In this case, the patient has an acute case of tenosynovitis in the peroneal tendon. Dr. Eric Bluman MD, PhD performs a debridement of the tendon, releasing the pressure from the abundant infected synovial fluid on the peroneal tendon.
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This article is the companion to the JoMI articles:
- Brostrom-Gould Procedure for Lateral Ankle Instability
by Eric Bluman, MD, PhD
- Deltoid Ligament Repair
by Eric Bluman, MD, PhD
- Five-Month Patient Follow-Up following Ankle Ligament Reconstruction
by Eric Bluman, MD, PhD
Table of Contents
- IV antibiotics were administered and a popliteal and saphenous nerve blocks were placed.
- Patient was placed in supine position.
- General Anesthesia was administered and a tourniquet was placed on left upper extremity.
- The patient was then turned onto a lateral position and a beanbag (deflated with a vacuum) held the patient in this position.
- Standard sterile prep and draping of the left lower extremity was done.
- The peroneal nerve of the left leg was padded and the medial prominences of the lower extremities were padded with foam.
- A curvilinear incision was marked out over the posterolateral aspect of the fibula following the path of the peroneous brevis tendon.
- The foot was then exsanguinated using an Esmarch bandage, and the tourniquet was inflated.
- The incision was made from approximately 4 cm above the distal tip of the patient's medial malleolus to the level of the tip of the medial malleolus.
- Great care was taken not to injure the peroneal nerve. Once it was identified, it was swept inferiorly and posteriorly.
- Soft tissue dissection was performed down to the retinaculum of the peroneal tendons.
- Sharp dissection was used to open this retinaculum. Within the retinaculum there was a significant amount of inflamed tenosynovium surrounding the peroneal tendons. Also a low-lying muscle belly of the peroneus brevis was present. This extended down through the retinaculum to the level of the inferior fibular groove.
- The tenosynovium was debrided back and the low-lying muscle belly was resected to a level above the start of the fibular groove.
- Peroneus Quartus was also debrided.
- Inspection of the fibular groove showed that it was shallow and almost flat. The tendons showed good stability within the groove even with dorsiflexion and eversion.
- Three woven sutures were then passed through the bone to fashion the retinaculum back to the posterior portion of the fibula. This was then oversewn with 2-0 Vicryl sutures.
- The peroneal tendon excursion was tested in the reconstructed groove and retinaculum. There was no catching. Free excursion of the tendons was noted.
- The wound was thoroughly irrigated and the skin was then closed in layered fashion.
- The wound was then cleaned and dressed using Xeroform, fluffs, and Webril.
- A posterior short leg plaster splint was applied in neutral position.
- The tourniquet was released and the splint held in place until its hardening.
After emergence from General Anesthesia, the patient was extubated by the Anesthetist and taken to the Post Anesthesia Recovery Unit.
So I'm gonna - I'm gonna draw some anatomy so that you guys can see it. So we've got the patient in a full lateral position - held in place with a bean bag. She's got an axillary roll in for protection of the nervous structures to the upper extremity. We've also got the peroneal nerve on the down leg free from any pressure to prevent any per - common peroneal nerve palsy. And we've got padding between the bony prominences of the leg so that there's no pressure associated complications intraoperatively. There's a stack of blankets underneath her foot to get her leg into a good position, and we also have a well-padded high thigh tourniquet on for hemostasis during the case.
This is the lateral aspect of the ankle and the foot. We've got the fibular prominence right here in the distal fibula, and of course, the peroneal tendons lie right behind here. We’ll just draw some rudimentary anatomic surface structures here to help us orient the case and make sure that we’re in the proper position throughout the - during the approach. I'm outlining the anterior portion of the fibula here and posteriorly the - the back edge of the fibula, and I'll put some hash marks here to indicate that that's bone. And the peroneal tendons live right behind here, and the incision will be right in line with this. And the peroneal tendons, of course, extend from the tip of the fibula down - at least the peroneus brevis goes down directly to the base of the 5th, and so if we need to do an extended incision down there to look, we can do that. And the peroneus longus, we’ll reflect underneath the cuboid - lateral portion of the cuboid - right about there.
