Congenital dislocation of the peroneal tendons in the calcaneovalgus foot

Modified posterior fibular groove deepening procedure with repair of the superior peroneal retinaculum for peroneal tendon subluxation

PURPOSE

To evaluate the clinical results of modified peroneal sulcus deepening combined with superior peroneal retinaculum repair in peroneal tendon subluxation treatment.

METHODS

From 2016 to 2020, 18 patients with peroneal tendon subluxation were diagnosed and treated; all patients underwent modified peroneal sulcus deepening combined with superior peroneal retinaculum repair. The visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS-AH) score, and subjective patient satisfaction were evaluated before surgery and during follow-up.

RESULTS

The operative time was 66.44 ± 5.22 min. All patients' surgical incisions showed grade A healing, and there were no complications. All patients were followed up for 24-48 months; no patients were lost to follow-up. At the last follow-up, the VAS and AOFAS-AH scores were significantly improved compared with those pre-operatively (P < 0.05). There was no significant difference in the activity of the 18 patients between pre- and post-operatively, and all patients recovered their normal gait before injury.

CONCLUSION

Modified fibular groove deepening combined with superior peroneal retinaculum repair for treating peroneal tendon subluxation may be a simple operation with minimal trauma, rapid recovery, and good clinical efficacy.

Nontraumatic Bilateral Recurrent Peroneal Tendon Dislocation with Pes Planovalgus: A Case Report

CASE

Peroneal tendon dislocation is a relatively infrequent problem. Most cases are traumatic, and nontraumatic cases are rare. In this case, a 21-year-old man had nontraumatic bilateral recurrent peroneal tendon dislocation on standing and pes planovalgus. We performed medial displacement osteotomy of the calcaneus for the pes planovalgus and reattachment of the retinaculum and groove deepening for the peroneal tendon dislocations.

CONCLUSION

The dislocations were attributed to the force of the tendon riding up the lateral malleolus on standing because of pes planovalgus. A good outcome was achieved by surgical intervention for both the pes planovalgus and peroneal tendon dislocations.

The ESSKA-AFAS international consensus statement on peroneal tendon pathologies

INTRODUCTION

Peroneal tendon injuries are a significant cause of lateral ankle symptoms in the active population. Accurate diagnosis and prompt treatment is important for minimizing the risk of long-term sequelae associated with chronic peroneal tendinopathy. Although several studies have been published on diagnostic strategies and treatment outcomes, there is no consensus on the optimal management of peroneal tendon pathologies.

PURPOSE

The purpose of this ESSKA-AFAS consensus statement was to conduct an international and multidisciplinary agreed guideline on management of patients with peroneal tendon pathologies.

METHODS

Using the Nominal Group Technique, a panel comprised of sixteen specialists spanning nine countries was convened by the ESSKA-AFAS board. In preparation for the meeting, relevant questions were identified and supported by a systematic literature search. During the meeting, the panel members gave presentations on each question, and the evidence supporting each subject was then vetted by open discussion. Statements were thereafter adjusted on the basis of the discussion and voted upon to determine consensus using a 0-10 range Likert scale. Agreement was confirmed when a mean score of at least 7.5 was reached.

CONCLUSION

This ESSKA-AFAS consensus statement on the optimal management of peroneal tendon pathologies is the result of international and multidisciplinary agreement combined with a systematic review of the literature.

LEVEL OF EVIDENCE

V.

The ESSKA-AFAS international consensus statement on peroneal tendon pathologies

INTRODUCTION

Peroneal tendon injuries are a significant cause of lateral ankle symptoms in the active population. Accurate diagnosis and prompt treatment is important for minimizing the risk of long-term sequelae associated with chronic peroneal tendinopathy. Although several studies have been published on diagnostic strategies and treatment outcomes, there is no consensus on the optimal management of peroneal tendon pathologies.

PURPOSE

The purpose of this ESSKA-AFAS consensus statement was to conduct an international and multidisciplinary agreed guideline on management of patients with peroneal tendon pathologies.

METHODS

Using the Nominal Group Technique, a panel comprised of sixteen specialists spanning nine countries was convened by the ESSKA-AFAS board. In preparation for the meeting, relevant questions were identified and supported by a systematic literature search. During the meeting, the panel members gave presentations on each question, and the evidence supporting each subject was then vetted by open discussion. Statements were thereafter adjusted on the basis of the discussion and voted upon to determine consensus using a 0-10 range Likert scale. Agreement was confirmed when a mean score of at least 7.5 was reached.

