The ESSKA-AFAS international consensus statement on peroneal tendon pathologies

Outcomes Following Modified Broström for Chronic Lateral Ankle Instability With and Without Peroneal Tendon Exploration

BACKGROUND

It is not known how peroneal tendon exploration influences results after modified Broström for lateral ankle instability. We propose peroneal exploration at the time of modified Broström will have similar outcomes as no peroneal exploration.

METHODS

A retrospective analysis was performed of patients undergoing modified Broström with and without peroneal exploration. Foot and Ankle Outcome scores and data regarding military retention were gathered and compared.

RESULTS

Seventeen patients were identified in the modified Broström only cohort and 24 in the peroneal exploration cohort. Patients had mean follow-up of 5 years in both cohorts. The mean FAOS in the modified Broström only cohort was 68 and 72 in the cohort with peroneal exploration (P = .541). When each FAOS subcategory was analyzed, no difference was identified in any subcategory. Eight of 17 patients (47%) in the modified Broström only cohort remained active duty compared with 8 of 24 patients (33%) in the modified Broström with peroneal exploration cohort (P = .518). One patient medically discharged in the modified Broström only cohort versus 6 in peroneal exploration cohort (P = .109). Overall satisfaction with the procedure was 12 of 17 (71%) in the modified Broström only cohort and 19 of 24 (79%) in the peroneal exploration cohort (P = .529).

CONCLUSIONS

No significant difference was identified between patients undergoing modified Broström alone or modified Broström with peroneal exploration. There was no significant difference in return to duty, medical discharge or patient satisfaction.

LEVELS OF EVIDENCE

Level III: retrospective case-control study with prospectively collected data.

Fibular morphology is not associated with incidence of peroneal tendon dislocation

PURPOSE

The association of peroneal tendon dislocation with peroneal bone morphology and postoperative redislocation rates remains unknown. This study compared the fibula morphology in patients with peroneal tendon dislocation with that in a control population.

METHODS

The study enrolled 48 patients who underwent surgery for peroneal tendon dislocation at our institution during between 2018 and 2023. Thirty-five patients with preoperative magnetic resonance imaging of the ankle were defined as Group D and 35 with magnetic resonance imaging of the ankle for other reasons and with similar background data were selected as the control group (Group C). The posterior tilting angle of the fibula, posterolateral angle and posterolateral edge angle were evaluated at the plafond level. The posterior tilting angle, posterolateral angle and retromalleolar bone shape according to the Rosenberg classification (flat, convex, concave) were evaluated at the midpoint between the plafond and the tip.

RESULTS

At the plafond level, the posterior tilting, posterolateral and posterolateral edge angles were 57.7 ± 11.1°, 123.8 ± 12.3° and 90.8 ± 13.7°, respectively, in Group D and 64.1 ± 15.4°, 121.1 ± 12.3° and 88.7 ± 12.2°, respectively, in Group C, with no significant differences. No significant between-group differences existed in the posterior tilting and posterolateral angles at the midpoint level. Moreover, no significant differences existed in distribution of the bone geometry according to the Rosenberg classification.

CONCLUSION

There were no differences in morphology between patients with peroneal tendon dislocation and controls. This study provides useful information on the indications for primary surgery and whether bony approach is useful for peroneal tendon dislocation.

LEVEL OF EVIDENCE

Level IV.

Differences in Retromalleolar Fibular Groove Morphology According to Level of Axial Computed Tomography Scans

Background

Studies have evaluated types of retromalleolar groove using axial magnetic resonance imaging at the level of 10 mm above the tip of the lateral malleolus. However, no evidence is available to support that this level is appropriate for evaluating retromalleolar groove morphology.

Purpose

To assess the influence of the level of axial computed tomography (CT) scans on the assessment of retromalleolar groove morphology.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

The study population included 122 patients (mean age, 27.9 ± 11.8 years; 69 males, 53 female) who underwent CT scans to evaluate foot or ankle pathologies between 2020 and 2023. The shape of the retromalleolar groove (concave, flat, convex, or irregular) at 3 levels of axial CT scans (8, 10, and 12 mm above the tip of the lateral malleolus) was assessed independently by 2 orthopaedic surgeons. The length from the tip of the lateral malleolus to the proximal tip of the fossa of the lateral malleolus was also measured on coronal CT scans.

Results

The type of retromalleolar groove was significantly different according to the level of CT scans (8 vs 10 mm, P = .0001; 10 vs 12 mm, P = .0001; 8 vs 12 mm, P = .001). The type of retromalleolar groove was the same at all 3 levels in 31.1% of patients (38/122). The length from the tip of the lateral malleolus to the proximal tip of the fossa of the lateral malleolus was <10 mm in 17.2% of patients (21/122).

Conclusion

The shape of the retromalleolar fibular groove was affected by the level at which the CT scan was obtained. Approximately 70% of the patients showed different types of retromalleolar grooves among the 3 CT scan levels.

