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Peroneal tendoscopy

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Abstract

Peroneal tendoscopy is an innovative technique that allows visualization of the tendons from the myotendinous junction to the peroneal tubercle, together with adjacent anatomic structures such as the recently unveiled vincula. Through a minimally invasive approach, it is possible to diagnose and treat several disorders, such as common tenosynovitis, accessory muscles, hypertrophic bony prominences, and thickened vincula, that can cause pain and tendon catching. Surgical morbidity and postoperative pain are significantly reduced when compared with open procedures. In this paper, the main indications for peroneal tendoscopy are discussed, the available literature is reviewed, and the surgical technique is described. Advantages of this procedure and current limitations are also presented. Anatomic and histological studies were also performed in order to verify: 1) the feasibility of peroneal tendoscopy for evaluation of peroneal tendons, using cadaver specimens; 2) the presence of nervous tissue in cadaver peroneal vincula as well as in tendoscopic vincula biopsies from patients undergoing surgery for chronic lateral ankle pain.

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Acknowledgments

The Authors are grateful to Luciano Mosso (MD, Pathologist) for the histological assistance and the critical observations. The Authors would also like to thank Radhika Srinivasan, PhD, for editing of the manuscript.

Disclosure

No conflicts of interest relevant to this article were reported.

Author information

Correspondence to Antonio Marmotti.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Cadaveric study. This movie describes the different steps of the cadaveric study: distal portal placement; sural nerve exposure; superficial dissection; superficial peroneal nerve exposure; dissection of the tendon sheath; and vincula exposure. (WMV 21232 kb)

Peroneal tendoscopy release of thickened vincula case 1. (MPG 13534 kb)

Video 1

Cadaveric study. This movie describes the different steps of the cadaveric study: distal portal placement; sural nerve exposure; superficial dissection; superficial peroneal nerve exposure; dissection of the tendon sheath; and vincula exposure. (WMV 21232 kb)

Video 2

Peroneal tendoscopy debridement of a partial tear with radiofrequency. This movie shows the debridement of a partial tear of peroneus brevis tendon with the aid of a 90° small radiofrequency wand. (M1V 2827 kb)

Video 3

Peroneal tendoscopy II portal placement. This movie shows the placement of a proximal portal assisted by transillumination, with the aid of an 18 gauge spinal needle; an underlying tear of the peroneus brevis tendon can be observed. (M1V 7471 kb)

Video 4

Peroneal tendoscopy release of thickened vincula case 1. (MPG 13534 kb)

Video 5

Peroneal tendoscopy release of thickened vincula case 2. These movies show the release of a thickened vincula in a patient complaining of lateral ankle pain and a clinical picture of chronic ankle instability; tendoscopy was performed for persistent pain at the posterior margin of lateral malleolus after at least 4 months of non-operative treatment; intraoperative findings of a vincula lesion (thickening/scarring) was treated by a selective release of the thickened portion with the help of a small arthroscopic biter. (M1V 7939 kb)

Video 6

Peroneal tendoscopy tendoscopic exploration of peroneal tendons part I. (M1V 7192 kb)

Video 7

Peroneal tendoscopy tendoscopic exploration of peroneal tendons part II. These movies show an overall view of peroneal tendons with the endoscope introduced through the distal portal. (M1V 7661 kb)

Video 8

Peroneal tendoscopy tendoscopic exploration in tenosynovitis. This movie shows a panoramic view of peroneal tendons in a clinical picture of tenosynovitis. (M1V 4936 kb)

Supplement 1

Peroneal tendoscopy histological study. This presentation shows the results of the histological study. Immunohistochemistry was performed on vincula cadaveric samples and vincula biopsies taken from patients undergoing tendoscopy for persistent pain at the posterior margin of the lateral malleolus, in which an intraoperative finding of a vincula lesion (thickening/scarring) was found. Biopsies were evaluated by Haematoxylin/Eosin (H/E) staining and by immunohistochemistry for S-100. Cadaveric vincula samples were evaluated by H/E staining and by immunohistochemistry for S-100, p 75 (low-affinity neurotrophin receptor), NGFR (nerve growth factor receptor, CD271), myelin basic protein (MBP), PGP 9.5 (pan-neuronal marker protein gene product), Neurofilament (NF), Vimentin (as an undifferentiated marker for both nervous and vascular structures). As positive controls, samples from the sural nerve and the sinus tarsi expansion of inferior extensor retinaculum were also harvested and evaluated by H/E staining and immunohistochemistry. (PPT 10372 kb)

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Marmotti, A., Cravino, M., Germano, M. et al. Peroneal tendoscopy. Curr Rev Musculoskelet Med 5, 135–144 (2012). https://doi.org/10.1007/s12178-012-9123-1

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Keywords

  • Tendoscopy
  • Peroneal tendons
  • Vincula
  • Cadaver study
  • Histological study
  • Foot
  • Ankle
  • Foot and ankle
  • Musculoskeletal