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subluxation – Case series and review of the literature
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FAS-843; No. of Pages 6 Foot and Ankle Surgery xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Peroneal tendon dislocation/subluxation – Case series and review of the literature Nikiforos Pandelis Saragas MBBCh (Wits), FCS (SA) Ortho, MMed (Ortho Surg) (Wits)a,b,*, Paulo Norberto Faria Ferrao MBChB (Pret), FCS (SA) Orthoa,b, Ziyaad Mayet BSc (Wits), MBChB (Medunsa), FC Ortho (SA), MMed Orth (Wits)a,b, Hooman Eshraghi MBBCh (Wits), FC Ortho (SA)a,b a b
Netcare Linksfield Orthopaedic Sports & Rehabilitation Centre (Clinic), Johannesburg, South Africa Orthopaedic Department, University of the Witwatersrand, Johannesburg, South Africa
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 February 2015 Received in revised form 31 May 2015 Accepted 1 June 2015
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. ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Peroneal tendons Subluxation/dislocation
1. Introduction Dislocating or subluxing peroneal tendons are a relatively infrequent pathology which is often misdiagnosed as an ankle sprain particularly in the acute setting. It affects mainly young adults and most frequently during sporting activities. Dislocating peroneal tendons are mostly due to avulsion of the superior peroneal retinaculum (SPR) from its fibular insertion.
* Corresponding author at: PO Box 1153, Highlands North, 2037 Johannesburg, South Africa. Tel.: +27 11 485 1974; fax: +27 11 640 5313. E-mail address: [email protected] (N.P. Saragas).
In fact Das De and Balasubramaniam [1] suggested the stripped retinacular pocket was similar to the Bankart lesion of the shoulder. Subluxation of the peroneal tendons was first described in a ballet dancer by Monteggia in 1803 [2]. 1.1. Anatomy Proximally, the common peroneal sheath passes through a fibro-osseous tunnel known as the retro-malleolar groove. This groove is covered with fibro-cartilage with the peroneus longus tendon lying posterolateral to the peroneus brevis tendon. The groove varies in depth and shape. The shape of the groove is determined by a cartilaginous ridge which enhances the depth [3].
http://dx.doi.org/10.1016/j.fas.2015.06.002 1268-7731/ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Saragas NP, et al. Peroneal tendon dislocation/subluxation – Case series and review of the literature. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.06.002
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FAS-843; No. of Pages 6 N.P. Saragas et al. / Foot and Ankle Surgery xxx (2015) xxx–xxx
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The SPR is a fibrous band that originates from the posterolateral aspect of the fibula, passes over the tendons and inserts most commonly onto the calcaneus and Achilles tendon sheath, although there are several distinct insertional variations [4] (Fig. 1). The SPR functions as the primary restraint to peroneal tendon subluxation [5]. 1.2. Mechanism of injury Dislocation or subluxation often occurs during sporting activities or any other manouvre which includes the sudden, reflexive contraction of the peroneal muscle during dorsiflexion of the everted foot or during an acute inversion injury to the dorsiflexed ankle [6]. An inadequate groove, lateral ankle instability, laxity of the SPR and congenital absence of the SPR may increase the risk of subluxation [7,8]. 1.3. Examination A history of an acute injury is often misdiagnosed as an ankle sprain, although swelling, tenderness and ecchymosis posterior to the lateral malleolus can be demonstrated in a subluxation [6]. A concomitant ankle ligament sprain or a longitudinal split of the peroneus brevis [9] maybe present. In the more chronic subluxation or dislocation, patients experience pain and at times may describe a snapping or popping sensation in the lateral ankle and hindfoot. There is a long differential diagnosis and therefore, a detailed history and physical examination are essential. Peroneal tendon subluxation may be obvious when the patient walks. Dislocation can be visualized by rotating the ankle and feel whether the tendons subluxate anteriorly. Pain, palpable clicking, snapping or crepitus of the tendons may be elicited by active dorsiflexion and eversion of the ankle or by active circumduction of the foot [6]. 1.4. Investigations Weightbearing anteroposterior, lateral and oblique radiographs are required in all symptomatic ankles. Radiographs including a calcaneal axial view, are important to identify or exclude other pathologies. A small avulsion fracture of the lateral malleolus termed a ‘‘fleck’’ sign indicates injury of the SPR [10]. CT scan can further define bony abnormalities and is particularly important in determining retro malleolar groove shape and depth. Dynamic ultrasonography can confirm peroneal subluxation. The examination however, is operator dependant. Static MRI with the ankle dorsiflexed may demonstrate tendon displacement [11], but can also grade injuries of the SPR as well as defining the retro malleolar groove more accurately [10,12].
