Technique tip: tubularizing flat tendons in foot and ankle surgery

We describe a novel technique of tubularizing flat tendons in tendon transfer procedures, including Jones procedure and Chrisman-Snook reconstruction. The technique strengthens the tendon, facilitates passage and fixation through bony tunnels, and helps protect it from fraying.     

Technique tip: 3D printing surgical guide for pes cavus midfoot osteotomy

BackgroundPes cavus can be defined as an abnormal elevation of the longitudinal arches, which is often secondary to a muscle imbalance. This deformity affects the foot’s three dimensions (3D) and our osteotomies are usually planned on a lateral (two-dimension) X-ray. Are we really considering all the spatial components of the deformity? The aim of this study is to present a technique tip to identify the apical plane of the pes cavus deformity and perform a midfoot dorsal-based wedge resection osteotomy by using customized 3D printed surgical guides.MethodsThree patients underwent the presented technique, all for the indication of symptomatic neuromuscular pes cavus with both anterior and posterior deformity.Results3D-printed patient-specific guides help the surgeon to minimize human error, improving intraoperative accuracy, while reducing surgical time and intraoperative X-ray exposure.ConclusionsClosing wedge midfoot osteotomy to correct anterior pes cavus may be an interesting indication to use customized 3D printed surgical guides.     

Surgery for recurrent dislocation of the peroneal tendons

Thirty-five patients with recurrent dislocation of the peroneal tendons were operated a.m. Du Vries. One patient had bilateral dislocations. The dislocation was traumatic in 28 cases and idiopathic in eight. Peroperative complications occurred in eight of the 36 patients due to malposition of a screw, fracture of the malleolus and/or fracture of the bone graft.

The follow-up period was 5 years. In 31 cases the functional results were satisfactory. Five cases were unsatisfactory due to re-dislocation, subluxation or a vague feeling of instability. The inserted screw was the cause of moderate complaints in 15 cases.

The Du Vries' operation is technically difficult; the sliding bone graft must be of adequate size; the position of the screw should be checked radiographically during the operation; and the screw should be removed when the bone graft has healed.     

Superior retinaculoplasty for recurrent dislocation of peroneal tendons

BACKGROUND: Although dislocation of peroneal tendons is an uncommon injury, if it does occur, daily and sports activities may be restricted because of snapping of the tendons and pain in the posterolateral aspect of the ankle joint. Many operative procedures have been reported for this pathology, including anatomic reattachment of the retinaculum, bone block procedures, tissue-transfer procedures, and groove-deepening. However, no procedure has been established as the "gold standard." Successful results were reported after anatomic reattachment of the detached superior peroneal retinaculum and periosteum of the fibula. We have modified the procedure to reduce operative invasiveness and introduced a method to determine proper tension when suturing the retinaculum to the fibula. METHODS: In our retinaculoplasty, the false pouch was opened through one incision, and the retinaculum was sutured to the fibula while measuring the tension, avoiding too tight or too loose suturing. We performed this procedure in 20 patients with symptomatic dislocation of peroneal tendons in whom conservative treatment had failed. We followed them over 2 years, and clinical results were evaluated. RESULTS: No patient had re-dislocation of the peroneal tendons during the followup period. Fifteen of 18 patients who had been involved in sports activities returned to their previous activities without reducing their activity levels. All patients acquired full range of motion of the ankle joint postoperatively. The preoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores improved significantly (p value < 0.01) postoperatively. CONCLUSIONS: This study demonstrated that the described repair successfully treated patients with symptomatic dislocation of the peroneal tendon and should be considered for this pathology.     

创伤性腓骨肌腱滑脱的诊治体会

创伤性腓骨肌腱滑脱非临床上常见病,易被很我医生忽略,未行适当治疗,至晚期形成习惯性腓骨肌腱滑脱,需手术治疗.2004年10月至2009年6月收治此类患者6例,均属晚期,行手术治疗后效果满意,现报告如下. 1 临床资料     

Tibia fracture after fibula resection for distal peroneal bypass

The lateral approach to the distal peroneal artery has been used by vascular surgeons for 25 years. No complications specifically related to this approach have previously been reported. We reviewed 18 cases of peroneal bypass for limb salvage using the lateral approach with fibula resection and found that two of these cases had ipsilateral tibia fractures within 1 year of the bypass. Eight out of 18 cases were women, and two of these eight had tibia fracture. Both women suffered from osteoporosis. We conclude that tibia fracture is a possible complication of this approach, especially in elderly women with osteoporosis.     

Dislocation of peroneal tendons: a new operative treatment

Traumatic dislocation of the peroneal tendons is not a common complaint. However, in athletic individuals it can cause significant disability. Although some authors advocate conservative management, this is only effective in up to 60% of cases and most authors believe that recurrent, symptomatic peroneal dislocations should be treated operatively. Various methods have been described in the literature using bony procedures or autologous tissue. We describe a new method using polyester tape. This is a simple procedure and we present five patients, all of whom returned to pre-morbid activities, in one case that of marathon-running and two to professional football. The advantage of this method is that it avoids damaging adjacent structures to provide stability and we show magnetic resonance imaging (MRI) evidence of tissue ingrowth into the tape without associated damage.     

