SLR - June 2020 - Greg S. Lifferth
Reference: Nishikawa DRC, Duarte FA, Saito GH, et al. Minimally Invasive Tenodesis for Peroneus Longus Tendon Rupture: A case Report and Review of Literature. World J Orthop. 2020;11(2):137-144. Published 2020 Feb 18. doi:10.5312/wjo.v11.i2.137Scientific Literature Review
Reviewed By: Greg S. Lifferth, DPM
Residency Program: Creighton University – Phoenix, AZ
Podiatric Relevance: Peroneal tendon injuries are frequently treated by podiatrists today who focus on sports medicine injuries. Though repair of peroneal tendon pathology is frequently performed through an open approach, this article details a minimally invasive approach for peroneal tenodesis in the setting of a complete rupture. The authors advocate a two incisional approach rather than the traditional lateral curved incision to minimize wound dehiscence, sural nerve injury and preserving integrity of soft tissue, notably the superior peroneal retinaculum.
Methods: Presented is a 50-year old female with isolated peroneal tendon pain due to an ankle inversion injury. After six months of failed conservative therapy and MRI confirmed an isolated peroneal longus rupture, the patient underwent a minimally invasive tenodesis procedure using a two-incision approach.
A distal 3-centimeter longitudinal incision was made extending from the base of the fifth metatarsal along the course of the peroneal tendon proximally. This incision provided access for dissection of the tendon sheath, release of the peroneal longus tendon at the cuboid groove. A proximal 3-centimeter incision made 1 centimeter posterior to the distal fibula and 1 centimeter above the lateral malleolus. The peroneal longus tendon was retracted proximally through this incision and underwent debridement and further resected. A side by side tenodesis of the peroneus longus tendon to the peroneus brevis tendon was performed through the proximal incision using 1-vicryl; this was done above the superior peroneal retinaculum to avoid bulky/inflamed tendon or scar tissue from passing within the retro malleolar groove.
Post-operatively, the patient remained non-weight bearing for two weeks in a cast, followed protected weight bearing for four weeks. Passive ROM for dorsiflexion and plantarflexion were only permitted during six weeks with transition to inversion/eversion movement and proprioception after. VAS and AOFAS hindfoot score were assessed at three, six and 14 months.
Results: The authors reported no post-operative complications, and patient returned to full activity with a VAS score of zero and AOFAS hindfoot score of 90 and 98 at three, six and 14 moths. Additionally, peroneal muscle strength was noted to be 5/5.
Conclusions: Presented here is a minimal invasive approach for performing a peroneal tenodesis that aims to minimize the risks of wound complications and excessive scar tissue surrounding a traditional repair. Additionally, the post op management protocol listed was well executed and logical. There is concern that only the proximal portion, not the distal portion of the peroneal longus tendon underwent tenodesis; this would only add increased plantar flexion and leave the tibialis anterior unbalanced. Otherwise, the minimally invasive-two incision approach discussed here may be useful in patients who are at high risk.