Minimally Invasive Peroneal Tenodesis Assisted by Peroneal Tendoscopy: Technique and Preliminary Results

Introduction: Peroneal disorders are a common cause of ankle pain and lateral instability and have been described in as much as 77% of patients with lateral ankle instability. Clicking, swelling, pain, and tenderness in the peroneal tendons track are frequent symptoms, but they can be confused with other causes of lateral ankle pain. The management of peroneal disorders can be conservative or surgical. When the conservative treatment fails, surgery is indicated, and open or tendoscopic synovectomy, tubularization, tenodesis or tendon transfers can be performed. The authors present a surgical technique of tendoscopy associated to minimally invasive tenodesis for the treatment of peroneal tendon tears, as well as the preliminary results of patients submitted to this procedure. Methods: Four patients with chronic lateral ankle pain who were diagnosed with peroneal brevis pathology were treated between 2020 and 2022 with tendoscopic-assisted minimally invasive synovectomy and tenodesis. Using a 2.7 mm 30° arthroscope and a 3.0 mm shaver blade, the entire length of the peroneus brevis tendon and most parts of the peroneus longus tendon can be assessed within Sammarco's zones 1 and 2. After the inspection and synovectomy, a minimally invasive tenodesis is performed. Results: All patients were evaluated at least six months after surgery. All of them reported improvement in daily activities and in the Foot Function Index (FFI) questionnaire (pre-surgery mean FFI = 23.86%; post-surgery mean FFI = 6.15%), with no soft tissue complications or sural nerve complaints. Conclusion: The tendoscopy of the peroneal tendons allows the surgeon to assess their integrity, confirm the extent of the lesion, perform synovectomy, prepare the tendon for tenodesis, and perform it in a safe and minimally invasive way, reducing the risks inherent to the open procedure.

Surgical treatment options for chronic instability of the peroneal tendons: a systematic review and proportional meta-analysis

INTRODUCTION

Several surgical techniques for chronic instability of the peroneal tendons have been reported. Yet, the most optimal technique has not been clarified. This study aims to perform a systematic review and meta-analysis of all existing evidence and compare all published surgical techniques in both the athletic as the nonathletic population.

MATERIALS AND METHODS

A systematic review and a proportional meta-analysis, with a random-effects model, were carried out according to the PRISMA guidelines, using the keywords "chronic luxation" OR "instability" AND "peroneal tendon" AND "treatment" OR "treatment protocol". Four surgical techniques were compared in patients with chronic peroneal instability, comprising superior peroneal retinaculum (SPR) repair or replacement, groove deepening procedures (primarily with additional SPR operations), rerouting procedures, and bony procedures (respectively group S, G, R and B). Outcomes of interest include the pre- and postoperative American orthopedic foot and ankle society hindfoot score, return to sports, postoperative redislocation and complications. Pooled estimates of the last two outcomes were obtained.

RESULTS

For the systematic review, 31 studies were eligible. Of these, 25 papers met the criteria for inclusion in the meta-analysis. All techniques demonstrated a clinical improvement postoperatively. Group B, however, demonstrated overall more unsatisfactory results, and higher complication rates were observed for both group R and group B. The latter was established by the proportional meta-analysis as well [95% confidence interval group S: (0.01-0.10); group G: (0.02-0.10); group R: (0.13-0.57); group B: (0.24-0.40)]. Concerning surgical efficacy (= no postoperative redislocation), no significant difference was statistically observed. Finally, considerable differences in study quality were identified.

CONCLUSION

Surgical treatment results in excellent clinical and functional outcomes in patients with chronic peroneal instability. More inferior results were demonstrated for rerouting and bony procedures. However, no high-quality studies are available and future randomized controlled trials are necessary to advocate for the most advantageous approach.

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.

Anatomic Features of Patients With Recurrent Peroneal Tendon Dislocation

BACKGROUND

There are several anatomic variations of the peroneal muscles and lateral malleolus of the ankle that may play an important role in the onset of peroneal tendon dislocation.

PURPOSE

To investigate the anatomic variations of the retromalleolar groove and peroneal muscles in patients with and without recurrent peroneal tendon dislocation using magnetic resonance imaging (MRI) and computed tomography (CT).

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 30 patients (30 ankles) with recurrent peroneal tendon dislocation who underwent both MRI and CT before surgery (PD group) and 30 age- and sex-matched patients (control [CN] group) who underwent MRI and CT were included in this study. The imaging was reviewed at the level of the tibial plafond (TP level) and at the center slice between the TP and the fibular tip (CS level). The appearance of a malleolar groove (convex, concave, or flat) and the posterior tilting angle of the fibula were assessed on CT images. The appearance of accessory peroneal muscles, height of the peroneus brevis muscle belly, and volume of the peroneal muscle and tendons were assessed on MRI scans.

RESULTS

There were no differences in the appearance of the malleolar groove, posterior tilting angle of the fibula, or accessory peroneal muscles at the TP and CS levels between the PD and CN groups. The peroneal muscle ratio was significantly higher in the PD group than in the CN group at the TP and CS levels (both P < .001). The height of the peroneus brevis muscle belly was significantly lower in the PD group than in the CN group (P = .001).

CONCLUSION

A low-lying muscle belly of the peroneus brevis and a larger muscle volume in the retromalleolar space were significantly associated with peroneal tendon dislocation. Retromalleolar bony morphology was not associated with peroneal tendon dislocation.

