Significance of sesamoid ossification in peroneus longus tendon ruptures

Ruptures of the peroneus longus tendon are uncommon, with a small number of case reports found in published studies. The presence of an os peroneum can predispose the peroneus longus tendon to rupture at the cuboid level with or without concomitant fracture, or fracture through a partite os peroneum. Whether the os peroneum can be represented by various stages of ossification is still a matter of debate. We present 2 cases of acute peroneus longus tendon rupture at the cuboid notch in the presence of an intact os peroneum in the ossified and nonossified form. We treated patients with excision of the os peroneum and tenodesis of the peroneus longus to the peroneus brevis tendon.     

Bilateral Peroneus Longus Tendon Rupture Through a Bipartite Os Peroneum

Peroneus longus rupture with associated involvement of the os peroneum is an uncommon injury, and a small number of cases have been reported. Several mechanisms of injury have been suggested, but the most accepted theory is due to an inversion force placed on a cavovarus foot type. The sesamoid often becomes the focal point of the mechanical stresses and may fracture. Although the purpose of the sesamoid 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 repair is complicated because of the inability to access the tendon as it courses deep within the midfoot. We present a bilateral case of peroneus longus rupture with involvement of the os peroneum in a patient with a cavovarus foot type. The injuries were sustained from an identical mechanism and occurred almost 1 year apart. In both situations, a peroneus longus to peroneus brevis tendon transfer was performed above 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 os peroneum to occur bilaterally.     

Fracture of the os peroneum with rupture of the peroneus longus tendon. A case report and review of the literature

Subcutaneous rupture of the peroneus longus tendon occurring through a fracture of the os peroneum sesamoid in the foot, confirmed at surgery, is a rare injury, possibly with only one previously reported case. In the present case, the patient fell from a curb with the foot and ankle in supination; to prevent the fall, the patient forcibly everted the foot and ankle. Differential diagnosis of the injury includes chronic ankle ligament sprains, avulsion of the bony insertion of the peroneus brevis tendon, peroneal tendon subluxation, trauma to a congenitally multipartite os peroneum, and calcific tendonitis of the peroneus longus tendon. Primary repair with surgical approximation of the fractured os peroneum was performed with a satisfactory outcome.     

Peroneus longus tendon rupture as a cause of chronic lateral ankle pain

Rupture of the peroneus longus tendon with an associated fracture of the os peroneum is an uncommon injury, which may present as chronic lateral ankle instability. There have been only seven cases documented in the literature since 1966. A case of chronic peroneus longus tendon rupture with os peroneum fracture is presented. The authors review their clinical, radiographic, and operative treatment of this patient and review the literature of this unusual injury.     

Stress fracture of an os peroneum

Fracture of the os peroneum is relatively rare, and a stress fracture of the os peroneum is even rarer. We report a case of stress fracture of the os peroneum in a 38-year-old laborer who had been working in a crouching position. X-rays showed a multipartite os peroneum. Bone scintigram showed uptake at the os peroneum. The histology of the excised os peroneum revealed various stages of fracture healing. Excision of the fractured os peroneum and reconstruction of the peroneus longus tendon by end-to-end suture resulted in an excellent outcome.     

Spontaneous Fracture of the Os Peroneum With Rupture of the Peroneus Longus Tendon

Rupture of the peroneus longus tendon with or without an associated os peroneum fracture is rare and uncommonly encountered in the published data. Owing to the infrequent nature, a high index of suspicion is required. Otherwise, the opportunity for the injury to result in a delayed or missed diagnosis is increased. We report the case of a 39-year-old male with spontaneous rupture of the peroneus longus tendon and associated fracture of the os peroneum. The spontaneous rupture and fracture were diagnosed from the history, physical examination, and imaging findings. The patient elected to undergo operative repair, with excellent results, full recovery, and full return to normal function.     

Surgical treatment of the symptomatic os peroneum

The os peroneum is an accessory bone found in approximately 10% of the population. It is located in the distal portion of the peroneus longus tendon adjacent to, or plantar to, the cuboid. The bone can become symptomatic when multipartite or fractured. If conservative measures fail, surgical excision of the ossicle is performed and provides symptomatic relief. A case of symptomatic os peroneum treated surgically is presented, with illustrations of the surgical technique.     

Nonoperative Treatment of an Os Peroneum Fracture in a High-level Athlete: A Case Report

Background  

The os peroneum is a sesamoid bone in the peroneus longus tendon. Fractures of the os peroneum are rare. Some authors recommend surgery for active patients.     

