Dr. J:

Saw your article on peroneus tears/ruptures so....

Any idea why I’m having difficulty finding a surgeon (Kansas City) that will attempt a primary repair, with or without graft, of a peronus longus rupture with fractured os perineum (xray & MRI confirm).

Am I expecting to much to find someone who will attempt a primary repair instead of cut & splice to brevis?

From a middle aged guy that takes soccer balls away from high school varsity soccer players, goes sking on black slopes, backpacks/hikes mountains etc. in areas where cell phones do not work etc. And understands why the PL tendon is very usefull going after a soccer ball.

Basically my summer and fall are ruined and probably winter also.

So tell me more about this...if the os peroneum is intact, then is the PL tear a longitudinal tear? It's still intact but just split?

Jeff

OSP is clearly broken with some displacement. There are three different x-rays over 6 weeks with no change is displacement. Immobilized seine the occurrence and no change in displacement. MRI write up states "tear" proximal to OSP. I am not able to specifically determine if longitudinal or traverse tear. However, I can feel "movement" along "path" if I relax and mind tweak the area. So I suspect that its not a traverse tear and thus a longitudinal split caused by the OSP fracture. X-rays of OSP show a vertical crack running directionally across foot if that means anything. Everyone I've seen (3) just want to cut the tendon and splice it to brevis. However, and please correct me if I’m wrong, it is my understanding that this tendon is one of the arch supports and from a mobility perspective, is key to pulling the inside forefoot down/under as is needed for soccer ball kicks and other movement like that. I see write-ups that indicate that primary repairs are done. And I do understand that grafts sometimes fail. And I understand that a "deep" traverse tear may not be repairable due to "access" issues. I guess trying to determine if my expectations are realistic for a primary repair or if I'm in a small town syndrome situation related to quantity of surgeons that can do a primary repair. Also, any thoughts about only removing the "small" portion of the cracked osp and then tying down the loose edges of the tendon? The OSP is rather large and one Doc stated to remove both pieces of the osp would actually leave nothing connected. Thus, splice to Brevis. Thanks for your thoughts. PS, otehr foot hurts same spot but osp xray there was negative for displaced parts.

You're right. The peroneus longus cuts under the foot and pulls the medial foot down. Another way to say it is that it pronates the foot.

As surgeons, we're supposed to give you the worse case scenarios. I have to admit that the os peroneum is a tough little guy to get out. So you would want to have someone experienced with the anatomy. The technique is not so tough, it's just that access from the lateral side of the foot is a bit limited since the os peroneum is so deep.

I always read my folks the riot act, but I've not had one of those that have required a graft. You just shell out the os peroneum and rest the tendon for 8-10 weeks so that the tendon can gain a bit of strength. I've found grafting to be necessary as long as you're careful with your dissection. But you're right, worse case scenario would be tenodesis to the brevis tendon. In that case you do loose the function of the longus to pronate, but you still have the plantar flexion force of the longus (secondary action of the longus)

There's a good article out there (forget the author) that describes that when there's more than a 4mm separation of the fracture fragments, there's a significant tear. Anything less than 4mm and the tear is minor. This was an MRI study that related the separation of the fracture fragments to severity of tendon tear. Might want to Google that one.

Jeff

Yes, exactly, due to another issue elsewhere I did my research as soon as first diagnosis was in. I have seen the article you mention. The directional of the “crack” in the OS is exactly why I mentioned how mine was positioned and the separation appears to be “less than”. For mine the MRI doc could only find a density change in the OS, not an actual crack. Xray does show the crack however.

Thus, in a roundabout way you have answered my original question of whether my expectations are reasonable in actually finding a surgeon who will try for a primary repair. Not finding one yet is what has me on edge. I am still waiting for appointments for the, supposedly, #1 & #2 guys in town. 5 month wait for the #1 guy.

Followup question: If the OS is "sizable" I have been told that removing it would be a defacto deep traverse tear. This is what one guy said along with his intention for a brevis splice. Although I think I understand the mechanics of his statement, this is where I would think that a graft would be implemented. Any thoughts on this?

Anyway, I’m off to New York City to see if I can find a surgeon there. Will be visiting my folks at same time. I'll wave as I go by.

Funny we're talking about this. I've been treating a 68 y/o gal for a fractured os peroneum. It's obvious on plain film and she's failed to respond to conservative care. So I sent her for an MRI to r/o any significant tear that I can't see on x-ray. The MRI read specifically was focused on the os peroneum which couldn't be visualized on MRI. The suggestion was for a CT scan but the CT scan wouldn't be able to visualize any tendon tear. I was a bit disappointed in the MRI read.

So what are we going to do? I'm going ahead and recommending the excision of the os peroneum. I've never seen a defect so big that the peroneus longus couldn't heal. I'm sure that can occur but I've not seen it. But then again, it's our job as surgeons to read you the riot act first...just in case. Sure, you can tenodese the longus to the brevis. But that'd be a last ditch repair and I think somewhat unlikely.

Jeff

The more research I do, the more frequent the data clarifies. Amazing for something that's supposed to be "rare". Anyway, restating from earlier e-mails, three (3) docs from kc (two surgical podiatrists and one ortho/ankle/foot surgeon) would not even consider a primary repair of longus peronus and would only do the cut/abandon the longus connecting to 1st met and splice the longus tail to the brevis. So... went to NJ and it only took about a 5 minute conversation (ignoring the prior reference/referral work that my mom, a 50 year RN who knows surgeons in north jersey, helped with) and signed up for a primary repair with 1st objective being a butt end splice if removing the OSP parts (two fragments, one large) leaves the longus disconnected, with 2nd option being a double splice using brevis as a bridge to attempt to retain a connection to the longus piece that connects under the foot to 1st met. He gave me the disclaimers of tendons do not have a blood supply and also if longus was shredded he wouldn't have a choice but I said I understood which I do. He also has an issue with the ATFL which I knew was a bit loose and he wants to Bromstom that. He's thinking a week and a half in a surgical cast and then 5+/- weeks in a hard cast, then a few weeks in a boot, with PT.

So what do you think of this? Are you aware of any other surgical option to retain the longus tendon connection to 1st met?

Of course, I have spent so much time on this that, finally, my appt. with the #2 guy in KC is later this week. I’m planning on going and having him take a look also as a sanity check on the NJ doc. However, he does not take my insurance. But, he’ll do the work at a place that does so it’s just the surgeon’s fee that would be out of network. Sigh. Maybe I’ll trade a couple horses (pureblood Arabians with papers), no chickens or goats though. I assume he takes cash as a last resort. So, cost of that vs. cost of a few round trips to NJ may be a deciding issue.

Last, I still have appts pending with the #1 guy in KC (late sept) and a guy in NYC (mid Sept) that may end up getting cancelled as I’m getting really tired with the boot I’m wearing.

I'm going to guess that the primary issue is two things. First, the longus can be tough to access. When you look at the anatomy texts, you'd tend to think that the longus tendon is easy to access and treat, but in the OR, it's a tough dissection and therefore a bit challenging to treat. And that leads to the second issue...that's why these guys are reluctant to tackle it simply because in their opinions, they know it's going to be a tough job. Some of depends upon the difficult nature of the surgery, but the other issue is tendon healing. It's just going to be a given that tendon heals slower than molasses. The longer it takes to heal, the greater you are at risk for re-injury.

Jeff