Radiological features accompanying peroneus brevis split rupture revealed on magnetic resonance imaging - a cohort study

BACKGROUND

Peroneal split tears are an underrated cause of ankle pain. While magnetic resonance imaging (MRI) is useful for diagnosis, split tears are challenging to identify. The aim of the study was to investigate the association of peroneus brevis split rupture with abnormalities of the superior peroneal retinaculum (SPR), anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), joint effusion, morphology of the malleolar groove, presence of the bone marrow oedema and prominent peroneal tuberculum.

METHODS

Ankle MRI cases were assessed by independent observers retrospectively in two groups: one with peroneus brevis split tears (n = 80) and one without (control group, n = 115). Two observers evaluated the soft tissue lesions, and three graded the bone lesions. Fisher's exact test and Pearson correlation were used for analysis. The Bonferroni-Holm method (B-H) was used to adjust for multiple comparisons.

RESULTS

Only bone marrow edema in the posterior part of the lateral malleolus was significantly (p < 0.05) more common in the split tear group after applying B-H. SPR total rupture was seen only in the experimental group. No differences in incidence of ATFL and CFL lesions or other SPR lesions were noticed (p < 0.05).

CONCLUSION

Bone marrow edema in the posterior part of the lateral malleolus is associated with peroneus split tears on MRI.

Normal Distal Excursion of the Peroneus Brevis Myotendinous Junction

A low-lying peroneus brevis muscle belly has been described as a risk factor for the development of peroneal tendon pathology, but this finding has primarily been described based on cohorts with pre-existing clinical findings. Therefore, the objective of this investigation was to evaluate the frequency of apparently abnormal low-lying muscle bellies from a series of subjects without clinical or imaging findings of peroneal tendon pathology. One hundred consecutive MRIs were reviewed with measurement of the distance from the distal peroneal myotendinous junction to the tip of the fibula. This distance was observed to be 23.9 ± 8.8 mm (10.8-55.4 mm; 95% confidence interval 22.2-26.7 mm). If one assumed that a myotendinous junction within 2 cm of the distal tip of fibula represented an abnormal low-lying muscle, then we observed 37% of extremities without clinical or radiographic evidence of peroneal tendon pathology that would be considered anatomically "abnormal." When a low-lying muscle belly was defined as occurring within 2 cm of the distal tip of the fibula, then a probability analysis of our data distribution found a 32.6% probability for individuals to have an "abnormally" low-lying muscle belly. These results indicate that what has traditionally been defined intraoperatively as an abnormally low-lying peroneus brevis muscle belly might simply represent intraoperative confirmation bias of relatively normal structural anatomy.

Peroneus Longus and Peroneus Brevis: A Review on Pathology and Updated Treatments

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Peroneus longus (PL) and peroneus brevis (PB) pathologies involve a variety of etiologies and degrees of dysfunction, which complicates their diagnoses.

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Patient presentation includes a spectrum of disease; however, despite advanced imaging, a misunderstanding of the pathology and diagnostic algorithms has contributed to continued misdiagnoses.

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This article summarizes the anatomy and the pathophysiology of the PL and the PB; it also provides updated treatment options and their associated outcomes in order to illuminate an often-misunderstood topic.

Peronealsehnenverletzungen

Hintergrund

Verletzungen der Peronealsehnen gelten als häufig unterdiagnostizierte Ursache lateraler Rückfußschmerzen. Prädisponierende Ursachen sind u. a. eine chronische laterale Instabilität sowie ein Rückfußvarus, da dies zu einer Überbelastung der Peronealsehnen führt. Klinisch äußern sich Peronealsehnenverletzungen meist unspezifisch mit lateralen Rückfußschmerzen.

Material und Methoden

In der Untersuchung zeigen sich Schmerzen bei Aktivierung der Sehnen gegen Widerstand. Die Sonographie zur Diagnostik bietet die Möglichkeit einer dynamischen Untersuchung, in der Magnetresonanztomographie (MRT) können gleichzeitig weitere Strukturen beurteilt werden. Zu unterscheiden sind eine Tendinopathie der Sehnen, eine Instabilität mit Luxation oder Subluxation verbunden mit Pathologien des superioren Peronealsehnenretinakulums sowie Längssplit und komplette Sehnenruptur. Bei Tendinopathien und Längsrissen erfolgt die Therapie primär konservativ. Ein kompletter Riss und eine Läsion über 50 % sollten operativ versorgt und, falls möglich, direkt genäht werden. Alternativ sind eine Tenodese oder ein Sehnenersatz mit einem Graft zu evaluieren.

Ergebnisse

Bei Patienten mit einer Peronealsehneninstabilität führen die Naht oder Rekonstruktion des superioren Peronealsehnenretinakulums zu guten Resultaten. Eine frühe Therapie zeigt eine bessere Heilungschance und kann somit zu einem besseren Outcome führen.

Schlussfolgerung

Zusammenfassend kann gesagt werden, dass bei chronischen lateralen Rückfußschmerzen an eine Peronealsehnenverletzung gedacht und bei Verdacht auf eine Läsion eine MRT oder eine Sonographie zur Bestätigung respektive Ausschluss der Diagnose durchgeführt werden sollte.

