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Guido LaPorta, DPM, MS
Director Podiatric Medical Education
Community Medical Center
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Male Speaker: Okay, so we’re going to finish off before the break with this discussion on instability of the ankle. There’re a number of situations, which can produce this, and I would like to touch on a number of them for you and bring out some pertinent points that I’ve found interesting that have kept me out of trouble and gotten me into trouble. From a historical perspective, when you look at the peroneal tendons on the lateral side of the ankle, pathology can present itself in any one of the number of ways and Dr. Williams touched on this earlier with both the Achilles tendon and the tibialis posterior tendon. So, you can have a tenosynovitis, which involves the sheath of the tendon or you can have a tendinosis, which in fact involves the very substance of the tendon. Longitudinal splits are basically an MRI phenomenon. Now, when I grew up as a resident, we didn’t have MRI. We had no idea what an acquired adult flatfoot was. We had no idea what longitudinal splits in a tendon were, and it was only after MRIs became available and almost all feet were sent for MRIs in the beginning, that these types of pathologies became obvious. With respect to the peroneal tendon, as accurate as an MRI is for the tibialis posterior tendon, it is not that accurate for peroneal tendons. The MRI, on a peroneal tendon will tell you if you have longitudinal splits; it will tell you if you have a complete rupture, and everything else is a crapshoot. So, I would never ever prepare my surgical plan or my explanation to the patient based on the MRI. I would tell them quite frankly that the MRI has identified pathology. Frequently when we go in, we find something different. What we have to do depend on what we find and the ranges of what we might have to do are from A to H, okay. So, I think the patient really needs to know that. Sometimes, you go in and a classic MRI reading of mild-to-moderate or moderate-to-severe tenosynovitis or tendinosis and find a pristine tendon, both brevis and longus, and the pathology is in the retinaculum. Well, you did not know that pre-op, and it definitely changes what you need to do. Patients can present with an os peroneum, ruptures, and they can be acute and/or chronic. Now, we obviously know that there is a common sheath for both peroneals, and then each peroneum has its own separate sheath in the area of the peroneal tubercle and all of these areas, including beneath the cuboid, where the longus makes a right angle turn on its way to the first ray are potential areas of pathology. The clinical presentation is simple. These patients present with lateral ankle or hind foot pain. In fact, they usually come in and say, “My ankle hurts,” and then it is up to you as the clinician to figure out what in fact is going on. The pain is always worse with activity. In fact, many of these patients will tell you when they wake up in the morning, they have no swelling, they have no discomfort, and then as the day goes on, all of that worsens. They usually have swelling behind and above the malleolus. They can have subluxation, partial or complete, of the peroneal tendons. Many will complain of sensing a snapping sensation. Most of them have a history of inversion ankle sprain. It is unusual that they will present without some history. They may have forgotten it, but if you question them enough, you can or they can remember an episode of an inversion sprain. Some will just present with what is known as an eversion lag or weakness. When you ask them to utilize their peroneus brevis and longus, there is somewhat of a lag between when they begin to contract and when you actually get a forceful contraction.
There are a number of ways you can make a diagnosis. Obviously, you always start with an x-ray, and then depending on what you are looking for, you can pick the best study if you need one. So, you can get a CT scan, an MRI. You can sometimes do tenography or tenoscopy. Tenoscopy seems to be gaining some popularity recently. I think in the couple of years, I’ve only done two or three tenoscopies, and it is a very useful technique for a tendon pathology that you can catch early. One of the problems I usually find with peroneal tendon pathology is that the patient has been told by someone that it’s just a mild sprain, your x-rays are negative, don’t worry about it. If it continues to bother you, go see someone. Well, by the time they get in sometimes, it is a tad too late, and then you go through your hierarchy of treatment, your NSAIDs, your immobilization or functional bracing, physical therapy and orthosis. I think, it is imperative that you have a discussion with your physical therapist on what you think that physical therapy should be, because it is not unusual for a patient to come back and be actually made worse by physical therapy because it may have been too aggressive and the reason is that simply the therapist did not understand what you were sending them over for or the complexity of this patient’s problems. So, when your therapist contacts your office and asks for a copy of the progress note, send it. Make sure that they are as informed as possible about what you are actually expecting from their treatment. Now, there are a number of classifications in the literature you may wish to be familiar with. Sobel printed one in which he divided peroneus brevis tendinopathy into four grades, all the way from grade 1, which is simply a flattened tendon and progressing on toward partial-thickness split, less than 1 cm; full-thickness split, less than 2; and full-thickness split greater than 2. Is this a useful classification? In my opinion, no. They probably should be divided into two, flattened tendon and split, because that determines the difference in what your treatment program was going to be. Brandes and Smith have a more useful classification. They decide or have defined three zones, A, B and C. The superior inferior retinaculum and the cuboid notch and then have defined three types of pathology: adhesions and thickening, partial tears and complete tears; and I think this is a much more useful classification because it is tied towards treatment. By the way, all group 3 are complete tears in this classification occurred at the level of the cuboid notch or when there was an os peroneum at the level of the os peroneum. With regards to the superior peroneal retinaculum, Eckert and Davis divided this into three grades, where the retinaculum was elevated from the fibula or you have a fibrocartilaginous ridge elevated from the fibula with the retinaculum attached or a grade 3 where you have a cortical fragment avulsed with the retinaculum. This is also a very useful classification because this is exactly the way it happens clinically, and it does determine whether or not you actually have to just simply suture repair the retinaculum or reattach it through drill holes or via osteotomy of the fibula.