CONCLUSION

This ESSKA-AFAS consensus statement on the optimal management of peroneal tendon pathologies is the result of international and multidisciplinary agreement combined with a systematic review of the literature.

LEVEL OF EVIDENCE

V.

Peroneal tendon dislocation/subluxation - Case series and review of the literature

BACKGROUND

Dislocating or subluxing peroneal tendons is a relatively infrequent injury. Although infrequent it is very debilitating for the athlete. This retrospective study addresses primarily the surgical technique.

METHODS

Twenty-three patients between 2005 and 2014 were operated on for symptomatic dislocating or subluxing peroneal tendons. Five patients presented in the acute phase and 18 patients were late cases. Twenty patients were available for follow-up at a mean of 53.1 months. Three patients were classified as Stage III and 17 as Stage I/II. The procedures varied from pure repair of the superior peroneal retinaculum (SPR), reattachment of the SPR, groove-deepening or a combination of the above. No one procedure was favoured over the other. The choice of procedure was decided intraoperatively depending on the findings.

RESULTS

The mean postoperative VAS score was 1.5 with a mean AOFAS score of 85. Sixteen patients rated their results as excellent, one as good, one uncertain and two poor. The results showed no one procedure superior to another with respect to chronicity, stage or satisfaction score.

CONCLUSIONS

Several procedures have been described for this condition. Most published studies however, comprise of a small cohort of patients with good results following surgery. The surgical techniques vary and depend largely on the surgeon's clinical experience and preference. The authors conclude that the surgical technique described in this article is largely successful with a low complication rate and a high satisfaction rate.

Sliding fibular graft repair for the treatment of recurrent peroneal subluxation

BACKGROUND

Because recurrent peroneal subluxation can produce functional impairment in athletes, most authors suggest operative intervention for patients who fail nonoperative treatment. The present report introduces the modified sliding fibular graft repair for this pathology.

METHODS

This retrospective study was conducted to analyze the clinical results for 26 patients with recurrent peroneal subluxation who underwent this procedure with a follow-up of a minimum of 3 years.

RESULTS

Intraoperative observations revealed 15 convex grooves and 11 shallow sulci with a low-lying peroneus brevis muscle belly in 6 patients and a peroneus quartus muscle in 4 patients. All underwent the procedure plus excision of redundant muscle and tendon repair, with an improvement rate of 88.5% according to American Orthopaedic Foot & Ankle Society (AOFAS) score at the final visit. All but 3 patients returned to normal function in 4.4 months with no infection, nonunion, or intra-articular screw placement. A total of 8 patients had minor complications including neurapraxia, synovitis, stress fracture, and delayed union.

CONCLUSION

We found that an anomalous fibular groove plus tendon variants could lead to a further decrease in the volume of the osteofibrous tunnel and might be the reason for recurrent peroneal dislocation; thus, our modified procedure may be a reasonable treatment for this pathological malposition. We found less functional recovery in aged patients due to a higher incidence of tendon tear and postoperative complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Treatment of recurring peroneal tendon subluxation in athletes: endoscopic repair of the retinaculum

Traumatic peroneal tendon subluxation is a rare lesion that occurs most frequently during sporting activities and generally after an ankle sprain. There is consensus regarding the need for surgical stabilization in symptomatic patients, but there is also a general agreement that acute subluxation or dislocations may require surgery in the athlete. Many surgical techniques have been described to treat this lesion. Overall, studies have reported excellent or good results in 90% of cases, although there have been reports of significant complications following open surgical procedures. Endoscopic anatomical retinacular repair offers an attractive alternative to open repair and may reduce complications and allow early return to sports.

Tendoscopic treatment of recurrent peroneal tendon dislocation

PURPOSE

To study the possibility of tendoscopic treatment of recurrent peroneal tendon dislocation.

METHODS

The case of one patient is described including the tendoscopic technique to deepen the fibular groove.

RESULTS

In this single case, there were no complications, recovery time was short, and there was no recurrence of peroneal tendon dislocation.

CONCLUSION

Though it seems possible to deepen the fibular groove tendoscopically, further studies are necessary to determine the role of tendoscopy in recurrent peroneal tendon dislocation.

Review of common and unusual causes of lateral ankle pain

Lateral ankle pain is a common clinical presentation having several important causes, including lateral ligament injury, peroneal tendon injury, sinus tarsi syndrome, and nerve entrapments. However, other causes should be kept in mind in patients with unusual patterns of pain or intractable symptoms. We present a review of common and some unusual causes of lateral ankle pain including a review of post-operative imaging findings following surgery for lateral ankle ligament and peroneal tendon injuries.