Intraosseous Anchorage of a Collagen Matrix Graft to Enhance Repair of Peroneus Brevis Tendon Degeneration

INTRODUCTION

Chronic degeneration of the peroneus brevis tendon (PBT) at its insertion to the base of the fifth metatarsal is uncommon; however, when present it can be a challenge to treat. Repair of the PBT often requires tubularization with or without a peroneus longus tendon transfer. These repairs, however, may not provide resultant full muscle strength, especially if ostectomy of the fifth metatarsal base is required. We report outcomes following a novel technique for anatomic repair of degenerative PBT with intraosseous fifth metatarsal base fixation of a collagen matrix graft.

METHODS

Thirteen consecutive patients (14 procedures) with degeneration of PBT that underwent tendon repair augmented with collagen matrix graft from 2011 to 2019 were reviewed retrospectively. We present outcome data of these 13 patients that were followed for at least 12 months.

RESULTS

Muscle strength, complications, and patient-reported subjective outcomes were reported. There were 10 females and 3 males. Average age was 49.1 years, and average follow-up was 34.9 months. Muscle strength was reported at 5/5 to the PBT by the final follow-up for 92% of patients. There were minimal complications, 84.6% (11/13) of patients had no limitation in activity level, and 92% (12/13) would recommend this procedure to a friend.

CONCLUSION

Outcomes for this novel repair technique for insertional degenerative PBT have never been reported before and show excellent results with long-term follow-up.

Peroneus brevis tendon injuries: Report of two cases and review of literature

The incidence of peroneal tendon disorders in the population is unknown and they are usually overlooked. We report two cases of peroneus brevis injuries and a comprehensive literature review was performed. The first case was a 53-year-old man presented with persistent pain on the lateral aspect on the left ankle during the last four years and difficulty to bear weight during the last year. MRI showed longitudinal tear of peroneus brevis tendon and the patient underwent surgical treatment. The second case was a 46-year-old woman with persistent pain on the lateral aspect of the ankle with a history of a road traffic accident two years ago. Although MRI showed a peroneus brevis tendon tear, this was a false positive finding. Surgical treatment revealed no tear and symphysiolysis managed to relieve patient's symptoms. Even though MRI is the most effective diagnostic tool in depicting peroneal tendon injuries, there are false positive findings. In cases when symptoms persist, surgical exploration is indicated.

Treatment of Recurrent Peroneal Tendon Dislocation by Peroneal Retinaculum Reattachment Without Fibular Groove Deepening

There are numerous studies recommending fibular groove deepening in the surgical treatment of peroneal tendon dislocation; however, there are some disadvantages to fibular groove deepening procedures. In this study, we evaluated the results of anatomic reattachment of the peroneal retinaculum without fibular groove deepening as a treatment for traumatic peroneal tendon dislocation. Thirty-six patients with recurrent peroneal tendon dislocation, who underwent retinaculum repair without a fibular groove deepening procedure performed by 2 surgeons between March 2004 and March 2017, were enrolled in this study. Resubluxation of tendon, pain on inversion and eversion power of the ankle were monitored. The range of motion of inversion and eversion were measured and then compared to that of the contralateral side. American Orthopedic Foot and Ankle Society (AOFAS), visual analog scale (VAS), Foot Function Index (FFI) scores were obtained for all patients preoperatively and at the final follow-up. Postoperative complications such as infection, sural nerve injury, and recurrence were monitored. Thirty-four patients fully recovered without resubluxation of tendon. Two patients were injured again while playing soccer 6 months after the surgery and fast running 20 months after the surgery respectively. One patient had sural nerve injury. But the symptom was relieved at 6 months after the surgery. None of the patients had weakness of evertor. None of the patients had limited ankle motion. Mean AOFAS, VAS, FFI score improved significantly (p = .02, .01, .02). In conclusion, for the treatment of recurrent dislocation of the peroneal tendon reattachment of the superior retinaculum only without groove deepening followed by proper rehabilitation is sufficient.

[Peroneal tendon pathologies : From the diagnosis to treatment]

Peronealsehnenpathologien sind selten, jedoch häufig unterdiagnostiziert. Eine Assoziation mit einer chronisch lateralen Sprunggelenkinstabilität sowie mit einer varischen Rückfußachse kann bestehen. Pathologien der Sehnen lassen sich in 3 Kategorien einteilen: Tendinitis und Tenosynovitis, Sehnenrisse und Rupturen sowie Sehnensubluxation und Sehnenluxation. Die Magnetresonanztomographie ist die Standardmethode zur radiologischen Beurteilung. Die Diagnose und Behandlung basieren jedoch in erster Linie auf Anamnese und klinischer Untersuchung. Eine primär konservative Therapie kann versucht werden, ausgenommen bei Peronealsehnenluxationen des professionellen Sportlers. Die chirurgische Therapie sollte gezielt auf die zugrunde liegende Pathologie abgestimmt werden und kann dementsprechend divers von der tendoskopischen Synovektomie bis zur anatomischen Reparatur des superioren peronealen Retinakulums mit Vertiefung der retromalleolären Rinne ausfallen. Die postoperativen Ergebnisse zeigen eine hohe Patientenzufriedenheit und niedrige Reluxationsraten.