And you just want to be posterior at the posterior aspect of the - of the fibula - yeah - actually, we can go probably a bit little anterior to that and just take it off the anterior portion here. Do you want - do you want me to do the approach? Yeah - it’s probably better. Alright, so we're gonna - so we’re gonna need some skins hooks. Okay. Alright.
Alright, so let’s do a polish please. I’ll shape this up a little bit, okay? So you want more to be on bone? Not necessarily, I...
So we're using a - an Esmarch dressing to exsanguinate the lower extremity and give us a bloodless field. Then we've got a micro sagittal saw, guys? No it will not. Okay, can we get the tourniquet up to 250 please?
Good. Starting. Skin hooks please, and forceps please. Bovie. These are some just cutaneous vessels that we're gonna electro-cauterize to maintain hemostasis, both during this portion of the procedure and - and postoperatively. We can advance through the tissues here using the electrocautery on cut to help maintain that hemostasis.
Now I'm just gonna feel here to make sure that we got the right plane and that we're staying in the right approach to the sheath. Right - right back here we’re on bone.
So I'm gonna make a full thickness cut and enter his sheath right here. So that's pretty much where you cut through the superior - yeah, in the - we’re - we’re - we’re going right through the superior peroneal retinaculum. And you can see here - now the tendons are exposed. Let me have a Metzenbaum scissors please. It’s the posterior here where you have to be a little bit careful about tearing into the sural nerve? Yeah, the sural nerve is running, you know, generally in this direction. It's not - if you're in the plane that we’re in, it's not too much of a problem. Certainly, you need to be vigilant for it when you're - when you're doing your exposure.
We’re just opening up the retinaculum a little farther, and you can see the tendons in here. Now this yellow tissue in here is nah - is a little abundant, and that's - this is some tenosynovium, which is a nourishing tissue for the tendon. A little bit is normal and desirable, but this is - this is, you know again, pretty abundant here, and although it looks yellow right now, if we hadn't exsanguinated the limb, this would be much more pink and would show much more clear signs of inflammation.
Let me have a Freer elevator. So one of the things that you can notice here as we open this up a little farther is this - this more pinkish red tissue is actually the - the inferior extent or extension of the peroneus brevis tendon, and you'll see this when I lift the peroneus longus out of the way. You'll see there's a lot of tenosynovitis tenosynovium associated with it and even some adhesions, and when I reflect this out of the way and - and demonstrate, you can see this lowline peroneus brevis a little more clearly. And that - that peroneus brevis is in somewhat of a mass occupying lesion. You've only got so much space in your fibular groove and the - in the - within the sheath here, and as the tendons have excursion back and forth, that can get driven down farther and create somewhat of a stenotic lesion. And so in these cases we - we remove that lowline peroneus brevis muscle belly to give the peroneal tendons a little bit more room to move.
Metzenbaum scissors please. You can see with this - this is the peroneus brevis tendon here. It is - it's effaced and flattened out, and there is some curvature to it. This is not too abnormal. It's a bit thin. There's a small tear here within the tendon. I don't know if you guys can make that out. The good news for this patient is that this is less than - at a point that is less than 50% the diameter of the tendon, and it is very superficial. And I think that in her case it would be advantageous - rather than try and repair this and put suture material in there - is just too excise this portion. It's not going to weaken the tendon significantly, and it's going to get rid of the tear and - and help her in pain control. The tear is right here.
And this is a good reason why this case, you know, probably - if we had done this tendoscopically, you know, with a scope - this is very hard to - it’d be easy - easily identifiable, but to go in there and remove this through either biters or arthroscopic instruments is a little more difficult - and it would require a lot of shaving. It’s a pretty tenacious tissue, so it's - this has worked out for the best that this woman did not have a tendoscopic procedure.
You can see more of this low-lying peroneus brevis here. And back here - this is the peroneal groove on the backside of the fibula. Normally, there's a nice cradle here - curvature on the backside of the fibula - fibular groove - to hold these peroneal tendons. She's very flat, so we're going to reevaluate after we debride all the tendons and - and all of the tenosynovitis to see how her tendons move and how they lay within the sheath at the end of the procedure. She may need to have a groove deepening procedure, but we're gonna reevaluate that once we clean out this low-lying peroneus brevis and some of this tissue here. Okay, Arvind, go ahead and release that.
