The application of peroneal tenography in patients with lateral calcaneal pain after fracture union

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The application of peroneal tenography in
patients with lateral calcaneal pain after
fracture union

• Wei Chen, MD Qi Zhang, MD

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Incidence of calcaneal fractures

• Calcaneal fractures account for 2 of all
  fractures
• Calcaneal fractures responsible for 60 of major
  tarsal injuries
• 80-90 cases occur in young and adults

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Backgroud

• Patients who sustain calcaneal fracture
  especially dislocated intra-articular calcaneal
  fracture often suffer chronic sequelae at
  follow-ups.
• The lateral calcaneal pain, as one of the most
  common sequelae, remains a challenge to the
  orthopaediac surgeons.

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Hypothesis

• A hypothesis is that the calcaneus becomes wider
  during fracture healing which will cause
  compression of the peroneal tendon sheath.
• The friction between tendon and surrounding
  structure during the motion of ankle joint will
  result in tenosynovitis in the sheaths.

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The purpose of our study

• To verify the hypothesis by adapting the imaging
  technique of peroneal tenography
• To explore in depth of the correlation between
  lateral calcaneal pain, calcaneal width and
  peroneal tendon sheath impingement

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Instruments
SIEMENS Somatom sensation 64
Iohexol Injection
Fluorosopic C-arm
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Patients

• Patients who have significant lateral calcaneal
  pain secondary to calcaneal fracture were
  included in the study.
• 74 patients with unilateral calcaneal pain were
  located from the trauma registry from March 2006
  to October 2008.

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• 57 males and 17 females
• average age 39 years (17 to 72 years)
• 46 left feet and 28 right feet
• 43 cases treated with open reduction and internal
  fixation
• 31 cases managed with closed reduction with
  percutanous fixation and casting

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• The mean duration from operation on the calcaneal
  fracture to the occurrence of lateral calcaneal
  pain was 4.7 months (ranged from 2.5 months to 11
  months).

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Measurement of the calcaneal width

• The maximum width of each calcaneus at the
  sustentaculum tali level was measured on the
  coronal section of CT images

B
A
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Peroneal Tenography

• Bilateral peroneal tenography was performed to
  examine compression on the peroneal tendon sheaths

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• Radiographs in anteroposterior view of the ankle
  joint and the lateral views of calcaneus obtained
  after injection using a fluoroscopic C-arm

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Statistical analysis

• Performed using SPSS 13.0 for Windows.
• The correlation among lateral calcaneal pain,
  increasing calcaneal width and peroneal tendon
  sheath impingement was analyzed with bivariate
  correlation(spearman's rank correlation).

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Results

• The width of calcaneus at the level of
  sustentaculum tali
• 48.69mm4.42mm (ranged from 41.05mm to 56.62mm)
  for healed calcaneus
• 44.32mm2.76mm (ranged from 37.25 mm to 51.87mm)
  for the unaffected calcaneus
• The width of the injured calcaneus is
  4.14mm1.68mm larger than the width of the
  unaffected calcaneus

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Compression on tendon sheath

• If the increased width of the calcaneus was
  within 3mm, the contrast medium passed through
  the tendon sheath smoothly.
• If the width of the injured calcaneus was
  increased more than 3mm, the contrast medium did
  not pass through the tendon sheath smoothly,
  indicating compression of the tendon sheaths.

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• The peroneal tenography revealed evidence of
  compression of the peroneus longus and peroneus
  brevis tendon sheaths in 68.9 (51/74) cases
• The width of the injured calcaneus is
  5.15mm1.17mm larger than the width of the
  unaffected calcaneus in the 51 cases.

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Severity of the compression

• The constriction of tendon sheath is graded as 3
  levels with the normal tendon sheath being the
  reference.

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B

• Severity 1 the width of compressed area was less
  than 1/3 of the normal width of the contralateral
  tendon sheath

A
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• Severity 2 the width of the compressed sheath
  was greater than 1/3 but less than 2/3 of the
  width of the contralateral tendon sheath

B
A
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• Severity 3 the width of tendon sheath is
  compressed to less than 1/3 of normal width, or
  contrast media failed or only a bit passed
  through the tendon sheath at the lateral aspect
  of calcaneus.

B
A
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TABLE 1. The compression of the peroneus longus
and brevis tendon sheath
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Assessment of lateral pain

• The lateral calcaneal pain level evaluated based
  upon Numerical Pain Rating Scale.
• Scores on NPRS range from 1 to 8

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TABLE 2. The lateral calcaneal pain
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Statistic analysis

• Correlations between compression of the tendon
  sheaths and the lateral calcaneal pain(Rs0.93,
  plt0.001)
• Correlations between the increasing calcaneal
  width and the lateral calcaneal pain(Rs665,
  plt0.001)
• Correlations between the increasing calcaneal
  width and the compression of tendon
  sheath(Rs0.545, plt0.001).

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Concl-usion

• The correlation between the compression of the
  tendon sheaths and the lateral calcaneal pain is
  better that that between the increasing calcaneal
  width and the lateral calcaneal pain.
• The severity of lateral calcaneal pain was
  primarily related to the compression of tendon
  sheath and only related indirectly to calcaneal
  widening.

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Concl-usion

• In our study, the tenography revealed no marked
  tuberosity and nodule, indicating that the cause
  of their pain is not tenosynovitis
• The exclusion of tenosynovitis as the cause and
  marked evidence of compression strongly suggest
  that the compression on peronoeus tendon sheath
  is responsible for the pain.

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Surgical interventions

• Five cases who suffered severe lateral calcaneal
  pain were managed operatively.
• During operation, the peroneus longus and brevis
  tendon were found to be compressed by the
  widening calcaneus.
• The protrudent new bone in the lateral calcaneus
  was resect.

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Case presentation
A
B
C

• Follow-ups were done and all 5 patients have no
  complains of recurrence of lateral calcaneal pain
  with a mean duration of 4 months(ranged, 3 months
  to 7 months)

D
E
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Limitations

• Surprisingly, no evidence of compression from the
  tenography of the peroneus tendon sheath in the
  other 23 cases.
• Other factors may contribute to the lateral
  calcaneal pain.
• They will be verified by sonography, CT scan or
  MRI, and electromyography in further study.

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Acknowledgement

• We present the paper on behalf of Yingze Zhang,
  MD Wei Chen, MD Xicheng Li, MD Qi Zhang,
  MDYanling Su, MD, MPH
• We wish to thank Dr. Qingxian Wang and Xiaolin
  Zhang for their assistance in the preparation of
  the paper.

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