Ruptur der Peroneus-longus-Sehne bei Os peroneum

Zusammenfassung Akzessorische Fußknochen und speziell das Os peroneum sind ein häufiger Nebenbefund am Fußskelett. Die Ruptur der Peroneus-longus-Sehne ist eher selten und tritt hauptsächlich bei vorgeschädigten Sehnen auf.Bei dem hier dargestellten Fall handelte es sich um einen knöchernen Ausriß der langen Peroneussehne mit darinliegendem Os peroneum bei einem Patienten mit chronischem Alkoholabusus.

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Rupture of the peroneus longus tendon with an Os peroneum. A case report

Accessory bones of the foot and specially the os peroneum are a frequently accidental finding in x-ray. A rupture of the peroneus tendon is rare and most times only to find at preinjured tendons.This case report shows a distal tearing out of the peroneus tendon from the bone with a supplementary os peroneum at a patient with chronical abuse of alcohol.

     

Stenosing tenosynovitis and impingement of the peroneal tendons associated with hypertrophy of the peroneal tubercle.

We report three patients with lateral ankle and foot pain, with the diagnosis of stenosing tenosynovitis of the peroneus longus tendon associated with a markedly enlarged peroneal tubercle. Stenosing tenosynovitis of the peroneus longus tendon associated with an atraumatically enlarged peroneal tubercle has rarely been reported, and these reported cases were associated with an os peroneum. One of our patients had no demonstrable associated os peroneum but did have a bony tunnel enveloping the peroneus longus tendon. Our other two patients had an os peroneum, but were asymptomatic at the lateral outer border of the cuboid tunnel; one patient had involvement of the peroneus longus and brevis tendons.     

Lasso Stitch with Peroneal Retinaculoplasty for Repair of Fractured Os Peroneum: A Report of Two Cases

Fracture of the os peroneus with retraction of the peroneus longus tendon can lead to weakness, instability, and progressive foot deformity. Treatment recommendations vary and include simple immobilization, repair of the fractured ossicle, excision of part or all of the fractured ossicle with repair of the tendon and tenodesis with the peroneus brevis tendon. We present two patients treated with excision of the proximal fragment and repair of the tendon to the distal fragment with relief of pain and restoration of function. The distal fragment was captured with a looped suture which allowed avoidance of a plantar exposure while still achieving an adequate repair. We also describe a technique for retinaculoplasty of the inferior peroneal retinaculum which we believe important to prevent postoperative adhesions to the tendon.     

Os peroneum fracture with sural nerve entrapment neuritis

The os peroneum is a sesamoid bone contained in the peroneus longus tendon. When present, it usually is located at the plantar lateral aspect of the cuboid. The author presents a case of os peroneum fracture causing sural nerve entrapment. A review of literature is also presented.     

Sonographic Evaluation and Sonographic-Guided Therapeutic Options of Lateral Ankle Pain: Peroneal Tendon Pathology Associated with the Presence of an Os Peroneum

Clinical implications of acute injuries of the os peroneum have been described, with the recommendation in some cases being the excision of the bone fragments. We describe the spectrum of sonographic appearances associated with pain in the region of the os peroneum, document associated peroneal tendon pathology, and describe the use of sonography to direct and guide therapeutic and/or diagnostic injections. All sonographic examinations in our ultrasound database from Jan 1, 2001–Jan 30, 2007 with the words “os peroneum” were reviewed. Patients were cross-referenced in our radiology database to find relevant foot or ankle radiographs for correlation. There were 47 patients (18 men and 29 women, age range 16 to 83) referred for sonographic evaluation of lateral foot and/or ankle pain who had an os peroneum identified during the sonographic evaluation. Eighteen patients were referred specifically for targeted injection of the lateral ankle, including peroneal tendon sheath injections (N = 10), calcaneocuboid joint injections (N = 1), and injections around symptomatic os peroneum (N = 7). All 47 patients had tendinosis of the peroneus longus, in varying degrees of severity. Radiographs were available for correlation in 28 patients. The causes of lateral ankle pain with a co-existent os peroneum are multifactorial and may not directly relate to the presence of an os peroneum. Ultrasound can be of value in separating out the specific etiology for pain, as well as provide a method for problem solving by the performance of targeted diagnostic or therapeutic injections in the lateral ankle.     

The influence of insoles with a peroneal pressure point on the electromyographic activity of tibialis anterior and peroneus longus during gait

Background

Peroneus longus acts as a foot evertor and pronator, thus ensuring stability of the talocrural joint by curbing inversion movement of the rearfoot. Increased activation of the peroneus longus muscle in the stance phase could have a stabilising effect on the ankle joint. This study aimed to determine whether the activity of the peroneus longus muscle could be increased by the targeted use of a specially formed lateral pressure element in a customised orthopaedic insole.

