Comparison of MRI and Operative Findings in Peroneal Tendon Disorders in an Active

Duty Population

CPT Shawn Boomsma, DOPGYIII, Orthopaedic Surgery

Dwight D. Eisenhower Army Medical CenterFort Gordon, GA

Disclaimer

• The views expressed in this presentation are solely those of the authors and do not reflect an endorsement by or the official policy of the U.S. Army, the Department of Defense, or the U.S. Government.

• The author has no conflicts to disclose

Introduction

• Ankle sprains are common injuries especially in the military

• Waterman1 found an overall incidence of 58.4 ankle sprains per 1000 person-years at the US Military Academy compared to estimated 5-7 sprains per 1000 person-years in the civilian population

• These injuries can lead to chronic ankle pain and instability

• Peroneal tendon disorders are an overlooked cause of lateral ankle pain and a significant amount of patients are misdiagnosed on their initial examination2,3,4

• These disorders can be due to trauma, overuse, degeneration and/or chronic inflammation resulting in tendinopathy, tenosynovitis and tears/ruptures

• Anatomic variants such as a low lying peroneus brevis muscle belly or peroneus quartus muscle belly can also be a causative factor4,5

• Magnetic resonance imaging (MRI) findings of peroneal tendon pathology include fluid collection around or within the sheath, swelling, splitting of the tendons, interstitial/intrasubstance tears or dislocation.

• Previous studies comparing MRI with intraoperative findings have shown mixed results3,4,5,6

• Purpose of this study was to compare MRI findings of peroneal tendon pathology to intraoperative findings in a military population

Materials/Methods

• A retrospective review was performed of patients undergoing peroneal tendon exploration by a fellowship trained foot/ankle surgeon from 2009 to 2014.

• Inclusion criteria: – 1) patients who underwent peroneal tendon exploration– 2) had a preoperative MRI of the affected ankle in the radiology

system– 3) available operative report for review – 4) were active duty, reservist or national guard soldiers at time of their

surgery

• All MRI studies were retrospectively reviewed by a board certified radiologist blinded to the purpose of the study

• A cohort of patients with ankle MRIs and no known peroneal tendon disorders were used to match 1:1 by age, gender and laterality– Purpose was to decrease any potential

hindsight bias

• The MRI read was then compared to the intraoperative findings for each patient, specifically looking for:– Peroneus longus/brevis tears– Peroneus longus/brevis tendinopathy– Tenosynovitis– Injury to superior peroneal retinaculum

• Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using Microsoft Excel ®

Results

• Thirty two patients were included in the study

Average age 32 years of age (range 19-55)

Gender 25 Males (76%)

Concomitant surgery 20 Modified Brostrum (63%), 4 ankle arthroscopy (12.5%), 1 metatarsal/calcaneal osteotomy (3%)

Low lying peroneus brevis muscle belly

22 patients (69%)

Peroneus Quartus 7 patients (22%)

• * two patients had tears of both tendons

MRI Positive

Surgery Positive

Sensitivity Specificity

Peroneus Brevis tears 14 13* 69% 74%

Peroneus Longus tears 12 4* 75% 68%

Tenosynovitis 2 12 8% 95%

Peroneus Longustendinopathy

5 2 0% 83%

Peroneus Brevis tendinopathy

2 2 0% 93%

Superior Peroneal Retinaculum injury/tear

0 3 0% 100%

Discussion/Conclusion

• 41% of patients with a low lying muscle belly had a concomitant peroneus brevis tear, which is higher than previously reported7,8

• 22% of patients had a peroneus quartus tendon which is similar to findings from other studies9

• Conclusion: Service members with lateral ankle pain and a low lying peroneus brevis or peroneus quartus on preoperative imaging should undergo evaluation for associated peroneus brevis tendon tears.

References• 1. Waterman, BR; Belmont, PJ; Cameron, KL; DeBerardino, TM; Owens, BD:

Epidemiology of Ankle Sprain at the United States Military Academy. Am J Sports Med. 38:797-803, 2010.

• 2. DIGiovanni, BF; Fraga, CJ; Cohen, BE; Shereff, MJ: Associated injuries found in chronic lateral ankle instability. Foot Ankle Int. 21:809-815, 2000.

• 3. Dombek, MF; Lamm, BM; Saltrick, K; Mendicino, RW; Catanzariti, AR: Peroneal tendon tears: a retrospective review. J. Foot Ankle Surg. 42:250-258, 2003.

• 4. Heckman, DS; Reddy, S; Pedowitz, D; Wapner, KL; Parekh, SG: Operative treatment for peroneal tendon disorders. J. Bone Joint Surg. Am. 90:404-418, 2008.

• 5. Park, HJ; Lee, SY; Park, NH, et al.: Accuracy of MR findings in characterizing peroneal tendons disorders in comparison with surgery. Acta Radiol. 53:795-801, 2012.

• 6. Lamm, BM; Myers, DT; Dombek, M, et al.: Magnetic resonance imaging and surgical correlation of peroneus brevis tears. J. Foot Ankle Surg. 43:30-36, 2004.

• 7. Freccero, DM; Berkowitz, MJ: The Relationship Between Tears of the Peroneus Brevis Tendon and the Distal Extent of its Muscle Belly: An MRI Study. Foot Ankle Int. 27:236-239, 2006.

• 8. Geller, J; Lin, S; Cordas, D; Vieira, P: Relationship of a low-lying muscle belly to tears of the peroneus brevis tendon. Am Journ Orth. 32:541-544, 2003.

• 9. Selmani, E; Gjata, V; Gjika, E: Current concepts review: peroneal tendon disorders. Foot Ankle Int. 27:221-228, 2006.