So first thing I'm gonna do is to take some forceps and the Metzenbaum scissors, and I'm going to come down here. I'm gonna try and find the most distal extent of this - of this tenosynovitis. It seems to be going down a little farther. I'm gonna actually extend my incision so that I can get a good view of that. The other thing that we can do before we go ahead and do that is actually try and move the tendons - actually try and pull on them manually. Let me have a little retractor please. Let’s see if we can find the most distal extent without extending the skin incision. It's going down pretty far, and I think it's probably advantageous for us to just go ahead and extend it a little bit. Okay. Let me have a knife please.
Again, the sural nerve should be inferior anatomically to where we are, and - but we - we do need to be careful of branches here. You can see. Let me have Metzenbaum scissors. Luckily, we haven't encountered any components of the sural nerve yet. That's looking pretty better - that's better. You can see how - how distal this - this stuff extends, and there's the retinaculum again.
Is that also where you would expect the vincula or that's more on the surface? The vincula to the - to the tendons? Yeah. You - you would expect to see them. You can see them in here. Not - not - not such a common finding down here.
Okay. Let me have some skin - skin hook retractors. So what Arvind’s doing here is he's going to hold back the retinaculum, and what I'm going to do right now is free up some of this tissue. I'm gonna keep my tips down so that I'm not - I’m staying away from the tendon. I do have to be careful that I do not buttonhole the superior pert - peroneal retinaculum. But I am staying right on it, and I'm trying to remove as much of this inflammatory tissue as I can. Again, being very careful not to buttonhole. I'm going to turn my scissors over there. I don't want a buttonhole that, and I'm in a safe place in terms of the tendon. You can see here, there are some - there’s a little bit of blood supply here. We're gonna buzz that with the electrocautery so that she doesn't develop any hematoma within the sheath at the conclusion of the case.
And that's pretty clear. That's the end. You can see here, it's very much cleared up now, and this is pretty much the end of what we’re seeing. And we're taking this off of the peroneus longus here. And a lot of this may indeed be attached to the peroneus brevis as well, so we're gonna try and do this as much en bloc as possible. You can see there now - now the peroneus brevis looks to be pretty clear of it. I'm going to just elevate it, and that's pretty good.
You can see now, there's still some attachments here to the - the peroneus brevis muscle belly as well as a peroneus brevis tendon, so we're gonna work on that. Gonna have Arvind just reflect this posteriorly so that we can go ahead and work on the peroneus brevis, and there you go. You get a good view of - this is a very effaced tendon. It's very flattened, which is not uncommon, and - but this is a - is a pretty distal extension of this peroneus brevis muscle belly. And again - and may, in her, represent a mass occupying lesion, and so we're just gonna - we're gonna clear it right off the tendon and take it as a single block with that inflammatory tissue. And then - again, so. Greg, can I have you put a hand here?
So again, peroneus brevis is now anterior - peroneus longus, posterior. We've got the muscle belly being resected here from - from - from the tendon itself, and this inflammatory tissue still is a little bit adherent to the superior peroneal retinaculum. I’ve turned my scissors around to - to prevent any buttonholing of the superior peroneal retinaculum.
And we got a little bleeder there, and we’ll elect - that is not at all an uncommon effect. That's almost always there. Again, to prevent any postoperative hematoma within the sheath, we’ll electro-cauterize that. And it may bleed again as we advanced up a little bit, but we can always go back and obtain hemostasis. Can I get a little Kocher please? So what I'll do is apply a little Kocher clamp on this, and then because we're not going to continue up much farther - good.
And you don't have to take it up too far just - just basically to the terminus of the groove, and once we're there, I'm gonna have Greg and Arvind hold the muscle - the tendon - out of the way. I'm gonna take the electrocautery and cut, and I'm just going to then transect or amputate this muscle belly here. And again in, an effort to ob - obtain and maintain hemostasis because there will be a cut surface of muscle within the sheath, and so minimizing blood within the sheath in post-operative period is good.