Modified rerouting procedure for failed peroneal tendon dislocation surgery

Recurrent dislocation of the peroneal tendons following operative treatment is relatively uncommon, but can be difficult to treat. We asked whether subligamental transposition of the peroneus brevis tendon, fibular grooving, and reattachment of the superior peroneal retinaculum for failed peroneal tendon dislocation surgery would achieve a stable fixation of the peroneal tendons and whether there would be restrictions of ROM or instability of the hindfoot. We reviewed six female patients (mean age, 24.5 years) with general laxity of joints preoperatively and at 6 weeks and 3, 6, and 12 months postoperatively. Within 1 year postoperatively no recurrence was found. In two ankles the extension was restricted 5 degrees to 10 degrees . In another pronation and supination was restricted 5 degrees each. Stability of the ankle increased in four patients and stayed unchanged in two. AOFAS score increased from a mean value of 36 +/- 20.6 preoperatively to 90 +/- 7 postoperatively at 1 year. We conclude transposition of the peroneus brevis tendon is a reasonable treatment for failed peroneal tendon dislocation surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic study (prospective case series). See Guidelines for Authors for a complete description of levels of evidence.

Concomitant rupture of achilles tendon and superior peroneal retinaculum: a case report

A case of a concomitant rupture of the Achilles tendon and superior peroneal retinaculum is presented. This combination of injuries has only been reported once in the available literature. The intraoperative findings revealed a mid-substance failure of the superficial peroneal retinaculum, which is also a rare finding. It is suggested that mid-substance failure of this structure be included within the existing classification scheme for superficial peroneal retinacular tears. The authors also discuss the probable pathoanatomical features of these combined injuries and a proposed mechanism of injury.

The Singapore operation for chronic recurrent peroneal tendon subluxation--short-term follow-up in four patients

BACKGROUND

Recurrent peroneal tendon subluxation is an uncommon condition which is usually the result of sports related trauma. This injury may be misdiagnosed resulting in long-term disability. Most authors would recommend surgical treatment for patients who have a long history or in patients in whom conservative treatment has failed. Surgical treatment can also be considered in the acute phase when managing young athletic individuals.

METHODS

We report the outcome in four patients who underwent the Singapore operation for chronic peroneal tendon subluxation. All patients were operated on by the same surgeon and followed up at regular intervals with a minimum follow-up of two years.

RESULTS

In all four patients a Bankart type lesion was found in association with subluxation solely of the peroneus longus tendon. Following repair all patients returned to pre-injury activity levels within six months.

CONCLUSION

In our experience the Singapore operation is technically easy to perform and offers excellent results with high patient satisfaction levels.

A rare pentad of foot and ankle deformities in hyperlax children

OBJECTIVE

The aim of this paper is to describe the clinical features and radiological appearance of a rare and complex lower leg and foot deformity in hyperlax children.

METHODS

Four children were included in the study; of these, two had bilateral feet involvement. All deformities were present since birth, comprising a pentad of conditions: (1) pathologic external tibia and fibula torsion, (2) ball and socket ankle joint with medial subluxation and talus medial subluxation, (3) excessive hindfoot valgus, (4) peroneal and Achilles tendon displacement anterior to the lateral malleolus and (5) generalized ligament laxity. All children had failed cast manipulation. Only two had undergone a minimal soft tissue procedure, but there had been no improvement.

RESULTS

All patients were ambulatory and pain free at the mean age of 6.5 years.

CONCLUSION

Conservative or minimal soft tissue procedures are not effective in restoring the anatomy of such feet.

Foot and ankle imaging in the athlete

Foot and ankle injuries are among the most common of all sports-related injuries. Many injuries are simplistic from a diagnostic standpoint, whereas others require a high level of suspicion and the use of appropriate diagnostic imaging modalities. Whether a professional athlete or a weekend warrior, all athletes want minimal disruption to their sporting activity and a quick return to competition. An accurate diagnosis aids in the development of an appropriate rehabilitation program and in return to activity. This article reviews the more common foot and ankle injuries seen in the podiatrist's office and the preferred imaging modalities used to evaluate them.

Acute and chronic peroneal tendon dislocations

Peroneal tendon dislocation is an infrequent sports injury and can be difficult to diagnose. Posterior fibula tenderness and pain with eversion are useful signs to discriminate this from an ankle sprain. In the acute setting, a direct repair provides good results but may need to be augmented with additional soft tissue or bony restraints. For chronic injuries there are several methods of reconstruction, all with acceptable outcomes, although bone block procedures have the highest rate of secondary procedures.