1.5. Classification Eckert and Davis [3] first classified acute SPR injuries leading to peroneal tendon instability. Oden [13] added a fourth grade later (Table 1). A further category of intrasheath subluxation of the peroneus longus and brevis tendons within the peroneal groove and an otherwise intact retinaculum was described by Raikin et al. These were diagnosed with dynamic ultrasound [14]. 2. Material and method Between March 2005 and June 2014 a total of 23 patients had been treated surgically for dislocation/subluxation of the peroneal tendons by the two senior authors (NPS and PF). The inclusion criteria were symptomatic (pain and/or dysfunction) subluxing or dislocating/dislocated tendons. There were seventeen males and six females with a mean age of 35.5 years (range 20–50 years) at surgery. The mechanism of injury was primarily sport related (Table 2). All patients except for the very acute cases had extensive physiotherapy and biokinetics, prior to being referred to the unit. The patients presented at various periods following their injury. Presentation was the typical painful snapping of the tendons, constant pain in the case of chronically dislocated tendons, tenderness or apprehension with examination, not unlike in the unstable shoulder. The period between injury and surgery was on average 17.8 months (range 0.25–108 months). Five patients presented in the acute phase (6 weeks) and 18 patients were late cases. In three patients, the radiographs showed a flake of bone related to the fibula groove. This was confirmed intraoperatively (Eckert and Davis Stage III), whereas the remainder of the patients were classified as Stage I/II. All Stage III patients were late cases. The decision to operate however was made purely on a clinical basis and not according to stage or chronicity of the problem. One patient had been unsuccessfully operated elsewhere 12 months previously. No ethics approval was necessary as surgery for symptomatic dislocating tendons is an accepted method of treatment and the technique used is not too dissimilar from previously described techniques. 2.1. Surgical technique Three patients had purely a repair of the superior peroneal retinaculum (‘‘pants over vest’’). Thirteen patients had reattachment of the SPR. Seven patients had groove deepening with the reattachment. Table 1 Classification of disorders involving the superior peroneal retinaculum. Grade Eckert and Davis [3] I The superior peroneal retinaculum is separated from the fibrous lip and lateral malleolus, but still attached to the periosteum on the posterior aspect of the fibula Peroneus longus dislocated anteriorly II The distal portion of the dense fibrous lip on the posterior edge of the lateral malleolus is elevated with the retinaculum III A thin fragment of the bone is avulsed with the retinaculum when it is torn loose from its anterior attachment Oden [13] IV
Fig. 1. Anatomy of the superior peroneal retinaculum.
The superior peroneal retinaculum is elevated from its posterior attachment and is usually found lying deep to the tendons
Please cite this article in press as: Saragas NP, et al. Peroneal tendon dislocation/subluxation – Case series and review of the literature. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.06.002
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Table 2 Mechanism of injury. Ankle twist Rugby Motor vehicle accident Squash Off road biking Horse riding Ice hockey Snow skiing Water skiing Zip line
8 5 2 2 1 1 1 1 1 1
Fig. 3. Diagrammatic representation of dislocated peroneal tendons.
2.2. Author’s preferred method The patient is placed supine with a bolster under the ipsilateral buttock. The procedure is performed under tourniquet control. A longitudinal incision is made, extending from about 5 cm proximal to 2 cm beyond the tip of the lateral malleolus along the posterolateral edge of the fibula and along the course of the peroneal tendons. The SPR is visualized and often the peroneal tendons are dislocated, resting on the posterolateral surface of the fibula in a pocket created by the avulsed SPR (Figs. 2 and 3). The retinaculum is then incised longitudinally along the posterolateral border of the fibula and elevated from the posterolateral surface of the fibula. The tendons are inspected carefully for any damage and repaired accordingly. The groove-deepening, if required, is performed at this stage. 2.3. Groove-deepening procedure Multiple drill holes are made along the posterolateral and posteromedial edges of the groove for approximately 3 cm. The drill holes are then connected with a sharp osteotome and a bony flap is elevated. The cancellous bone beneath the flap is removed. The bony flap is then returned to its place and gently impacted to a depth of about 5 mm with a gentle slope deeper towards the posteromedial edge so that the posterolateral edge acts as a ‘‘shelf’’ to contain the relocated peroneal tendons (Fig. 4). This method maintains the fibro-cartilaginous surface of the groove (to prevent adhesions).
Once the peroneal tendons are reduced, the posterolateral surface of the fibula is roughened using a nibbler or osteotome so that the repaired retinaculum will scar down onto it. Three holes are drilled in the postero lateral edge of the trough and the SPR is reattached/repaired with absorbable sutures as shown in the following figures and illustrations (Figs. 5–11). The posterolateral meniscoid cartilaginous lip is generally incorporated in the repair (for the purpose of this study, no mention of damage was made in the medical records). Postoperatively, the patient is mobilized in a nonweightbearing short leg cast (viz. ankle lateral collated ligament repair), in neutral for 4 weeks. The authors feel that with adequate repair, there is no need to immobilize the ankle in neither inversion nor eversion. Thereafter progressive weight bearing is allowed in an ankle brace for a further 6 weeks. Physical therapy commences once the patient is out of the cast. Gentle range of motion exercises are begun till the patient is fully weight bearing at approximately 10 weeks. Strengthening and proprioception exercises commence thereafter. Return to sporting activities in 5–6 months. Additional procedures included peroneal tendon repair, Gould Bro¨strom procedure, arthroscopic debridement of the ankle and calcaneal osteotomy (Table 3). Complications: mild paraesthesia over the sural nerve distribution in one patient. 3. Results Twenty patients were available for follow-up.