Chronic dislocation of the peroneal tendons have a number of different approaches that you can utilize. You can simply do a repair of the superficial peroneal retinaculum. You can do a tissue transfer in order to strengthen the retinaculum. You can re-route the tendons in order to prevent dislocation, bone block procedures usually involving an osteotomy of the fibula, or you can do groove deepening procedures, which involve literally hollowing out the fibula and then hitting the back of the fibula with a blunt instrument in order to increase the groove. Certainly, it is work intensive to do that, but that is a very successful procedure. So, when we look at a peroneum that has been ruptured and you look at this, you can see this present in one of three ways. Now, in this particular case, the superficial peroneal retinaculum is still attached to the fibula, so the tear occurred closer to the fibula, but in the substance of the retinaculum, and this is the one you like to see because you can simply go in, inspect the tendons and repair the retinaculum. If you look at the lower border of the fibula, you will notice that there is a fibrocartilaginous rim in that area, and that is still attached to the fibula that can be ruptured off with the retinaculum. When it presents that way, it is very difficult to re-attach that fibrocartilaginous rim to the fibula. You usually need to dissect that out of the retinaculum, and then drill holes in order to attach the retinaculum back to the fibula. You can inspect the tendons, look for longitudinal tears, look for chronic synovitis, make sure you look at the undersurface of the tendons, that’s where most of the pathology occurs, so you can look at the dorsal surface of the tendon and it can look pristine, and all you simply have to do is turn it over, and you’ll find pathology, and you’ll see in the brevis, which is in the Adson that there’s a longitudinal split just below the fibula, which will need to be repaired. You can look deep in the grooves at the synovial tissue. Any chronic synovial tissue, which is dark red as opposed to bright red needs to be debrided because it’s significant for a chronic injury and you would not want to leave that behind in these particular situations. So, once you’ve debrided the tendon, you then have to make a decision, “Do I need to tubularize it, do I need to repair it, do I need to anastomose the brevis to the longus, do I need to put some kind of augmentation tissue in the tendon in order to strengthen it.” Once you’ve made that decision and you’ve carried that out, then you can repair the retinaculum, and as you see here, a simple retinacular stitch for the superficial peroneal retinaculum, the tendon repaired and then reattached to the fibula through a drill hole. So, the plantar flap is brought up to the fibula and then once that has been attached, then the top surface of the retinaculum is flipped over, vest over pants in order to repair the retinaculum, and you get a very nice strong repair in that particular instance. Many times, you’re not able to do it as neatly. It depends on how the retinaculum is torn, but the majority of the retinacular tear in the vicinity of the fibula, it’s rare that you get a mid-substance or a distal tear, and that does make repair somewhat more tenable. Whatever suture you want to use there is basically up to you. I tend to use a non-absorbable suture, although there is really no issue, I don’t think, in using an absorbable suture provided it’s there for a couple of months before dissolving.
