Surgical Treatment for Stenosing Peroneal Tenosynovitis.

BACKGROUND:: Stenosing peroneal tenosynovitis (SPT) is an uncommon entity that is equally difficult to diagnose. We evaluated our outcomes with a local anesthetic diagnostic injection followed by surgical release of the sheath and calcaneal exostectomy. METHODS:: Eleven patients diagnosed with SPT underwent surgery between 2006 and 2014. Upon initial presentation, all patients reported a persistent history of pain along the ankle. Ultrasound-guided injections of anesthetics were administered into the peroneal tendon sheath to confirm the diagnosis. In patients with a confirmed diagnosis of SPT, we proceeded with surgical intervention with release of the peroneal tendon sheath and debridement of the calcaneal exostosis. Retrospective chart review was performed, and functional outcomes were assessed using the Foot and Ankle Outcome Score (FAOS). FAOS results were collected pre- and postoperatively and were successfully obtained at 1 year or greater. RESULTS:: Of these patients, all showed significant improvements ( P < .05) in 4 of 5 categories of the FAOS (pain, daily activities, sports activities, and quality of life). CONCLUSION:: We present a case series in which the peroneal tendon sheath was diagnostically injected with anesthetic to confirm a diagnosis of SPT. In each of these cases, symptomatic improvement was obtained following the injection. With the fact that many of these patients had advanced imaging denoting no significant tears, we believe that this diagnostic injection is paramount for the success of surgical outcome. LEVEL OF EVIDENCE:: Level IV, retrospective case series.

Optimal Starting Point for Fifth Metatarsal Zone II Fractures: A Cadaveric Study.

BACKGROUND: Identifying the optimal starting point for intramedullary fixation of tibia and femur fractures is well described in the literature using a retrograde or anterograde technique. This technique has not been applied to the fifth metatarsal, where screw trajectory can cause iatrogenic malreduction. The generally accepted starting point for the fifth metatarsal is "high and inside" to accommodate the fifth metatarsal's dorsal apex and medial curvature. We used a retrograde technique to identify the optimal starting position for intramedullary fixation of fifth metatarsal fractures. METHODS: Five matched cadaveric lower extremity pairs were dissected to the fifth metatarsal neck. An osteotomy was made to access the intramedullary canal. A retrograde reamer was passed to the base of the fifth metatarsal to ascertain the ideal entry point. Distances from each major structure on the lateral aspect of the foot were measured. Computed tomography scans helped assess base edge measurements. RESULTS: In 6 of 10 specimens, the retrograde reamer hit the cuboid with a cuboid invasion averaging 0.7 mm. The peroneus brevis and longus were closest to the starting position with an average distance of 5.1 mm and 5.7 mm, respectively. Distances from the entry point to the dorsal, plantar, medial, and lateral edges of the metatarsal base were 8.3 mm, 6.9 mm, 9.7 mm, and 9.7 mm, respectively. CONCLUSION: Optimal starting position was found to be essentially at the center of the base of the fifth metatarsal at the lateral margin of the cartilage. Osteoplasty of the cuboid or forefoot adduction may be required to gain access to this site. CLINICAL RELEVANCE: This study evaluated the ideal starting position for screw placement of zone II base of the fifth metatarsal fractures, which should be considered when performing internal fixation for these fractures.