Methods

This was a laboratory-based study that utilised a randomised crossover design. Thirty-four healthy participants walked along a walkway in neutral footwear wearing a control insole or a sensorimotor insole with a lateral pressure point adjacent to the tendon of the peroneus longus muscle. The electromyographic muscle activity of the peroneus longus and tibialis anterior muscles was measured using surface electromyography. Contact with the ground was recorded via two pressure sensors under the sole of the shoe. Muscle activity during the stance phase was analysed in the time and amplitude domains and compared statistically with paired t-tests for both insole types.

Results

In 27 out of the 34 participants, an additional activity peak of the peroneus longus muscle was observed in the loading response phase with the sensorimotor insole, which reached its maximum at 29.7 % (±4.5 %) of the stance phase. When averaged over all 34 participants, the integrated electromyographic output for the peroneus longus in the mid-stance phase revealed a significant higher activity (p?<?0.001, post hoc power?=?0.98, effect size: Cohen’s d?=?0.71) with the sensorimotor insole (18.1?±?11.3 % MVCs) than with the control insole (11.2?±?7.7 % MVCs). No significant effects were established for the other gait phases or for the tibialis anterior.

Conclusions

An increase of muscle activity of the peroneus longus muscle was observed during the loading response and mid-stance phase, when orthopedic insoles with a lateral pressure point were worn. We conclude that the pressure point changes afferent information and leads to an increased peroneus longus activation in the time interval in which the pressure point exerted pressure on the peroneal tendon.

     

Flexor tendon injuries following plate fixation of distal radius fractures: a systematic review of the literature

Background

Flexor tendon rupture is a rare but major complication associated with volar plate fixation of distal radius fractures.

Materials and methods

We performed a systematic review to evaluate the demographics, clinical profile, treatment and outcome of flexor tendon rupture following volar plate fixation of distal radius fracture. Electronic searches of the MEDLINE, EMBASE, and Cochrane databases for systematic reviews and conference proceedings were performed. Studies were included if they reported flexor tendon rupture (partial or complete) as a complication of distal radius fracture plating (all levels of evidence).

Result

Our search yielded 21 studies. There were 12 case reports and 9 clinical studies. A total of 47 cases were reported. There were 11 males and 23 females (n = 16 studies). The mean age was 61 years old (range 30–85). The median interval between the surgery and flexor tendon rupture was 9 months (interquartile range, 6–26 months). Twenty-nine plates were locking and 15 were nonlocking (n = 20 studies). FPL was the most commonly ruptured tendon (n = 27 cases, 57 %), with FDP to index finger being the second most common (n = 7 cases, 15 %). Palmaris longus tendon graft and primary end-to-end repair were the most common surgical methods used in cases of FPL tendon rupture.

Conclusion

Flexor tendon rupture is a recognised complication of volar plating of distal radius fracture. Positioning of the plate proximal to the “watershed” line and early removal of the plate in cases with plate prominence or warning symptoms can reduce the risk of this complication.     

Checkrein deformity--an unusual complication associated with a closed Salter-Harris Type II ankle fracture: a case report.

This article presents a case of tethering of the flexor hallucis longus (FHL) tendon (checkrein deformity) and rupture of the posterior tibialis tendon after a closed Salter-Harris Type II ankle fracture. Delayed repair was affected by tenolysis of the FHL and flexor digitorum longus tendons and tenodesis of the posterior tibialis to the flexor digitorum longus tendon. This case represents the first such report of concomitant entrapment of the FHL tendon and rupture of the posterior tibialis tendon after a closed ankle fracture.     

Results of pronator quadratus repair in distal radius fractures to prevent tendon ruptures

Background:

Distal radius fractures are one of the the most common adult fractures encountered during the clinical practice of an orthopedic surgeon.^1,2 Although several methods of treatment are suggested for these fractures, there are still controversies about the best treatment approach in the literature. Volar plating of distal radius fracture is a method of treatment which has become increasingly popular. One of the complications of this technique is flexor tendon rupture. The purpose of this study was to evaluate the protectiveness of complete repair of pronator quadratus muscle against flexor tendon rupture.

Materials and Methods:

From September 2010 to September 2012, a consecutive series of 157 patients who were younger than 60 years with unstable distal radius fractures were included in the study. A standard volar approach to the distal radius was carried out. The radial and distal ends of pronator quadratus muscle were meticulously elevated from the radius and after volar plate fixation of the fracture, pronator quadratus muscle was restored to its normal insertion. We achieved full coverage of the plate with this muscle and followed the patients postoperatively.

Results:

A total of 135 patients were studied. The mean age of patients was 34 ± 10 years (range 20-60 years). One 55-year-old diabetic female patient with flexor tendon rupture was identified. The flexor pollicis longus tendon had ruptured 16 months after surgery.