You can repair some of these with Ortholine [15:16]. I’ll show you this technique in just a minute. Ortholine [phonetic] is kind of a textile and instead of harvesting a tendon or using a cadaveric specimen, I prefer using a synthetic. I believe its much more tissue friendly. There is less revascularization that has to go on. Remember, that any time you do a free tendon transfer or use a cadaveric tendon, that the healing process requires that that tendon re-vascularize, which means it will increase in size, two to four times its original size, and that can be an issue, especially in a very subcutaneous area such as the lateral ankle. Now, here’s a debridement with a repair of tendon sheath. You can see the blue arrow pointing to this tendon pathology in the longus. This is significant. On your right on top, you see the area debrided and then once that debridement has occurred, the retinaculum is in fact repaired. Now, everything there was a nice consistent structure, so it was able to be repaired very nicely. Here’s a peroneus brevis repair, and you can see what shape that tendon is in. You can tell in this area where it should be nice and white and pristine, there’re signs of chronic inflammation and synovitis. So, all of this has to be debrided. Usually, when you debride a tendon like this, you don’t have very much left over. So, you can look at the longus, look at all of these structures in this area. I debride whatever is not healthy. Here, tubularization is done so that the diseased portions of the tendon are in fact removed. Now, if you don’t remove too much from this tendon and you have good substance left behind, you simply have to repair it and suture those two areas together. In this particular case, by the time you are done debriding, you don’t have very much left. You have some very thin strands, and what I like to do, is take a piece of Ortholine [phonetic] which you see in your upper right hand portion of the slide, the white structure along with the vascular tape, and that sutured into the tendon, and then I’m going to place it through the mid-substance of the tendon and run a suture along the entire course, suturing that into place and then cut out the excess. So, what I’ve done is I have replaced the tendon that has been removed with this textile-like structure strengthening it, it’s buried, so I don’t really have to worry about it being an irritant in the surrounding soft tissue and it imparts immediate strength. I would much rather do that than harvesting a tendon and/or using some kind of cadaveric structure. Post-op management for that is non-weight-bearing in a cast for two weeks, and then, functional bracing for four weeks. That usually means, I let them walk in a cam walker, well protected. I don’t start physical therapy until the fourth week until the tendon itself has developed enough strength to withstand therapy that’s in fact going to be useful. I’ve them do active PT for two weeks, and then have them do an at-home program, most of what they need to do, unless they have significant edema and they need some massage or interferential pump therapy, they can do the therapy at home. I don’t let them participate in athletic activity for three months and most of the time they’re in an orthosis. The question is for how long should they wear that and that’s an individual determination that you need to make. Should they’ve a structural deformity, which is going to lead to additional problems, then the orthosis is for life.
If it’s simply a situation of re-training or protection, it may be for as little as a year or two that the orthosis is recommended, but that’s individual decision. If in fact the patient has significantly weakened or at-risk ankle, give serious consideration to an orthoses that goes above the level of the malleoli as opposed to just an in-shoe orthoses. Be cognizant with peroneal ruptures. These are very, very difficult to repair. They’re usually as a significant amount of retraction. The rupture usually occurs at the level of the cuboid notch. It’s an area that is not very vascular, and it’s difficult to repair this. Typically, it requires some type of grafting and again this is an area where I utilize the textile in order to impart strength to this particular area. You really need to be cognizant about combination procedures you do. For instance, I frequently see patients who have had a tendon repair and an arthrodesis. Unfortunately, the post-op course of those two procedures is entirely different, and one of those procedures is going to suffer. So that if you start to move that peroneal tendon at four weeks prior to your arthrodesis being solid, you may in fact affect the result of the arthrodesis. So, many times, you’ve to stage your approach to this and it is to the patient’s benefit that you do that. Many of these patients have a varus heel, especially those who have an unstable lateral ankle and you may have to combine the repair on the lateral side with a valgization ankle. I can’t tell you how many referrals I’ve gotten for a lateral ankle stabilization and the patient comes in with a full-blown cavus foot, and they have an abductovarus heel, and you can obviously stabilize the lateral structures there with anything you want, but if the anatomy, which determines function is abnormal, you need to address that and you can address that either staged or in one sitting depending on what combination of procedures you need to do. Patients who present with peroneal spasm may have coalition, so I think you are obligated to rule that out. That can simply be done with x-ray, but if you’ve any suspicion of a coalition, I think you’re obligated to get a CT scan and/or an MRI in order to investigate that further. One of the techniques that I like to do is reconstruction of the ligaments and retinaculum using Ortholine [phonetic] and this by the way is in the Sobel article. If you get that article, this is a very good flowsheet that just gives you a thought process and how to think about the peroneal tendon. Now, I’m a big fan of augmentation procedures, and I like to use many of the products by Arthrex, even though I shouldn’t mention their name; I’m not a consultant of theirs, so I am not plugging their product because they’re paying me obscene amounts of money. I’m plugging their product because they work and they are very easy to apply. One of the procedures simply is for Brostrom procedure, probably the most commonly used lateral ankle stabilization, usually done in conjunction with an arthroscopy. When I do it, it’s an arthroscopically assisted lateral ankle stabilization. So, what that means is, I make a little centimeter and a half incision on the lateral side of the ankle so that I can debride the ankle in about 30 seconds as opposed to an hour futzing around with all the water that doesn’t work and the light source doesn’t work and everything else that doesn’t work. So, I make a little arthrotomy, I debride the ankle, I repair the tendon, and then I augment it with an internal brace, and that simply involves drilling a hole in the fibula; it’s a 2.7 mm drill bit, and then it is tapped, and then you insert a little larger 3.5 mm swivel lock that has this fiber tape. Then, you drill a hole in the talus.
