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Allograft Reconstruction of Irreparable Peroneal Tendon Tears

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Allograft Reconstruction of Irreparable Peroneal Tendon Tears DOJ 10.5005/jp-journals-10017-1022 ORIGINAL RESEARCH Allograft Reconstruction of Irreparable Peroneal Tendon Tears: A Preliminary Report Allograft Reconstruction of Irreparable Peroneal Tendon Tears: A Preliminary Report William R Mook MD, James A Nunley MD ABSTRACT appreciated.1,2 The symptoms of peroneal tendon disorders Background: Peroneal tendon injuries represent a significant are also often vague and misdiagnosed on initial 2-4 but underappreciated source of lateral ankle pain. Partial presentation. Peroneal tendon dysfunction can be thickness tears of the peroneus brevis amenable to direct repair attributed to tendonitis, chronic tenosynovitis, subluxation, techniques are common. Irreparable tears are uncommon and fraying, longitudinal fissuring, partial tears and complete require more complex surgical decision-making. Intercalary 5-9 segment allograft reconstruction has been previously described tears. These abnormalities can be observed with as a treatment option; however, there are no reports of the concomitant chronic ankle instability, cavovarus foot outcomes of this technique in the literature. We present our deformities, low-lying peroneus brevis muscle bellies, results utilizing this technique. superior peroneal retinacular insufficiency, fibular bone Materials and methods: A retrospective chart review was spurs, and following severe ankle sprains.6,10-12 conducted to identify all patients who underwent intercalary allograft reconstruction of the peroneus brevis. Mechanism of Several classification systems have been described to injury, concomitant operative procedures, pertinent radiographic characterize peroneal tendon tears in order to improve the findings, pre- and postoperative physical examination, decision-making in operative management.4,13 Acute partial intercalary graft length, medical history, visual analog scores (VAS) for pain, short form-12 (SF-12) physical health survey, thickness tears can often be tubularized or repaired lower extremity functional scores (LEFS), and complications primarily. However, chronic tendon injuries often require were reviewed. other treatment options including autologous tendon Results: Eight patients with eight peroneus brevis tendon transfers, tendon lengthening, allograft reconstructions or ruptures requiring reconstruction were indentified. Mean synthetic graft reconstruction.14-19 Redfern and Myerson20 follow-up was 15 months (range, 10-31). The average length of the intercalary segment reconstructed was 12 cm ± 3.9 (range, have proposed an algorithm for systematically addressing 8-20). The average postoperative VAS decreased to 1.0 ± 1.6 peroneal tendon tears based on the intraoperative findings. from 4.0 ± 2.2 (p = 0.01). No patient had a higher postoperative If one tendon is torn and irreparable, tenodesis of the two pain score than preoperative pain score. Average postoperative eversion strength improved from 3.5 ± 1.2 to 4.81 ± 0.37 (p = peroneal muscles is recommended. Others have 0.03). The average SF-12 survey improved from 41.1 ± 12.3 to recommended tendon transfer, which has also been reported 50.2 ± 9.31 (p = 0.06). The average LEFS improved from 53.3 with satisfactory results.21 While both of these offer a ± 17.0 to 95.25 ± 10.0 (p = 0.02). Four patients experienced relatively simple and perhaps less technically demanding sensory numbness in the sural nerve distribution, and two of these were transient. There were no postoperative wound healing options, the results of autologous tendon transfers are often complications, infections, tendon reruptures or reoperations. No hampered by donor site morbidity and theoretically alter allograft associated complications were encountered. All patients normal gait mechanics. returned to their preoperative activity levels. The use of an allograft tendon for reconstruction of an Conclusion: Allograft reconstruction of the peroneus brevis can improve strength, decrease pain, and yield satisfactory patient- intercalary segment defect is a novel technique with several reported outcomes. Importantly, this can be successfully advantages. Allograft reconstructions include shorter performed without incurring the deleterious effects associated operative times and a greater availability of graft sizes.22 with tendon transfer procedures. Our results suggest that Additionally, by restoring the muscle-tendon unit, preinjury allograft reconstruction may be a safe and reasonable alternative in the treatment of irreparable peroneal tendon ruptures. gait mechanics can potentially be restored without Level of evidence: Therapeutic level IV. sacrificing the function of donor or local tendons. Numerous authors have reported satisfactory