Fig. 2. Dislocated peroneal tendons. SPR – superior peroneal retinaculum.
Fig. 4. Deepening of the groove.
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Fig. 5. Relocated peroneal tendons.
Fig. 8. Knots tied on lateral edge of trough and same suture passed through anterior portion of SPR.
One had a simple repair, one had purely a reattachment of the SPR and one had associated groove deepening and peroneus brevis repair. Of the late cases the average postoperative AOFAS score was 82.3 (range 36–100) and the VAS score was 1.1 (range 0–5). The overall VAS score was 1.1 (range 0–5) and AOFAS score was 86.5 (range 36–100). Sixteen patients rated their results as excellent, one as good, one uncertain (Juvenile Chronic arthritis patient) and two poor. No patients were professional athletes and all returned to their previous sporting activities bar the JCA patient and the two poor results. All returned to their daily activities however the poor results related to persistent pain in both patients and persistent swelling in one. The cohort number was too small for any statistical analysis. Fig. 6. Attaching posterior portion of SPR to the lateral edge of the trough.
All patients completed a VAS and AOFAS questionnaire at a mean of 53.1 months with a minimum of 6 months following surgery (range 6–109 m). Patients who were operated on in the acute phase had an average postoperative VAS score of 1 (range 0–1) and AOFAS score of 100.
4. Discussion Dislocating or subluxing peroneal tendons is a relatively infrequent injury that most published articles, albeit small cohort of patients, advocate surgical treatment.
Fig. 7. Peroneal tendons relocated.
Fig. 9. SPR repaired after roughening the lateral surface of the lateral malleolus.
Please cite this article in press as: Saragas NP, et al. Peroneal tendon dislocation/subluxation – Case series and review of the literature. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.06.002
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Table 3 Additional procedures. Peroneus brevis repair Peroneus longus repair Peroneus brevis + peroneus longus repair Peroneus brevis repair + Gould Bro¨strom procedure Arthroscopic debridement ankle Dwyer calcaneal osteotomy Arthroscopic debridement ankle + peroneus brevis repair
Fig. 10. Diagrammatic representation of suture passing. 1–4: direction of suture.
Acute grade I and possibly grade III injuries may be treated conservatively in a short leg cast with the foot in neutral to slight inversion for 6 weeks. This allows healing of the SPR to adhere to the postero-lateral aspect of the fibula [7]. This non-operative treatment however, may be associated with a high rate of failure [3]. Several operative procedures have been advocated: (1) Anatomic repair of the SPR may be performed in both the acute as well as the chronic dislocations [15,16]. (2) Groove-deepening procedures may be utilized with the anatomic repair as required [14,17–19]. (3) Bone-block procedures were first described by Kelly in 1920 [20]. These may be associated with non-union, tendon irritation and tendon adhesions [7,9]. (4) Tissue transfer to reinforce the retinaculum. These are not currently recommended [21]. (5) Rerouting the peroneal tendons beneath the calcaneo fibular ligament [22,23]. (6) Sliding fibular graft [24]. (7) Endoscopic repair of the SPR has recently given good short- to medium-term results [25]. Often the fibular groove deepening is combined with retinaculum repair. A recent study compared retinaculum repair with and without fibular groove deepening. The authors found good outcome scores
6 3 2 1 1 1 1
for both techniques with the isolated retinaculum repair being a faster and simpler technique irrespective of the groove morphology [26]. Most published articles are limited to a relatively small number of case series or reports. Majority of them, however report good or excellent results [14–19,22–27]. The surgical techniques vary and depends largely on the surgeon’s clinical experience and preference. Two patients treated with a simple repair were late cases and one in the acute setting. The one poor result related to a patient who had surgery for subluxing peroneal tendons elsewhere. As a result of his persistent pain, swelling and chronic dislocated tendons, he had revision surgery at 18 months from his original surgery. Intraoperatively it was noted that both peroneal tendons were dislocated but intact. The P.B. was adhered to scar tissue and the groove was filled with scar tissue. A groove deepening procedure was added to the SPR reattachment. At the last follow-up, the patient had a high uric acid level as well as significant arthrosis in both subtalar and talo-navicular joints. Furthermore, he had developed a bony spur over the lateral malleolus causing impingement of the tendons. His persistent symptoms may well be related to these co-morbidities. The second patient with a poor satisfaction rate complained of ankle pain rather than the peroneal tendons/surgery. Both the above poor results were not directly related to the procedure, but do affect the overall scores. There was no significant difference in satisfaction rate between the reattachment and the reattachment with groove deepening procedures (AOFAS 90.6 vs 91.7 and VAS 0.75 vs 0.5 respectively) or age. Two of the three dissatisfied patients had only a reattachment of the SPR and one had a groove deepening procedure as well. Furthermore, the different suture techniques related to the number of knots. Itwas noted that the extra knots were superfluous. As the technique evolved so were the knots lessened. The earlier patients received two extra knots, this made no difference to the ultimate success of the procedure or satisfaction of the patients. Initially CT scan was undertaken preoperatively to identify the shallow figular groove for potential groove deepening. Intraoperatively though, the authors relied less and less on the preoperative CT scan findings and the decision to deepen the groove was made when the tendons did not remain reduced spontaneously. Furthermore, the authors concluded that the classifications, although elegant, did not help with the ultimate decision for surgical intervention. A weakness of this study is the small retrospective cohort of patients. 5. Conclusions
Fig. 11. Diagrammatic representation of alternate suture passing technique. 1–5: direction of suture.
