under certain circumstances. The pres-ence of an os peroneum has been reported to occur in 5% to26% of individuals. (3, 4, 6, 7, 13, 17, 26, 33–45). Grantidentified an os peroneum in 26% of 92 cadaveric dissections(41). Burman and Lapidus reviewed 1000 radiographs andfound a 14% incidence of the os peroneum (39). A collectiveeffort by the Anatomical Society identified that the os pero-neum was present in 20% of 225 feet (37). They also identifiedthat fibrocartilaginous thickening within the tendon occurs atthe cuboid notch in 55% of feet (37). Sarrafian reported thatfibrocartilaginous thickening is always present and is fullyossified in 20% of cases (13, 17, 19, 34, 42). Edwards alsoreported ossification of the os peroneum in 20% of cases (46).The os peroneum may also demonstrate partism. In a radio-graphic review, Burman and Lapidus found that when the osperoneum is present, 19% were bipartite and 1% were multi-partite (39). Bianchi indicated that 25% of patients with an osperoneum may be partite (47).

The most common injury to the peroneus longus tendonis a longitudinal split (19, 22). Complete transverse ruptureis rare. The presence of an os peroneum has been listed asan etiologic factor to peroneus longus tendon rupture or tear(3, 5, 15, 17). Partite sesamoids may render the tendon moresusceptible to rupture/fracture because of a potential innatearea of weakness between the sesamoid fragments. A non-displaced fracture of the os peroneum is not always a
straightforward diagnosis in the presence of partism. A

oid.

partite os peroneum may be mistaken for a fracture whenthere is a specific history of trauma. Displaced fragments ofbone with ragged edges may be easily distinguished. None-theless, peroneus longus ruptures and discontinuity associ-ated with an os peroneum fracture or fracture through apartite os peroneum is an uncommon event.

In this case report, the radiographic appearance of the frac-tured os peroneums is suggestive that the os peroneum mayhave been partite because the edges of the bone-displaced bonefragments had both smooth and rough edges. We were fortu-nate to have magnetic resonance imaging of the left side beforeand after the injury, confirming the presence of partism on theleft side. It appears that the os peroneum fracture occurredthrough the partite region (Figs 4 and 6). This suggests that apartite os peroneum may be predisposed to fracture through thesynchondrosis site. McMaster’s observations that tendon rup-tures may occur at the insertion of tendon into bone furthersupport the concept that the os peroneum may predispose theperoneus longus tendon to rupture (48).

FIGURE 6 MRI (T1-weighted sequence) of left lower extremity imperoneum). The fracture occurred at the partite region of the sesam

Repairing peroneus longus ruptures at the cuboid notch with

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or without the presence of an os peroneum is a surgicaldilemma because it may be difficult to access the distal stumpof the tendon deep in the midfoot. Ruptures with a small osperoneum and little gapping of the tendon ends may be re-paired with an end-to-end anastomosis, as long as the distaltendon end is accessible. In some situations, tendon graftingmay be needed to augment the repair (15, 17, 21, 31, 29, 36,49–53). Harvest sites for tendon grafting of the peroneuslongus have included the plantaris tendon, peroneus teritius,half of the peroneus brevis, or deep fascia (15, 18, 29). Pero-neus longus rupture with a large os peroneum and a signifi-cantly displaced fragment is a more challenging situation.Cerclage wiring of the os peroneum fracture may be per-formed. Peacock et al reported primary repair of an os pero-neum fracture by weaving nonabsorbable suture through theossicle and tendon (3). Many would argue the purpose offixating an os peroneum fracture altogether because it willremain a point of possible tendon weakness. Some advocateexcising the fractured bone segments (3, 5, 6, 15, 17, 21, 36).

iately after injury demonstrating fracture of the os peroneum (os
med
However, if primary tendon repair is attempted after removing


the fractured sesamoid, then a significant tendon defect mayremain, possibly precluding an end-to-end repair. Saxenaand Cassidy do not recommend primary repair with gap-ping greater than 1 cm (5).

Other options for repair of a peroneus longus rupture with osperoneum fracture involve the following: 1) removing thefractured os peroneum and performing a peroneus longus toperoneus brevis tendon transfer above the ankle, 2) peroneuslongus tenodesis to the cuboid, or 3) a peroneus longus teno-desis to the lateral calcaneus (9, 10, 33, 51, 54). In thesescenarios, the plantarflexion and eversion function of the per-oneus longus is maintained at the ankle and subtalar joint;however, the plantarflexory effect on the first ray is lost (10,15). The aforementioned techniques avoid a second harvestsite for tendon grafting and avoid the complications associatedwith accessing the plantar midfoot. Moreover, the risk ofre-rupture of the repair site is eliminated, though failure of thetendon transfer may occur. Patients with concomitant nonre-pairable or nonsalvageable tendinosis of the peroneus longustendon are excellent candidates for these procedures.

In our patient, we performed a peroneus longus to pero-

FIGURE 7 Intraoperative image of the left lower extremity demon-strating the peroneus longus rupture with fractured os peroneumretained within the tendon end. Note tendinosis of the peroneuslongus tendon just proximal to the fractured sesamoid.

neus brevis tendon transfer bilaterally.


Primary repair was precluded because of the large size offractured bipartite os peroneum and associated tendinosis ofthe peroneus longus tendon. At the time of surgery, weconsidered performing a free tendon graft; however, thiswould require a lengthy graft that would be difficult tosecure to the distal stump. Accessing the distal peroneuslongus tendon stump after excision of the large distal osperoneum fracture fragment would be challenging and,most importantly, would likely not provide enough remain-ing peroneus longus tendon to anastamose to the peroneusbrevis at the cuboid notch.

If the distal peroneus longus tendon stump is unable to bere-anastomosed to the peroneus brevis, then removal of thedistal os peroneum fracture fragment is probably not nec-essary. We believe that the risks of removal are greater thansimply leaving the fracture fragment undisturbed. Gainingaccess to the distal os peroneum fracture fragment at thecuboid notch potentially exposes the sural nerve to injury aswell as increases the risk for deep complications such ashematoma, vascular injury, and/or scar tissue formation. Ifthe retained distal fractured os peroneum becomes symp-tomatic, then it could be removed in the future. The greaterconcern is the loss of peroneus longus effect on the first ray,which may potentially result in first ray elevatus. Loss ordampening of peroneus longus in patients with pes cavova-rus may be advantageous in certain circumstances. Becauseour patient had both lateral ankle instability and a cavovarusfoot type, we performed a peroneus longus to peroneusbrevis tendon transfer above the ankle joint and left thedistal fracture fragment undisturbed. Because we werepleased with the clinical and functional result obtained withthe right lower extremity surgery, the same procedure wasperformed on the left lower extremity.

Conclusion

The peroneus longus tendon may be susceptible to injury inthe presence of an os peroneum. While the purpose of thesesamoid is to protect the tendon from rupture at the cuboidnotch, the presence of a partite os peroneum may actuallyencourage fatigue (tear/rupture) under certain circumstances.We present a case of traumatic bilateral peroneus longus rup-ture with fracture of a partite os peroneum in a patient with acavovarus foot type. A peroneus longus to peroneus brevistendon transfer was performed above the ankle joint.

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bilateral peroneus longus tendon rupture …...bilateral peroneus longus tendon rupture through a...

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