Peroneal Tendons Rupture in a Closed Talar Body Fracture: A Rare Injury

The combination of tendon and ligament ruptures with fracture of the talus is very rare. We demonstrate our experience in the acceptable management of a 34-year-old male referred with a closed comminuted fracture of the talar body after falling 7 meters. During the surgery, complete rupture of the peroneus brevis tendon, partial rupture of the peroneus longus tendon, and an avulsed superficial deltoid ligament from medial malleolus were found. Twelve months after open reduction and internal fixation of the talar body fracture and repair of the peroneal tendons and superficial deltoid ligament, the patient was satisfied, without any talar dome collapse, sclerosis, or arthritic changes. It is recommended to take care of possible tendon or ligament ruptures during fixation of talar fractures in cases of high-energy trauma.

Pathologies of the Peroneals: A Review

Peroneal tendon disorders remain an often overlooked source of lateral hindfoot pain and tenderness. Medical professionals who specialize in foot and ankle care are still far more likely to diagnose a peroneal tendon disorder as an ankle injury. In fact, acute peroneal dislocations are misdiagnosed in up to 40% of cases. The major subsets of peroneal disorders include peroneal tendonitis and tenosynovitis, painful os peroneum syndrome, subluxation, and tearing of the peroneal tendons. Proper history and physical exam maneuvers must be performed to help identify the source of the injury and differentiate these categories. Detailed imaging through X-ray and magnetic resonance imaging must also be used to diagnose the etiology of the patient's condition in order to direct management. Currently, there is very limited knowledge on peroneal pathologies, and treatment protocol is highly variable and limited to expert opinion. Despite the individual preferences and nuances held by each surgeon when it comes to operating, the overarching principles that guide appropriate management of tendonitis, subluxation, and tendon tear should maintain a higher level of consistency. Therefore, the authors of this review aim to elucidate the most current methods to diagnose these disorders as well as evidence-based practices for optimal management.Levels of Evidence: Level V.

Importance of Space-Occupying Anatomical Variations in Peroneal Tendoscopy

BACKGROUND

We hypothesized that peroneal tendons disorders are more commonly associated with anatomical variations, which could overcrowd the retrofibular groove.

METHODS

This single-center retrospective case study covered 84 consecutive cases that had undergone peroneal tendoscopy. Peroneal tendoscopy was performed on 82 patients, predominantly female (3:1) with a median age of 46 years. The preoperative evaluation and all the procedures were performed by a single surgeon using a standardized technique.

RESULTS

Two patients required revision surgery 8 and 52 months after the index procedure due to persistent posterolateral ankle pain. Peroneal tendoscopy was performed as a solitary procedure in 45.1% (37/82) of cases, while the remaining cases involved peroneal tendoscopy as a supplementary procedure. Low-lying peroneus brevis muscle belly (LLMB) was the most common finding in this series in 53.7% (44/82) of cases. In 41.5% (34/82) of cases, longitudinal tears of the peroneus brevis tendon were noted. Some patients presented with more than 1 concomitant peroneal tendon pathology. The LLMB was observed in 23.5% (8/34) of cases with a longitudinal tear of the peroneus brevis tendon.

CONCLUSION

Peroneal tendon anatomical variations, especially LLMB, were associated with the presence of peroneus brevis tendon ruptures and intrasheath peroneal tendon subluxations as well as posttraumatic posterolateral ankle pain. Due to high rates of undiagnosed and misdiagnosed cases of LLMB preoperatively, we believe special care should be taken to recognize it during tendoscopy. Peroneal tendoscopy is a high-efficiency, low-complication method to treat some peroneal tendon conditions.

LEVEL OF EVIDENCE

Level IV, case series.

A false-pouch closure technique with an intact superior peroneal retinaculum for recurrent dislocation of the peroneal tendon

Purpose

To evaluate the usefulness of the false-pouch closure technique with an intact superior peroneal retinaculum (SPR).

Methods

From 2016 to 2020, 30 patients with recurrent dislocation of the peroneal tendon were treated with the current procedure. Clinical outcomes, including the time to resume running, the rate and time to return to sports, and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hind Foot score, were evaluated preoperatively and at the last follow-up.

Results

The rate of return to the pre-injury level of sports activity was 93.3%, and the mean duration to return to running and sports was 8.0 ± 2.8 weeks (range: 3–12 weeks) and 14.4 ± 3.2 weeks (range: 10–24 weeks), respectively. The mean preoperative AOFAS score was 79.7 ± 9.6 points (range: 41–90), which improved significantly to 98.9 ± 3.2 (87–100) postoperatively (p < 0.01).

Conclusion

The false-pouch closure technique with suture tape and anchors had a reliable clinical outcome and can enable the early return of patients to their sports activities.

Level of evidence

IV, Case series

Lateral Heel Pain Caused by Impingement of Hypertrophic Peroneal Tubercle and Os Peroneum

Hypertrophic peroneal tubercle (HPT) is an overgrowth of the peroneal tubercle located on the lateral aspect of the hindfoot, which could cause tenosynovitis of the peroneus longus tendon. Os peroneum (OP) is an accessory ossicle that exists in the peroneus longus tendon at the lateral aspect of the calcaneocuboid joint. Both HPT and OP can cause lateral foot pain and occasionally require surgical treatment. We encountered a case of lateral foot pain of HPT coexisting with OP. Careful preoperative magnetic resonance imaging, dynamic ultrasonographic image, and block injection suggested an impingement of HPT and OP as a cause of lateral foot pain. Surgical resection of HPT, while retaining OP, successfully achieved pain relief in the patient. To the best of our knowledge, this is the first report presenting a case of HPT coexisting with OP successfully treated without OP resection.