The authors have concluded that surgical treatment of dislocating/subluxing peroneal tendons following failed conservative treatment is generally successful. The described surgical technique of reattaching the superior peroneal retinaculum
Please cite this article in press as: Saragas NP, et al. Peroneal tendon dislocation/subluxation – Case series and review of the literature. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.06.002
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following fibular groove-deepening when indicated was found to be an effective method of preventing adherence of the tendons and recurrence of the subluxation. The results showed no one procedure superior to another with respect to chronicity, stage or satisfaction score. Conflict of interest The authors wish to declare that there has been no financial or personal relationships with other people or organizations that has inappropriately influenced this study. No grants or any other funding from any source has been received. References [1] Das De S, Balasubramaniam P. A repair operation for recurrent dislocation of peroneal tendons. J Bone Joint Surg Br 1985;67:585–7. [2] Monteggia GB. Instituzioni chirurgiche. Edz. Milan: G Maspero; 1813–1815. p. 336–41. [3] Eckert WR, Davis Jr EA. Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976;58:670–2. [4] Hodges Davis W, Sobel M, Deland J, Bohne WHO, Patel MB. The superior peroneal retinaculum: An anatomic study. Foot Ankle Int 1994;15:271–5. [5] Niemi WJ, Savidakis Jr J, De Jesus JM. Peroneal subluxation: a comprehensive review of the literature with case presentations. J Foot Ankle Surg 1997;36:141–5. [6] Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG. Current concepts review: operative treatment for peroneal tendon disorders. J Bone Joint Surg Am 2008;90:404–18. [7] Selmani E, Gjata V, Gjika E. Current concepts review: peroneal tendon disorders. Foot Ankle Int 2006;27:221–8. [8] Purnell ML, Drummond DS, Engber WD, Breed AL. Congenital dislocation of the peroneal tendons in the calcaneovalgus foot. J Bone Joint Surg Br 1983;65:316–9. [9] Maffulli N, Ferran NA, Oliva F, Testa V. Recurrent subluxation of the peroneal tendons. Am J Sports Med 2006;34:986–92. [10] Church CC. Radiographic diagnosis of acute peroneal tendon dislocation. Am J Roentgenol 1977;129:1065–8.