Staged reconstruction for chronic rupture of both peroneal tendons using Hunter rod and flexor hallucis longus tendon transfer: a long-term followup study

BACKGROUND

Long-term followup (over 5 years) of staged reconstruction for chronic ruptures of both peroneal tendons using a Hunter rod and the flexor hallucis longus (FHL) tendon is presented.

METHODS

Seven patients with chronic ruptures of both peroneal tendons who had at least two previous surgeries that failed were treated with excision of the remaining portion of the peroneal tendons and implantation of a Hunter rod to the insertion of the peroneus brevis. Patients performed passive range of motion exercises for 3 months before removal of the Hunter rod and transfer of the FHL into the newly formed sheath, attaching it to the insertion of the peroneus brevis on the fifth metatarsal. The patients' ages ranged from 30 to 57 (average 38) years. All were women. All had at least two previous failed procedures (range two to six). The average time from initial injury to the index surgery was 4.6 (range 2 to 7) years. Patients were evaluated by physical examination and a questionnaire. The average range of followup was 8.5 years (range 143 to 167 months).

RESULTS

All wounds healed without complications. One patient (a workers' compensation patient) had continued complaints of pain and ambulated with a molded ankle-foot orthosis (MAFO). The remaining six patients reported complete relief of symptoms and returned to full preinjury levels of activity. One patient required a Broström ankle ligament repair 2 years after tendon transfer for a new injury but has remained pain free for the last 62 months. There were five excellent, one good, and one fair result. All patients stated they would repeat the surgery.

CONCLUSION

Staged reconstruction with excision of the remaining portion of the peroneal tendons and reconstruction with a Hunter rod and FHL transfer has been shown to be an effective long-term treatment for chronic peroneal tendon ruptures.

Failed treatment of peroneal tendon injuries

As with most musculoskeletal disorders, understanding the anatomy and function of the peroneus longus and brevis tendons is paramount to the appropriate diagnosis and treatment of their pathologic conditions. This article helps the reader prevent treatment failures by reviewing the anatomy, function, and common treatment options for various disorders of the peroneal tendons. Finally, a discussion of common treatment failures will highlight pitfalls to be avoided.

Bilateral congenital peroneal tendon subluxation

Congenital subluxation of the peroneal tendons is an uncommon, but not rare condition. In almost all cases, it will spontaneously resolve without requiring any treatment. Presented is a case report of the condition affecting the patient bilaterally. The subluxation did not resolve and the patient was subsequently treated with a modification of the Kelly procedure.

Fibular grooving for recurrent peroneal tendon subluxation

Twelve ankles in 11 consecutive patients with recurrent peroneal tendon dislocations were studied after undergoing a fibular grooving procedure. The mean age of the patients was 25 years (range, 13 to 45). The mean time from initial injury to surgery was 18 months, and the mean follow-up time was 6 years. All patients had preoperative peroneal tenderness; 9 of 12 ankles had active peroneal tendon subluxation on examination. All patients had failed results from nonoperative treatments of rehabilitation and bracing. Before the fibular grooving procedure, 10 ankles were shown to have intraarticular pathologic changes on arthroscopic evaluation. Postoperatively, there were no resubluxations. Eleven ankles were pain-free, 10 had full and symmetric range of motion, and 1 patient lost 3 degrees of eversion. Ten patients were able to return to full unrestricted activities including all previous sports. Eleven ankles were rated as excellent results. Complications included suture abscesses in two patients and refractory pain in one patient who had multiple surgeries for subtalar pain but had no peroneal resubluxation. Recurrent peroneal tendon subluxation is an uncommon problem. An accurate diagnosis is essential. The fibular grooving procedure appears to reproducibly alleviate resubluxation of the peroneal tendons and diminish pain. It also allows for retainment of motion and subsequent return to work and sports with a high satisfaction rate.