CT scan assessment of the dimensions and morphological variations of the peroneal tubercle

PURPOSE

The hypertrophied peroneal tubercle may result in lateral ankle pain with peroneal tendon tenosynovitis and rupture. The aim of this study was to evaluate different configurations and dimensions of the normal peroneal tubercle using two-dimensional CT scan.

METHODS

Totally, 100 normal CT scans of cases older than 18 years of age were assessed to determine the shape of the peroneal tubercle. Moreover, height, length and width of different configurations of the normal peroneal tubercle were measured in axial and coronal sections of the ankle CT scans.

RESULTS

Four different configurations based on the axial cut of the calcaneus were found; single-convex (59%), double-convex (24%), plateau (9%), and convex-concave (8%) without statistically significant difference between genders (p-value: 0.526). Totally, mean of height, length and width were 4.42 ± 1.38 mm, 28.88 ± 6.58 mm and 17.17 ± 3.85 mm, respectively. Although mean of the height in the single-convex and the double-convex types were 4.5 ± 1.4 mm and 5.0 ± 1.4 mm, respectively, the highest peroneal tubercle in the single-convex and the double-convex group were 10.2 mm and 8.5 mm, respectively.

CONCLUSIONS

In cases with lateral ankle pain and suspicious to hypertrophied peroneal tubercle, two-dimensional CT scan can be an available practical modality to identify the pathological type of the peroneal tubercle based on the presented classification and normal values. As previously reported in the literature, considering cut-off point of 5 mm could result in overdiagnosis of the hypertrophied peroneal tubercle, especially in single-convex type; however, clinical correlation is always paramount.

LEVEL OF EVIDENCE

Level IV.

Successful reconstruction of distal peroneus longus tendon dislocation associated with a split lesion - a case report

BACKGROUND

Peroneal tendon injuries are one of the differential diagnoses in lateral ankle and rearfoot pain. While partial tears are not uncommon, peroneal tendon dislocation at the peroneal tubercle is very rare. Until now, only three papers have been published, presenting five cases of peroneus longus tendon dislocation over the peroneal tubercle. This report adds a previously undescribed case of a peroneus longus tendon split tear that was partially dislocated and entrapped over the peroneal tubercle. The respective operative approach and the outcome are described.

CASE PRESENTATION

A 25-year-old international top-level speed skater developed a painful mass over the lateral calcaneal wall. There was no specific inducing injury in his medical history. In contrast to previous reports, according to the patient's history, a snapping phenomenon was not present. Conservative treatment was not effective. By inspection and palpation an enlarged peroneal tubercle was assumed. During operative exploration, we found an incomplete longitudinal split tear of the peroneus longus tendon, which was partially dislocated and entrapped over the peroneal tubercle. This mimicked an enlarged peroneal tubercle. A portion of the split tendon was resected. A deepening procedure of the flat groove of the peroneus longus tendon below the peroneal tubercle and a transosseous reconstruction of the avulsed inferior peroneal retinaculum were performed. After six months, the patient had completely reintegrated into his elite sport and has been free of symptoms since then.

CONCLUSIONS

From the presented case it can be speculated that the inferior peroneal retinaculum was overused, worn out, detached, or ruptured due to overpronation and friction the lateral edge of the low-cut speed skating shoe. Then the peroneus longus tendon experienced substantial friction with the peroneal tubercle with possible dislocation during ankle motion. This frictional contact may have finally led to further degeneration and a longitudinal tear of the tendon. Obviously, dislocations can develop insidiously resulting in lesions of the peroneus longus tendon at the peroneal tubercle, ultimately leading to a tendon entrapment. This mimics an enlarged tubercle. The pathology is very rare and can be successfully addressed surgically.

Tendoscopic peroneal retinaculum repair for recurrent peroneal tendon dislocation enables earlier return to sports than the open procedure

PURPOSE

The purpose of this study was to evaluate whether tendoscopic peroneal retinaculum repair for patients with recurrent peroneal tendon dislocation (RPTD) is more useful than an open procedure.

METHODS

Twenty-five patients with RPTD were retrospectively reviewed. Twelve patients (13 ankles) with RPTD underwent the open procedure (Group A) between 2008 and 2014, and 13 patients (14 ankles) underwent the tendoscopic procedure (Group B) between 2014 and 2017. Evaluation parameters included clinical results [the Japanese Society for Surgery of the Foot (JSSF) ankle-hind foot scale], operation time, complications, return to sports, and recurrence.

RESULTS

Postoperative JSSF ankle/hindfoot scale scores were significantly better than the pre-surgical scores in both groups. The mean operation time was significantly longer in Group B than in Group A (75.7 ± 20.5 vs 38.4 ± 10.5 min). There was one recurrence in Group A, but none in Group B. Group A had no complications, and Group B had one wound infection. Group B, excluding the case of infection, could return to sports earlier than Group A, excluding the recurrent case (13.4 ± 1.5 vs 12.2 ± 0.6 weeks).

CONCLUSIONS

This tendoscopic procedure needs longer operation time and is more technically demanding, but it is a useful procedure, because it is less invasive and can accelerate return to sports.