[11] Shellock FG, Feske W, Frey C, Terk M. Peroneal tendons: Use of kinematic MR imaging of the ankle to determine subluxation. J Magn Reson Imaging 1997;7:451–4. [12] Rosenberg ZS, Bencardino J, Astion D, Schweitzer ME, Rokito A, Sheskier S. MRI features of chronic injuries of the superior peroneal retinaculum. Am J Roentgenol 2003;181:1551–7. [13] Oden RR. Tendon injuries about the ankle resulting from skiing. Clin Orthop Relat Res 1987;216:63–9. [14] Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. J Bone Joint Surg Am 2008;90:992–9. [15] Ferran NA, Maffulli N, Oliva F. Management of recurrent subluxation of the peroneal tendons. Foot Ankle Clin 2006;11(3):465–74. [16] Hui JHP, Das De S, Balasubramaniam P. The Singapore operation for recurrent dislocation of peroneal tendons. J Bone Joint Surg Br 1998;80:325–7. [17] Zoellner G, Clancy Jr W. Recurrent dislocation of the peroneal tendon. J Bone Joint Surg Am 1976;61(2):292–4. [18] Porter D, McCarroll J, Knapp E, Torma J. Peroneal tendon subluxation in athletes: fibular groove-deepening and retinacular reconstruction. Foot Ankle Int 2005;26(6):436–41. [19] Kollias SL, Ferkel RD. Fibular grooving for recurrent peroneal tendon subluxation. Am J Sports Med 1997;25(3):329–35. [20] Kelly RE. An operation for the chronic dislocation of the peroneal tendons. Br J Surg 1920;7:502–4. [21] Canale ST, editor. 10th ed., Campbell’s operative orthopaedics, vol. 4, 10th ed. St. Louis: Mosby Year Book; 2003. p. 4210–2. [22] Martens MA, Noyez JF, Mulier JC. Recurrent dislocation of the peroneal tendons. Results of re-routing the tendons under the calcaneo fibular ligament. Am J Sports Med 1986;14(2):148–50. [23] Steinbo¨ck G, Pinsger M. Treatment of peroneal tendon dislocation by transposition under the calcaneo fibular ligament. Foot Ankle Int 1994; 15(3):107–11. [24] Micheli LJ, Waters PM, Sanders DP. Sliding fibular graft repair for chronic dislocation of the peroneal tendons. Am J Sports Med 1989;17(1):68–71. [25] Guillo S, Calder JDF. Treatment of recurring peroneal tendon subluxation in athletes. Endoscopic repair of the retinaculum. Foot Ankle Clin NA 2013;18: 293–300. [26] Cho J, Kim J-Y, Song D-G, Lee W-C. Comparison of outcome after retinaculum repair with and without fibular groove deepening for recurrent dislocation of the peroneal tendons. Foot Ankle Int 2014;35(7):683–9. [27] Escalas F, Figueras JM, Merino JA. Dislocation of the peroneal tendons. Long term results of surgical treatment. J Bone Joint Surg Am 1980;62(3): 451–3.
Please cite this article in press as: Saragas NP, et al. Peroneal tendon dislocation/subluxation – Case series and review of the literature. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.06.002
FAS-843; No. of Pages 6 Foot and Ankle Surgery xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Peroneal tendon dislocation/subluxation – Case series and review of the literature Nikiforos Pandelis Saragas MBBCh (Wits), FCS (SA) Ortho, MMed (Ortho Surg) (Wits)a,b,*, Paulo Norberto Faria Ferrao MBChB (Pret), FCS (SA) Orthoa,b, Ziyaad Mayet BSc (Wits), MBChB (Medunsa), FC Ortho (SA), MMed Orth (Wits)a,b, Hooman Eshraghi MBBCh (Wits), FC Ortho (SA)a,b a b
Netcare Linksfield Orthopaedic Sports & Rehabilitation Centre (Clinic), Johannesburg, South Africa Orthopaedic Department, University of the Witwatersrand, Johannesburg, South Africa
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 February 2015 Received in revised form 31 May 2015 Accepted 1 June 2015
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. ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Peroneal tendons Subluxation/dislocation
1. Introduction Dislocating or subluxing peroneal tendons are a relatively infrequent pathology which is often misdiagnosed as an ankle sprain particularly in the acute setting. It affects mainly young adults and most frequently during sporting activities. Dislocating peroneal tendons are mostly due to avulsion of the superior peroneal retinaculum (SPR) from its fibular insertion.
* Corresponding author at: PO Box 1153, Highlands North, 2037 Johannesburg, South Africa. Tel.: +27 11 485 1974; fax: +27 11 640 5313. E-mail address: [email protected] (N.P. Saragas).
In fact Das De and Balasubramaniam [1] suggested the stripped retinacular pocket was similar to the Bankart lesion of the shoulder. Subluxation of the peroneal tendons was first described in a ballet dancer by Monteggia in 1803 [2]. 1.1. Anatomy Proximally, the common peroneal sheath passes through a fibro-osseous tunnel known as the retro-malleolar groove. This groove is covered with fibro-cartilage with the peroneus longus tendon lying posterolateral to the peroneus brevis tendon. The groove varies in depth and shape. The shape of the groove is determined by a cartilaginous ridge which enhances the depth [3].