This is usually done at a 45-degree angle, so you don’t penetrate the joint. This is done with a 3.4 mm drill bit, you tap it, you can get away sometimes without tapping the fibula, especially in soft bone, but you must tap the talus very hard bone, especially in the body, and then you attach that fiber tape over the anterior talofib ligament in order to augment it, or in some cases, the anterior talofib isn’t there, and your fiber tape becomes the ligament. So, that’s placed in there with the swivel lock and then the fiber tape is in place giving you a good repair of that ligament. How about lateral ankle reconstruction? There’s also an Arthrex system that allows you to repair not only the ligaments, but also the retinaculum and both the anterior talofib and the calcaneal fib. You can use cadaveric tendon. It comes pre-sized and pre-whip-stitched, so this is wonderful because you don’t have to waste any time doing this. You can almost do this percutaneously. So, it’s done in very similar way, drill a hole in the talus and attach it, drill a hole through the fibula in two different areas and string your cadaveric tendon through that, and then once you come out the apex of the fibula, you bring it back below, very important, below the peroneal tendons. I’ve seen that done the opposite way where it is brought in over the peroneal tendons, and that does a wonderful job of stenosing the peroneal tendons so that they don’t work at all. Remember, the calcaneofibular ligament is deep to the peroneal tendons, and that’s exactly where it should be routed. So, you drill a hole then into the calcaneus and you attach it with a swivel lock into the calcaneus and you have your final construct is in anatomic repair of the anterior tib and the calcaneofib ligament. As a general rule, the anterior talofibular ligament is part of the ankle joint capsule. It, therefore, since it will be bathed in synovial tissue, has the ability to granulate and repair on its own. The calcaneofibular ligament, on the other hand, is extracapsular. Once it is torn, it will not repair on its own. So, if something is telling you that maybe I should wait. If the calcaneofibular ligament is involved, don’t necessarily wait because that is not going to repair. The anterior talofib, on the other hand, gives you some time to think about that. Here is a percutaneous repair we do. Why do we like this? We like this because we can get people into very aggressive physical activity in about four weeks. We make four percutaneous or minimally invasive approaches, talar neck, calcaneal body, front and back of the malleolus.
We use Ortholine [phonetic], which again is a textile. Most recently we have been using XForce, which is a very similar material; both are biodegradable in anywhere from 5 to 8 years. So, the incision is made just about, and we locate this on C-arm, where we want to attach these ligaments, and this incision is made down to bone, same thing on the talar area, same thing front and back of the fibula. So, we will place a drill hole from anterior to posterior in the fibula, we will attach the Ortholine [phonetic] to our hole in the calcaneus, underneath the peroneals through the fibula and then route it subcutaneously to the talar head and neck and place that into the talus with a Bio-Tenodesis screw. This is an extremely quick procedure. It’s basically a 10 or 12 minute lateral ankle stabilization. More importantly, in four weeks, this patient can afford to be extremely aggressive. We let these patients walk in a cam walker immediately and these patients do extremely well. You can also repair the deltoid with similar technology and in this particular case the deltoid internal brace repairs, both the superficial and deep layers of the deltoid in a very quick fashion and very strong repair. These again are done with fiber tape and 4.75 swivel locks. So, the moral of the story is make a diagnosis, now, my residents love me, but when they hate me, it’s because I say, make a diagnosis. I am so sick of listening to people at meetings and everywhere, I would say, “What do you do for that?” “Well, I gave it a shot.” “What were you treating?” “Well, I gave it a shot.” “Well, what was your diagnosis?” “The steroid worked pretty well.” So, like you can’t, I don’t think be accurate or be critical of your success or failures until you know what you are treating and step one is make a diagnosis, and if in fact, you then want to give it a shot after you know what you are treating, be my guest, but the point is that I really think that 50% or better of foot and ankle pathology are treated with steroid injections only because there is pain and nobody has an idea what it is they are treating, or if it fails, why it failed. Well, that’s really no way, I don’t think, to take care of foot and ankle pathology. Can you imagine your general surgeon? I just had an abdominal aneurysm repair on April 1st. Can you imagine my surgeon saying, “You know, I am not going to get an MRI. Why don’t we just open it up and see what’s going on?” I don’t think they would have done that, right? They would make a diagnosis first and that’s all I am imploring you to do, think diagnosis, know what you are treating, and then we have the technology, apply what’s necessary to fix what’s wrong.