Conclusions:

Pronator quadratus repair should be done in distal radius fracture to protect flexor tendons.     

Acute tibialis posterior tendon rupture associated with a distal tibial fracture

Tibialis posterior tendon ruptures associated with closed medial malleolar fractures are rare. This article describes the association of tibialis posterior tendon ruptures with closed, high-energy, distal tibia fractures. Tendon ruptures are likely to be identified intraoperatively or missed if clinical evaluation at acute injury is limited. A high index of suspicion is required to diagnose this injury. The consequences of an unrecognized tibialis posterior tendon rupture include progressive, painful pes planus deformities due to the unopposed action of the peroneus brevis muscle and lack of support of the medial longitudinal arch. Secondary operative intervention may be required. This article describes an intraoperative tenodesis technique between the tibialis posterior and flexor digitorum longus tendons when direct repair is not possible.A 48-year-old woman sustained a closed AO/Orthopaedic Trauma Association type 43A right lower-extremity distal tibia fracture and a traumatic left knee arthrotomy. Temporary stabilization with an external fixator was performed, followed by open reduction and internal fixation of the distal tibial fracture 6 days later. A periarticular nonlocking medial plate was applied, and the tibialis posterior tendon was shortened. We performed a direct tenodesis to the flexor digitorum longus tendon. At 1-year follow-up, the patient had made excellent progress, with no detectable muscle weakness, and was able to perform a single-leg toe raise.A review of the literature suggested which features of radiological evidence of tendon rupture should be examined, which may be useful in the current era considering most high-energy distal tibia or pilon fractures undergo examination with computed tomography.     

Peroneus quartus: prevalance and clinical importance

Introduction

The most common variant muscle of the ankle, peroneus quartus muscle, is located in the lateral leg compartment. In literature there is ambiguous nomenclature of this muscle because of its different origin and insertion sides. It is related to many pathologic conditions in the lateral ankle compartment but also it can be used as a tendon graft for reconstructive procedures.

Material and method

We dissected 115 cadaver legs and investigated prevalence of peroneus quartus. We also present 2 year result of a patient who had torn superior peroneal retinaculum reconstructed with peroneus quartus tendon.

Results

The peroneus quartus muscle, with a number of different attachments, was present in 5.2 % (6/115) of the legs. It most commonly arose from the peroneus brevis muscle and inserted into the retrotrochlear eminence of the calcaneus. Associated pathologies are longitudinal degeneration and tear in the tendon of peroneus brevis. There is no any association between the prevalence of peroneus quartus and the height of retrotrochlear eminence or presence of peroneal tubercule (p > 0.05). But there is strong relationship between peroneus brevis degeneration and peroneus quartus existence (p: 0.03). We also defined a new type of peroneus quartus with a bifurcated insertion around the peroneus brevis. In literature our case report is unique because we present a patient who has torn superior peroneal retinaculum which is reconstructed with peroneus quartus tendon with 2 year follow up.

Conclusion

Peroneus quartus may lead to some pathologic conditions (pain, snapping, tear, synovitis, etc.) in the lateral ankle compartment but it may be used to reconstruct some pathologic conditions. Orthopaedics, anatomists and radiologists should be aware of this accessory tendon structure because of its clinical importance.     

Adjacent tissue involvement of acute inflammatory ankle arthritis on magnetic resonance imaging findings

Purpose

The ankle joint and surrounding subtalar joint have several tendons in close proximity. This study was performed to investigate the concurrent adjacent tissue involvement on MRI findings when the surgical treatment is considered for an acute inflammatory arthritis of the ankle joint.

Methods

Consecutive patients with acute inflammatory ankle arthritis who visited the emergency room and underwent MRI were included. After interobserver reliability testing of MRI findings, adjacent tissue involvement in the acute inflammatory ankle arthritis were evaluated including flexor hallucis longus (FHL), flexor digitorum longus (FDL), tibialis posterior (TP), peroneus longus (PL), peroneus brevis (PB), extensor digitorum longus (EDL), tibialis anterior (Tib Ant), extensor hallucis longus (EHL), subtalar joint, talus, tibia, and calcaneus.

Results

Twenty-five patients (mean age 57.8 years; 16 males and nine females) were included. Of the 25 patients, 23 showed FHL involvement, 21 FDL, 21 TP, 15 PL, 15 PB, three EDL, 21 subtalar joint, six talus, six tibia, and five calcaneus on MR images. No Tib Ant or EHL involvement was observed on MR findings in acute inflammatory ankle arthritis.

Conclusions

Patients with acute inflammatory ankle arthritis showed frequent concomitant surrounding tissue involvement on MRI, which included FHL, FDL, TP, and subtalar joint. This needs to be considered when surgical drainage is planned for acute inflammatory ankle arthritis.