http://dx.doi.org/10.1016/j.fas.2015.06.002 1268-7731/ß 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Saragas NP, et al. Peroneal tendon dislocation/subluxation – Case series and review of the literature. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.06.002
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FAS-843; No. of Pages 6 N.P. Saragas et al. / Foot and Ankle Surgery xxx (2015) xxx–xxx
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The SPR is a fibrous band that originates from the posterolateral aspect of the fibula, passes over the tendons and inserts most commonly onto the calcaneus and Achilles tendon sheath, although there are several distinct insertional variations [4] (Fig. 1). The SPR functions as the primary restraint to peroneal tendon subluxation [5]. 1.2. Mechanism of injury Dislocation or subluxation often occurs during sporting activities or any other manouvre which includes the sudden, reflexive contraction of the peroneal muscle during dorsiflexion of the everted foot or during an acute inversion injury to the dorsiflexed ankle [6]. An inadequate groove, lateral ankle instability, laxity of the SPR and congenital absence of the SPR may increase the risk of subluxation [7,8]. 1.3. Examination A history of an acute injury is often misdiagnosed as an ankle sprain, although swelling, tenderness and ecchymosis posterior to the lateral malleolus can be demonstrated in a subluxation [6]. A concomitant ankle ligament sprain or a longitudinal split of the peroneus brevis [9] maybe present. In the more chronic subluxation or dislocation, patients experience pain and at times may describe a snapping or popping sensation in the lateral ankle and hindfoot. There is a long differential diagnosis and therefore, a detailed history and physical examination are essential. Peroneal tendon subluxation may be obvious when the patient walks. Dislocation can be visualized by rotating the ankle and feel whether the tendons subluxate anteriorly. Pain, palpable clicking, snapping or crepitus of the tendons may be elicited by active dorsiflexion and eversion of the ankle or by active circumduction of the foot [6]. 1.4. Investigations Weightbearing anteroposterior, lateral and oblique radiographs are required in all symptomatic ankles. Radiographs including a calcaneal axial view, are important to identify or exclude other pathologies. A small avulsion fracture of the lateral malleolus termed a ‘‘fleck’’ sign indicates injury of the SPR [10]. CT scan can further define bony abnormalities and is particularly important in determining retro malleolar groove shape and depth. Dynamic ultrasonography can confirm peroneal subluxation. The examination however, is operator dependant. Static MRI with the ankle dorsiflexed may demonstrate tendon displacement [11], but can also grade injuries of the SPR as well as defining the retro malleolar groove more accurately [10,12].
1.5. Classification Eckert and Davis [3] first classified acute SPR injuries leading to peroneal tendon instability. Oden [13] added a fourth grade later (Table 1). A further category of intrasheath subluxation of the peroneus longus and brevis tendons within the peroneal groove and an otherwise intact retinaculum was described by Raikin et al. These were diagnosed with dynamic ultrasound [14]. 2. Material and method Between March 2005 and June 2014 a total of 23 patients had been treated surgically for dislocation/subluxation of the peroneal tendons by the two senior authors (NPS and PF). The inclusion criteria were symptomatic (pain and/or dysfunction) subluxing or dislocating/dislocated tendons. There were seventeen males and six females with a mean age of 35.5 years (range 20–50 years) at surgery. The mechanism of injury was primarily sport related (Table 2). All patients except for the very acute cases had extensive physiotherapy and biokinetics, prior to being referred to the unit. The patients presented at various periods following their injury. Presentation was the typical painful snapping of the tendons, constant pain in the case of chronically dislocated tendons, tenderness or apprehension with examination, not unlike in the unstable shoulder. The period between injury and surgery was on average 17.8 months (range 0.25–108 months). Five patients presented in the acute phase (6 weeks) and 18 patients were late cases. In three patients, the radiographs showed a flake of bone related to the fibula groove. This was confirmed intraoperatively (Eckert and Davis Stage III), whereas the remainder of the patients were classified as Stage I/II. All Stage III patients were late cases. The decision to operate however was made purely on a clinical basis and not according to stage or chronicity of the problem. One patient had been unsuccessfully operated elsewhere 12 months previously. No ethics approval was necessary as surgery for symptomatic dislocating tendons is an accepted method of treatment and the technique used is not too dissimilar from previously described techniques. 2.1. Surgical technique Three patients had purely a repair of the superior peroneal retinaculum (‘‘pants over vest’’). Thirteen patients had reattachment of the SPR. Seven patients had groove deepening with the reattachment. Table 1 Classification of disorders involving the superior peroneal retinaculum. Grade Eckert and Davis [3] I The superior peroneal retinaculum is separated from the fibrous lip and lateral malleolus, but still attached to the periosteum on the posterior aspect of the fibula Peroneus longus dislocated anteriorly II The distal portion of the dense fibrous lip on the posterior edge of the lateral malleolus is elevated with the retinaculum III A thin fragment of the bone is avulsed with the retinaculum when it is torn loose from its anterior attachment Oden [13] IV
Fig. 1. Anatomy of the superior peroneal retinaculum.
The superior peroneal retinaculum is elevated from its posterior attachment and is usually found lying deep to the tendons
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Table 2 Mechanism of injury. Ankle twist Rugby Motor vehicle accident Squash Off road biking Horse riding Ice hockey Snow skiing Water skiing Zip line
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Fig. 3. Diagrammatic representation of dislocated peroneal tendons.