Traumatic peroneal tendon instability

To investigate the causes of, pathologic changes associated with, and treatment results after traumatic peroneal tendon subluxation or dislocation, we reviewed 11 cases in 10 patients at a mean followup of 29 months. We also describe a technique of superior peroneal retinacular repair combined with fibular rotational osteotomy. Excellent clinical and functional results were achieved in 9 of the 11 cases, enabling the patients to return to previous competitive sports by 3 months. There was one persisting subluxation that required further surgery. Another ankle, with chronic sepsis from previous surgery and documented degeneration of the ankle joint, had a recurrence of the infection and sequestration of the osteotomized fragment. The personal tendons, however, remained stabilized by the resultant scar tissue. We conclude that superior peroneal retinacular repair, with or without fibular rotational osteotomy, is a successful technique in treating both acute and recurrent instability of the peroneal tendons. It can be combined with a Bröstrom repair when there is concurrent peroneal tendon and anterolateral ankle instability. Peroneal tenosynovitis and tendon splitting were commonly found at operation, especially in cases of recurrent instability. The degree of pathologic change in the tendon did not affect the clinical result.

Lateral ankle instability as a cause of superior peroneal retinacular laxity: an anatomic and biomechanical study of cadaveric feet

The role of the competent superior peroneal retinaculum (SPR) as a primary restraint to peroneal tendon subluxation and mechanical attritional wear is clear. Injury to the SPR has classically been described as a dorsiflexion eversion movement of the ankle coupled with a forceful peroneal tendon reflex contraction. This mechanism, however, does not cause injury to the lateral collateral ligaments of the ankle and does not explain the coexistent findings of lateral ankle instability, laxity of the SPR, and concurrent peroneal tendon pathology. Anatomic studies reveal a parallel alignment of the calcaneal band of the SPR and the calcaneofibular ligament. A cadaveric model of ankle instability created by serial sectioning of the lateral collateral ligaments revealed increasing visual strain on the SPR with increasing degrees of ankle instability. These findings suggest the SPR serves as a secondary restraint to ankle inversion stress and that the force or forces that result in chronic ankle instability can also injure and attenuate the superior peroneal retinaculum.

The dynamics of peroneus brevis tendon splits: a proposed mechanism, technique of diagnosis, and classification of injury

The etiology of peroneus brevis splits is unclear. Because longitudinal splits in the peroneus brevis tendon do not necessarily effect the integrity or strength of the tendon, it is difficult to ascertain whether or not injury to the peroneus brevis tendon is present. Recent clinical, anatomic, and histologic reports have suggested that the split develops from prolonged mechanical attrition within the fibular groove as a result of ankle trauma with resultant lateral ankle instability and incompetency of the superior peroneal retinaculum with resultant subluxation of the peroneal tendons. This cascade of events may result in splitting of the peroneus brevis tendon. The purpose of this paper was to report the investigation of the mechanism by which peroneus brevis splits develop, to describe a technique of diagnosis, and to propose a classification of injury. Peroneus brevis splits are the result of a dynamic mechanical insult at the fibular groove. Laxity of the superior peroneal retinaculum combined with peroneus longus mechanical compression causes the peroneus brevis to splay out and eventually split over the sharp posterior edge of the fibula. Anatomic factors, such as a shallow fibular groove (congenital convex groove) or the presence of an anomalous low-lying peroneus brevis muscle belly or peroneus quartus tendon, may also play a role in this mechanism by interfering with the competence of the superior peroneal retinaculum.

Traumatic subluxation/dislocation of the peroneal tendons

Traumatic subluxation/dislocation of the peroneal tendons has been reported following a variety of sports-related activities. The peroneal musculature contracts reflexively during the injury and overcomes the restraining soft tissue. The tendons can then dislocate anteriorly from behind the distal fibula. Some patients have anatomical variations of the posterolateral ankle that predispose them to injury. If the physician is unaware of the injury, the diagnosis may be missed in the acute setting and can develop into a chronic, disabling condition. Treatment of the acute injury is controversial because advocates exist for both conservative and surgical therapies. The chronic, painful lesion should be treated operatively. A tremendous number of surgical procedures have been described for the treatment of chronic tendon dislocations. Choice of a surgical procedure depends upon the anatomy of the peroneal groove and the retinaculum, and the nature of the damage to the area.

Recurrent dislocation of the peroneal longus tendon as a complication of multiple osteochondromatosis

This is a report of recurrent dislocation of the peroneal tendon in a patient with multiple osteochondromatosis. The distorted anatomy at the ankle from the osteochondromas was the source of the tendon's recurrent dislocations. There were two areas in the ankle in which the retinacula supporting the tendons failed because of the osteochondromas. At the lateral site of fibula, the origin of the supporting retinacula was attenuated by the presence of an osteochondromas. At the medial site of fibula, a large osteochondroma distorted and widened the tibiofibular joint. The widening of the distal tibiofibular joint by this osteochondromas also attenuated the retinacula of the peroneal tendons, permitting their dislocation.