A repair operation for recurrent dislocation of peroneal tendons

A lesion similar to that described by Bankart in recurrent dislocation of the shoulder was seen in seven patients with recurrent dislocation of the peroneal tendons. Detachment of the periosteum had resulted in the formation of a false pouch on the surface of the lower end of the fibula; into this pouch the peroneal tendons could easily dislocate. Reattachment of the periosteum to drill holes in the fibula prevented dislocation, and this anatomical method of repair is described. This lesion is one of the causes of recurrent dislocation of the peroneal tendons.     

Blood supply of the peroneal tendons: Injection and immunohistochemical studies of cadaver tendons

We studied the vascular pattern of human peroneal tendons with injection techniques and immunohistochemically by using antibodies against laminin. The main blood supply arises from the peroneal artery. The distal part of the peroneus longus tendon is supplied by branches of the medial tarsal artery. Blood vessels enter the peritenon of both tendons via a mesotenon from the posterior aspect. From the peritenon, the blood vessels penetrate the peroneus brevis and peroneus longus tendons and anastomose with a longitudinally-oriented intratendinous network. The amount of vessels in the tendon substance is consistently less than in the surrounding peritenon. The distribution of blood vessels in the peroneal tendons is not homogeneous. In the region where the peroneus brevis tendon passes through the fibular groove, the longitudinally-oriented intratendinous vascular network is interrupted and the tendon is almost avascular. In this region, the tendon is squeezed between the peroneus longus tendon and the bony slide bearing of the lateral malleolus. The peroneus longus tendon has two avascular zones. In the region where the peroneus longus tendon curves around the lateral malleolus and the peroneal trochlea of the calcaneus, the anterior part of the tendon which is directed towards the pulley is avascular. A second avascular zone is located more distally in the region where the tendon changes direction and wraps around the cuboid.     

Blood supply of the peroneal tendons: Injection and immunohistochemical studies of cadaver tendons

We studied the vascular pattern of human peroneal tendons with injection techniques and immunohistochemically by using antibodies against laminin. The main blood supply arises from the peroneal artery. The distal part of the peroneus longus tendon is supplied by branches of the medial tarsal artery. Blood vessels enter the peritenon of both tendons via a mesotenon from the posterior aspect. From the peritenon, the blood vessels penetrate the peroneus brevis and peroneus longus tendons and anastomose with a longitudinally-oriented intratendinous network. The amount of vessels in the tendon substance is consistently less than in the surrounding peritenon. The distribution of blood vessels in the peroneal tendons is not homogeneous. In the region where the peroneus brevis tendon passes through the fibular groove, the longitudinally-oriented intratendinous vascular network is interrupted and the tendon is almost avascular. In this region, the tendon is squeezed between the peroneus longus tendon and the bony slide bearing of the lateral malleolus. The peroneus longus tendon has two avascular zones. In the region where the peroneus longus tendon curves around the lateral malleolus and the peroneal trochlea of the calcaneus, the anterior part of the tendon which is directed towards the pulley is avascular. A second avascular zone is located more distally in the region where the tendon changes direction and wraps around the cuboid.     

Blood supply of the peroneal tendons: injection and immunohistochemical studies of cadaver tendons

We studied the vascular pattern of human peroneal tendons with injection techniques and immunohistochemically by using antibodies against laminin The main blood supply arises from the peroneal artery. The distal part of the peroneus longus tendon is supplied by branches of the medial tarsal artery. Blood vessels enter the peritenon of both tendons via a mesotenon from the posterior aspect. From the peritenon, the blood vessels penetrate the peroneus brevis and peroneus longus tendons and anastomose with a longitudinally-oriented intratendinous network. The amount of vessels in the tendon substance is consistently less than in the surrounding peritenon. The distribution of blood vessels in the peroneal tendons is not homogeneous. In the region where the peroneus brevis tendon passes through the fibular groove, the longitudinally-oriented intratendinous vascular network is interrupted and the tendon is almost avascular. In this region, the tendon is squeezed between the peroneus longus tendon and the bony slide bearing of the lateral malleolus. The peroneus longus tendon has two avascular zones. In the region where the peroneus longus tendon curves around the lateral malleolus and the peroneal trochlea of the calcaneus, the anterior part of the tendon which is directed towards the pulley is avascular. A second avascular zone is located more distally in the region where the tendon changes direction and wraps around the cuboid.     

Distal metatarsal osteotomy for hallux valgus

Distal osteotomy of the first metatarsal with a step lateral displacement has been used in the treatment of 34 feet with hallux valgus.Stability of the osteotomy is achieved by a dorsomedial capsulorrhaphy. Suturing through drilled holes or internal fixation were not necessary. One case was complicated by dorsal tilt of the head of the metatarsal bone and required revision.