2.2. Author’s preferred method The patient is placed supine with a bolster under the ipsilateral buttock. The procedure is performed under tourniquet control. A longitudinal incision is made, extending from about 5 cm proximal to 2 cm beyond the tip of the lateral malleolus along the posterolateral edge of the fibula and along the course of the peroneal tendons. The SPR is visualized and often the peroneal tendons are dislocated, resting on the posterolateral surface of the fibula in a pocket created by the avulsed SPR (Figs. 2 and 3). The retinaculum is then incised longitudinally along the posterolateral border of the fibula and elevated from the posterolateral surface of the fibula. The tendons are inspected carefully for any damage and repaired accordingly. The groove-deepening, if required, is performed at this stage. 2.3. Groove-deepening procedure Multiple drill holes are made along the posterolateral and posteromedial edges of the groove for approximately 3 cm. The drill holes are then connected with a sharp osteotome and a bony flap is elevated. The cancellous bone beneath the flap is removed. The bony flap is then returned to its place and gently impacted to a depth of about 5 mm with a gentle slope deeper towards the posteromedial edge so that the posterolateral edge acts as a ‘‘shelf’’ to contain the relocated peroneal tendons (Fig. 4). This method maintains the fibro-cartilaginous surface of the groove (to prevent adhesions).
Once the peroneal tendons are reduced, the posterolateral surface of the fibula is roughened using a nibbler or osteotome so that the repaired retinaculum will scar down onto it. Three holes are drilled in the postero lateral edge of the trough and the SPR is reattached/repaired with absorbable sutures as shown in the following figures and illustrations (Figs. 5–11). The posterolateral meniscoid cartilaginous lip is generally incorporated in the repair (for the purpose of this study, no mention of damage was made in the medical records). Postoperatively, the patient is mobilized in a nonweightbearing short leg cast (viz. ankle lateral collated ligament repair), in neutral for 4 weeks. The authors feel that with adequate repair, there is no need to immobilize the ankle in neither inversion nor eversion. Thereafter progressive weight bearing is allowed in an ankle brace for a further 6 weeks. Physical therapy commences once the patient is out of the cast. Gentle range of motion exercises are begun till the patient is fully weight bearing at approximately 10 weeks. Strengthening and proprioception exercises commence thereafter. Return to sporting activities in 5–6 months. Additional procedures included peroneal tendon repair, Gould Bro¨strom procedure, arthroscopic debridement of the ankle and calcaneal osteotomy (Table 3). Complications: mild paraesthesia over the sural nerve distribution in one patient. 3. Results Twenty patients were available for follow-up.
Fig. 2. Dislocated peroneal tendons. SPR – superior peroneal retinaculum.
Fig. 4. Deepening of the groove.
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Fig. 5. Relocated peroneal tendons.
Fig. 8. Knots tied on lateral edge of trough and same suture passed through anterior portion of SPR.
One had a simple repair, one had purely a reattachment of the SPR and one had associated groove deepening and peroneus brevis repair. Of the late cases the average postoperative AOFAS score was 82.3 (range 36–100) and the VAS score was 1.1 (range 0–5). The overall VAS score was 1.1 (range 0–5) and AOFAS score was 86.5 (range 36–100). Sixteen patients rated their results as excellent, one as good, one uncertain (Juvenile Chronic arthritis patient) and two poor. No patients were professional athletes and all returned to their previous sporting activities bar the JCA patient and the two poor results. All returned to their daily activities however the poor results related to persistent pain in both patients and persistent swelling in one. The cohort number was too small for any statistical analysis. Fig. 6. Attaching posterior portion of SPR to the lateral edge of the trough.
All patients completed a VAS and AOFAS questionnaire at a mean of 53.1 months with a minimum of 6 months following surgery (range 6–109 m). Patients who were operated on in the acute phase had an average postoperative VAS score of 1 (range 0–1) and AOFAS score of 100.
4. Discussion Dislocating or subluxing peroneal tendons is a relatively infrequent injury that most published articles, albeit small cohort of patients, advocate surgical treatment.
Fig. 7. Peroneal tendons relocated.
Fig. 9. SPR repaired after roughening the lateral surface of the lateral malleolus.
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Table 3 Additional procedures. Peroneus brevis repair Peroneus longus repair Peroneus brevis + peroneus longus repair Peroneus brevis repair + Gould Bro¨strom procedure Arthroscopic debridement ankle Dwyer calcaneal osteotomy Arthroscopic debridement ankle + peroneus brevis repair
Fig. 10. Diagrammatic representation of suture passing. 1–4: direction of suture.