Take that Greg. I got that. So now you can see, there's the transected face of the low-lying peroneus brevis. Peroneus brev - peroneus longus, peroneus brevis muscle. We still have to deal with the small tear here, and we’ll do that now. Right there. Okay. Do you have a malleable? And I'll take a fresh 15 blade please. And at this point, you know, all that inflammatory tissue has been cleared off. You can see there's a lot more room in here, so I'm gonna use the backside of this - this forceps as a malleable. This is good. This is good. Alright, you can see here that the tear is located right here. It's about a third of the distance in the tendon, so - and it's very superficial. I don't think that putting suture in this is gonna be - it's gonna introduce foreign body and - and - it maybe a source of irritant. There is a lot of effacement in this tendon, so I think it's just easier to do a transaction here and cut out the torn section. And that's what we're doing right here.
Again this type - this amount of tendon being resected - that - this is - this would be difficult through a 2 - 2.7 mm scope with a rotary shaver - just because this tissue is so tenacious. So it's a lot easier to do this open.
And then we’ll complete it here - removal of the - the diseased portion of the tendon.
So now we'll reevaluate the tendons after they’re put back into the groove, and let me have another forceps if you will, Greg. So we'll just come over here. That seems pretty stable to me. We're gonna move the tendons around a little bit to make sure that dynamically they’re stable, and they stay in that groove even with - you know, this is with flexion and eversion. You can see it trying to roll out, but I think, you know, there's no frank dislocation. And this is with the sheath completely open, so once we do a repair of the sheath back - back up, it's gonna be even more stable. I - and I don't think we need to do a groove deepening on her. She did not have any preoperative sublex - dislocation, and so I think once we’ve removed that tissue and the mass from within the sheath, we're gonna be - she's going to feel much better. And she's not gonna - certainly not going to be unstable once we do our repair, so there's no - no need to do a groove deepening on this patient.
Alright, let's irrigate please. I’m a take one more check down here to make sure we've got all of that inflammatory tissue gone and got nice clean tendons down there.
So now we're gonna finish the case with a closure. It's gonna be a repair of the superior peroneal retinaculum here, and then we're gonna do a skin closure after that. I've left a little cuff of tissue here off of the fibula to sew to so that we're not selling directly to bone or periosteum and that makes the closure a bit easier.
Because she didn't have any prior dislocation preoperatively, we don’t really also have to think about ret - retinaculum plasty, right? Yeah, and that - that would be for cases where, at least for my algorithm, in terms of peroneal instability, if - if you do your groove deepening and you still even with the groove deepening, then have some indication that you're going to have problems maintaining the tendons in the groove then that's when you think about that. Or if it's a revision case where they've already had a groove deepening and some other - some other effort to keep the tendons in an anatomic position has failed, and you need something stronger to reinforce what was done previously. And that's a fairly unusual occurrence.
This open or tendoscopic? I think we are still in the infancy for tendoscopy as a whole. So yeah, you know, I think that not only - at most centers it's just not available, and - and the places where it is - in case it's like this - if you had started out with tendoscopy, I think that there would be certainly good indications to open because of the presence of the tear.
You think you would have - if we would have scoped her and saw the tear, do you think you would have opened her? I think that in the end probably. If - if we had gone ahead and done that, I think that you obviously make an effort to try and resect that diseased portion of tendon, and - and you can do that with some end-biters and - and a manual - endoscopic instruments and then finish up with a rotary shaver. But whether we would have been able to complete it at endoscopically, that's a - that’s a good question. I think this was certainly a good move for her - having it done open.
When you reapproximate, is it just anatomic or do you embrocate some - a little bit? You - you can. You can embrocate. It's - I think it’s difficult to create a stenotic condition that’s iatrogenic, but it certainly can be done if you really - you really embrocate too much, you can have it. I've seen it happen, but in - in some of these tissues will - they will shrink postoperatively cuz she's got a lot less volume within that sheath now than she had preoperatively. And I think you can - you can see that.
And I'm just using some figure-of-eight sutures, interrupted sutures, here to close this. I'm using absorbables. Certainly you can - depending on the situation, you can use non-absorbable sutures, but I don't think it's necessary in every case. Another thing to think about - this is - she's - she’s very thin, and - and her skin is - she's got thin skin. She's fair-skinned, and so, you know, you would - some of these sutures are green or blue in color. And you go right underneath the skin, and even if there's - even if there's no mechanical irritation from the suture, you can sometimes see the suture through the skin.