LEVEL OF EVIDENCE

III.

Peroneal Tendinosis and Subluxation

Peroneal tendinosis and subluxation are lifestyle-limiting conditions that can worsen if not properly diagnosed and treated. Adequate knowledge of ankle anatomy and detailed history and comprehensive physical examination is essential for diagnosis. Peroneal tendinopathy is likely to result from overuse, whereas subluxation often precipitates from forceful contraction of peroneals during sudden dorsiflexion while landing or abruptly stopping. In athletes, conservative measures remain first-line treatment of tendinopathy, but surgery is often immediately indicated in cases of recurrent symptomatic subluxation or dislocation. Surgical technique varies on the type, mechanism, and severity of injury, but most procedures have a high success rate.

Diagnosis and Operative Treatment of Peroneal Tendon Tears

Peroneal tendon tears are a common but under-recognized source of ankle pain and dysfunction. Recognition of the characteristic symptoms, physical findings, and imaging results of peroneal tendon tears is essential for accurate diagnosis and appropriate treatment. Acute, limited tears of a single peroneal tendon may be debrided and repaired. However, by the time operative treatment is undertaken, many tears of a single tendon are sufficiently advanced that the surgeon may need to consider excision of the nonviable segment and tenodesis of the damged tendon to the to the adjacent peroneal tendon. Irreparable tearing of both peroneal tendons may be treated with flexor tendon transfer and/or allograft reconstruction. This review article focuses on diagnosis and operative treatment of peroneal tendon tears, including the treatment algorithms, operative technique, and published outcomes.

Diagnosis and Operative Treatment of Peroneal Tendon Tears

Peroneal tendon tears are a common but under-recognized source of ankle pain and dysfunction. Recognition of the characteristic symptoms, physical findings, and imaging results of peroneal tendon tears is essential for accurate diagnosis and appropriate treatment. Acute, limited tears of a single peroneal tendon may be debrided and repaired. However, by the time operative treatment is undertaken, many tears of a single tendon are sufficiently advanced that the surgeon may need to consider excision of the nonviable segment and tenodesis of the damged tendon to the to the adjacent peroneal tendon. Irreparable tearing of both peroneal tendons may be treated with flexor tendon transfer and/or allograft reconstruction. This review article focuses on diagnosis and operative treatment of peroneal tendon tears, including the treatment algorithms, operative technique, and published outcomes.

Minimally invasive tenodesis for peroneus longus tendon rupture: A case report and review of literature

BACKGROUND

Peroneal tendon disorders are common causes of lateral hindfoot pain. However, total rupture of the peroneal longus tendon is rare. Surgical treatment for this condition is usually a side-to-side tenodesis of the peroneal longus tendon to the peroneal brevis tendon. While the traditional procedure involves a long lateral curved incision, this approach is associated with damage to the lateral soft tissues (up to 24% incidence).

CASE SUMMARY

A 50-year-old female had developed pain at the lateral aspect of the hindfoot 1 mo after an ankle sprain while walking in the street. Previous treatments were anti-inflammatory drugs, ice, rest and Cam-walker boot. At physical exam, there was pain and swelling over the course of the peroneal tendons. Ankle instability and cavovarus foot deformity were ruled out. Eversion strength was weak (4/5). Imaging showed complete rupture of the peroneal longus tendon associated with a sharp hypertrophic peroneal tubercle. Surgical repair was indicated after failure of conservative treatment (physiotherapy, rest, analgesics, and ankle stabilizer). A less invasive approach was performed for peroneal longus tendon debridement and side-to-side tenodesis to the adjacent peroneal brevis tendon, with successful clinical and functional outcomes.

CONCLUSION

Peroneus longus tendon tenodesis can be performed through a less invasive approach with preservation of the lateral soft tissue integrity.

Peroneal groove deepening as the treatment of peroneal tendon subluxation: A case report

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Subluxation of the peroneal tendon is relatively infrequent.

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Subluxation of the peroneal tendon often misdiagnosed as ankle sprain.

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Avulsion of the superior peroneal retinaculum from is the main cause of peroneal tendon subluxation.

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Good outcomes can be achieved by peroneal groove deepening and retinaculum ligament repair.

Introduction

Peroneal tendon subluxation is a relatively rare disorder that is often misdiagnosed as an ankle sprain. It affects mainly young adults, usually during sports activities. It is mostly caused by avulsion of the superior peroneal retinaculum (SPR) from its fibular insertion, which requires surgical intervention, especially for cases of symptomatic chronic peroneal tendon subluxation and/or dislocation. We reported a case of peroneal tendon subluxation of left ankle treated with peroneal groove deepening and retinaculum ligament repair, the objective of which is to illustrate the effectiveness of this procedure.

Case presentation

We present a case of a thirty-four-year old male with peroneal tendon subluxation of left ankle. The patient was injured while exercising two years prior to admission. He now reported pain and instability on the left ankle. We performed peroneal groove deepening and retinaculum ligament repair to treat this patient.

Discussion

Peroneal groove deepening and retinaculum ligament repair shows an excellent clinical outcome; after the procedure, there are no major complications such as infections, wound problems or permanent discomfort. Overall, the result of surgery had been considered satisfactory. Postoperatively, the ankle was placed in a below-knee, non–weight-bearing temporary cast in semi-equinus position for two weeks.