results of peroneal tendon Keywords: Peroneal tendon, Tendon rupture, Allograft, Tendon 21,23,24 reconstruction. reconstructions with autograft transfer. More recently, the use of acellular dermal matrix has been reported.25 We Mook WR, Nunley JA. Allograft Reconstruction of Irreparable Peroneal Tendon Tears: A Preliminary Report. The Duke have previously published our surgical techniques for Orthop J 2013;3(1):1-7. allograft reconstruction.26,27 To our knowledge there are no reports of the clinical results of single stage allograft INTRODUCTION reconstructions of peroneal tendons. The purpose of our Peroneal tendonopathy is a source of lateral ankle pain and study was to review the clinical outcomes associated with dysfunction that is often overlooked and under- this technique at our institution. We hypothesized that the The Duke Orthopaedic Journal, July 2012-June 2013;3(1):1-7 1 William R Mook, James A Nunley use of tendon allografts in the treatment of peroneal tendon ruptures is safe, effective, and yields favorable patient reported outcomes. MATERIALS AND METHODS After institutional review board approval, a retrospective review of the senior author’s (JAN) practice database at Duke University Medical Center was performed. A perioperative current procedural terminology (CPT) code database identified patients with irreparable peroneal tendon ruptures that had been reconstructed utilizing tendon allografts between July 2007 and April 2011. Patients’ charts Figs 1A and B: (A) Preoperative T2-weighted MRI sagittal section were reviewed and assessed for details of their mechanism at the level of the fibula depicting a complete rupture of the peroneus of injury, concomitant operative procedures, any pertinent brevis and longus tendons, (B) T2-weighted MRI axial section of the same patient’s tendon tears shown at the level of the ankle radiographic findings, pre- and postoperative physical joint examination, intercalary graft length, medical history, visual analog scores (VAS) for pain, short form-12 (SF-12) abnormalities. There was one patient with noninsulin- physical health survey, lower extremity functional scores dependent diabetes mellitus; otherwise, medical comorbi- (LEFS) and complications. dities were noncontributory. Average preoperative SF-12 physical health and LEFS were 41.10 ± 12.3 and 53.3 ± STUDY POPULATION 17.0, respectively. The average preoperative VAS for pain Eight patients were identified to have undergone intercalary was 3.5 ± 1.2 (range, 1-7). segment peroneal tendon allograft reconstructions. Approximately 40% (3 of 8 patients) reported an acute OPERATIVE TECHNIQUE inversion injury where they experienced an audible ‘pop’ All operative procedures were performed by the senior about the ankle immediately preceding presentation, the author (JAN) and an orthopaedic resident or fellow. Patients remaining 60% (5 of 8 patients) were presumed to have were positioned in the lateral decubitus position. Pre- chronic tears. Their mean age was 54 (range, 22-70) years operative antibiotics were administered. A thigh tourniquet at the time of surgery. Mean follow-up was 15 months was used to improve visualization. A longitudinal incision (range, 10-31 months). Four patients were male and four was fashioned over the posterolateral fibula. The incision were female. Five of eight surgeries were performed on the was extended distally to the base of the fifth metatarsal left side and three on the right. All eight cases involved (Fig. 2). The lesser saphenous vein and sural nerve were tears of greater than 50% of the cross-sectional area of the identified and protected when encountered while dividing peroneus brevis tendon. Concomitant procedures included subcutaneous tissue. The peroneal tendon sheath was then Brostrom-Gould lateral ligament reconstruction (one identified and opened proximally to distally. The contents patient), peroneus longus tenosynovectomy (three patients), were examined for evidence of crowding within the fibular excision of peroneus longus (one patient), peroneus longus groove, presence of an accessory peroneal muscle, presence repair (two patients), Dwyer calcaneal osteotomy (one and extent of tenosynovitis, as well as the status of the patient), peroneus longus to brevis transfer (one patient), superior peroneal retinaculum (Fig. 3). The proximal dorsal closing wedge osteotomy of 1st metatarsal (one peroneus brevis muscle was then identified and freed from patient), and fibular groove deepening (one patient). All surrounding tissue. The distal end was debrided until healthy patients underwent preoperative magnetic resonance appearing tissue was encountered. The distal tendon stump imaging (MRI), which revealed a tear of one or both of the was then identified at the base of the fifth metatarsal (Fig. 4). peroneal tendons (Figs 1A and B). Average preoperative The defect
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