Acute grade I and possibly grade III injuries may be treated conservatively in a short leg cast with the foot in neutral to slight inversion for 6 weeks. This allows healing of the SPR to adhere to the postero-lateral aspect of the fibula [7]. This non-operative treatment however, may be associated with a high rate of failure [3]. Several operative procedures have been advocated: (1) Anatomic repair of the SPR may be performed in both the acute as well as the chronic dislocations [15,16]. (2) Groove-deepening procedures may be utilized with the anatomic repair as required [14,17–19]. (3) Bone-block procedures were first described by Kelly in 1920 [20]. These may be associated with non-union, tendon irritation and tendon adhesions [7,9]. (4) Tissue transfer to reinforce the retinaculum. These are not currently recommended [21]. (5) Rerouting the peroneal tendons beneath the calcaneo fibular ligament [22,23]. (6) Sliding fibular graft [24]. (7) Endoscopic repair of the SPR has recently given good short- to medium-term results [25]. Often the fibular groove deepening is combined with retinaculum repair. A recent study compared retinaculum repair with and without fibular groove deepening. The authors found good outcome scores
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for both techniques with the isolated retinaculum repair being a faster and simpler technique irrespective of the groove morphology [26]. Most published articles are limited to a relatively small number of case series or reports. Majority of them, however report good or excellent results [14–19,22–27]. The surgical techniques vary and depends largely on the surgeon’s clinical experience and preference. Two patients treated with a simple repair were late cases and one in the acute setting. The one poor result related to a patient who had surgery for subluxing peroneal tendons elsewhere. As a result of his persistent pain, swelling and chronic dislocated tendons, he had revision surgery at 18 months from his original surgery. Intraoperatively it was noted that both peroneal tendons were dislocated but intact. The P.B. was adhered to scar tissue and the groove was filled with scar tissue. A groove deepening procedure was added to the SPR reattachment. At the last follow-up, the patient had a high uric acid level as well as significant arthrosis in both subtalar and talo-navicular joints. Furthermore, he had developed a bony spur over the lateral malleolus causing impingement of the tendons. His persistent symptoms may well be related to these co-morbidities. The second patient with a poor satisfaction rate complained of ankle pain rather than the peroneal tendons/surgery. Both the above poor results were not directly related to the procedure, but do affect the overall scores. There was no significant difference in satisfaction rate between the reattachment and the reattachment with groove deepening procedures (AOFAS 90.6 vs 91.7 and VAS 0.75 vs 0.5 respectively) or age. Two of the three dissatisfied patients had only a reattachment of the SPR and one had a groove deepening procedure as well. Furthermore, the different suture techniques related to the number of knots. Itwas noted that the extra knots were superfluous. As the technique evolved so were the knots lessened. The earlier patients received two extra knots, this made no difference to the ultimate success of the procedure or satisfaction of the patients. Initially CT scan was undertaken preoperatively to identify the shallow figular groove for potential groove deepening. Intraoperatively though, the authors relied less and less on the preoperative CT scan findings and the decision to deepen the groove was made when the tendons did not remain reduced spontaneously. Furthermore, the authors concluded that the classifications, although elegant, did not help with the ultimate decision for surgical intervention. A weakness of this study is the small retrospective cohort of patients. 5. Conclusions
Fig. 11. Diagrammatic representation of alternate suture passing technique. 1–5: direction of suture.
The authors have concluded that surgical treatment of dislocating/subluxing peroneal tendons following failed conservative treatment is generally successful. The described surgical technique of reattaching the superior peroneal retinaculum
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following fibular groove-deepening when indicated was found to be an effective method of preventing adherence of the tendons and recurrence of the subluxation. The results showed no one procedure superior to another with respect to chronicity, stage or satisfaction score. Conflict of interest The authors wish to declare that there has been no financial or personal relationships with other people or organizations that has inappropriately influenced this study. No grants or any other funding from any source has been received. References [1] Das De S, Balasubramaniam P. A repair operation for recurrent dislocation of peroneal tendons. J Bone Joint Surg Br 1985;67:585–7. [2] Monteggia GB. Instituzioni chirurgiche. Edz. Milan: G Maspero; 1813–1815. p. 336–41. [3] Eckert WR, Davis Jr EA. Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976;58:670–2. [4] Hodges Davis W, Sobel M, Deland J, Bohne WHO, Patel MB. The superior peroneal retinaculum: An anatomic study. Foot Ankle Int 1994;15:271–5. [5] Niemi WJ, Savidakis Jr J, De Jesus JM. Peroneal subluxation: a comprehensive review of the literature with case presentations. J Foot Ankle Surg 1997;36:141–5. [6] Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG. Current concepts review: operative treatment for peroneal tendon disorders. J Bone Joint Surg Am 2008;90:404–18. [7] Selmani E, Gjata V, Gjika E. Current concepts review: peroneal tendon disorders. Foot Ankle Int 2006;27:221–8. [8] Purnell ML, Drummond DS, Engber WD, Breed AL. Congenital dislocation of the peroneal tendons in the calcaneovalgus foot. J Bone Joint Surg Br 1983;65:316–9. [9] Maffulli N, Ferran NA, Oliva F, Testa V. Recurrent subluxation of the peroneal tendons. Am J Sports Med 2006;34:986–92. [10] Church CC. Radiographic diagnosis of acute peroneal tendon dislocation. Am J Roentgenol 1977;129:1065–8.
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Please cite this article in press as: Saragas NP, et al. Peroneal tendon dislocation/subluxation – Case series and review of the literature. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/j.fas.2015.06.002