Conclusion

The incidence rate of peroneal tendon subluxation is relatively low, and surgery is the primary treatment of this type of injury, with various available surgical methods available for the performing surgeon. Peroneal groove deepening and retinaculum ligament repair offers a satisfactory outcome.

Reattachment of the superior peroneal retinaculum versus the bone block procedure for the treatment of recurrent peroneal tendon dislocation: two safe and effective techniques

PURPOSE

Clinical outcomes between reattachment of the superior peroneal retinaculum (SPR) and the bone block procedure were compared in this study to elucidate which procedure was safer and more effective.

METHODS

From 2012 to 2016, 25 patients with recurrent peroneal tendon dislocation underwent the bone block procedure (group A), and another 22 patients underwent reattachment of the SPR (group B). American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Ankle Activity Score (AAS), time to return to sports activity, rate of return to sports level, range of motion (ROM) of the ankle, rate of recurrence, and overall patient satisfaction were collected to evaluate outcomes between the two groups.

RESULTS

In group A, 24 patients followed up at a mean period of 42.5 ± 16.7 months. The mean postoperative AOFAS score was 92.9 ± 3.9. The median time to return to sports activity was 6.0 months (IQR 4.3-6.0 months) with 19 patients (79.2%) returning to their previous sports level. Two patients experienced recurrent dislocation, and 22 patients (91.7%) were satisfied with the procedure. In group B, 20 patients followed up at a mean period of 35.8 ± 15.3 months. The mean postoperative AOFAS score was 95.0 ± 4.2. The median time to return to sports activity was 5.0 months (IQR 4.0-5.0 months) with 18 patients (90.0%) returning to their previous sports level. No recurrence was reported, and 18 patients (90.0%) were satisfied with the procedure. The time to return to sports activity in group B was significantly shorter than that in group A. There was no significant difference in complications or clinical outcomes between the two procedures.

CONCLUSION

Both procedures offered satisfactory results for recurrent peroneal tendon dislocation with low rates of recurrence and complications. However, the time to return to sports activity after the reattachment of the SPR was shorter than that after the bone block procedure.

LEVEL OF EVIDENCE

Retrospective Comparative Study, Level III.

Chronic Disorders of the Peroneal Tendons: Current Concepts Review of the Literature

Chronic disorders of the peroneal tendons are a common cause of posterolateral ankle pain, including tendinopathy, tendon instability, and chronic tendon tears. They are often preceded by ligamentous instability or predisposing anatomic abnormalities such as a shallow fibular groove or a cavovarus foot deformity. Given the substantial disability associated with chronic peroneal tendon disorders, it is important for orthopaedic surgeons to optimize the diagnostic and treatment strategies of these entities based on contemporary studies. This article reviews both classic and recent scientific evidence regarding the diagnosis and treatment of patients with chronic peroneal tendon disorders.

Clinical Outcomes and Complications of Peroneal Tendon Sheath Ultrasound-Guided Corticosteroid Injection

BACKGROUND

The treatment of symptomatic peroneal tendinopathy and tears traditionally begins with nonsteroidal anti-inflammatory drugs, activity modification, physical therapy, and immobilization, with surgery typically reserved for those failing nonoperative treatment. Ultrasound-(US)-guided peroneal tendon sheath (PTS) corticosteroid injection is an additional nonoperative modality, but limited data exist on its safety and efficacy. The purpose of this study was to assess clinical outcomes following US-guided PTS corticosteroid injection for chronic tendinopathy or tears.

METHODS

We retrospectively identified patients who had undergone US-guided PTS corticosteroid injection for pain due to peroneal tendinopathy, tears, or subluxation at our institution from 2012 to 2018. Underlying diagnosis was based on clinical examination, magnetic resonance imaging (MRI) results, and/or intraoperative findings, when available. Medical record data were supplemented by e-mail or telephone follow-up. Collected information included patient age, sex, body mass index (BMI), smoking status, workers' compensation status, prior surgeries about the foot and ankle, duration of symptoms prior to injection, perceived improvement in pain following injection and its duration, number of injections, progression to surgery, and any adverse outcomes of injection. We identified 96 patients (109 injections). Thirty-seven (38.5%) had previous foot and ankle surgery, with 17 (17.7%) having surgery specifically on the peroneal tendons.

RESULTS

Twenty-four of 96 (25%) progressed to have surgery on their peroneal tendons following injection. Following injection, 38/87 (43.7%) of patients reported 0-1 weeks of pain relief, 11/87 (12.6%) 2-6 weeks, 6/87 (6.9%) 7-12 weeks, and 32/87 (36.8%) greater than 12 weeks. Preinjection duration of symptoms was associated with postinjection duration of pain relief (P=.036). There were 2 reported complications (1.8%): 1 case of self-limited sural nerve irritation and 1 of peroneus longus tear progression.

CONCLUSION

Our study demonstrates US-guided PTS corticosteroid injection was safe and relatively effective in patients with symptomatic peroneal tendon tears or tendinopathy, including those who had undergone prior surgery, and may be considered in a comprehensive protocol of nonoperative management.

LEVEL OF EVIDENCE

Level IV, case series.