Peroneal Tendinopathy With Allograft

Indications

Chronic, irreparable tears (tears >50% of the cross sectional area) of either the peroneus longus, brevis, or both

Indications Pitfalls

One must make certain that the tendon cannot be repaired primarily after the débridement of the tendon and that an intercalary segment defect exists.
One must make sure that a preoperative magnetic resonance imaging (MRI) demonstrates a viable proximal muscle belly. If there is fibrofatty degeneration as demonstrated by MRI (or with surgical exploration), allograft reconstruction cannot work.

Indications Controversies

Options for treating chronic, irreparable tears include tenodesis, tendon transfer of a local tendon, and tendon reconstruction with a local autograft or an acellular dermal matrix.
Allograft reconstruction is a relatively new technique, and the long-term function of these allografts is not known.

The patient will complain of lateral retromalleolar ankle pain with or without symptoms of lateral ankle instability.
These patients will have considerable weakness with eversion compared with the contralateral limb and may also have painful inversion and eversion.
The peroneal tunnel compression test may be used to evaluate for peroneus longus tears. One applies pressure along the peroneal tendon sheath in the retromalleolar groove with the knee flexed to 90° and the foot in a resting plantar flexed position. If the first ray does not plantar flex, then a longus tear is suggested.
Weight-bearing ankle and foot radiographs should be obtained. If present, the os peroneum should be identified. Any displacement or fragmentation of this bone may indicate peroneal longus disruption.
MRI of the ankle demonstrates intrasubstance tears, degeneration, chronic thickening, scarring, or stenosis of the tendons; fluid in the sheaths may also be visualized.
Ultrasound examination is highly accurate as well.

Treatment Options

Tenodesis of the peroneus longus to brevis
Flexor hallucis longus (FHL) tendon transfer of a local tendon
Tendon reconstruction with a local autograft (peroneus tertius tendon, FHL, flexor digitorum longus, extensor digitorum brevis tendon slips to the third and fourth toes, plantaris, tensor fascia lata) in a two- or one-staged fashion
Tendon reconstruction with acellular dermal matrix

After placing a thigh tourniquet on the patient, place the patient into a lateral decubitus position using a bean bag.
One may also place the patient in a supine or “lazy lateral” position ( Fig. 68.1 ).

Positioning Pearls

When placing the patient in a lateral decubitus, ensure that all bony prominences are padded.

Positioning Pitfalls

If placing the patient in a lateral decubitus or lazy lateral position, one must make sure that the hip can externally rotate enough to look at the overall positioning of the foot.

Positioning Equipment

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