And - and again, she's got so much more room now, and I - I - she doesn't - she’s not gonna have any healing problems. And I don't think we need to really reinforce the repair with nonabsorbable sutures. She's going to do great with just - with these monocryls. Another thing to just be careful of - it’s obvious - but you need to make sure that you're not - you're not sewing the tendons into the sheath. It goes without saying, but always something to keep in mind. One of the things that we've - I don't know. There's not much in the literature regarding it - only a paper or two talking about this low-lying peroneus brevis. It's a - it - you can imagine, you know, you're - you're adding another lane of traffic, if you will, in the tunnel, and that - that creates stenosis. So you know and that - that will create increased pressure on each of the tendons, and you know, the peroneus brevis has already got a lot of pressure exerted on it by the longus. And so you add a muscle belly down in there, and you’ve - you know, you've created - you’ve created additional - additional problems. And so again we’ll - we’ll test her now, and this would be the risk - risk position - high-risk position for dislocation, dorsiflexion, and eversion. And she's - she's good.
So really the biggest concerns when you do this procedure is - is not to disrupt the retinaculum when you do the approach or when you repair the part appropriately, so you don't cause any iatrogenic subluxation or dislocation? Yeah.
Okay. So this is - could be pretty mundane, but I - I really consider this a big important part of each of the surgeries for foot and ankle orthopedics, and it’s basically construction of a splint. Some of my trainees will say that this is - this is my - my hang up. The splint has to be done - done well and done uniformly each time.
So I basically take 6 inch Webril - make a very healthy posterior padding for it. And then I use a 6 inch and two - two 4 inches - actually two 6 inches, we’ll use. And they're the same - the same length as this. It’s just wrapped end-over-end. So that's going to be the back slab, and then there’s gonna be two side gussets - each of the same length and also wrapped end-over-end. And then the second side gusset right here. Again, same length - wrapped end-over-end.
That's okay. I'll be happy to - to mop or sweep or whatever. And then in addition to that, on the outside we use a 6 inch Ace bandage and a 4 inch Ace bandage - and of course, use some 4-inch Webril to hold it in place.
Okay, so this is the posterior padding that's going to go on. And Arvind, the most important part of this whole process is the - is the holder. If you don't have a good holder, the splint can't - can't go on that well, so. You can see his - his right hand is over the top of the right arm is over the top of the knee, and his left is holding the foot in pos - foot and ankle in position. I'm just cutting some notches here so that we don't get any dog ears in the - in the padding, and then I'm gonna form fit the padding with some Webril here. That's good. Yep, okay. And then another one in the foot just to make sure we've got everything well conforming to her foot and well-padded. Nice. No, that's enough. Yeah, that's enough.
So next thing we do is use some 6 inch, and this is called delamination. We don't want any - we want to make it all uniform, and all the plaster layers to be sticking together. So I'm sort of squeegeeing out the the water, pressing the - the plaster together. And again, Arvind's key here. You're holding it. And then I'm going to make sure that it adheres to the underlying padding, so that it’s completely custom fit to her leg.
And then the side gussets are gonna go on. We’re going to do the same thing - make sure that these are - there's no lamina present. There's no - no layers. Make everything a single layer here - and again, just making sure it's perfectly conformed to her anatomy. And then the last side gusset on the lateral side.
And then the next thing we do is put on the Ace bandages. Start above the level of the - of the splint, so you can tuck it in at the end and work your way down. 4 inch goes first, followed by the 6 inch around the heel, slightly over the toes. Go ahead. Come on up on top again. 3, yeah please. You can put them on. It’s taped off right on the bottom. One more up there.
And then - and then it's put right on your sternum. Putting it on your sternum makes it flat. There's no rocker bottom to it. If you put it in your abdomen, it will press in and become curved, and you don't want that. You want to give them a nice flat foot plate.
Yeah please, and what I'll do is just tuck this in right here, and then just pop this so that they don't get too tight if there's an postoperative swelling. And we’ll do the same down here after the splint has set completely. Now you just wait until it hardens.
Last step is we just free up the toes here. Pop it right here so that she’s got enough room. That’s it.